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Centers of excellence and bundled payment models have driven perioperative optimization and surgical site infection (SSI) prevention with decolonization protocols and antibiotic prophylaxis strategies. We sought to evaluate time trends in the incidence of deep SSI and its causative organisms after six orthopaedic procedures in a US-based integrated healthcare system.We conducted a population-level time-trend study using data from Kaiser Permanente's orthopaedic registries. All patients who underwent primary anterior cruciate ligament reconstruction (ACLR), total knee arthroplasty (TKA), elective total hip arthroplasty (THA), hip fracture repair, shoulder arthroplasty, and spine surgery were identified (2009 to 2020). The annual incidence of 90-day deep SSI was identified according to the National Healthcare Safety Network/Centers for Disease Control and Prevention guidelines with manual chart validation for identified infections. Poisson regression was used to evaluate annual trends in SSI incidence with surgical year as the exposure of interest. Annual trends in overall incidence and organism-specific incidence were considered.The final study sample was composed of 465,797 primary orthopaedic procedures. Over the 12-year study period, a decreasing trend in deep SSI was observed for ACLR and hip fracture repair. Although there was variation in incidence rates for specific operative years for TKA, elective THA, shoulder arthroplasty, and spine surgery, no consistent decreasing trends over time were found. Decreasing rates of Staphylococcus aureus infections over time after hip fracture repair, shoulder arthroplasty, and spine surgery and decreasing trends in antibiotic resistance after elective THA and spine surgery were also observed. Increasing trends of polymicrobial infections were observed after TKA and Cutibacterium acnes after elective THA.The overall incidence of deep SSI after six orthopaedic procedures was rare. Decreasing SSI rates were observed for ACLR and hip fracture repair within our US-based healthcare system. Polymicrobial infections after TKA and Cutibacterium acnes after elective THA warrant closer surveillance.IV.

Among 25 291 and 4 921 830 people with and without hepatitis C, life expectancy at age 20 increased 1.8 years and 0.3 years from the interferon to interferon-free era, respectively. Increases were highest for racial and/or ethnic minority groups with hepatitis C.

BACKGROUND & AIMS: Treatment with the combination of ledipasvir and sofosbuvir for 12 weeks has been approved by the Food and Drug Administration for patients with genotype 1 hepatitis C virus (HCV) infection; some patients can be treated with an 8-week course. Guidelines recommend a 12-week treatment course for black patients, but studies have not compared the effectiveness of 8 vs 12 weeks in black patients who are otherwise eligible for an 8-week treatment regimen. METHODS: We conducted an observational study of Kaiser Permanente Northern California members with HCV genotype 1 infection who were eligible for 8 weeks of treatment with ledipasvir and sofosbuvir (treatment-naive, no cirrhosis, no HIV infection, level of HCV RNA

Objectives: The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data exist on factors associated with DAA initiation. Methods: We conducted a retrospective cohort study of HCV-infected Kaiser Permanente Northern California members aged ≥18 during October 2014 to December 2016, using Poisson regression models to evaluate demographic, behavioral, and clinical factors associated with DAA initiation. Results: Of 14 790 HCV-infected patients aged ≥18 (median age, 60; interquartile range, 53-64), 6148 (42%) initiated DAAs. DAA initiation was less likely among patients who were non-Hispanic black (adjusted rate ratio [aRR] = 0.7; 95% confidence interval [CI], 0.7-0.8), Hispanic (aRR = 0.8; 95% CI, 0.7-0.9), and of other minority races/ethnicities (aRR = 0.9; 95% CI, 0.8-1.0) than among non-Hispanic white people and among those with lowest compared with highest neighborhood deprivation index (ie, a marker of socioeconomic status) (aRR = 0.8; 95% CI, 0.7-0.8). Having maximum annual out-of-pocket health care costs >$3000 compared with ≤$3000 (aRR = 0.9; 95% CI, 0.8-0.9) and having Medicare (aRR = 0.8; 95% CI, 0.8-0.9) or Medicaid (aRR = 0.7; 95% CI, 0.6-0.8) compared with private health insurance were associated with a lower likelihood of DAA initiation. Behavioral factors (eg, drug abuse diagnoses, alcohol use, and smoking) were also significantly associated with a lower likelihood of DAA initiation (all P < .001). Clinical factors associated with a higher likelihood of DAA initiation were advanced liver fibrosis, HCV genotype 1, previous HCV treatment (all P < .001), and HIV infection ( P = .007). Conclusions: Racial/ethnic and socioeconomic disparities exist in DAA initiation. Substance use may also influence patient or provider decision making about DAA initiation. Strategies are needed to ensure equitable access to DAAs, even in insured populations.

U.S. guidelines recommend that patients coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) be prioritized for HCV treatment with direct-acting antiviral agents (DAAs), but the high cost of DAAs may contribute to disparities in treatment uptake and outcomes. We evaluated DAA initiation and effectiveness in HIV/HCV-coinfected patients in a U.S.-based healthcare system during October 2014–December 2017. Of 462 HIV/HCV-coinfected patients, 276 initiated DAAs (70% cumulative proportion treated over three years). Lower likelihood of DAA initiation was observed among patients with Medicare (government-sponsored insurance) versus commercial insurance (adjusted rate ratio [aRR] = 0.62, 95% CI = 0.46–0.84), patients with drug abuse diagnoses (aRR = 0.72, 95% CI = 0.54–0.97), patients with CD4 cell count

Strategic planning for hepatitis C virus (HCV) screening and treatment requires up-to-date information on the prevalence of HCV spontaneous clearance. Published estimates of HCV spontaneous clearance range from 15% to 60%.1-3 We conducted an observational study over 20 years to evaluate trends in the prevalence of HCV spontaneous clearance. Our goals were to estimate the proportion of HCV-antibody-positive patients who were viremic, and to identify factors associated with viremia, thus facilitating prediction of the number of patients needing treatment.

Background The high cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may present a barrier to access, thus contributing to disparities in treatment. However, few real-world data exist on factors associated with DAA uptake. Methods We conducted an observational study of Kaiser Permanente Northern California members with HCV infection, defined as a positive HCV RNA test or an HCV genotype, during the recent DAA era (i.e., October 2014–December 2016). To evaluate factors independently associated with DAA initiation, an adjusted Poisson model included age, sex, race/ethnicity, census-based neighborhood deprivation index, HCV genotype, advanced fibrosis (i.e., Fibroscan ≥9.5 kPa, if available; else FIB-4 >3.25), prior HCV treatment, drug abuse diagnosis, smoking, alcoholic drinks per week, HIV infection, and hepatitis B virus infection. Results We identified 18,140 HCV-infected individuals, of whom 6167 (34%) initiated DAA treatment. Treatment was less likely among Black (risk ratio [RR] 0.83, 95% confidence interval [CI]: 0.79-0.88) and Hispanic individuals (RR 0.92, 95% CI: 0.87-0.98) compared with White individuals, and among individuals with greater neighborhood-level economic disadvantage (quartile 3 vs. 1: RR 0.89, 95% CI: 0.85-0.94; quartile 4 vs. 1: RR 0.79, 95% CI: 0.75-0.83). Treatment was also less likely among those with a history of drug abuse (RR 0.87, 95% CI: 0.82-0.91), smoking (RR 0.84, 95% CI: 0.80-0.87), or more alcoholic drinks per week (1–7 vs. 0 drinks: RR 0.88, 95% CI: 0.82-0.93; 8-16 vs. 0 drinks: RR 0.72, 0.63-0.82); ≥17 vs. 0 drinks: RR 0.63, 95% CI: 0.49-0.80). There was a higher likelihood of treatment among individuals with advanced fibrosis (RR 1.39, 95% CI: 1.34-1.44), HCV genotype 1 (RR 1.97, 95% CI: 1.87-2.08), no prior HCV treatment (RR 1.44, 95% CI: 1.37-1.52), or HIV infection (RR 1.19, 95% CI: 1.08-1.30). Conclusion Although clinical factors appear to drive HCV treatment decisions, racial/ethnic and socioeconomic disparities exist in DAA uptake. Lifestyle factors, such as alcohol use and drug abuse, may also influence patient or provider decision-making regarding DAA initiation. Strategies are needed to ensure equitable access to DAAs, even in insured populations. Disclosures All authors: No reported disclosures.