Prescribing trends in direct-acting antivirals for the treatment of hepatitis C in Ontario, Canada
Abstract
Background: Direct-acting antivirals (DAA) offer an opportunity to cure hepatitis C. Reimbursement for DAAs has changed on two occasions since their inclusion on the Ontario public formulary. Whether these changes have appreciably modified prescribing patterns and increased access to DAAs is unknown. Methods: We conducted a repeated cross-sectional study of DAA reimbursement by the Ontario Public Drug Programs from January 1, 2012, to December 31, 2018, to summarize the use of DAAs in Ontario and describe changes in DAA prescribing physician specialties over this period. We measured the total number of users quarterly. Results are reported overall and by prescriber type. Results: A total of 27,116 individuals received a publicly funded prescription for a DAA from the first quarter (Q1) of 2012 to the fourth quarter (Q4) of 2018. Nearly two-thirds (n = 17,813; 65.7%) of all DAAs were prescribed by gastroenterologists, hepatologists, or infectious disease specialists. Use of DAAs over time appears to have had three major phases in uptake: (1) the introduction of DAA treatments on the Ontario public drug formulary as a prior authorization benefit in Q1 2015, (2) expanded listing of all DAAs as limited-use products on the formulary in Q1 2017, and (3) the introduction of newer DAAs in Q2 2018. Conclusions: Changes in listing of these agents had a direct impact on the use of DAAs overall. Generally, broader listing expanded access but did not appear to shift utilization patterns to primary care prescribers. Further understanding of who is not receiving treatment is needed.
Background
Chronic hepatitis C virus (HCV) infection places a substantial burden on the health of Canadians, accounting for more years of lost life than any other infectious disease in the country. HCV-associated morbidity and mortality are attributable to the progression of liver fibrosis over time, which can eventually result in decompensated cirrhosis, hepatocellular carcinoma, and the need for liver transplantation. The disease is estimated to affect more than a quarter of a million Canadians, with disproportionate representation among specific populations, such as people who inject drugs, immigrants from countries with a high prevalence of hepatitis C, Indigenous people, and street-involved youth (1–5). Because hepatitis C is highly transmissible and associated with serious clinical sequelae and high costs, with national drug spending of more than $2 billion since 2014, timely diagnosis and linkage to effective treatment is needed to optimize the health of people living with chronic HCV (2–4,6). The recent introduction of well-tolerated and easily administered direct-acting antivirals (DAAs) with cure rates exceeding 95% was a substantial breakthrough in the treatment of chronic HCV, and the growing use of these therapies has been associated with declining trends in HCV-related hospital admissions (7–9).
Compared with earlier treatments, DAAs are easier to tolerate, are administered over a shorter treatment period, and facilitate successful treatment of medically complex patients, such as those with cirrhosis and mental health issues (8,9). However, the characteristics of individuals prescribed DAAs and prescribing physician specialty are not well described. This information is important because reimbursement mechanisms and treatment guidelines for DAAs have changed on three occasions since the drugs were first approved for use in Canada. The first major change was the initial coverage of DAAs in April 2015 through the prior authorization program. The second change occurred in February 2017 when treatments were moved to the general formulary as limited use, and the third was in February 2018 when newer agents were also included on the formulary. Whether these recommendations and changes have appreciably modified prescribing patterns and increased access to DAAs through primary care physicians is unknown. We set out to describe the characteristics of individuals prescribed DAAs in Ontario between 2012 and 2018 and to describe changes in DAA-prescribing physician specialties over this period.
Methods
We conducted a repeated cross-sectional study examining prescription claims for DAAs reimbursed by the Ontario Public Drug Programs from January 1, 2012, to December 31, 2018. In a secondary analysis, we described the characteristics of patients who received a publicly funded DAA prescription between January 1, 2018, and December 31, 2018. Users were included in each calendar year if they had one prescription dispensed for any DAA reimbursed by the Ontario Public Drug Programs.
Data sources
We identified all publicly funded drug claims using the Ontario Drug Benefit (ODB) database. Public drug coverage in Ontario is provided to all residents aged 65 years and older, Ontario residents with financial needs (because of high drug costs, low income, or both), and those living in long-term care or in need of home care. We identified hospitalizations and emergency department visits using the Canadian Institute for Health Information’s Discharge Abstract Database and National Ambulatory Care Reporting System, respectively. We used the Ontario Health Insurance Plan (OHIP) Claims History database to identify physician visits. Beneficiary demographics, place of residence, and vital status information were obtained from the OHIP Registered Persons Database. Prescriber specialty was identified using the ICES Physician Database. These databases, which are securely linked using unique, encoded identifiers and analyzed at ICES (https://www.ices.on.ca), are routinely used to examine drug safety and effectiveness.
Analysis
In our primary analysis, we identified all individuals who were dispensed a DAA reimbursed by the Ontario Public Drug Programs. We report the total number and population-adjusted rate of users dispensed a DAA. Rates are reported per 1,000 Ontario population. The total number of users and rates are reported overall and by prescriber specialty for each quarter.
In our secondary analysis, we created a cohort of individuals who received a DAA prescription in calendar year 2018. Among this cohort, we defined patient characteristics at the time of the first DAA prescription. We report demographic information (age, sex, and socio-economic status), long-term-care-home status, major comorbidities (ie, asthma, chronic obstructive pulmonary disease, cancer, dementia, diabetes, HIV), receipt of opioid agonist therapy in the preceding year, history of opioid-related emergency department visit or hospitalization in the past 3 years, Charlson Comorbidity Index score, and prior receipt of DAAs. Comorbidities leverage established and validated cohorts and codes.
Results
Quarterly counts of DAA dispensing by prescriber specialty from 2012 to 2018 are depicted in Figure 1. A total of 27,116 individuals received a DAA prescription from the first quarter (Q1) of 2012 to the fourth quarter (Q4) of 2018. Gastroenterologists and hepatologists prescribed the most DAAs (12,521 recipients), followed by infectious disease specialists (5,292 recipients), other specialists (4,714 recipients), and general and family practitioners (2,481 recipients; other types of prescribers could not be categorized). DAA dispensing was low until the second quarter (Q2) of 2015, ranging from 13 to 406 recipients per quarter. Upon addition of the agents to the Exceptional Access Program (EAP), there was sharp growth in the remaining quarters of 2015, with number of recipients reaching 1,956 by the last quarter. The number of DAA beneficiaries then steadily decreased to 1,120 in the third quarter (Q3) of 2016, which was followed by a rise until the second and highest peak of 2,539 beneficiaries in Q2 2017 after the addition of agents to the general formulary in February 2017. From this point on, the trend was generally decreasing, except for a third, smaller peak at 2,101 in Q2 2018 after the addition of newer agents to the formulary. The trends were broadly similar across individual specialties as well, albeit with differences in magnitude.
Figure 1: Direct-acting antiviral dispensing among public drug beneficiaries from 2012 to 2018, by quarter and prescriber type
Notes: A = Initial public drug plan: prior authorization; B = Public drug plan expansion: limited use; C = Introduction of newer agents
GP/FP = General practitioner/family practitioner
The characteristics of ODB beneficiaries who received DAAs in 2018 are shown in Table 1. A total of 5,538 DAA beneficiaries were reported in 2018, among whom 2,209 (39.9%) received treatment from a gastroenterologist or hepatologist, 1,309 (23.6%) from an infectious diseases specialist, 759 (13.7%) by another specialist, and 530 (9.6%) from a general or family practitioner. The majority of recipients were aged older than 50 (n = 3,313; 59.8%), were male (n = 3,533; 63.8%), resided in an urban location (n = 4,915; 88.8%), or belonged to a lower neighbourhood income quintile (n = 3,535 [63.8%] in the lowest two quintiles). More than half (n = 3,057; 55.2%) of DAA recipients had a mental health diagnosis, and more than one-quarter (n = 1,592; 28.7%) were receiving opioid agonist therapy.
| Characteristic | No. (%)* | ||||
|---|---|---|---|---|---|
| Overall | Gastroenterologist or hepatologist | GP/FP | Infectious diseases specialist | Other specialist | |
| Beneficiaries | 5,538 (100.0) | 2,209 (39.9) | 530 (9.6) | 1,309 (23.6) | 759 (13.7) |
| Age, y, median (IQR) | 53 (41–61) | 57 (48–64) | 50 (38–57) | 47 (35–57) | 53 (41–61) |
| <24 | 152 (2.7) | 43 (1.9) | 17 (3.2) | 46 (3.5) | 26 (3.4) |
| 25–34 | 693 (12.5) | 177 (8.0) | 83 (15.7) | 259 (19.8) | 88 (11.6) |
| 35–49 | 1,380 (24.9) | 422 (19.1) | 160 (30.2) | 428 (32.7) | 196 (25.8) |
| 50–64 | 2,447 (44.2) | 1,063 (48.1) | 221 (41.7) | 472 (36.1) | 340 (44.8) |
| 65–74 | 706 (12.7) | 403 (18.2) | 46 (8.7) | 87 (6.6) | 85 (11.2) |
| ≥75 | 160 (2.9) | 101 (4.6) | ≤5 | 15–20† | 24 (3.2) |
| Sex: male | 3,533 (63.8) | 1,343 (60.8) | 357 (67.4) | 895 (68.4) | 469 (61.8) |
| Ontario Public Drug Program | |||||
| Seniors | 618 (11.2) | 369 (16.7) | 29 (5.5) | 68 (5.2) | 75 (9.9) |
| Trillium | 1,291 (23.3) | 674 (30.5) | 66 (12.5) | 195 (14.9) | 196 (25.8) |
| Home care | 21 (0.4) | 11 (0.5) | 0 | ≤5 | ≤5 |
| Other | 3,603 (65.1) | 1,153 (52.2) | 433 (81.7) | 1,042 (79.6) | 485 (63.9) |
| Urban residence | 4,915 (88.8) | 1,950 (88.3) | 480 (90.6) | 1,144 (87.4) | 706 (93.0) |
| Neighbourhood income quintile | |||||
| 1 (lowest) | 2,311 (41.7) | 820 (37.1) | 266 (50.2) | 595 (45.5) | 315 (41.5) |
| 2 | 1,224 (22.1) | 498 (22.5) | 110 (20.8) | 308 (23.5) | 155 (20.4) |
| 3 | 882 (15.9) | 373 (16.9) | 82 (15.5) | 197 (15.0) | 124 (16.3) |
| 4 | 607 (11.0) | 288 (13.0) | 34 (6.4) | 106 (8.1) | 88 (11.6) |
| 5 (highest) | 486 (8.8) | 226 (10.2) | 36 (6.8) | 90 (6.9) | 72 (9.5) |
| Comorbidities† | |||||
| Asthma | 1,106 (20.0) | 379 (17.2) | 122 (23.0) | 303 (23.1) | 141 (18.6) |
| Alcohol use disorder | 902 (16.3) | 277 (12.5) | 141 (26.6) | 195 (14.9) | 135 (17.8) |
| Chronic heart failure | 184 (3.3) | 102 (4.6) | 11 (2.1) | 19 (1.5) | 25 (3.3) |
| Chronic obstructive pulmonary disease | 1,287 (23.2) | 553 (25.0) | 118 (22.3) | 265 (20.2) | 167 (22.0) |
| Kidney disease | 195 (3.5) | 84 (3.8) | 9 (1.7) | 52 (4.0) | 30 (4.0) |
| Liver disease‡ | 1,039 (18.8) | 514 (23.3) | 56 (10.6) | 200 (15.3) | 137 (18.1) |
| Recent (past 5 y) cancer diagnosis | 151 (2.7) | 77 (3.5) | 8 (1.5) | 26 (2.0) | 17 (2.2) |
| Diabetes | 746 (13.5) | 355 (16.1) | 58 (10.9) | 138 (10.5) | 98 (12.9) |
| HIV | 191 (3.4) | 6 (0.3) | 25 (4.7) | 113 (8.6) | 23 (3.0) |
| Hypertension | 1,456 (26.3) | 759 (34.4) | 104 (19.6) | 233 (17.8) | 193 (25.4) |
| Major mental health diagnosis | 3,057 (55.2) | 920 (41.6) | 412 (77.7) | 932 (71.2) | 389 (51.3) |
| Receiving opioid agonist therapy | 1,592 (28.7) | 275 (12.4) | 289 (54.5) | 675 (51.6) | 183 (24.1) |
| Opioid-related hospital visit in past y | 159 (2.9) | 34 (1.5) | 26 (4.9) | 47 (3.6) | 28 (3.7) |
| Charlson Morbidity Index | |||||
| No hospitalizations | 3,941 (71.2) | 1,632 (73.9) | 361 (68.1) | 893 (68.2) | 543 (71.5) |
| 0 | 835 (15.1) | 262 (11.9) | 108 (20.4) | 241 (18.4) | 109 (14.4) |
| 1 | 337 (6.1) | 126 (5.7) | 34 (6.4) | 82 (6.3) | 43 (5.7) |
| 2 | 162 (2.9) | 68 (3.1) | 11 (2.1) | 38 (2.9) | 24 (3.2) |
| 3+ | 263 (4.7) | 121 (5.5) | 16 (3.0) | 55 (4.2) | 40 (5.3) |
| DAA characteristics Previous DAA course | 699 (12.6) | 258 (11.7) | 88 (16.6) | 205 (15.7) | 95 (12.5) |
Notes: In accordance with the Institute for Clinical Evaluative Sciences’ commitments in data-sharing agreements and to minimize risk of re-identification, the presence of small cells (counts <6) in any output or report have been limited and are not included in overall values. In addition, some totals may not add up to column totals because of missing data.
*
* Unless otherwise specified
†
† Percentages total more than 100 because patients could have multiple comorbidities
‡
‡ Excluding hepatitis
DAA = Direct-acting antivirals; GP/FP = General practitioner/family practitioner
Several notable differences can be identified among patients who received treatment from a gastroenterologist or hepatologist compared with a general or family practitioner. Patients of gastroenterologists and hepatologists were more likely to be aged older than 65 years (22.8% versus 8.7%) or to belong to the top two quintiles of neighbourhood socio-economic status (23.2% versus 13.2%). Patients who received treatment from a general or family practitioner were more likely to have a mental health diagnosis (77.7% versus 41.6%) or to be receiving opioid agonist therapy (54.5% versus 12.4%). Patients who received treatment from a gastroenterologist or hepatologist had a lower rate of previous DAA treatment (11.7% versus 16.6%). However, when comparing patients of general practitioners with patients of infectious disease specialists, the two groups displayed similar characteristics and rates of DAA treatment completion.
Discussion
There has been sharp and consistent growth in the number of publicly funded individuals prescribed DAA treatment in Ontario between 2012 and 2018, with the prescribing of these agents having three distinct peaks that align with major changes in reimbursement of these agents in Ontario and the introduction of newer agents. Prescribing of these agents is still largely done by gastroenterologists and hepatologists; infectious diseases specialists and general and family practitioners appear to care for more marginalized populations.
The use of DAAs over time appears to have three major phases in uptake: (1) the initial introduction of DAA treatments to the Ontario public drug formulary as a prior authorization benefit in early 2015, (2) expanded listing of all DAAs as limited-use products on the public drug formulary in early 2017, and (3) the introduction of pan-genotypic DAAs in 2018. The peaks in 2015 and 2018 are likely an effect of patients who deferred treatment initiation as they waited for publicly funded access or better treatments. Treatment restrictions on fibrosis levels and genotypes were also lifted in 2018. Previously, only people with late-stage liver disease were eligible for ODB coverage of DAAs, and those with genotype 2 or 3 did not have a DAA option. Data on how many patients were not treated during the study period are unavailable; however, evidence suggests that a significant number of people living with HCV in Canada remain untreated. In British Columbia, a DAA-era study found that fewer than half (38%) of those diagnosed with chronic HCV initiated treatment (10). Research has also found that particular groups face ongoing system-level barriers to HCV treatment (11,12). Although prescriptions may decrease over time as the number of individuals living with hepatitis C is reduced, expanded models of care that include a broader range of providers are likely required for HCV elimination (13,14).
Changes in the listing criteria of DAAs in Ontario’s public drug program have led to increased uptake of these agents. However, prescribing of DAAs among primary care prescribers does not appear to have increased. Our study found that, on average, specialists were treating more patients per prescriber than general practitioners, and nearly two-thirds of all DAA recipients received their DAA therapy from a specialist prescriber. This is concerning because specialists are more difficult to access than general practitioners, requiring a referral and long wait times, and are predominantly based in tertiary care centres, which are not often structured to provide the comprehensive and flexible support that some hepatitis C patients require. Another key finding of our study was the difference in populations served by provider type. A 2011 study of Canadian specialists found that 80% would not treat someone for HCV who was currently injecting drugs (15). Currently, it is unknown in Canada whether the advent of DAAs has shifted or changed attitudes toward patients with active injection drug use. Our data seem to suggest that people receiving treatment for opioid use in the past year are underrepresented in the patient groups of gastroenterologists and hepatologists; this finding may warrant further investigation.
If Ontario and other jurisdictions are to eliminate HCV, system-level changes are still required. HCV treatment guidelines and elimination strategies call for expanding the range of who delivers testing and for community-based models of care (16). In March 2020, the limited use criteria were further expanded to allow for a broader prescriber base for DAAs that includes nurse practitioners. More nurse-led models of care have the potential to increase treatment uptake, especially among marginalized populations because evidence suggests that nurse practitioners are more likely to provide care to people living in poverty and to provide outreach-based care than general practitioners in community settings (17). Additional policy changes, strategies, and community-based models of care that address upstream social determinants of health for clients, as well as barriers to HCV care at the provider level, will also be necessary. Provider barriers that have been identified include lack of educational training and concerns about the complexity of clients on existing caseloads (18,19). Barriers to broader primary care DAA prescribing specifically require further investigation. This suggests the importance of the expansion of HCV treatment through community-based interprofessional teams to support educational capacity building, offload client coordination from general practitioners, and provide additional support for clients to ensure successful treatment outcomes (20,21).
Our study is not without limitations that warrant discussion. First, only publicly funded prescription claims were available for analysis. Although this represents close to two-thirds of all DAA prescriptions in the province, the full picture of prescribing patterns is not known. It may miss some populations of patients who receive treatment through the compassionate release programs and are not eligible for any payer program. A similar study of DAA prescribing patterns in British Columbia in which all DAA prescriptions were analyzed found similar patterns; people with lower socio-economic status and those who used substances were more likely to have received their prescription from a general practitioner (22). Second, this study is also limited by a lack of access to diagnosis and lab information, meaning that we were not able to determine how many and which patients are not being treated. Third, this study categorized prescribers on the basis of the prescriber’s specialty. We do not have any insight into whether the prescriber was supported by another specialty or was integrated into the various types of multidisciplinary and team-based models of care currently available in Ontario. Finally, we were also unable to examine treatment outcomes.
Conclusion
The rate of DAAs reimbursed by the Ontario Public Drug Programs has experienced rapid and sustained growth that strongly correlates with changes in reimbursement, novel treatments, and treatment criteria over the 6-year study period. Our results highlight the difference in populations cared for by different types of prescribers and suggest that expanded access to DAAs through general practitioners could expand access to treatment among marginalized populations. Future work should explore and better understand the barriers in place for people living with hepatitis C who are not receiving DAA therapy to inform future investments.
Acknowledgements:
The authors thank Brogan Inc., Ottawa, for use of their Drug Product and Therapeutic Class Database.
Registry and Registration No. of the Study/ Trial:
N/A
Funding:
This study was funded by grants from the Ontario Ministry of Health and Long-Term Care (MOHLTC) and the Ontario Strategy for Patient-Orientated Research Support Unit, which is supported by the Canadian Institutes of Health Research and the Province of Ontario. It is also supported by the Institute for Clinical Evaluative Sciences (ICES), a non-profit research institute sponsored by the Ontario MOHLTC. The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions and statements expressed herein are those of the authors and not necessarily those of CIHI.
Peer Review:
This article has been peer reviewed.
References
1.Bolotin S, Feld JJ, Garber G, Wong WW, Guerra FM, Mazzulli T. Population-based estimate of hepatitis C virus prevalence in Ontario, Canada. PloS One. 2018;13(1):e0191184. https://doi.org/10.1371/journal.pone.0191184. Medline: 29360823
2.Greenaway C, Azoulay L, Allard R, et al. A population-based study of chronic hepatitis C in immigrants and non-immigrants in Quebec, Canada. BMC Infect Dis. 2017;17(1):140. https://doi.org/10.1186/s12879-017-2242-y. Medline: 28193199
Janjua NZ, Kuo M, Yu A, et al. The population level cascade of care for hepatitis C in British Columbia, Canada: the BC Hepatitis Testers Cohort (BC-HTC). EBioMedicine. 2016;12: 189–95. https://doi.org/10.1016/j.ebiom.2016.08.035. Medline: 27596150
4.Krajden M, Kuo M, Zagorski B, Alvarez M, Yu A, Krahn M. Health care costs associated with hepatitis C: a longitudinal cohort study. Can J Gastroenterol. 2010;24(12):717–26. https://doi.org/10.1155/2010/569692. Medline: 21165379
5.Lanini S, Easterbrook PJ, Zumla A, Ippolito G. Hepatitis C: global epidemiology and strategies for control. Clin Microbiol Infect. 2016;22(10):833–8. https://doi.org/10.1016/j.cmi.2016.07.035. Medline: 27521803
6.El Saadany S, Coyle D, Giulivi A, Afzal M. Economic burden of hepatitis C in Canada and the potential impact of prevention. Eur J Health Econ. 2005;6(2):159–65. https://doi.org/10.1007/s10198-004-0273-y. Medline: 15761777
7.Myers RP, Krajden M, Bilodeau M, et al. Burden of disease and cost of chronic hepatitis C infection in Canada. Can J Gastroenterol Hepatol. 2014;28(5):243–250. https://doi.org/10.1155/2014/317623. Medline: 24839620
8.Myers RP, Shah H, Burak KW, Cooper C, Feld JJ. An update on the management of chronic hepatitis C: 2015 consensus guidelines from the Canadian Association for the Study of the Liver. Can J Gastroenterol Hepatol. 2015;29(1):19–34. https://doi.org/10.1155/2015/692408. Medline: 25585348
9.Shah H, Bilodeau M, Burak KW, et al. The management of chronic hepatitis C: 2018 guideline update from the Canadian Association for the Study of the Liver. CMAJ. 2018;190(22):E677–87. https://doi.org/10.1503/cmaj.170453. Medline: 29866893
10.Bartlett S, Yu A, Chapinal N, et al. The population level care cascade for hepatitis C in British Columbia, Canada as of 2018: impact of direct acting antivirals. Liver Int. 2019;(12): 2261–72. https://doi.org/10.1111/liv.14227. Medline: 31444846
11.Young S, Wood E, Milloy MJ, et al. Hepatitis C cascade of care among people who inject drugs in Vancouver, Canada. Subst Abus. 2018;39(4):461–468. https://doi.org/10.1080/08897077.2018.1485128. Medline: 29949450
12.Socías ME, Ti L, Wood E, et al. Disparities in uptake of direct-acting antiviral therapy for hepatitis C among people who inject drugs in a Canadian setting. Liver Int. 2019;39(8): 1400–7. https://doi.org/10.1111/liv.14043. Medline: 30653809
13.Canadian Network on Hepatitis C Blueprint Writing Committee and Working Groups. Blueprint to inform hepatitis C elimination efforts in Canada. 2019. https://www.canhepc.ca/sites/default/files/media/documents/blueprint_hcv_2019_05.pdf (Accessed March 2020).
14.Lambdin BH, Bluthenthal RN, Zibbell JE, Wenger L, Simpson K, Kral AH. Associations between perceived illicit fentanyl use and infectious disease risks among people who inject drugs. Int J Drug Policy. 2019;74: 299–304. https://doi.org/10.1016/j.drugpo.2019.10.004. Medline: 31733979
15.Myles A, Mugford GJ, Zhao J, Krahn M, Wang PP. Physicians’ attitudes and practice toward treating injection drug users with hepatitis C: results from a national specialist survey in Canada. Can J Gastroenterol. 2011;25(3): 135–9. https://doi.org/10.1155/2011/810108. Medline: 21499577
16.Biondi MJ, Feld JJ. Hepatitis C models of care: approaches to elimination. Can Liver J. 2020;3(2):165–76. https://doi.org/10.3138/canlivj-2019-0002.
17.Dahrouge S, Muldoon L, Ward N, Hogg W, Russell G, Taylor-Sussex R. Roles of nurse practitioners and family physicians in community health centres. Can Fam Physician. 2014;60(11):1020–7.
18.Marshall AD, Grebely J, Dore GJ, Treloar C. Barriers and facilitators to engaging in hepatitis C management and DAA therapy among general practitioners and drug and alcohol specialists—the practitioner experience. Drug Alcohol Depend. 2020;206: 107705. https://doi.org/10.1016/j.drugalcdep.2019.107705. Medline: 31718924
19.Johnson S, Aluzaite K, Taar A, Schultz M. Identifying barriers to treatment of HCV in the primary care setting. Hepatol Int. 2019;13(1):58–65. https://doi.org/10.1007/s12072-018-9902-x. Medline: 30377928
20.Mason K, Dodd Z, Guyton M, et al. Understanding real-world adherence in the directly acting antiviral era: a prospective evaluation of adherence among people with a history of drug use at a community-based program in Toronto, Canada. Int J Drug Policy. 2017;47:202–208. https://doi.org/10.1016/j.drugpo.2017.05.025. Medline: 28619394
21.Tookey P, Mason K, Broad J, Behm M, Bondy L, Powis J. From client to co-worker: a case study of the transition to peer work within a multi-disciplinary hepatitis c treatment team in Toronto, Canada. Harm Reduct J. 2018;15(1): 41. https://doi.org/10.1186/s12954-018-0245-7. Medline: 30107808
22.Clementi EM et al. Treatment differential in HCV treatment prescribers in British Columbia over time. Poster presented at Annual Meeting of the Canadian Association for the Study of the Liver, Canadian Network on Hepatitis C, and Canadian Association of Hepatology Nurses; Montreal, Quebec; February 2020.
Information & Authors
Information
Published In
Canadian Liver Journal
Volume 4 • Number 1 • Winter 2021
Pages: 51 - 58
Copyright
Copyright © 2021.
History
Published ahead of print: 18 December 2020
Published in print: Winter 2021
Published online: 9 August 2021
Keywords:
Authors
Contributions:
Conceptualization, MT, KM, ZD, TG; Methodology, MT, KM, ZD, MG, JP, DM, TG; Investigation, MT, DM, TG; Data Analysis, DM; Writing – Original Draft, MT, KM, MG; Writing – Review and Editing, MT, KM, ZD, MG, JP, DM, TG; Supervision, TG.
Disclosures:
JP reports receiving a research grant from Gilead. None of the other authors have any conflicts of interest to declare.
Ethics Approval:
The study protocol was approved by an ethics committee, and the ethics certificate information is available from the authors upon request.
Informed Consent:
Informed consent was obtained from the patients.
Metrics & Citations
Metrics
Related Content
Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
Download article citation data for:
Canadian Liver Journal 2021 4:1, 51-58
Canadian Liver Journal 2021 4:1, 51-58