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标题：Racial Differences in the Evaluation and Treatment of Hepatitis C Among Veterans: A Retrospective Cohort Study
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作者：Christine M. Rousseau ; George N. Ioannou ; Jeffrey A. Todd-Stenberg 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2008
卷号：98
期号：5
页码：846-852
DOI：10.2105/AJPH.2007.113225
语种：English
出版社：American Public Health Association
摘要：Objectives. We examined the association between race and hepatitis C virus (HCV) evaluation and treatment of veterans in the Northwest Network of the Department of Veterans Affairs (VA). Methods. In our retrospective cohort study, we used medical records to determine antiviral treatment of 4263 HCV-infected patients from 8 VA medical centers. Secondary outcomes included specialty referrals, laboratory evaluation, viral genotype testing, and liver biopsy. Multiple logistic regression was used to adjust for clinical (measured through laboratory results and International Classification of Diseases, Ninth Revision , codes) and sociodemographic factors. Results. Blacks were less than half as likely as Whites to receive antiviral treatment (odds ratio [OR]=0.38; 95% confidence interval [CI]=0.23, 0.63). Both had similar odds of referral and liver biopsy. However, Blacks were significantly less likely to have complete laboratory evaluation (OR=0.67; 95% CI=0.52, 0.88) and viral genotype testing (OR=0.68; 95% CI=0.51, 0.90). Conclusions. Race is associated with receipt of medical care for various medical conditions. Further investigation is warranted to help understand whether patient preference or provider bias may explain why HCV-infected Blacks were less likely to receive medical care than Whites. Hepatitis C virus (HCV) is the leading chronic blood-borne pathogen in the United States, infecting approximately 2.7 million Americans. 1 In response to several reports indicating that HCV was more common among veterans than among the general US population, 2 ^– 6 the Department of Veterans Affairs (VA) conducted a nationwide survey of HCV infection among veterans who used VA facilities; it found that prevalence was at least twice as high among veterans. 7 This increased prevalence, which was found to be associated with traditional risk factors of infection (e.g., transfusion, intravenous drug use) likely to be more common among users of VA facilities, left the VA facing significant challenges in providing medical care for this population. Antiviral therapy has improved over the past decade, especially with the introduction of interferon and ribavirin combination therapy. 8 ^– 13 However, because these antiviral treatments have several contraindications, only 13% to 30% of infected individuals are eligible for therapy. 14 ^– 16 Furthermore, because of possible side effects, long antiviral treatment duration, limited efficacy, and high antiviral treatment cost, many choose not to be treated. 15 Black Americans are twice as likely to be infected with HCV as White Americans 1 and have several characteristics associated with lower treatment response rates (e.g., greater transcriptional response to interferon, high frequency of genotype 1 infection, high Histo-logical Activity Index 17 scores, increased weight, increased iron stores). 1 ^, 18 ^– 20 Blacks have also been shown to be less likely to respond to interferon monotherapy. 21 ^– 23 Although there is some evidence to suggest that combination therapy at least partially eliminates this difference, 19 more recent studies have reported that Whites are more likely than are Blacks to have sustained response to peginterferon alfa-2b and ribavirin. 24 ^– 26 Nevertheless, antiviral treatment remains recommended for HCV-infected individuals regardless of race. 27 In the VA, Blacks have been found to be less likely than Whites to undergo diagnostic imaging and treatment for a variety of conditions, including cerebrovascular disease, peripheral vascular disease, esophageal cancer, and psychosis. 28 ^– 33 Provider racial bias, clinical factors, sociodemographic factors (race, economic status, marital status, homelessness, etc.), or patient preference for medical treatment could explain these observed differences. However, race was not associated with delay in seeking care or with attitudes, beliefs, and experiences related to cardiac care at VA facilities. 34 ^, 35 Because the VA system has a relatively homogeneous patient population with regard to sociodemographic status and is an equal access health care system, sociodemographic factors are less likely to be involved in racial differences associated with treatment than in private sector health care. Because treatment decisionmaking for HCV infection is complex, involving several clinical and sociodemographic factors, treatment practices are relatively subjective, allowing potential biases to become more evident. Furthermore, the substantial risk of side effects, combined with the incomplete viral response to therapy, results in some patients electing to defer therapy. We sought to determine whether there were racial differences in the evaluation and treatment for HCV in the VA system.