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State of Care for Veterans with Chronic
Chapter 2 - Veterans with Chronic Hepatitis C (HCV)
The diagnosis of chronic hepatitis C (HCV) includes both screening for historical exposure to HCV and confirmatory testing for the presence of chronic infection with HCV. Completion of confirmatory testing as a measure of quality of care is discussed in Section 6.1. Approximately 15% to 20% of those exposed to HCV will naturally clear the infection and do not experience chronic infection. (2.1) Those with chronic HCV should be linked to care for baseline assessment, education, implementation of risk reduction strategies (e.g., vaccinations, counseling and assistance on decreasing alcohol use), and assessment for antiviral therapy. This report focuses on Veterans with evidence of chronic HCV (e.g., a measurable HCV viral load); these patients are referred to as Veterans with chronic HCV.
Number in Care
Nationally, in 2008 there were 147,352 Veterans in VHA care with chronic HCV. Based on sampling performed in 1999 to 2002, the prevalence of chronic HCV in the general U.S. population was estimated to be 1.3% by the Centers for Disease Control and Prevention (CDC). (2.2) With 5.6 million Veterans receiving VHA care in 2008, a crude estimate of known prevalence of chronic HCV in VHA for 2008 was 2.6% - twice the rate reported by the CDC. The number of Veterans in VHA care identified with chronic HCV has increased from 111,521 in 2000 to 147,352 in 2008 (Figure 1). In 2001, VHA established performance goals to increase risk assessment and testing for HCV. The identification of an additional 30,000 Veterans with chronic HCV was likely related to the establishment of those goals and not to new infections.
Location of Care
Figure 2 shows each of the 21 VISNs. The number of Veterans with chronic HCV in VHA care per VISN in 2008 ranged from 2,480 in VISN 2 to 14,019 in VISN 16 (Figure 3). Nine of the VISNs each had over 7,000 Veterans with chronic HCV in VHA care (VISNs 4, 6-8, 11, 16, 20-22). For information on the number of Veterans with chronic HCV in VHA care in each VISN in earlier years, see Appendix A.
Although the total number of Veterans with chronic HCV in VHA care changed little from 2005 to 2008, there was a geographic shift in their distribution toward VISNs in the Southeast. Comparing 2005 to 2008, VISNs with increases of at least 200 Veterans with chronic HCV included VISNs 7 (+455), 6 (+453), and 8 (+270). In contrast, VISNs 3 (-523), 22 (-465), 16 (-386), and 11 (-351) each decreased by more than 300 patients. The shift in geographic distribution may be due in part to Veterans transferring care within VHA and expanded screening and testing for hepatitis C; however additional investigation is required to further understand this geographic shift.
At the local healthcare system level, Veterans with chronic HCV were seen at each of the 128 local systems which are responsible for reporting on all local VHA health care. In 2008, HCV patient caseload by healthcare system ranged from 26 to 4,476, with the majority of healthcare systems caring for between 700 and 1,500 Veterans with chronic HCV.
Figure 4 depicts the distribution of the 128 VHA healthcare systems by caseload. The 41 healthcare systems with large HCV caseloads (over 1,500) care for 60% of all Veterans with chronic HCV. Healthcare systems with chronic HCV caseloads between 501 and 1,500 (n=60) care for 35% of the chronic Veteran population and the 24 facilities with HCV caseloads less than 501 care for 5% of the population.
Almost 12% of Veterans with chronic HCV received care at more than one healthcare system and 3.5% received care at more than one VISN during 2008. A complete listing of the number of Veterans with chronic HCV at each local healthcare system can be found in Appendix A.
The majority of Veterans with chronic HCV were men (97%); nonetheless, the VHA provides care to a substantial number (over 4,200) of women Veterans with chronic HCV. Although the proportion of Veterans with chronic HCV in VHA care who were male has remained stable over the past five years, as the percentage of female Veterans in VHA care increases, the number of HCV infected female Veterans may also increase. According to CDC estimates, the prevalence of HCV in American females is one-half that of men. (2.2)
In 2008, Whites comprised almost half of Veterans with chronic HCV in VHA care (49%, Figure 5). Blacks comprised 31% of the VHA population with chronic HCV - a substantially greater proportion than the overall Veteran population in VHA care in which 11% were identified as Black. (2.3) Just over five percent of Veterans with chronic HCV identified themselves as Hispanic or Latino, which is very similar to the 5.7% Hispanic population served by the VHA overall. Less than 1% of HCV infected Veterans were American Indian, Alaskan Native, Asian, Native Hawaiian, or Pacific Islander. Because reporting of race and of ethnicity among Veterans in VHA care is not complete, the actual percentages may vary from those reported.
A comparison of the age by decade of life of Veterans with chronic HCV in VHA care in 2000, 2004 and 2008 is presented in Figure 6. Since 2000, the mean age of Veterans with chronic HCV has increased from 49.8 to 56.3 years. In 2008, 88% of Veterans with chronic HCV in VHA care were age 50 or older and more than one in four Veterans with chronic HCV was over the age of 60.
Since 2003, incidence rates of acute HCV in the US have generally remained stable within each age group, increasing only slightly among persons aged 25 - 39 years and those aged >40 years. (2.4) According to the CDC, peak prevalence of acute HCV infection in the general US population in 2007 occurred among persons aged 40-49. (2.2) In VHA, there are no data on the incidence of acute HCV.
The impact of HCV disease on the long-term management of other chronic conditions common in the elderly and vice versa is still largely unknown. As the affected population ages, HCV will complicate the management of other co-morbid conditions to a greater degree. VHA is in the unique position of caring for a large older Veteran population with chronic HCV; much can be learned about their care. This report describes the prevalence of some of the other chronic conditions common in the elderly in Veterans with chronic HCV in Chapter 4.
According to CDC information from 1998, chronic HCV causes 8,000-10,000 deaths each year and accounts for almost half of the approximately 4,000 liver transplantations done each year. (2.1) Since death from HCV liver disease usually occurs 20 or more years after the initial infection, CDC expects deaths from chronic HCV to rise sharply in the next 10 years. (2.5) VHA has already begun to see an increase in deaths from all causes among Veterans with chronic HCV. Between 2000 and 2008, the annual number of all cause deaths recorded for Veterans with chronic HCV rose from 1,259 (1,129 per 100,000 in VHA care) to 5,967 (4,049 per 100,000 in VHA care), respectively. The PHSHG is acutely interested in understanding the causes associated with this increase in deaths including the impact of chronic hepatitis C.
- In Care. A Veteran is considered in VHA care for this report if they had at least one outpatient visit or an inpatient stay or filled an outpatient prescription in the defined time period.
- Demographics. Age was calculated at the midpoint of the time period under evaluation. Race is classified using the Office of Management and Budget (OMB) categories published in the Federal Register on July 9th, 1997 and include American Indian or Alaskan Native, Asian or Pacific Islander, Black, and White. For Ethnicity, persons were classified as of Hispanic origin or not. For the race/ethnicity, Hispanic Veterans (of any race) were identified first based on the Veteran.s ethnicity field. We then used the race field for remaining Veterans to identify if they should be mapped to Black, White, and Other. The "Other" group includes "American Indian or Alaskan Native" and "Asian or Pacific Islander."
- Deaths. Dates of death were obtained from both Veterans Health Administration and the Veterans Benefits Administration files.
- Centers for Disease Control and Prevention. Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease*. MMWR 1998;47 (No. RR-19):14
- CDC. Surveillance for Acute Viral Hepatitis - United States, 2007. MMWR May 22, 2009;58 (No. SS-3). Available at www.cdc.gov/mmwr/PDF/ss/ss5803.pdf.
- The data on the entire Veteran population can be found at http://www1.va.gov/vetdata. Data was last accessed on March 23, 2010.
- CDC Division of Viral Hepatitis. Statistics and Surveillance. Available at: www.cdc.gov/hepatitis/HCV/HCVfaq.htm#section1". Last updated June 9, 2009
- Wise M, et al. Changing trends in hepatitis C-related mortality in the United States, 1995-2004. Hepatology 2008; 10.1002/hep.22165.