Introduction
Approximately 3.5 million people are chronically infected with hepatitis C virus (HCV) in the U.S., 80% of whom are “baby boomers” (born between 1945 and 1965).1 Most infected individuals are not aware of their infections despite availability of treatments that may reduce their risk of HCV-related diseases, including chronic hepatitis, cirrhosis, and liver cancer.2 To curb the growing burden of these HCV-associated diseases, the U.S. Preventive Services Task Force (USPSTF) recommended one-time HCV testing for baby boomers in 2013.3 The authors previously noted low HCV testing prevalence among baby boomers in 2013, at baseline4; however, it is unknown whether HCV testing has changed following the USPSTF recommendation.
Methods
Data from the 2013 and 2015 National Health Interview Survey, including 23,967 baby boomers, were used. Self-reported HCV blood testing was the primary study outcome. Analyses were restricted to respondents with non-missing HCV testing data (n=21,827). Weighted prevalence of HCV testing (ever) was calculated by sociodemographic and lifestyle factors. Multivariable prevalence ratios (PRs) and 95% CIs of HCV testing according to the 2015 survey were estimated using predicted margins. Interaction terms between survey year and each covariate were included in additional models using 2013 and 2015 survey data to determine if changes in HCV testing varied across subgroups; none were statistically significant (data not shown). All statistical analyses were conducted in 2016 with SAS-callable SUDAAN, version 9.0.3.
Results
From 2013 to 2015, HCV testing prevalence among baby boomers slightly increased from 12.3% to 13.8% (p=0.013) (Table 1). Of the 76.2 million estimated baby boomers in 2015, only 10.5 million reported ever receiving HCV testing. Relative to privately insured adults, those with Medicare plus Medicaid (PR=1.83, 95% CI=1.32, 2.53), Medicaid only (PR=1.35, 95% CI=1.04, 1.76), or military insurance (PR=1.62, 95% CI=1.16, 2.26) had higher HCV testing prevalence. HCV testing was also greater in men versus women (PR=1.25, 95% CI=1.08, 1.44) and among people who had lived with someone with hepatitis versus those who did not (PR=2.44, 95% CI=2.01, 2.96). Individuals with less than or only a high school diploma had lower HCV testing than college graduates (PR=0.63, 95% CI=0.48, 0.82 and PR=0.58, 95% CI=0.48, 0.72, respectively).
Note: Boldface indicates statistical significance (p<0.05).
There was a small, albeit statistically significant, increase in HCV testing (from 12.3% to 13.8%) among baby boomers 2 years after the 2013 USPSTF recommendation for one-time HCV testing. Reasons for the overall slow uptake of testing may include barriers to preventive care; unapparent symptoms; lack of awareness of the need to be tested among patients, who may not be fully covered by insurers2; and lack of physician awareness of the USPSTF recommendations. The relatively higher prevalence of testing in military-insured individuals may reflect ongoing HCV testing in the Veterans Health Administration to reduce the disproportionately high burden of HCV-associated disease in this population.5, 6, 7
Approximately 3.5 million people are chronically infected with hepatitis C virus (HCV) in the U.S., 80% of whom are “baby boomers” (born between 1945 and 1965).1 Most infected individuals are not aware of their infections despite availability of treatments that may reduce their risk of HCV-related diseases, including chronic hepatitis, cirrhosis, and liver cancer.2 To curb the growing burden of these HCV-associated diseases, the U.S. Preventive Services Task Force (USPSTF) recommended one-time HCV testing for baby boomers in 2013.3 The authors previously noted low HCV testing prevalence among baby boomers in 2013, at baseline4; however, it is unknown whether HCV testing has changed following the USPSTF recommendation.
Methods
Data from the 2013 and 2015 National Health Interview Survey, including 23,967 baby boomers, were used. Self-reported HCV blood testing was the primary study outcome. Analyses were restricted to respondents with non-missing HCV testing data (n=21,827). Weighted prevalence of HCV testing (ever) was calculated by sociodemographic and lifestyle factors. Multivariable prevalence ratios (PRs) and 95% CIs of HCV testing according to the 2015 survey were estimated using predicted margins. Interaction terms between survey year and each covariate were included in additional models using 2013 and 2015 survey data to determine if changes in HCV testing varied across subgroups; none were statistically significant (data not shown). All statistical analyses were conducted in 2016 with SAS-callable SUDAAN, version 9.0.3.
Results
From 2013 to 2015, HCV testing prevalence among baby boomers slightly increased from 12.3% to 13.8% (p=0.013) (Table 1). Of the 76.2 million estimated baby boomers in 2015, only 10.5 million reported ever receiving HCV testing. Relative to privately insured adults, those with Medicare plus Medicaid (PR=1.83, 95% CI=1.32, 2.53), Medicaid only (PR=1.35, 95% CI=1.04, 1.76), or military insurance (PR=1.62, 95% CI=1.16, 2.26) had higher HCV testing prevalence. HCV testing was also greater in men versus women (PR=1.25, 95% CI=1.08, 1.44) and among people who had lived with someone with hepatitis versus those who did not (PR=2.44, 95% CI=2.01, 2.96). Individuals with less than or only a high school diploma had lower HCV testing than college graduates (PR=0.63, 95% CI=0.48, 0.82 and PR=0.58, 95% CI=0.48, 0.72, respectively).
| Characteristic | Unadjusted prevalence | 2013 vs 2015, p-value | aPR (95% CI) among respondents in the 2015 surveybb | |
|---|---|---|---|---|
| 2013, % (95% CI) | 2015, % (95% CI) | |||
| Total | 12.3 (11.5, 13.1) | 13.8 (12.9, 14.7) | 0.013 | |
| Race/ethnicity | ||||
| Non-Hispanic white | 12.4 (11.5, 13.4) | 13.9 (12.9, 15.0) | 0.037 | 1.00 |
| Hispanic | 11.5 (9.3, 14.0) | 11.3 (9.2, 13.9) | 0.928 | 0.96 (0.71, 1.30) |
| Non-Hispanic black | 12.6 (10.7, 14.7) | 14.5 (12.2, 17.3) | 0.224 | 1.09 (0.87, 1.35) |
| Non-Hispanic Asian | 10.1 (7.4, 13.7) | 13.9 (10.0, 18.9) | 0.151 | 1.24 (0.84, 1.83) |
| Non-Hispanic other | 19.5 (12.0, 29.9) | 25.4 (16.6, 36.9) | 0.366 | 1.61 (1.01, 2.55) |
| Health insurance | ||||
| Private | 11.7 (10.6, 12.9) | 12.8 (11.7, 14.0) | 0.200 | 1.00 |
| Medicaid | 16.5 (13.0, 20.8) | 18.5 (15.1, 22.6) | 0.469 | 1.35 (1.04, 1.76) |
| Medicaid+Medicare | 21.3 (16.0, 27.7) | 26.1 (19.9, 33.4) | 0.318 | 1.83 (1.32, 2.53) |
| Medicare | 9.5 (7.9, 11.4) | 12.5 (10.8, 14.4) | 0.012 | 0.89 (0.74, 1.06) |
| Military | 22.1 (17.6, 27.5) | 22.5 (16.9, 29.2) | 0.928 | 1.62 (1.16, 2.26) |
| Uninsured | 11.2 (9.2, 13.4) | 11.1 (8.6, 14.2) | 0.956 | 0.96 (0.70, 1.31) |
| Other | 17.1 (13.4, 21.5) | 17.9 (13.2, 23.8) | 0.804 | 1.22 (0.86, 1.74) |
| Sex | ||||
| Female | 11.1 (10.1, 12.3) | 12.4 (11.3, 13.5) | 0.110 | 1.00 |
| Male | 13.5 (12.3, 14.8) | 15.4 (14.0, 16.9) | 0.060 | 1.25 (1.08, 1.44) |
| Education | ||||
| College graduate | 13.7 (12.2, 15.3) | 14.5 (12.9, 16.2) | 0.463 | 1.00 |
| Some college | 15.2 (13.7, 16.8) | 16.5 (14.9, 18.4) | 0.245 | 1.03 (0.86, 1.22) |
| HS or GED | 8.9 (7.4, 10.6) | 11.0 (9.4, 12.8) | 0.088 | 0.58 (0.48, 0.72) |
| Less than HS diploma | 9.3 (7.7, 11.2) | 11.4 (9.4, 13.8) | 0.149 | 0.63 (0.48, 0.82) |
| Marital status | ||||
| Married | 11.3 (10.3, 12.4) | 13.1 (12.1, 14.3) | 0.015 | 1.00 |
| Not currently marriedcc | 14.0 (12.7, 15.3) | 15.3 (13.7, 17.1) | 0.226 | 1.09 (0.94, 1.28) |
| Never married | 14.2 (12.1, 16.6) | 14.3 (12.1, 16.8) | 0.973 | 0.93 (0.75, 1.16) |
| Born in U.S. | ||||
| Yes | 12.5 (11.6, 13.4) | 14.2 (13.2, 15.2) | 0.011 | 1.00 |
| No | 11.3 (9.5, 13.3) | 12.0 (10.1, 14.3) | 0.578 | 0.89 (0.67, 1.19) |
| Alcohol consumption | ||||
| 0−1 drinks/day | 12.2 (11.4, 13.1) | 13.9 (13.0, 14.9) | 0.007 | 1.00 |
| ≥2 drinks/day | 12.9 (10.7, 15.4) | 12.8 (10.0, 16.2) | 0.973 | 1.23 (0.93, 1.61) |
| Lived with someone with hepatitis | ||||
| No | 9.5 (8.8, 10.3) | 11.2 (10.4, 12.1) | 0.004 | 1.00 |
| Yes | 29.4 (24.4, 35.0) | 27.9 (23.3, 33.0) | 0.688 | 2.44 (2.01, 2.96) |
Note: Boldface indicates statistical significance (p<0.05).
aWeighted number receiving hepatitis C virus testing in 2013 was 9,144,299 and in 2015 was 10,511,639. Weighted number eligible for hepatitis C virus testing in 2013 was 74,506,656 and in 2015 was 76,178,472. Weighted numbers take into account the assigned sampling weights of respondents.
bIncludes 10,176 respondents from the 2015 survey only. Model is adjusted for race/ethnicity, health insurance, sex, education, marital status, alcohol consumption, and having lived with someone diagnosed with hepatitis.
cIncludes divorced, separated, and widowed. aPR, adjusted prevalence ratio; GED, General Educational Development test; HS, high school; NHIS, National Health Interview Survey.
Discussion
Greater HCV testing in those with dual Medicare and Medicaid and Medicaid-only insurance coverage may reflect more risk factors for HCV and associated diseases in this population.8 People with lower educational attainment and the uninsured had especially suboptimal HCV testing, despite having greater HCV burden, perhaps as a result of lower awareness about testing and barriers to accessing care.1 Limitations of this study include recall bias due to self-reported HCV testing and exclusion from the National Health Interview Survey of institutionalized baby boomers (e.g., incarcerated individuals and active-duty military) in whom HCV testing and infection may be more common.6, 7 The HCV testing estimates are substantially lower than those from recent studies among baby boomers,9, 10 where 90% of patients in a safety net clinic were tested, and in a New York community hospital where testing increased from 47% before to 88% after an intervention to improve HCV testing was put into place.9, 10 The lower proportion of HCV testing in the current study’s population could be a result of under-reporting of HCV testing, as well as differences between the current study population and these institutional-based studies.9,
Conclusions
Prevalence of HCV testing among baby boomers did not substantially increase and remains low 2 years after the USPSTF recommendation in 2013. Notably, only 10.5 million of 76.2 million baby boomers reported ever receiving HCV testing. These findings underscore the need for increased awareness for HCV testing among healthcare providers and baby boomers and other innovative strategies such as state-mandated HCV testing.
http://www.ajpmonline.org/article/S0749-3797(17)30092-2/fulltext
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