Rachel Lutz

This article was originally published in ContagionLive.

A new US Centers for Disease Control and Prevention (CDC) report shows disparities among 

 (HCV) treatment with direct-acting antiviral (DAA) depending on insurance type.

A team of investigators from the CDC identified data from approximately 2 million insured adults diagnosed with hepatitis C between January 2019 and October 2020 in order to categorize those who are receiving treatment based on sex, age, race, insurance type, and by state Medicaid treatment restrictions.

The cohort included hepatitis C patients from all 50 states enrolled in private insurance plans, Medicare Advantage, or Medicaid managed care.

Treating hepatitis C with DAA is recommended for all persons with the infections, with few exceptions.

Left untreated, hepatitis C can lead to advanced liver disease, liver cancer, and death, but while treatment with DAA can cure 95% of cases, more than 14,000 hepatitis C-related deaths were reported in the US in 2019.

After an initial analysis, the investigators found 47,678 hepatitis C patients that met inclusion criteria. Medicaid managed care insured 79% of that group.

DAA treatment began within 360 days of receipt of a positive hepatitis C test among people enrolled in Medicaid, Medicare, and private insurance at rates of 23%, 28%, and 35%, respectively.

A majority of privately insured patients (84%) initiated DAA treatment within 180 days of their positive test, compared to 75% of Medicaid and 77% of Medicare recipients in that same window of time.

Treatment initiation was lower among Medicaid and private health insurance recipients aged 18-29 years, compared with patients aged 50-59 years.

The lowest odds of DAA treatment initiation were lowest among patients aged 18-29 and 30-39 years with Medicaid.

“Everyone with hepatitis C should have access to lifesaving treatment, regardless of race, ethnicity, age or insurance status,” CDC Acting Principal Deputy Director Debra Houry, MD, MPH, 

 “What these data tell us is that at best, only one in three people are treated within a year of being diagnosed and we must reduce the barriers and get more people treated for hepatitis C in our country. This is critical to stop preventable deaths and prevent new infections.”

After analyzing treatment initiations by race, initiation was lowest among persons of other races (20%) and those missing race information (19%).

Initiation was highest in all race groups among privately insured patients but was lowest among persons with missing race information.

Treatment initiation was similar among most racial groups after adjusting the analysis, but Medicaid recipients who were Black or reported other races had lower prevalence of treatment relative to White Medicaid recipients.

Asian patients with Medicare had higher rates of treatment initiation compared to their white counterparts.

Additionally, male sex was consistently linked to lower treatment initiation across all insurance types.

“Removing barriers to treatment is a critical step, as is increasing screening for hepatitis C,” Carolyn Wester, MD, MPH, director of CDC’s Division of Viral Hepatitis, said in the same statement. We estimate about 40% of people with hepatitis C in the US are unaware of their infection—testing is the first step to accessing curative treatment.”

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Treatment initiation was lower among Medicaid and private health insurance recipients aged 18-29 years, compared with patients aged 50-59 years. 

Barriers Remain for Better Hepatitis C Virus Care

Diabetes medication is linked to a reduced risk of 

 and age-related macular degeneration (AMD), but not cataracts, according to an 

Led by Wishal D. Ramdas, MD, PhD, Department of Ophthalmology, Erasmus University Medical Center, investigators evaluated 3 independent studies conducted between 1990 and 2014 in order to determine the association between diabetes and eye diseases such as OAG, AMD, and cataracts. The study participants were monitored for OAG, AMD and cataracts and had at least 1 follow up visit. Plus, the investigators collected data on the participants’ glucose levels, diabetes medication use, and ophthalmological exams.

Ultimately, the investigators included 11,260 participants in their analysis. The mean age of the participants was 65 years and a little more than half of the patients were women (58 percent, or 6,610). Type 2 diabetes had been diagnosed in 2,406 patients. Metformin had been prescribed to about half of those patients, while 20 percent received other diabetes medication, and 21 percent received lifestyle advice only, the investigators observed.

Those with type 2 diabetes and eye disease were significantly older than those without eye disease, the study authors noted, and cataract was more frequently present in woman compared to men.

Eye disease diagnoses were as follows, according to the investigators:

OAG was diagnosed in 324 of 7,394 patients

AMD was diagnosed in 1,935 of 10,933 patients

Cataract was diagnosed in 4,203 of 11,260 patients

However, in untreated type 2 diabetes, the study authors noted a higher risk of OAG, AMD, and cataract for the participants. When type 2 diabetes was treated with metformin, the study authors observed a lower risk of OAG. Furthermore, other diabetes medication such as insulin or sulfonylurea derivates had a lower risk of AMD, while no diabetes medication was associated with a risk for cataract.

The mean follow up period was 9.9 years for OAG, 8.2 years for AMD, and 7.9 years for cataract. In that time, 4,191 participants developed OAG (182 patients), AMD (869 patients), or cataract (3,140 patients). From that group, 285 patients received metformin while 145 others received other diabetes medication.

The study authors determined that the lifetime risk for OAG for patients taking metformin was lower than for patients with untreated diabetes and those taking other diabetes medication.

The lifetime risk for AMD in patients taking metformin was similar to those going untreated for their diabetes. The patients taking other diabetes medication had the lowest lifetime risk for AMD, the study authors wrote.

The lifetime risk for cataract did not differ between patients being treated with metformin, other diabetes medication, untreated diabetes patients, or individuals without diabetes.

“Results of this cohort study suggest that diabetes medication was associated with a reduced risk of OAG and AMD; however, no association was found between treatment with diabetes medication and cataract,” Ramdas concluded. “Metformin was associated with a lower risk of OAG, and treatment with other diabetes medication was associated with a lower risk of AMD.”

The study, "Association of Diabetes Medication With Open-Angle Glaucoma, Age-Related Macular Degeneration, and Cataract in the Rotterdam Study," was published in 

The meta-analysis included more than 11,000 patients with between 8 and 9 years of mean follow-up periods. 

Diabetes Medication Associated with Lower Risk of Eye Diseases

The presence of residual subretinal fluid (SRF) could be linked to slightly better best-corrected visual acuity (BCVA) when treating neovascular age-related macular degeneration (nAMD), according to an original investigation and meta-analysis 

Investigators from Toronto, Canada conducted a systematic meta-analysis of published literature regarding patients with anti-VEGF patients in order to examine the relationship between residual retinal fluid, SRF, and IRF with visual acuity following anti-VEGF treatment. 

The study authors pulled studies between January 2005 and August 2021 using the Medline, Embase, and Cochrane Library databases. Yhey included studies that reported visual acuity in nAMD patients categorized by the presence or absence of residual SRF, IRF, or any retinal fluid after receiving intravitreal bevacizumab, ranibizumab, aflibercept, or brolucizumab.

Ultimately, the study authors found 11 studies eligible for inclusion for their analysis, including 6 randomized clinical trials made up of 3,092 eyes. For the studies that were included, the mean age per study ranged from 72 to 79 years, the investigators wrote. 

The mean baseline BCVA in ETDRS letter score ranged from 47 to 69, the investigators added, but noted that in 3 studies the mean baseline BCVA in the SRF presence group was 62 and the mean baseline BCVA for the SRF absence group was 55. In 3 other studies, the study authors said the mean baseline BCVA for the IRF presence group was 51 and the mean baseline BCVA for the IRF absence group was 52.

In 7 studies, there were ≥1 outcomes that compared eyes with no SRF and eyes with SRF at last observation, and the study authors learned that eyes with SRF had a better BCVA at last observation when compared to eyes without SRF at last study observation. They also found that there was no difference in change in BCVA from baseline among eyes with and without SRF at last study observation. Additionally, there was no difference in retinal thickness between the groups at last study observation.

Another 7 studies examined ≥1 outcomes comparing eyes with and without IRF at last study observation. From those studies, the investigators observed that eyes without IRF had a better BCVA compared to those with IRF at last study observation. Eyes without IRF had a better change in BCVA compared to eyes with IRF, but there was no observed difference in retinal thickness at last study observation between the two groups at last study observation, the study authors wrote.

A majority of the studies reported on comparing eyes with and without retinal fluid, finding that eyes with no retinal fluid at last study observation had a better BCVA compared to those with retinal fluid. Eyes without retinal fluid had a better change in BCVA compared to eyes with retinal fluid at last observation. Finally, the study authors learned that eyes without retinal fluid had a thinner retinal thickness at last study compared to the eyes with retinal fluid.

“We found that the BCVA in eyes with residual SRF was slightly better than eyes without SRF but these findings were driven in large part by one study,” study author Peter J. Kertes, MD, told 

. “The BCVA was worse in eyes with IRF than those without IRF. While these findings support tolerance of residual SRF when treating nAMD, future clinical trials would be needed to confirm the association of residual SRF on BCVA outcomes.”

However, the presence of residual IRF was associated with substantially worse BCVA at last study observation and less improvement of BCVA from baseline. 

Presence of Residual Subretinal Fluid May Be Linked to Better BCVA in nAMD Treatment

Media and clinic education programs aimed to improve guideline-based aspirin use for preventing 

 (CVD) were not successful, according to new findings from a non-randomized controlled trial. 

Investigators, led by Russell V. Luepker, MD, MS, Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, conducted their trial between 2015 and 2020 to determine if community and clinic education interventions improve guideline-based aspirin use for the prevention of cardiovascular disease. The study authors noted that overuse as well as underuse of low-dose aspirin as a form of primary prevention of cardiovascular disease is common.

The investigators compared Minnesota, the intervention state, to 4 Upper Midwestern adjacent states that served as controls. Minnesota conducted a statewide campaign to distribute billboards, newspaper articles, and other print material, in addition to radio announcements, and the promotion of an Ask About Aspirin website, the study authors said. They also described how primary care clinics identified appropriate aspirin candidates and how those clinicians received continuing education about aspirin.

Investigators conducted 8,342 cross-sectional telephone surveys of men aged 45 - 79 years and women aged 55 - 79 years in 3 phases (baseline, plus 2- and 4-years post-intervention), they said. About half the participants continued through the study and their aspirin use was evaluated using a questionnaire, the study authors said.

Race was self-reported by the participants as mostly white (97%) compared to other races and ethnicities, the study authors reported. However, risk factors for cardiovascular disease – including hypertension, hyperlipidemia, diabetes, and smoking – were similar over the 3 surveys, after adjustments for age.

There were 58 billboards placed throughout Minnesota in the first 6 months of the intervention period, though most were changed at 3 months. Radio announcements were distributed to local stations and articles were distributed to local newspapers and health system newsletters, the study authors detailed.

More than 1 million visitors reached the Ask About Aspirin website, and about 53,000 completed the self-assessment for aspirin candidacy. Of those, about half completed the relevant questions and were advised to consult their physician regarding potential aspirin use. There is no data connecting website visits to physician follow-up due to privacy concerns, investigators noted.

About a quarter of the largest Minnesota health systems participated in the Ask About Aspirin program, which included a 1-credit continuing medical education module. In all, 378 physicians earned the credit, plus a group of 747 physician assistants, nurse practitioners, nurses, and other professionals with direct patient contact, the study authors said.

They additionally noted that google searches for low-dose aspirin benefits showed 7,000 news stories during the study period, in print and digital media.

Participants in Minnesota had reported awareness of the Ask About Aspirin media campaign around 4 to 6%, compared to 2 to 3% of surrounding states throughout the study period, the study authors found. At baseline and year 2 of the survey, the investigators observed that the media messages were predominantly favorable, but didn’t differ significantly between the intervention and control states. 

By year 4, the study authors found the messages not in favor of aspirin use increased significantly and were more often seen or heard in Minnesota. Mixed messages (both positive and negative) increased between years 2 and 4 of the surveys in all states, the study authors said.

The study authors also found that trends in aspirin use discussions with clinicians reportedly increased, but not significantly in Minnesota.

“A 4-year multichannel campaign using professional education, clinic interventions, and analog and digital media did not appear to produce a population-wide improvement in appropriate aspirin use,” Luepker concluded.

Association of a Community Population and Clinic Education Intervention Program With Guideline-Based Aspirin Use for Primary Prevention of Cardiovascular Disease

The media campaign to improve aspirin use included billboards, radio ads and print articles, in addition to a dedicated website. 