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Regional and Rural-Urban Differences in the Use of Direct-acting Antiviral Agents for Hepatitis C Virus

The Veteran Birth Cohort

Njei, Basile, MD, MPH*; Esserman, Denise, PhD; Krishnan, Supriya, DSc; Ohl, Michael, MD, MSPH§; Tate, Janet P., ScD, MPH; Hauser, Ronald G., MD; Taddei, Tamar, MD; Lim, Joseph, MD#; Justice, Amy C., MD, PhD**

doi: 10.1097/MLR.0000000000001071
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Background: Veterans with hepatitis C virus (HCV) infection may face geographic obstacles to obtaining treatment.

Objective: We studied the influence of region and rural versus urban residence on receipt of direct-acting antiretroviral (DAA) medications for HCV.

Subjects: Veterans receiving care within Veterans Affairs Healthcare System born between 1945 and 1965.

Research Design: This is a observational study using national electronic health record data.

Measures: Receipt of DAAs was defined as ≥1 filled prescription from January 1, 2014 to December 31, 2016. Region (South, Northeast, Midwest, and West) and residence (urban, rural-micropolitan, small rural towns, and isolated rural towns) variables were created using residential zone improvement plan codes and rural-urban commuting area (RUCA) codes. Multivariable models were adjusted for age, race, sex, severity of liver disease, comorbidities, and prior treatment experience.

Results: Among 166,353 eligible patients 64,854 received, DAAs. Variation by rural-urban residence depended on region. In unadjusted analyses, receipt varied by rural-urban designations within Midwest, and West regions (P<0.05) but did not vary within the South (P=0.12). Southern rural small town had the lowest incidence of DAA receipt (40.1%), whereas the incidence was 52.9% in Midwestern isolated rural towns. In adjusted logistic analyses, compared with southern urban residents (the largest single group), southern rural small town residents had the lowest odds ratio, 0.85 (95% confidence interval, 0.75–0.93), and Midwestern residents from isolated and small rural towns had the highest odds (odds ratio, both 1.27) to receive treatment.

Conclusions: Substantial geographic variation exists in receipt of curative HCV treatment. Efforts are needed to provide more equitable access to DAAs.

*Department of Gastroenterology and Hepatology, Yale University School of Medicine

Department of Biostatistics, Yale University School of Public Health, VA Connecticut Healthcare System, New Haven

Department of Internal Medicine, Yale University School of Medicine, VA Connecticut Healthcare System, West Haven, CT

§Veterans Rural Health Resource Iowa City VA Medical Center, University of Iowa Carver College of Medicine, Iowa City, IA

Center for Biomedical Data Science, Yale University School of Medicine, VA Connecticut Healthcare System

Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, VA Connecticut Healthcare System, West Haven

#Department of Internal Medicine, Yale University School of Medicine, VA Connecticut Healthcare System, New Haven

**Yale University School of Medicine, VA Connecticut Healthcare System, West Haven, CT

Supported by NIH/NIAAA (U24 AA020794, U01 AA027090, U10 AA013566), VA-ORH (OMAT 7436), NIH/NCATS (UL1TR001863).

The authors declare no conflict of interest.

Reprints: Amy C. Justice, MD, PhD, Medicine and Public Health, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516. E-mail: amy.justice2@va.gov.

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