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Viral Hepatitis

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Veteran Data Reports on Viral Hepatitis

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State of Care for Veterans with Chronic
Hepatitis C

Chapter 6 - Assessing Quality of Care in Veterans with Chronic HCV

In 2006, PHSHG began drawing on data from the CCR to construct measures for selected clinical topics important in caring for Veterans with chronic HCV. These measures were developed using existing treatment recommendations and clinical practice guidelines from the PHSHG and from professional societies. The following clinical topics have been used to assess the quality of care delivered to Veterans with chronic HCV in VHA care: confirmation of chronic HCV, hepatitis A and B screening and vaccination, HIV testing, influenza vaccination, and tobacco cessation pharmacologic treatment. In addition, rates of screening for HCC among Veterans with chronic HCV and cirrhosis and of non-selective beta-blocker use in Veterans with chronic HCV hospitalized with esophageal variceal hemorrhage were assessed. Sustained virologic response rates were assessed for Veterans with chronic HCV treated with pegylated interferon and ribavirin. To permit assessment of trends over time, data on each clinical topic are presented for the years 2000 through 2008 where available.

Although the majority of the data are complete and accurate, these quality measures are limited by data quality. Data not captured by the EMR, captured in a non-standard fashion, or using non-standard terms is not available for CCR based assessments and may lead to underestimates of performance. VHA providers who document diagnoses, outside VHA medications, and other activities only within progress notes, will not have that information counted in a report such as this one. These data limitations impact our care ascertainment and should be kept in mind while reading this chapter.

Confirming Chronic HCV

Blood tests for HCV antibodies were first approved by the FDA in 1992. HCV viral load testing for chronic infection became available a few years later. While national HCV antibody or viral load testing rates in all Veterans in VHA care over time are not available, we can observe the uptake of both HCV antibody and viral load testing among Veterans in the CCR (Figure 12).

Figure 12: Cumulative Number of Veterans in the CCR Tested for HCV Antibodies and Viral LoadCumulative Number of Veterans in the CCR Tested for HCV Antibodies and Viral Load

Since up to 20% of all persons infected with HCV will naturally clear active viral disease, a HCV viral load test is required to assess the presence of chronic infection. (6.1) The percent of Veterans in the CCR with a positive HCV antibody test result who had HCV viral load testing has increased from 81% in 2000 to 89% in 2008 (Figure 13).

Figure 13: Percent of Veterans in the CCR with a Positive HCV Antibody Test who had HCV Viral Load TestingPercent of Veterans in the CCR with a Positive HCV Antibody Test who had HCV Viral Load Testing

To address the remaining gap in testing for chronic hepatitis C infection, PHSHG has established a policy requiring "reflex testing" or the completion of screening and confirmatory testing, including tests for chronic infection with a single blood draw. This policy and others developed by the PHSHG can be found at http://www.hepatitis.va.govLink will take you to our Viral Hepatitis internet site.

Hepatitis A and Hepatitis B Infection

Many patients who have acquired HCV infection may be at risk for acquiring hepatitis A or B, both of which are preventable diseases. These patients could benefit from effective hepatitis A and hepatitis B vaccination. Screening for hepatitis A and B and subsequent vaccination, if indicated, is important in providing comprehensive HCV medical care and is recommended by the Advisory Committee on Immunization Practices (ACIP). (6.2, 6.3) VHA guidelines on the management and treatment of hepatitis C infection published in 2006 recommend testing for hepatitis A and B in all Veterans with chronic HCV to evaluate for past infection with hepatitis A and hepatitis B, chronic hepatitis B infection and to assess the need for hepatitis A and/or B immunization. (6.4) In 2007, the VHA began reporting the number of HCV infected Veterans who were vaccinated against hepatitis A and hepatitis B where there was no evidence of chronic hepatitis B or past exposure to hepatitis A or hepatitis B. PHSHG also measures the overall rate of screening for immunity to these two viral diseases; however this information is not routinely posted online.

Hepatitis A

The overall rates of screening for immunity to hepatitis A increased from 33% to 76% among Veterans with chronic HCV in VHA care between 2000 and 2008. Over this period, Veterans with chronic HCV without documented immunity to hepatitis A were vaccinated at increasing rates, from 20% in 2000 to 53% in 2008. In addition, an increasing number of Veterans with chronic HCV were vaccinated for hepatitis A without testing for hepatitis A immunity; in 2008, 24% of those without hepatitis A antibody testing received a hepatitis A vaccination. Together, the percent of Veterans with chronic HCV immune to or vaccinated against hepatitis A increased from 18% to 65% between 2000 and 2008 (Figure 14).

Figure 14: Rates of Hepatitis A Antibody Testing and Vaccination in Veterans with Chronic HCVRates of Hepatitis A Antibody Testing and Vaccination in Veterans with Chronic HCV

Twelve VISNs had documented testing rates of 75% or more for hepatitis A antibodies in 2008. In two VISNs, at least 75% of Veterans with chronic HCV in VHA care in 2008 had documented immunity to or were vaccinated against hepatitis A. Table 6 provides VISN level data for hepatitis A immunity/vaccination for 2008.

Hepatitis B

While the overall rates of screening for past exposure to hepatitis B were higher than hepatitis A, screening rates for hepatitis B, like those for hepatitis A, increased between 2000 (59%) and 2008 (89%). Veterans with chronic HCV not found immune to or chronically infected with hepatitis B were vaccinated at increasing rates, from 21% in 2000 to 48% in 2008. In addition, an increasing number of Veterans with chronic HCV were vaccinated without testing for hepatitis B immunity; 15% of those without hepatitis B antibody testing received a hepatitis vaccination. Together, the percent of Veterans with chronic HCV immune to or vaccinated against hepatitis B increased from 39% in 2000 to 70% in 2008 (Figure 15).

Figure 15: Rates of Hepatitis B Antibody Testing and Vaccination in Veterans with Chronic HCVRates of Hepatitis B Antibody Testing and Vaccination in Veterans with Chronic HCV

All VISNs had documented testing rates for hepatitis B antibodies higher than 75%. In six VISNs, at least 75% of their Veterans with chronic HCV in VHA care in 2008 had documented immunity to or were vaccinated against hepatitis B (Table 6).

Table 6. Hepatitis A and Hepatitis B Immunity and Vaccination Rates in Veterans with Chronic HCV in VHA Care in 2008
Number in CarePercent with VHA HAV Immunity or VaccinePercent with VHA HBV Immunity or Vaccine*

* Percent is calculated among Veterans with chronic HCV in VHA care eligible to HBV vaccine and excludes those Veterans co-infected with hepatitis B. Abbreviations: HAV, hepatitis A virus; HBV, hepatitis B virus

Nation147,35265%70%
VISN (number)
VA New England Healthcare System (1)5,12666%75%
VA Healthcare Network Upstate New York (2)2,48057%73%
VA NY/NJ Veterans Healthcare Network (3)6,95259%82%
VA Healthcare (4)7,74571%78%
VA Capitol Health Care Network (5)6,28176%83%
VA Mid-Atlantic Health Care Network (6)8,16464%71%
VA Southeast Network (7)9,58354%59%
VA Sunshine Healthcare Network (8)13,39267%72%
VA Mid South Healthcare Network (9)6,93361%64%
VA Healthcare System of Ohio (10)5,17058%67%
Veterans in Partnership (11)7,00357%63%
VA Great Lakes Health Care System (12)5,91360%70%
VA Heartland Network (15)5,38464%64%
South Central VA Health Care Network (16)14,01962%65%
VA Heart of Texas Health Care Network (17)6,31377%77%
VA Southwest Health Care Network (18)6,70361%64%
Rocky Mountain Network (19)4,04666%66%
Northwest Network (20)8,60771%73%
Sierra Pacific Network (21)8,67082%77%
Desert Pacific Healthcare Network (22)10,89967%77%
VA Midwest Health Care Network (23)4,23553%61%

For Veterans with chronic HCV in 2008, the national rate of co-infection with chronic hepatitis B in those who were assessed for HBV status (70%) was approximately 8% (as indicated by a VHA laboratory record of positive hepatitis B surface or 'e' antigen or detectable hepatitis B viral load).

As evidenced by the wide variation in rates observed among VISNs, improved screening and vaccination for hepatitis A and B deserves attention. Efforts to educate primary care and substance use providers on the recommendations and benefits of hepatitis A and B screening and vaccination should be undertaken as one means to improve these rates. The significant number of Veterans who received vaccination without the determination of immune status may be due to the co-formulation of hepatitis A and B in a single vaccine product and to questions regarding the cost effectiveness of hepatitis A screening relative to vaccine cost and risk of vaccination. VHA providers might benefit from a cost benefit analysis of this issue.

HIV Testing

Several national guidelines, including those from the American Association for the Study of Liver Diseases (AASLD) and the VHA Hepatitis C Resource Center Program and National Hepatitis C Program Office, recommend that all HCV infected patients be tested for HIV infection. (6.4, 6.5) HCV and HIV co-infection increases the risk of HCV-related liver damage, can lengthen the duration of HCV therapy in HCV genotype 2 and 3, and lowers HCV treatment response rates. Thus the need for HIV diagnosis and treatment in these individuals is high.

In 2008, 56% of Veterans with chronic HCV in VHA care had been tested for HIV infection, an increase from 39% in 2000. (Figure 16). In 2008, the highest HIV testing rate at any VISN was 71%. Five VISNs had HIV testing rates in Veterans with chronic HCV less than 50% (Table 7). More than 5,800 Veterans with chronic HCV in VHA care in 2008 have been identified as HIV positive.

Figure 16: Maximum and Minimum HIV Testing Rates in Veterans with Chronic HCV over Time by VISNMaximum and Minimum HIV Testing Rates in Veterans with Chronic HCV over Time by VISN

Table 7. HIV Testing Rates in Veterans with Chronic HCV in VHA Care in 2008
Number in CarePercent with VHA HIV Test Ever
Nation147,35256%
VISN (number)
VA New England Healthcare System (1)5,12653%
VA Healthcare Network Upstate New York (2)2,48056%
VA NY/NJ Veterans Healthcare Network (3)6,95265%
VA Healthcare (4)7,74553%
VA Capitol Health Care Network (5)6,28168%
VA Mid-Atlantic Health Care Network (6)8,16471%
VA Southeast Network (7)9,58353%
VA Sunshine Healthcare Network (8)13,39260%
VA Mid South Healthcare Network (9)6,93353%
VA Healthcare System of Ohio (10)5,17053%
Veterans in Partnership (11)7,00349%
VA Great Lakes Health Care System (12)5,91352%
VA Heartland Network (15)5,38446%
South Central VA Health Care Network (16)14,01957%
VA Heart of Texas Health Care Network (17)6,31366%
VA Southwest Health Care Network (18)6,70347%
Rocky Mountain Network (19)4,04645%
Northwest Network (20)8,60746%
Sierra Pacific Network (21)8,67058%
Desert Pacific Healthcare Network (22)10,89964%
VA Midwest Health Care Network (23)4,23548%

Although emphasis has been placed on HIV testing for Veterans with HCV, testing rates remain low. PHSHG believes that this is due in part to the historical barriers requiring written informed consent for HIV testing in VHA. As of August 2009, Federal law and regulations were changed and VHA policy updated replacing the requirement written informed consent for HIV testing with verbal consent in VHA. Further, VHA policy now endorses routine HIV testing for all Veterans not just those with identifiable risk factors for HIV. With these policy changes in place, PHSHG has begun a broad campaign to increase HIV testing among Veterans in VHA care, in collaboration with VHA stakeholders in primary care, mental health, medicine, nursing, women's health, and other disciplines.

Influenza Vaccination

Each year, VHA conducts a nationwide campaign to maximize influenza vaccination among Veterans and healthcare providers. The VHA bases the influenza vaccination program on recommendations of the U.S. Advisory Committee on Immunization Practices (ACIP). One target group for annual influenza vaccination in these recommendations has been persons with chronic liver disease. (6.6) Forty-six percent of Veterans with chronic HCV in VHA care during the 2007/2008 influenza season had documentation that they received an influenza vaccination from VHA. This percentage represents an increase over previous influenza vaccination campaigns; vaccination rates of 28%, 37% and 40% were observed in 2001/2002, 2003/2004, and 2005/2006, respectively. Across VISNs, the documented rate of influenza vaccination in 2007/2008 for Veterans with chronic HCV ranged from 37% to 59% (Table 8).

Table 8: Influenza Vaccination Rates in Veterans with Chronic HCV in VHA Care in 2007/2008 Influenza Season
Number Eligible for Influenza VaccinationPercent with VHA Influenza Vaccine during 2007/2008 Influenza Season
Nation138,14646%
VISN (number)
VA New England Healthcare System (1)4,79145%
VA Healthcare Network Upstate New York (2)2,35245%
VA NY/NJ Veterans Healthcare Network (3)6,34050%
VA Healthcare (4)7,11953%
VA Capitol Health Care Network (5)5,80154%
VA Mid-Atlantic Health Care Network (6)7,59250%
VA Southeast Network (7)8,78450%
VA Sunshine Healthcare Network (8)12,36548%
VA Mid South Healthcare Network (9)6,35543%
VA Healthcare System of Ohio (10)4,84737%
Veterans in Partnership (11)6,59542%
VA Great Lakes Health Care System (12)5,47948%
VA Heartland Network (15)5,07850%
South Central VA Health Care Network (16)13,00545%
VA Heart of Texas Health Care Network (17)5,83759%
VA Southwest Health Care Network (18)6,13844%
Rocky Mountain Network (19)3,70547%
Northwest Network (20)7,90842%
Sierra Pacific Network (21)8,01345%
Desert Pacific Healthcare Network (22)10,00342%
VA Midwest Health Care Network (23)3,94946%

Influenza vaccination rates documented in the EMR and thus generated from the CCR likely underestimate the number of Veterans with chronic HCV actually vaccinated. VHA providers may not consistently document that a Veteran received influenza vaccination outside of VHA (such as in a community program or pharmacy) or may not document it in a standard manner that is accessible to the CCR. VHA assesses national influenza vaccination rates by age group (50-64 years and 65 years and older) and Veterans with spinal cord injury (SCI) through an automated and manual electronic medical record audit performed at each local healthcare system and reports on Veterans in these groups. (6.7) The documented national rate of influenza vaccination for those 50 - 64 years old, those 65 and older, and those with an SCI for the 2008/2009 influenza vaccination period were 69%, 83% and 80%, respectively. These national influenza vaccination rates for Veterans who meet ACIP guidelines for vaccination were higher than the 46% observed in Veterans with chronic HCV, one other group recommended by ACIP to receive influenza vaccination.

Tobacco Cessation

Tobacco dependence is prevalent among Veterans with chronic HCV. Sixty-two percent of these Veterans had a diagnosis of tobacco use at some time while in VHA care, and 37% had a current diagnosis of tobacco dependence in 2008, which was substantially higher than the 22% prevalence in the overall Veteran population and the 21% prevalence in the general population. (6.8)

The 2008 Update of the Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence states that it is essential for clinicians and healthcare delivery systems to consistently identify and document tobacco use status and provide tobacco cessation treatment to every tobacco user seen in a healthcare setting. Just over 46% of Veterans with chronic HCV who had a VHA diagnosis of tobacco use had ever received a medication to treat tobacco dependence, and 20% received tobacco cessation medications in 2008. VISN rates for cessation treatment in 2008 ranged between 13% and 29% (Table 9). Additional work is needed to determine how to assist VHA healthcare providers and Veterans with chronic HCV in managing tobacco dependence.

Table 9. Tobacco Use and Pharmacotherapy Rates in Veterans with Chronic HCV in VHA Care in 2008
Number in CarePercent with VHA Diagnosis of Tobacco Use EverPercent with VHA Diagnosis of Tobacco Use in 2008Percent with VHA Pharmaco- therapy EverPercent with VHA Pharmaco- therapy in 2008
Nation147,35262%37%46%20%
VISN (number)
VA New England Healthcare System (1)5,12664%41%54%26%
VA Healthcare Network Upstate New York (2)2,48068%42%50%22%
VA NY/NJ Veterans Healthcare Network (3)6,95252%30%42%19%
VA Healthcare (4)7,74561%38%52%19%
VA Capitol Health Care Network (5)6,28156%32%51%22%
VA Mid-Atlantic Health Care Network (6)8,16461%38%46%21%
VA Southeast Network (7)9,58361%35%48%22%
VA Sunshine Healthcare Network (8)13,392 59%36%41%18%
VA Mid South Healthcare Network (9)6,93363%38%45%20%
VA Healthcare System of Ohio (10)5,17076%50%53%23%
Veterans in Partnership (11)7,00365%41%48%20%
VA Great Lakes Health Care System (12)5,91366%42%50%23%
VA Heartland Network (15)5,38466%41%50%22%
South Central VA Health Care Network (16)14,01964%36%49%20%
VA Heart of Texas Health Care Network (17)6,31356%31%45%18%
VA Southwest Health Care Network (18)6,70365%38%41%16%
Rocky Mountain Network (19)4,04663%40%50%23%
Northwest Network (20)8,60766%41%52%21%
Sierra Pacific Network (21)8,67062%39%44%18%
Desert Pacific Healthcare Network (22)10,89955%31%35%13%
VA Midwest Health Care Network (23)4,23568%44%60%29%

Screening for Hepatocellular Carcinoma in Veterans with Chronic HCV and Cirrhosis

The VHA Hepatitis C Practice Recommendations recommend screening patients with HCV and cirrhosis for hepatocellular carcinoma (HCC) using alpha-fetoprotein (AFP) and abdominal imaging every six to twelve months. (6.9) The annual rate of VHA screening with both AFP and imaging in Veterans with chronic HCV and cirrhosis increased from 29% in 2000 to 45% in 2008. The annual rates for AFP alone and for imaging studies alone remained relatively stable at approximately 11% each over these years (Figure 17). Data from the CCR does not allow differentiation of tests performed specifically for screening for HCC from tests performed for other reasons. The sum of rates for any type of screening test (either AFP or imaging or both) performed increased from 54% to 68% from 2000 to 2008.

Figure 17: Rates of AFP Testing and/or Abdominal Imaging in Veterans with Chronic HCV and Cirrhosis Rates of AFP Testing and/or Abdominal Imaging in Veterans with Chronic HCV and Cirrhosis

In 2008, the percentage of Veterans with chronic HCV and cirrhosis receiving both an AFP and abdominal imaging ranged across VISNs from 35% to 60% (Table 10). Four VISNs provided both tests to at least 50% of such Veterans.

Table 10. Percent of Veterans with Chronic HCV with Cirrhosis in VHA Care in 2008 Who Were Screened for Hepatocellular Carcinoma
Number with Cirrhosis in CarePercent with AFP OnlyPercent with Imaging OnlyPercent with BothPercent with Either
Nation16,01411%12%45%67%
VISN (number)
VA New England Healthcare System (1)6769%10%45%64%
VA Healthcare Network Upstate New York (2)32213%15%35%63%
VA NY/NJ Veterans Healthcare Network (3)68013%10%47%70%
VA Healthcare (4)96310%13%48%71%
VA Capitol Health Care Network (5)45312%10%46%68%
VA Mid-Atlantic Health Care Network (6)99410%8%57%75%
VA Southeast Network (7)1,0339%15%40%64%
VA Sunshine Healthcare Network (8)1,65112%12%49%73%
VA Mid South Healthcare Network (9)7689%18%41%68%
VA Healthcare System of Ohio (10)58112%12%38%62%
Veterans in Partnership (11)67811%14%41%66%
VA Great Lakes Health Care System (12)64611%14%41%66%
VA Heartland Network (15)60210%12%48%70%
South Central VA Health Care Network (16)1,30412%11%43%66%
VA Heart of Texas Health Care Network (17)99012%8%55%75%
VA Southwest Health Care Network (18)84611%12%38%61%
Rocky Mountain Network (19)413 7%16%48%71%
Northwest Network (20)1,0918%12%43%63%
Sierra Pacific Network (21)1,02313%9%51%73%
Desert Pacific Healthcare Network (22)1,05912%12%46%70%
VA Midwest Health Care Network (23)5126%8%60%74%

Though room for further improvement exists, HCC screening efforts have improved over the past eight years. During this time, VHA has focused on educating providers to increase their awareness of the importance of HCC screening.

As described above, the prevalence of advanced liver disease, including cirrhosis, has increased to 13% of chronic HCV Veteran patients in care. VHA leadership should be aware of the workload impact of full adherence to the HCC screening guidelines and the likelihood for increased utilization of VHA health care resources with the increase in the number of Veterans with chronic HCV, cirrhosis, and HCC.

Use of Nonselective Beta Blockers in Veterans Hospitalized for Esophageal Variceal Hemorrhage

Esophageal varices are present in about 50% of cirrhotic patients and the presence of esophageal varices correlates with the severity of liver disease. (6.10) Patients with esophageal varices develop variceal hemorrhage at a rate of about 12% to 15% per year. The mortality rate associated with each episode of esophageal variceal hemorrhage (EVH) is approximately 15% to 20%. (6.10) Hence, one of the main prophylactic measures in the care of a patient with cirrhosis is the prevention of the first EVH (primary prophylaxis).

Two therapies are currently accepted for the prevention of the first EVH: non-selective beta-blockers (NSBBs) and endoscopic variceal ligation. In patients with esophageal varices, NSBBs (propranolol and nadolol) have been shown to significantly reduce the incidence of first EVH and mortality. In patients with small varices that are not at a high risk of hemorrhage, NSBBs have been effective in delaying variceal growth, and thereby preventing EVH.

The VHA Hepatitis C Resource Centers currently recommend use of NSBBs in patients with cirrhosis who have medium or large varices to prevent primary and recurrent EVH. (6.10) PHSHG reports on the use of NSBBs in Veterans with chronic HCV who were discharged from a VHA hospital with a first diagnosis of EVH. For this population, PHSHG assesses whether the Veterans were receiving NSBBs 120 days prior to the admission, during that hospital stay, at the time of discharge, and at 180 days after discharge. Because NSBBs are contraindicated in some patient (for example, due to asthma and lack of tolerance), this population includes some Veterans for whom NSBBs would not be prescribed. From 2000 to 2006, the most recent period with data available for this analysis, the number of Veterans admitted for their first EVH in VHA care increased from 328 to 690. The percent of Veterans with chronic HCV in care with a first EVH increased from 0.29% in 2000 to 0.46% in 2006.

As mentioned above, there is significant mortality following an EVH. Figure 18 shows the percent of Veterans with chronic HCV alive at discharge and 180 days following first admission for EVH. Nationally, there was no change between 2000 and 2006 in the percentage alive at hospital discharge while the percent alive 180 days after discharge declined from 81% in 2000 to 71% in 2006.

Figure 18: Percentage of Veterans with Chronic HCV Alive Following First Admission for EVHPercentage of Veterans with Chronic HCV Alive Following First Admission for EVH

Among Veterans with chronic HCV, the rates of NSBBs use prior to, during, and following admission for a first EVH from 2000 through 2006 are shown in Figure 19. Rates of NSSB use were highest during the hospital stay. Between 2000 and 2006, rates of NSBB use increased before, during, and after admission. During this period, NSBB use increased from 21% to 29% prior to the first admission for variceal hemorrhage and from 49% to 57% during the stay. In 2000, 37% of Veterans with chronic HCV with a first EVH were discharged with a prescription for a NSBB, compared with 41% in 2006. The percent of those on a NSBB at 180 days after such a hospital discharge increased from 38% to 46% between 2000 and 2006.

Figure 19. Rates of NSBB Use Prior to Admission, During Hospitalization, and Following a First Admission for EVH in Veterans with Chronic HCVRates of NSBB Use Prior to Admission, During Hospitalization, and Following a First Admission for EVH in Veterans with Chronic HCV

Across VISNs, the number of VHA admissions for first EVH in 2006 ranged from 7 (VISN 2) to 59 (VISNs 8 and 20). Across VISNs with at least 10 cases, the rate of NSBB use prior to the admission for first EVH in Veterans with chronic HCV ranged from minimum of 19% to a maximum of 43%, while the NSBB rate during such hospitalizations ranged from 41% to 75% (Figure 20 and Table 11).

Figure 20. Maximum and Minimum VISN Rates for NSBB Use by VISN in Veterans with Chronic HCV and First Admission for EVH in 2006Maximum and Minimum VISN Rates for NSBB Use by VISN in Veterans with Chronic HCV and First Admission for EVH in 2006

Table 11. Use of Non-Selective Beta Blockers (NSBB) in Veterans with Chronic HCV Hospitalized with First Esophageal Variceal Hemorrhage (EVH) in 2006
VISN NumberNumber with EVH AdmissionPercent on NSBB prior to AdmissionPercent on NSBB During AdmissionNumber Alive at DischargePercent on NSBB at DischargeNumber Alive 180 Days after DischargePercent on NSBB on 180 Days after Discharge

*Please refer to the other VISN level tables in this report for the full VISN name.

Abbreviation: NR, not reported if less than 10 cases in the year.

National69029%55%62937%49246%
12040%50%1937%1765%
27NRNRNRNRNRNR
32825%54%2631%1942%
43531%63%3339%3033%
51638%75%1540%1070%
62520%56%2344%1947%
74624%52%4342%2825%
85929%41%5129%4151%
93119%52%2744%2442%
102532%52%2232%1942%
113333%64%3033%2143%
122330%61%2241%1861%
152330%61%2124%1759%
165627%59%5246%3845%
173639%67%3333%2654%
183132%45%2639%2030%
192442%54%2241%1741%
205925%59%5546%4542%
215328%57%4933%3845%
224120%51%3633%2756%
231921%42%1828%1553%

Though NSBB use has increased recently, greater attention is needed to the initiation of NSBBs before, during, and after admission for first EVH for Veterans with chronic HCV. Large variation exists between VISNs in use of NSBBs. The number of first ever diagnoses of EVH among Veterans with chronic HCV increased from 2000 to 2006. This trend is continuing; there were 800 admissions for first EVH in Veterans with chronic HCV in 2008. There is significant all- cause mortality during hospitalization and in the 6 months following discharge among patients with chronic HCV and EVH and mortality rates have increased in recent years. More work is needed to understand the reasons why mortality has trended higher over time.

Sustained Virologic Response after HCV Treatment

The goal of HCV antiviral therapy is to eradicate the HCV virus in hopes of reducing complications and death from HCV infection. Effectiveness of treatment is evaluated by assessing virologic response. A sustained virologic response (SVR) is defined as an undetectable HCV RNA level 24 weeks after the end of treatment. As indicated above, the current standard of care for HCV treatment is the combination of pegylated interferon and ribavirin. In randomized, controlled trials of pegylated interferon plus ribavirin that were the basis for FDA approval, an SVR was observed in 42% to 46% of those infected with HCV genotype (GT) 1 and in 76% to 82% of those infected with HCV GT 2 or 3. (6.11, 6.12, 6.13) Ninety-five percent of Veterans with chronic HCV in VHA care have one of these three genotypes, with the majority having GT1.

For this report, a Veteran was considered to have attained a SVR if he or she had an undetectable HCV viral load on all HCV viral load tests after the end of HCV antiviral treatment, at least one of which was a minimum of 12 weeks after ending treatment. HCV viral load tests taken 12 weeks after the end of treatment were accepted because 98% of relapses occur within the first 12 weeks after ending treatment (6.14, 6.15) and because of the scheduling variability of routine medical care. Tests taken more than 12 weeks after the end of treatment were also accepted because of the scheduling variability of routine medical care.

Among the 20,477 Veterans with chronic HCV who initiated their first VHA course of pegylated interferon and ribavirin between 2002 and 2006, the SVR rate was 26%, 62%, and 52%, for genotypes 1, 2 and 3, respectively. When comparing the year 2002 to the year 2006, there was an increase in SVR rates from 21% to 27% for those with HCV GT1, from 57% to 60% for HCV GT2, and from 43% to 53% for HCV GT3 (Figure 21). The year-to-year trend in SVR rates for all three genotypes increased from 2002 to 2003, followed by a leveling off from 2003 to 2006. Cumulative numbers treated and SVR rates for the nation along with VISN ranges are presented in Table 12. The highest VISN SVR rates were 32% for HCV GT1, 77% for HCV GT2 and 63% for HCV GT3.

Figure 21. SVR Rates in Veterans with Chronic HCV after First VHA Course of Pegylated Interferon and Ribavirin Treatment Initiated between 2002 and 2006SVR Rates in Veterans with Chronic HCV after First VHA Course of Pegylated Interferon and Ribavirin Treatment Initiated between 2002 and 2006

Table 12. SVR Rates by VISN in Veterans with Chronic HCV Initiating First VHA Pegylated Interferon and Ribavirin between 2002 and 2006
GT1 Number TreatedGT1 Percent with SVRGT2 Number TreatedGT2 Percent with SVRGT3 Number TreatedGT3 Percent with SVR
Nation15,42426%3,06262%1,96152%
VISN (number)
VA New England Healthcare System (1)75623%19460%11251%
VA Healthcare Network Upstate New York (2)31628%4955%3459%
VA NY/NJ Veterans Healthcare Network (3)66420%11555%5155%
VA Healthcare (4)92925%13763%8252%
VA Capitol Health Care Network (5)67222%6865%1963%
VA Mid-Atlantic Health Care Network (6)80226%12360%6846%
VA Southeast Network (7)75222%13256%5949%
VA Sunshine Healthcare Network (8)1,64325%30659%19144%
VA Mid South Healthcare Network (9)56322%10652%6057%
VA Healthcare System of Ohio (10)59124%10262%5450%
Veterans in Partnership (11)64723%12466%8254%
VA Great Lakes Health Care System (12)70829%10277%7654%
VA Heartland Network (15)74030%15860%8850%
South Central VA Health Care Network (16)1,51726%30167%18360%
VA Heart of Texas Health Care Network (17)50723%12760%7751%
VA Southwest Health Care Network (18)69931%16864%12154%
Rocky Mountain Network (19)27528%6757%5149%
Northwest Network (20)52131%18063%13955%
Sierra Pacific Network (21)84432%21469%18455%
Desert Pacific Healthcare Network (22)66024%13965%11945%
VA Midwest Health Care Network (23)61832%15061%11143%

There are likely several reasons why SVR rates among Veterans in VHA care were lower than those reported in clinical trials. First, the Veteran population is a real-world population which is very different than the cohort of patients enrolled in HCV clinical trials. Second, clinical trials likely have greater resources to encourage and actively support adherence and on-therapy retention than are available in routine clinical practice. Third, VHA has a higher proportion of HCV-infected African-Americans (the majority with HCV GT1), a population known to have lower SVR rates and Veterans with multiple co-morbidities including mental illness and substance abuse which have been shown to decrease response rates. (6.17, 6.17)

There are few published data on SVR rates for groups outside of clinical trials making it difficult to place VHA rates in the appropriate context. However, it is possible to assess regional variability across VHA by assessing rates at the VISN level. Variation in SVR rates across VISNs may offer an opportunity to identify best practices for treating various Veterans populations (e.g. those with concurrent mental illness) from sites with high SVR rates. Further studies are necessary to understand the Veteran, healthcare provider and system variables that influence clinical evaluation and treatment practices, including the offer of HCV antiviral therapy and its acceptance.

Methods

  1. HCV Confirmatory testing: Veterans with a detectable HCV viral load or a HCV genotype test with a genotype identified (e.g., genotype 1) qualifies as having completed HCV confirmatory testing.
  2. Hepatitis A (HAV) and Hepatitis B (HBV): Veterans with an outpatient visit, admission, or outpatient prescription fill in 2008 were first assessed for the receipt of testing for HAV or HBV exposure or previous vaccination (antibodies to HAV or HBV surface or core antigens) or for active hepatitis B infection (positive result for HBV viral load, e antigen, or surface antigen). Next, those with no evidence of past immunity to HAV or HBV or active HBV disease were assessed for the receipt of HAV or HBV vaccine. Inpatient and outpatient prescription records and procedure codes were reviewed for receipt of HAV or HBV vaccine or combination products during and prior to 2008.
  3. HIV: Veterans with an outpatient visit, admission, or outpatient prescription fill in 2008 were assessed for the receipt of a laboratory test for HIV during or prior to 2008.
  4. Influenza vaccination: Veterans with an outpatient visit, admission, or outpatient prescription during the 2007/ 2008 influenza vaccination campaign were assessed for the receipt of vaccination, refusal of vaccination, history of allergy to the vaccine or eggs, or documentation of vaccination outside of VHA.
  5. Tobacco cessation: Veterans with an outpatient visit, admission, or outpatient prescription fill in 2008 were assessed for a history of a tobacco use diagnosis from ICD-9 codes linked to outpatient visits or admissions. Medications for tobacco cessation included nicotine replacement therapy, bupropion (FDA-approved formulations and strengths), and varenicline,
  6. HCC screening in cirrhotics: Veterans with an outpatient visit, admission, or outpatient prescription fill in 2008 were assessed for a diagnosis of cirrhosis using ICD-9 diagnosis codes. Receipt of AFP testing or abdominal imaging was identified by a CCR record for these tests with a test date in 2008 and similarly for abdominal imaging (including ultrasound, computerized tomography, and magnetic resonance imaging).
  7. Non-selective Beta Blocker use: Veterans were considered to have received NSBB during each of the four time periods of interest if they had an outpatient, or inpatient prescription or unit dose medication record in CCR. "Upon discharge" included a fill date on the discharge date or within 7 days after discharge. "180 days after discharge" included Veterans receiving a NSBB on day 180 after discharge or a drug supply on day 180 carried over from a previous outpatient prescription. NSBBs include oral formulations of propranolol, timolol, or nadolol alone or in combination products.
  8. Sustained Virologic Response (SVR) rates: Veterans with CCR records that characterized HCV genotype who filled at least one outpatient prescription for pegylated interferon and ribavirin between Jan 1, 2000 and Dec 31, 2006 and had a calculated end of treatment and post treatment evaluation period date on or before Dec 31, 2008 were included. Veterans were identified as having a SVR if they had an undetectable HCV viral load on all HCV viral load tests after the end of HCV antiviral treatment including at least one HCV viral load result a minimum of 12 weeks after the end of their HCV treatment

References

  1. CDC. Surveillance for Acute Viral Hepatitis - United States, 2007. MMWR May 22, 2009;58 (No. SS-3). Available at http://www.cdc.gov/mmwr/PDF/ss/ss5803.pdf.
  2. Centers for Disease Control and Prevention. Hepatitis A FAQ for health Professionals. http://www.cdc.gov/hepatitis/HAV/HAVfaq.htm#vaccineLink will take you outside the VA website.. Accessed March 23, 2010
  3. Center for Disease Control and Prevention. Hepatitis B Virus FAQ. http://www.cdc.gov/hepatitis/HBV/HBVFaq.htm#treatmentLink will take you outside the VA website.. Accessed March 23, 2010
  4. Yee HS, Currie SL, Darling JM, Wright TL. Management and treatment of hepatitis C viral infection: recommendations from the Department of Veterans Affairs hepatitis C resource center program and the national hepatitis C program office. Am J Gastro 2006; 101:2360-2378.
  5. Management and Treatment of Hepatitis C Virus Infection in HIV-Infected Adults: Recommendations from the Veterans Affairs Hepatitis C Resource Center Program and National Hepatitis C Program Office. Am J Gastroenterol. 2005 Oct;100(10):2338-54.Link will take you outside the VA website.
  6. Fiore AE, Shay DK, Broder K. Prevention and control of influenza: recommendations of the advisory committee on immunization practices (ACIP), 2008. MMWR August 8, 2008; 57(RR07); 1-60.
  7. National Clinical Performance Indicator on Influenza vaccination. http://www.qualityofcare.va.gov/reports/graph.cfm?measure=13. Accessed June 1, 2010. Data on spinal cord injury provided by verbal communication.
  8. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008
  9. Hepatitis C and Hepatocellular Carcinoma. Accessed March 23, 2010
  10. Garcia-Tsao G, Lim J, et al. Management and Treatment of Patients with Cirrhosis and Portal Hypertension. Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program. Am J Gastroenterol 2009; 104:1802-1829.
  11. Manns MP, McHutchison JG, Gordon SC, et al. Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: A randomised trial. Lancet 2001;358:958-65.
  12. Fried MW, Shiffman ML, Reddy KR, et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med 2002;347:975-82.
  13. Heathcote EJ, Shiffman ML, Cooksley WG, et al. Peginterferon alfa-2a in patients with chronic hepatitis C and cirrhosis. N Engl J Med 2000;343:1673-80.
  14. Martinot- Peignoux M, Christianne S, Pierre RM, et al. Assessment of serum HCV RNA at week 12 post-treatment is as relevant as week 24 to predict SVR in patients with chronic hepatitis C treatment with pegylated interferon plus ribavirin. Hepatology. 2009;50(4):S118.
  15. Zeuzem S, Heathcote EJ, Shiffman ML, et al. Twelve weeks of follow-up is sufficient for the determination of sustained virologic response in patients treated with interferon alpha for chronic hepatitis C. J Hepatol. Jul 2003;39(1):106-111.
  16. Muir AJ, Bornstein JD, Killenberg PG. Peginterferon alfa-2b and ribavirin for the treatment of chronic hepatitis C in blacks and non-Hispanic whites. N Engl J Med 2004;350:2265-71.
  17. Backus LI, Boothroyd DB, Philips BR et al. Predictors of response of US veterans to treatment for the hepatitis C virus. Hepatology. Jul 2007;46(1):37-47.