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State of Care for Veterans with Chronic
Chapter 7 - Chronic HCV Quality Care in VHA
and the Future
For the past two years, PHSHG has used CCR data to assess and report internally on a number of quality indicators based on accepted guidelines or treatment recommendations. On a routine basis, reports on patient volume, demographics, rates of common conditions, and selected indicators of quality are disseminated to all VHA HCV providers and posted internally for access by the broad VHA audience. This State of Care Report builds on that foundation and presents an overall view of care for Veterans with chronic HCV. Information reported here supports the mission of PHSHG to improve the health of Veterans. This information, along with assessment of trends over time, has been useful within VHA in planning staffing, projecting cost, and understanding where improvements in VHA care can be made.
The VA is able to provide a real world perspective on the care and treatment of the largest population of individuals with chronic HCV in the US. While there are several aspects of the VHA that make it a unique healthcare system, sharing the VHA HCV experience with the general community is particularly important given the increased prevalence of HCV in our Veteran population. The overall older age of this population can provide insights that may help non-VHA providers understand what to expect as their patients with HCV age in the decades ahead.
Indicators of quality care have been developed and implemented by the PHSHG as part of a national strategy to assess and improve chronic HCV care. The National Quality Forum (NQF), a private, not-for-profit, public benefit corporation established to develop and implement a national strategy for health care quality measurement and reporting has recently endorsed performance measures for chronic HCV care. Many of the endorsed measures are comparable to the current list of quality indicators for chronic HCV care developed by PHSHG. As is done in the case of HIV care, PHSHG will incorporate NQF measures into future quality assessment and improvement efforts.
Data in this State of Care report will help to identify areas for possible improvement, including assessment of national performance rates and examination of variation in performance across geographic regions. Further, this data helps identify and focus the detailed review of care delivery processes needed to identify barriers to achieving higher quality care. Removing barriers can require legislative changes (e.g., consent for HIV testing), VHA policy changes (e.g., the requirement for reflexive confirmatory HCV testing), development or refinement of practice guidelines (e.g., Management and Treatment of Hepatitis C Viral Infection from the VHA HCRC Program), and development of tools for monitoring population health (e.g., CCR software) along with ongoing interventions to assure providers have access to the latest evidence based information on HCV. The PHSHG will continue to assess and address quality of care issues, monitoring for emerging issues and ways to improve quality.
One of the most important trends in the data in this report is the increasing prevalence of advanced liver disease among Veterans with chronic HCV in VHA care. Since the majority of Veterans with chronic HCV in VHA care were exposed during the Vietnam War era, their increasing age translates into a longer duration of chronic hepatitis C and increasing risk of cirrhosis, HCC, and end-stage liver disease. Not surprisingly, the data in Chapter 5 shows increasing caseloads for all of these complications, particularly HCC.
Improving clinical outcomes in patients with chronic HCV - especially those at highest risk for complications - depends on early identification of HCV patient, efficient linkage to care, evidence-based interventions to reduce modifiable risks for disease progression, and use of effective treatments for HCV and its complications. This paradigm is based on emerging data that the risk of advanced liver disease in HCV-infected Veterans can be significantly lowered by addressing co-morbidities and successful antiviral treatment in an interdisciplinary care model (7.1, 7.2) , while early detection of HCC can allow liver transplantation or other curative therapies. (7.3)
Clearly, this chain of actions can only be applied to patients who are diagnosed with chronic HCV. Thus, an important goal of the PHSHG is to support and encourage screening for HCV and the initiation of HCV-specific care as soon as a diagnosis of chronic HCV is made. Fundamental to this goal is the confirmation of chronic HCV infection. Timely detection of HCV infection allows the implementation of interventions to reduce further transmission, provide care and treatment to reduce disease progression, provide ongoing monitoring and management of clinical status and potentially, the delivery of pharmacologic therapy. Recent change in VHA regulation requiring reflex confirmatory testing for all Veterans who are HCV antibody positive is expected to significantly decrease unconfirmed cases in the future.
It is important to know more about the stage at which Veterans are first identified with HCV infection and at what stage they seek VA HCV care. Ideally, Veterans with chronic HCV should not have that diagnosis made at the time they present with advanced liver disease or liver cancer. Education, targeting healthcare system staff that work in areas of high HCV prevalence (primary care, mental health, substance abuse and homeless outreach programs) about the natural history of chronic HCV including the need for screening and testing is key to early identification, prompt referral and linkage to appropriate HCV care. The Clinical Public Health Programs Office (CPHP) has been actively engaged in addressing this fundamental component of a comprehensive HCV disease management program.
By the same token, effectively addressing HCC and other complications of chronic HCV infection requires early recognition and referral for therapy as soon as possible. Again, education of providers, particularly in primary care, about these issues is a central part of improving clinical outcomes for patients with more advanced liver disease, along with use of decision support tools such as clinical reminders. CPHP is overseeing projects by the Hepatitis C Resource Centers to improve clinical surveillance rates and timely diagnostic work-ups for patients with suspected HCC. The CCR reports on cirrhosis, HCC caseloads, and mortality will be extremely helpful in gauging the effects of such interventions.
Given the size, age, and racial diversity of VHA's HCV population, VHA can provide information on this population that will be of value both within VA and to the HCV treating community in general. As the Veteran HCV population with cirrhosis and its associated complications continues to grow, it will be important to identify and address specific challenges to ensure the best care possible. Issues related to the availability of new HCV treatments and adherence to them, the management of multiple co-morbidities, and the consequences of advanced liver disease will add to the complexity of caring for HCV. Activities such as the development of quality indicators specific to HCV care helps capitalize on the knowledge and insight of HCV providers with years of experience and is a source of guidance for future providers. Recent changes in VHA regulations requiring reflex confirmatory testing for all Veterans who are HCV antibody positive is expected to significantly decrease the number of unconfirmed cases in the future. PHSHG will continue efforts to support and educate primary care providers to co-manage the aging population of Veterans with chronic HCV and to adapt their practices as newer therapies become available.
The increase in chronic liver disease underscores the need to ensure that each new generation of Veterans has the knowledge and skills to prevent HCV infection and recognizes , the importance of being tested for HCV for those at risk. There is a continuing need for efforts to promote HCV testing and for Veteran targeted programs that increase awareness of HCV prevention, testing and management.
Future work to improve the quality of HCV care will be based in part on understanding of the variation in VHA care between VISNs and healthcare systems. The information presented in this State of Care Report on antiviral therapy and on quality of care measures indicates that the potential exists to learn more about which approaches are successful and which are not from those facilities with high and low performance rates. To better understand local models of care, PHSHG recently completed a survey of clinicians providing HCV care. Linking survey information to various measures of treatment and quality presented in this report will begin the process of identifying characteristics associated with better outcomes. Additional work will be required by the PHSHG to more clearly understand care delivery at the local VHA healthcare system level. Then, PHSHG team will develop and assist VHA in the effective dissemination and implementation of products and models of care designed to address specific quality issues. Such products will support VHA providers as they develop solutions to local issues in the provision of HCV care. Such solutions may be exportable to other disease states or to other VHA facilities.
- Knott A, Dieperink E, Willenbring ML, Heit S, Durfee JM, Wingert M, Johnson JR, Thuras P, Ho SB. Integrated psychiatric/medical care in a chronic hepatitis C clinic: effect on antiviral treatment evaluation and outcomes. Am J Gastroenterol. 2006 Oct;101(10):2254-62.
- Anand BS, Currie S, Dieperink E, Bini EJ, Shen H, Ho SB, Wright T; VA-HCV-001 Study Group. Alcohol use and treatment of hepatitis C virus: results of a national multicenter study. Gastroenterology. 2006 May;130(6):1607-16.
- Forner A, Reig ME, de Lope CR, Bruix J. Current strategy for staging and treatment: the BCLC update and future prospects. Semin Liver Dis. 2010 Feb;30(1):61-74.