Hospitalizations in immigrants and non-immigrants with chronic hepatitis C infection in Québec

Chronic hepatitis C (HCV) causes considerable morbidity and mortality in Canada due to liver cirrhosis, liver failure and liver cancer that could be prevented through early screening and treatment. Immigrants are an underappreciated group at risk for HCV, often originating from high prevalence countries. This study examined all-cause and liver-related healthcare utilization in persons diagnosed with HCV in Québec from 1991-2007 in order to summarize burden over the study period. To address the gap in the literature with respect to immigrants, we estimated and compared all-cause and liver-related healthcare utilization in HCV-infected immigrants and non-immigrants (1998–2007), identifying predictors of utilization. We performed a retrospective longitudinal cohort study using HCV cases reported to the Québec mandatory disease reporting database from 1991-2007. Cases were linked to demographic and health services data and followed until death, healthcare non-admissibility, or study completion. Outcomes included inpatient visits, in-hospital days, and day surgeries. Liver-related events were identified using discharge and procedure codes. Numbers of all-cause and liver-related inpatient stays, in-hospital days, and day surgeries occurring each year from 1991-2007 were computed and stratified by immigrant status. Mean events per subject and the proportion of subjects with ≥1 event were calculated for each outcome, stratified by immigrant status. Negative binomial regression was used to compare rates of hospitalizations and in-hospital days adjusting for age and sex.We identified 22,589 and 20,139 linked cases of chronic HCV from 1991-2007 and 1998-2007 respectively; 9% of cases were immigrants. At diagnosis, immigrants were older (47.6 vs 43.2y), more likely to be female (46.7 vs 31.9%), and to have liver cancer (0.2% vs 0.1%). Mean time to HCV diagnosis after arrival was 9.8 ± 6.9 years. Non-immigrants had a 2-10 fold higher prevalence of HCV-related risk factors, including substance abuse and HIV. Annual healthcare utilization increased over the study period, driven by increasing cohort size as prevalent cases were diagnosed. Non-immigrants were more likely to have ≥1 hospitalization during follow-up compared to immigrants (43% vs 28%). Most common non-liver primary discharge diagnoses for non-immigrants were mental disorders (27.8%) and injury/poisoning (11.9%) whereas for immigrants they were pregnancy-related (13.2%) and mental disorders (10.7%). Non-immigrants had a higher burden of all-cause hospitalizations and days in hospital, with more visits (1.35 vs 0.62) and in-hospital days (15.49 vs 7.10) on average per subject and a higher proportion with ≥1 hospitalization (42.6% vs 28.2%). In contrast, the proportion of subjects with ≥ 1 liver-related hospitalization and mean numbers of visits and in-hospital days were similar for immigrants and non-immigrants. When hospitalization rates were adjusted for age and sex, immigrant status was associated with lower rates of all-cause and liver-related hospitalizations (All-cause RR: 0.45, 95% CI: 0.40–0.51; Liver-related RR: 0.53 [0.40–0.70]) and in-hospital days (All-cause RR: 0.57 [0.49–0.67]; Liver-related RR: 0.63 [0.42–0.93]).Rising annual healthcare utilization in reported HCV in Québec is attributable to an increase in the number of identified cases and may underestimate true burden as cases prior to 1998 were not consistently reported. Higher burden of all-cause hospitalizations in non-immigrants likely reflects more prevalent lifestyle comorbidities. Immigrants had a similar burden of liver-related hospitalization despite having fewer risk factors for disease progression. Older age of HCV-infected immigrants appeared to be a key driver of this, which is supported by the delay observed between arrival and HCV diagnosis and higher prevalence of HCC at diagnosis. These results highlight the importance of early HCV screening and treatment in this population.

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