Social Determinants of Health May Limit Linkage to Outpatient HCV Care


Patients who missed their initial HCV treatment appointment had greater housing instability, transportation difficulty, and a history of medication non-adherence.

Carlo Foppiano Palacios, MD | Credit: Cooper University Health Care

Carlo Foppiano Palacios, MD

Credit: Cooper University Health Care

Findings from a recent study are providing clinicians with an overview of factors impacting successful linkage to outpatient hepatitis C virus (HCV) care and causing patients to fall off of the care cascade.1

Results of the case-control retrospective chart review showed patients who missed their initial scheduled infectious disease clinic appointment for HCV treatment had greater rates of housing instability, transportation difficulties, and medication non-adherence compared to patients who attended their first treatment appointment.1

According to the World Health Organization (WHO), an estimated 50 million people have chronic hepatitis C virus infection globally. In 2016, the WHO Global Health Sector Strategy on viral hepatitis set a goal to eliminate viral hepatitis as a public health problem by 2030 with a 90% reduction in incidence and a 65% reduction in mortality. Direct-acting antiviral (DAA) medicines can cure more than 95% of persons with hepatitis C infection, but access to diagnosis and treatment is low and often hindered by certain social determinants of health.2,3

“After HCV screening, the subsequent step is establishing HCV, but risk factors for missing an initial HCV evaluation appointment have not been established,” Carlo Foppiano Palacios, MD, assistant professor of medicine and infectious diseases specialist at Cooper Medical School of Rowan University, and colleagues wrote.1

To identify factors limiting successful linkage to outpatient HCV care, investigators conducted a case-control study in which they matched patients who were scheduled for but did not attend their appointment at the Center for Infectious Diseases at the University of Maryland Medical Center to patients who attended their treatment appointment. Patients with a positive HCV antibody or viral load polymerase chain reaction (PCR) test were included and propensity score matched based on their age at the scheduled appointment date, appointment date, and reported sex.1

A total of 1539 patients were identified, 161 (10.5%) of whom did not attend their HCV clinical appointments. Investigators matched these patients in a 1:1 ratio to 161 patients who attended their scheduled appointments, noting the groups were well matched for baseline characteristics.1

Specifically, investigators pointed out age was similar across both groups, with a mean age of 48.5 years in the unlinked group and 49.8 years in the linked group (P = .40). Both the unlinked and linked groups were predominantly male (55.3% and 52.8%, respectively; P = .74). They also observed similar rates of alcohol use disorder (52.2% vs 60.2%; P =.18), substance use disorders (85.1% vs 85.1%; P = 1.00), and psychiatric diagnoses (71.4% vs 70.8%; P = 1.000) across both groups. However, investigators noted there were more Black patients (72.7% vs 60.9%; P = .03) and fewer White patients (26.7% vs 37.3%; P = .056) in the linked group compared to the unlinked group.1

Upon analysis, patients in the unlinked group had significantly greater rates of housing instability (60.9% vs 39.8%; P <.001), transportation difficulty (65.8% vs 29.8%; P <.001), and history of medication non-adherence (60.9% vs 36.6%; P <.001) compared to patients in the linked group. Multivariate logistic regression analysis incorporating factors with a P-value of <.10 on bivariate analysis showed transportation difficulty (95% CI, 0.17-0.51; P <.001), outpatient testing (95% CI, 1.01-18.26; P = .04), and inpatient testing (95% CI, 0.04-0.46; P = .002) were associated with linkage to care.1

Investigators pointed out fewer patients in the unlinked group received DAA therapy in their medical system than the linked group (0% vs 30.4%; P <.001) and by the end of 2018, more patients in the linked group were alive than in the unlinked group (99.4% vs 95.7%; P = .07).1

They also noted several potential limitations to these findings, including their reliance on electronic medical record documentation to determine risk factors, the lack of generalizability to other settings, and the lack of consideration for system-level barriers to HCV care that may limit the transition to outpatient HCV care.1

“Our study highlights the role of social determinants of health in care transitions, particularly within the transition to outpatient HCV care,” investigators concluded.1 “Patients referred to outpatient HCV care should be screened for barriers to care and provided additional support to help address the factors that may limit their HCV care and improve the likelihood of successful continuity.”


  1. Foppiano Palacios C, Dubose B, Schmalzle S. Risk Factors Associated With Unsuccessful Linkage to Outpatient Hepatitis C Care. Cureus. doi:10.7759/cureus.58313
  2. World Health Organization. Hepatitis C. Newsroom. April 9, 2024. Accessed May 16, 2024.
  3. World Health Organization. WHO releases first-ever global guidance for country validation of viral hepatitis B and C elimination. June 25, 2021. Accessed May 16, 2024.
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