@PremierHA #AdvisorLive. Download today s slides at

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1 @PremierHA #AdvisorLive Download today s slides at

2 Logistics Audio Use your computer speakers or dial in with the number on your screen Notes Download today s slides from the event post at premierinc.com/events Questions Use the Questions and Answers box or Twitter #AdvisorLive Recording This webinar is being recorded. View it later today on the event post at premierinc.com/events 2

3 Faculty Radha Hussain, PharmD, AAHIVP Clinical #AdvisorLive Enter your questions on the right side of your webinar screen 3

4 Polling Question 1 What percentage of patients are chronically infected with HCV, but are unaware they have the infection? A. 10% B. 30% C. 50% D. 80% 4

5 Polling Question 2 Which of the following is true about the prevalence of Hepatitis C? A. HCV infected patients have less hospitalizations compared to non- HCV infected patients B. Less lost workdays resulting in more work productivity C. Treatment for HCV-infected patients can lead to a cure D. Deaths resulting from HCV-infected patients are less than HIVinfected patients 5

6 Polling Question 3 Transmission of hepatitis C is primarily through percutaneous exposure to blood A. True B. False 6

7 Polling Question 4 A HCV nucleic acid test to detect viremia is necessary to: A. Confirm current active HCV infection B. Used as a guide to clinical management C. Detect the quantity of virus present D. All of the above 7

8 Polling Question 5 Patient- related barriers to treatment initiation include: A. Distance to a specialist B. Short treatment duration C. Lack of Adverse effects D. High treatment efficacy 8

9 Outline Pathology of Hepatitis C Prevalence of Chronic Hepatitis C Populations at Risk Hepatitis C Screening and Testing Advances in the Science of Hepatitis C Recommendation for Linkage to Care Model of Specialty Pharmacy 9

10 Introduction Viral hepatitis is a silent epidemic, and we can only defeat it if we break that silence. Now is the time to learn the risk factors for hepatitis; talk to family, friends, and neighbors who may be at risk; and to speak with healthcare providers about strategies for staying healthy... [L]et each of us lend our support to those living with hepatitis and do our part to bring this epidemic to an end. - President Barack Obama World Hepatitis Day Proclamation July 26,

11 Pathology of Hepatitis C Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States Acute HCV may result from exposure to the virus through various routes Asymptomatic or nonspecific symptoms Will spontaneously clear in 20 to 50% of patients Chronic HCV is ongoing inflammation of the liver cells lasting longer than six months May lead to cirrhosis (scaring of the liver) or liver cancer Department of Health and Human Services. Action Plan for the Prevention, Care & Treatment of Viral Hepatitis. Available at Accessed on 05/09/16 11

12 Prevalence of Chronic HCV 3.5 million HCV- infected persons in the U.S million in the general population - 800,000 incarcerated, institutionalized or homeless Silent epidemic -50% of all infected patients are unaware they are infected - At greater risk for severe complications from the disease and increasing transmission Leading infectious cause of death - Claim 12,000-18,000 lives each year - Leading cause of liver cancer and most common reason fro liver transplantation - Deaths outpaced those due to HIV Economic Consequences - More Hospitalizations compared to non-hcv infected (24 vs.7%) - Increased societal costs (HCV employees had more lost workdays, resulting in lost productivity) Treatment can lead to a cure - Reductions in HCV liver-related diseases and death (cirrhosis, end- stage liver disease and liver cancer) 12 Department of Health and Human Services. Action Plan for the Prevention, Care & Treatment of Viral Hepatitis. Available at Accessed on 05/09/16

13 Populations at Risk Persons who inject drugs (PWID) Born to a HCV-infected mother Men who have sex with men (MSM) Transmission is primarily through percutaneous exposure to blood Receipt of blood products before 1992 Receipt of clotting factor concentrates before 1987 Long-term dialysis, needle stick injuries Having been incarcerated Received a tattoo in an unregulated setting HIV co-infected Solid-organ transplant receipts 13 AASLD/IDSA/IAS USA. HCV testing and linkage to care. Available at Accessed on 5/4/16.

14 HCV Screening and Testing Harmonization of the CDC and USPSTF recommendations for HCV screening in 2013 HCV screening in persons at high risk for infection as well as one time screening for HCV infection in baby boomers Accounts for nearly ¾ of all HCV infections, with a five-times prevalence (3.25%) than other persons» Reflecting a higher incidence of HCV infections in the 1970s and 1980 (peaking at 230,000, compared with 15,000 in 2009) Increase provider and public awareness of the importance of hepatitis C screening Improve HCV testing rates Identify millions of Americans previously unaware of their infection status Directing them to lifesaving care that can prevent serious complications from undiagnosed HCV disease AASLD/IDSA/IAS USA. HCV testing and linkage to care. Available at Accessed on 5/6/16. 14

15 HCV Screening and Testing 15

16 HCV screening and Testing All persons recommended for HCV testing Positive HCV antibody test Positive HCV nucleic acid test Initiation of HCV therapy FDA- approved tests Current (active) HCV infection Past infection that has resolved False-positive test result Detect viremia Confirm active HCV infection Guide clinical management Test for HCV genotype AASLD/IDSA/IAS USA. HCV testing and linkage to care. Available at Accessed on 3/1/16. 16

17 HCV Treatment Advances In the pipeline for Sofosbuvir + Velpatasvir <2011 PEG- IFN & Ribavirin 2011 Telaprevir & Boceprevir 2013 Simeprevir & Sofosbuvir) 2014 Harvoni & Viekira Pak 2015 Daclatasvir 2016 Zepatier 48 treatment weeks treatment weeks treatment weeks 8-24 treatment weeks 12 treatment weeks treatment weeks Maximum Cost per Treatment $38,700. $81,445. $300,720. $189,000 $300,000. $73,000 17

18 HCV Treatment Advances 18

19 Recommendation for Linkage to Care Practitioner with expertise in assessment of liver disease severity and HCV treatment All patients with current HCV infection and a positive HCV RNA test result Possible referral for consideration of liver transplantation Advanced fibrosis or cirrhosis (stage F3 or above) Estimated 13% -18% of HCV-infected persons had received treatment by 2013 Negative health outcomes Result of inappropriate practitioner assessment and delays in linkage to care 19 AASLD/IDSA/IAS USA. HCV testing and linkage to care. Available at Accessed on 5/9/16.

20 Barriers to Treatment Initiation Patient-related barriers to treatment initiation 1. Contraindications to treatment (medical or psychiatric comorbidities) 2. Lack of acceptance of treatment (e.g. asymptomatic nature of disease, competing priorities, low treatment efficacy, long treatment duration and adverse effects) 3. Lack of access to treatment (e.g. cost and distance to specialist) Practitioner-related barriers 1. Perceived patient-related barriers (e.g. fear of adverse effects, treatment duration, cost and effectiveness 2. Lack of expertise in HCV treatment 3. Lack of specialty referral resources 4. Resistance to treating persons currently using illicit drugs and alcohol 5. Concern about cost of HCV treatment 20 AASLD/IDSA/IAS USA. HCV testing and linkage to care. Available at Accessed on 5/9/16

21 Strategies to address lack of access to Specialists Models involving close collaboration between primary care practitioners and subspecialists Uses telemedicine and knowledge networks to overcome geographic distances to specialists Project ECHO Uses videoconferencing to render HCV care and treatment to New Mexico s large rural and underserved population Uses case- based learning and real-time feedback from a multidisciplinary team of specialists (i.e. GI, infectious disease pharmacology and psychiatry practitioners) Expanded access to HCV infection treatment in populations that might otherwise remained untreated 21 AASLD/IDSA/IAS USA. HCV testing and linkage to care. Available at Accessed on 5/9/16

22 Model of Specialty Pharmacy Services- (Commcare Specialty Pharmacy) Done when more updated lab results reveal a clinical state mentioned above or condition impacting QOL- e.g. Debilitating fatigue, Women of childbearing age who wish to get pregnant 22

23 Questions Hepatitis C isn t that the one I was vaccinated for? No. Stay tuned: a review of the polling questions is next 23

24 Your questions Enter your questions in this window on your webinar screen or #AdvisorLive 24

25 Polling Question 1 What percentage of patients are chronically infected with HCV, but are unaware they have the infection? A. 10% B. 30% C. 50% D. 80% 25

26 Polling Question 2 Which of the following is true about the prevalence of Hepatitis C? A. HCV infected patients have less hospitalizations compared to non- HCV infected patients B. Less lost workdays resulting in more work productivity C. Treatment for HCV-infected patients can lead to a cure D. Deaths resulting from HCV-infected patients are less than HIVinfected patients 26

27 Polling Question 3 Transmission of hepatitis C is primarily through percutaneous exposure to blood A. True B. False 27

28 Polling Question 4 A HCV nucleic acid test to detect viremia is necessary to: A. Confirm current active HCV infection B. Used as a guide to clinical management C. Detect the quantity of virus present D. All of the above 28

29 Polling Question 5 Patient- related barriers to treatment initiation include: A. Distance to a specialist B. Short treatment duration C. Lack of Adverse effects D. High treatment efficacy 29

30 Join the Hepatitis C management collaborative Clinics across the country share best practices for identifying patients with HCV and linking them to specialty care. Free, 18-month collaborative to improve patient outcomes is guided by Andrew Muir, MD, Chief, Division of Gastroenterology, and Director, Gastroenterology and Hepatology Research, Duke Clinical Research Institute, Duke University School of Medicine. Premier is accepting 25 clinics. Participants receive CME credit, access to an online community, guidance on upcoming HCVrelated core measures. Participating clinics can count this project toward meeting quality improvement requirements for professional associations. Contact Jeff Vawter, jeff_vawter@premierinc.com,

31 Thank you for joining us For more information, contact: Jeff Vawter, Senior Director, Quality Education and Delivery Want to find out more about today s topic? Answer the poll question here now. Connect with Premier 31