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State of Care for Veterans with Chronic
Chapter 4 - Other Diseases and Conditions
Other Diseases and Conditions Seen in Veterans with Chronic HCV
Concurrent health issues, or co-morbidities, add to the complex health needs of Veterans with chronic HCV. PHSHG compiles information on the rates of co-morbid conditions in Veterans with chronic HCV in VHA care both for those who have ever had the co-morbid condition and those who have a new diagnosis in the year. Understanding the number of existing and new cases of various co-morbid conditions is important for administrators preparing workload and budget projections and for providers who must assess how these conditions affect the management of HCV. For example, the level of healthcare utilization for an otherwise healthy Veteran with chronic HCV may be very different than for someone with diabetes, a substance use disorder, and depression as well as chronic HCV.
In 2008, several co-morbid conditions requiring chronic medical management were present in approximately 25% or more of the population with chronic HCV in VHA care at VHA: hypertension (63%), dyslipidemias (34%), esophageal disease (30%) and diabetes (26%). Mental illness, another important clinical condition impacting HCV care was also highly prevalent in Veterans with chronic HCV; depression (56%), neuroses or anxiety disorders (33%), and Post Traumatic Stress Disorder (PTSD) (26%). Substance use was also quite prevalent in the HCV infected Veteran population with 55% reporting a history of alcohol abuse, 39% with a history of illicit drug use and almost 62% reporting a history of tobacco use. Tobacco use will be addressed in greater detail in Chapter 6. The substantial percentage of Veterans with chronic HCV affected by co-morbid conditions highlights the need for consistent preventive care and routine monitoring. Several of these conditions can be exacerbated or caused by HCV itself and/or by HCV antiviral medications. That may be the case for the 21% of Veterans with chronic HCV with anemia and the 26% with diabetes. It may also be the case for more than half of Veterans with chronic HCV who were affected by mental illness and substance use. Of the co-morbid conditions first diagnosed for Veterans with chronic HCV in 2008, anemia and depression were among the most common. Table 3 presents the rates of co-morbid conditions first diagnosed or ever diagnosed by VHA among Veterans with chronic HCV in VHA care in 2008.
Hepatitis B co-infection was present in approximately 8% of Veterans with chronic HCV while 3.8% were known to be co-infected with HIV. The prevalence of chronic hepatitis B and HIV infection and screening rates for HIV infection are discussed in more detail in Chapter 6.
|Co-morbid Condition Group||Co-morbid Condition||Percent with First VHA Diagnosis of Condition in 2008||Percent with VHA Diagnosis of Condition Ever*|
|* Refers to the percent of those Veterans with chronic HCV in care in 2008.|
|Cerebral Vascular Conditions||0.4%||2.5%|
|Conduction Disorders / Dysrhythmias||1.2%||10.3%|
|Congestive Heart Failure||0.8%||5.1%|
|Ischemic Heart Disease||1.2%||15.0%|
|Decompensated Liver Disease||1.2%||5.3%|
|Malignancy||Colon / Rectum||0.2%||0.9%|
|Kidney / Renal Pelvis||0.1%||0.6%|
|Lung / Bronchus||0.3%||1.0%|
|Melanoma of the Skin||0.0%||0.4%|
|Oral Cavity / Pharynx||0.1%||0.8%|
|Mental Illness||Bipolar Disorder||0.7%||11.7%|
|Neuroses and Anxiety States||1.7%||33.3%|
|Metabolic||Diabetes, Type I||0.1%||5.2%|
|Diabetes Type II and Unspecified||2.1%||25.5%|
|Renal||Renal Failure, Acute||1.6%||5.4%|
|Renal Failure, Chronic||1.2%||6.1%|
|Substance Use||Alcohol Use||2.5%||54.5%|
|Illicit Drug Use||1.7%||39.3%|
|Other and Unspecified Drug Use||1.5%||31.6%|
|Viral Diseases||Hepatitis B||0.5%||7.7%|
Cirrhosis and Associated Complications
According to the CDC, 5-20% of those infected with chronic HCV will develop cirrhosis over a period of 20 to 30 years and 1-5% will die from liver cancer or cirrhosis. (4.1) The risk of cirrhosis is further increased by alcohol use. Based on the epidemiology of HCV in the US and age of Veterans with chronic HCV, the majority of Veterans with chronic HCV in VHA care in recent years were likely infected during the Vietnam War era (1964 - 1975). Given the natural history of chronic HCV, one would expect to see increasing numbers of conditions related to progression of liver disease including cirrhosis.
Cirrhosis is an important cause of morbidity and mortality in HCV disease and represents the end stage of chronic liver disease. The main complications of cirrhosis are related to the development of liver insufficiency and portal hypertension and include ascites, variceal hemorrhage, jaundice, hepatic encephalopathy, and hepatorenal and hepatopulmonary syndromes. Once a patient with cirrhosis develops signs of decompensation, duration of survival is significantly reduced. (4.2, 4.3) Given that many patients with liver disease are asymptomatic for a long period of time, it is very difficult to accurately establish its prevalence and incidence both in the general population and among Veterans. Nevertheless, in 2006, chronic liver disease and cirrhosis was the 12th leading cause of death in the U.S. (4.4) To understand the prevalence and impact of cirrhosis and its associated complications, PHSHG reports on Veterans with new diagnoses of cirrhosis (first VHA diagnosis in the year) and Veterans with existing diagnoses of cirrhosis (ever had a diagnosis of cirrhosis) (Figure 8).
In 2008, there were over 19,000 Veterans with chronic HCV in VHA care who also had a diagnosis of cirrhosis ever, representing 13% of Veterans with chronic HCV in care. At the VISN level, the caseload of Veterans with chronic HCV and cirrhosis ever ranged from 364 to 1,950 (Table 4) and percentage of Veterans with chronic HCV and cirrhosis ever ranged from 9% to 19%. At the local healthcare system level, the comparable caseload ranged from 1 to 683 cases and the comparable percentage ranged from 4% to 30%.
|Number in Care||# in VHA Care with First Diagnosis of Cirrhosis||# in VHA Care with Diagnosis of Cirrhosis Ever|
|VA New England Healthcare System (1)||5,126||107||778|
|VA Healthcare Network Upstate New York (2)||2,480||42||364|
|VA NY/NJ Veterans Healthcare Network (3)||6,952||128||808|
|VA Healthcare (4)||7,745||177||1,136|
|VA Capitol Health Care Network (5)||6,281||87||539|
|VA Mid-Atlantic Health Care Network (6)||8,164||176||1,164|
|VA Southeast Network (7)||9,583||205||1,231|
|VA Sunshine Healthcare Network (8)||13,392||304||1,950|
|VA Mid South Healthcare Network (9)||6,933||136||903|
|VA Healthcare System of Ohio (10)||5,170||111||689|
|Veterans in Partnership (11)||7,003||141||812|
|VA Great Lakes Health Care System (12)||5,913||108||751|
|VA Heartland Network (15)||5,384||100||700|
|South Central VA Health Care Network (16)||14,019||264||1,565|
|VA Heart of Texas Health Care Network (17)||6,313||218||1,207|
|VA Southwest Health Care Network (18)||6,703||153||999|
|Rocky Mountain Network (19)||4,046||82||490|
|Northwest Network (20)||8,607||196||1,282|
|Sierra Pacific Network (21)||8,670||173||1,194|
|Desert Pacific Healthcare Network (22)||10,899||240||1,296|
|VA Midwest Health Care Network (23)||5,126||107||608|
The percentage of cases of cirrhosis in Veterans with chronic HCV has increased by one to two percentage points per year over the past 8 years. Work by the PHSHG to prepare VHA for this increasing caseload of Veterans with cirrhosis is underway. Resources for these Veterans, ranging from materials on screening for hepatocellular carcinoma (see Chapter 4) to pre- and post- liver transplant care will need to be increased to meet future demand. Materials for both clinicians and Veterans can be found at http://www.hepatitis.va.gov
Hepatocellular carcinoma (HCC) accounts for 80-90% of all liver cancers, is more common in men than women and currently is generally seen in those between the ages of 50 and 60. Annually, approximately 1% to 2% of persons with chronic HCV and cirrhosis develop HCC. The incidence of HCC in the US as well as in the VHA has been increasing and this is likely due to the large pool of people with longstanding HCV infection. (4.5) Over 4,824 cases of HCC were diagnosed in Veterans with chronic HCV between 2000 through 2008. The number of new diagnoses, the number receiving ongoing care, and the cumulative number of cases recorded in VHA are presented in Figure 9.
The cumulative number of new HCC diagnoses continues to increase at a rate that exceeds the increase in patients receiving ongoing care for their chronic HCV and HCC. The divergence of these trends is mainly due to limited treatment options for HCC, resulting in a one-year survival rate of less than 50%. (4.6) Additional information on screening for HCC can be found in Chapter 6.
In 2008, new cases of HCC among Veterans with chronic HCV were diagnosed in all VISNs and in all but 10 of the 128 local healthcare systems. One and a half percent (1.5%) of all Veterans with chronic HCV in VHA care in 2008 had been diagnosed with HCC (see table 3). PHSHG is working on a number of initiatives to assist VHA clinicians in screening, diagnosing and treating HCC. One particular area of future quality assessment for the PHSHG is to understand access to HCC treatment given the need to coordinate Hepatology, Diagnostic Radiology, Interventional Radiology, Oncology, Surgery, Liver Transplant, and Palliative care activities.
- Diagnosis. For the analysis of co-morbid conditions, cirrhosis, and HCC, a Veteran is considered to have a diagnosis if he or she had at least one diagnosis (ICD-9) from an admission (of any rank) or from two outpatient encounters occurring on separate dates. For more information, contact the PHSHG. In the case of outpatient coding, if the two dates were in different years, then the condition is recorded as first ever in the earlier year.
- Cirrhosis. Includes ICD-9 codes for cirrhosis and complications associated with this chronic condition (esophageal varices, spontaneous bacterial peritonitis, hepatic coma, portal hypertension, hepatorenal syndrome).
- http://www.cdc.gov/hepatitis/HCV/HCVfaq.htm#section1, viewed March 23, 2009.
- Okazaki I, Maruyama K, Funatsu K, Kashiwazaki K, Tsuchiya M. Ten year survival rate of 131 patients with liver cirrhosis excluded the association of liver carcinoma at the establishment of diagnosis. Gastroenterol Jpn. 1980;15(4):350-4.
- Saunders JB, Walters JR, Davies AP, Paton A. A 20-year prospective study of cirrhosis. Br Med J (Clin Res Ed). 1981 Jan 24;282(6260):263-6.
- Heron M, Hoyert DL, Murphy SL et.al. Deaths: Final Data for 2006. National Vital Statistics Reports. 2009:57(14)
- Davila JA, Morgan RO, Shaib Y, McGlynn KA, El-Serag HB Hepatitis C infection and the increasing incidence of hepatocellular carcinoma: a population-based study.Gastroenterology. 2004 Nov;127(5):1372-80.
- Cabibbo G, Enea M, Attanasio M, Bruix J, Craxì A, Cammà C. A meta-analysis of survival rates of untreated patients in randomized clinical trials of hepatocellular carcinoma. Hepatology. 2010, Apr; 51(4): 1274-83]