State of Care for Veterans with Chronic Hepatitis C
Department of Veterans Affairs Veterans Health Administration Office of Public Health and Environmental Hazards Public Health Strategic Health Care Group
November 2010
Preface
The purpose of this report is to characterize the state of care of the population of Veterans with chronic hepatitis C (HCV) within the US Department of Veterans Affairs‟ (VA) Veterans Health Administration (VHA). The first step in providing responsive care is to learn about the affected population. This report describes the distribution of Veterans with chronic HCV within VHA and provides basic demographic data on this population. Additionally, the report describes pharmacologic treatment, other conditions commonly seen in Veterans with chronic HCV, and indicators of healthcare quality including screening, monitoring, and outcomes assessment. This report contains information that can be used to assess and guide interventions to improve the quality of care VHA delivers to Veterans with chronic HCV.
The report has a series of chapters, each covering a limited aspect of VHA care for Veterans with chronic HCV. Please refer to the Table of Contents for a quick reference to key sections within each chapter. The report contains summary information at the national, regional (Veterans Integrated Service Network, or VISN), and local healthcare system levels. To improve readability, large tables appear in the Appendix; smaller tables and figures appear within the text. References and general methods are described at the end of each chapter.
This is the first comprehensive summary report on Veterans with chronic HCV produced by the Public Health Strategic Healthcare Group (PHSHG). PHSHG was assigned responsibility for the National Hepatitis C Clinical Program in 2001. Since then, PHSHG has initiated numerous educational, training, and quality initiatives, the majority led by the National Hepatitis C Resource Centers, targeting various VHA providers responsible for hepatitis C care. In 2006, PHSHG, in conjunction with the Office of Information Technology, launched a new population management tool, the Clinical Case Registry (CCR), which greatly expanded access both locally and nationally to medical information for Veterans with chronic HCV. Data from the CCR serves as the foundation for this report. Where available, comparisons are made between Veterans with chronic HCV in care recently and during earlier periods.
With the goal of continual improvement in VHA care for Veterans with chronic HCV, PHSHG is committed to making these data available to front-line clinicians, VHA policy makers and researchers. This report would not be possible without the efforts of VHA staff located at VHA facilities across the county. PHSHG staff who are responsible for review of the quality of HCV care and who were instrumental in the development of this report are listed in the acknowledgements section. This report is dedicated to them and to the Veterans we serve.
Janet Durfee, RN, MSN, APRN Acting Chief Consultant Public Health Strategic Healthcare Group Office of Public Health and Environmental Hazards
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Table of Contents
Preface Executive Summary Chapter 1 - Background and Perspective
Page
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  • 1.1  Department of Veterans Affairs, Veterans Health Administration
  • 1.2  Overview of Program Office and Quality Initiatives
  • 1.3  Electronic Medical Records, the Clinical Case Registry (CCR), and CCR
Reports 4
Chapter 2 – Veterans with Chronic Hepatitis C (HCV) 6
2.1 Number in Care 6 2.2 Location of Care 7 2.3 Demographics 9 2.4 Deaths 11
Chapter 3 – Services Provided to Veterans with Chronic HCV 12 Chapter 4 – Other Diseases and Conditions 15 4.1 Other Diseases and Conditions Seen in Veterans with Chronic HCV 15 4.2 Cirrhosis and Associated Complications 17 4.3 Hepatocellular Carcinoma 20 Chapter 5 – Antiviral Therapy for Chronic HCV 22 Chapter 6 – Assessing Quality of Care in Veterans with Chronic HCV 26
  • 6.1  Confirming Chronic HCV 26
  • 6.2  Hepatitis A and Hepatitis B Infection 28
  • 6.3  HIV Testing 32
  • 6.4  Influenza Vaccination 34
  • 6.5  Tobacco Cessation 36
  • 6.6  Screening for Hepatocellular Carcinoma in Veterans with
    Chronic HCV and Cirrhosis 38
  • 6.7  Use of Nonselective Beta Blockers in Veterans Hospitalized for Esophageal Variceal Hemorrhage 40
6.8 Sustained Virologic Response after HCV Treatment 45 Chapter 7 – Chronic HCV Quality Care in VHA and the Future 50
7.1 Quality
7.2 Future Initiatives
Acknowledgements Appendix
50 51 54 56
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Executive Summary
The Department of Veterans Affairs (VA), Veterans Health Administration (VHA) is the largest single provider of hepatitis C (HCV) care in the United States. According to Clinical Case Registry data, between 2000 and 2008, 287,410 Veterans in VHA care screened positive for antibodies to HCV and 189,065 (65%) were identified with chronic HCV infection. In 2008, VHA clinicians cared for over 147,000 Veterans with chronic HCV; these Veterans were cared for in every one of VHA‟s 21 Veterans Integrated Service Networks (VISNs) and at every one of the 128 VHA local healthcare systems across the United States. Of the 5.6 million Veterans in VHA care in 2008, one of every 38 (2.6%) had a diagnosis of chronic HCV. The number of Veterans with chronic HCV in VHA care has been relatively stable over the past 5 years with approximately 8% entering VHA care and approximately 8% leaving (including deaths) VHA care each year. In 2008, caseloads of Veterans with chronic HCV ranged from 2,480 to 14,019 across VISNs and from 26 to 4,476 across local VHA healthcare systems. In 2008, the typical Veteran with chronic HCV was White (49%), 56 years old, male (97%), with a history of co- morbidities including hypertension (63%) and depression (56%). This group has a significant history of tobacco use (62%) and alcohol use (54%), complicating the management of chronic HCV. More than one in eight had a history of cirrhosis and over 900 new cases of hepatocellular carcinoma (HCC) were diagnosed in 2008. The proportion of those in care with advanced liver disease, including cirrhosis and liver cancer, has grown significantly over the past 8 years.
Nationally, Veterans with chronic HCV receive high quality care at the VHA as reflected in rates of guideline-concordant HCV-specific care, recommended prophylaxis, screening for conditions important to public health, and outcomes measures; however room for improvement exists. National VHA rates of providing guideline-recommended clinical preventive services for Veterans with chronic HCV receiving care in 2008 included: confirmation of hepatitis B immunity or vaccination 70%, confirmation of hepatitis A immunity or vaccination 65%, HIV testing 56%, influenza vaccination 46%, and screening for HCC in Veterans with chronic HCV and cirrhosis 45%. By 2008, over 31,000 had received antiviral therapy for HCV; they represent one-fifth of the Veterans with chronic HCV in VHA care in 2008. Attainment of a successful HCV antiviral treatment outcome, referred to as sustained virologic response (SVR), was lower in VHA compared to drug registry trials, as might be expected due to differences in patient population.
As the report shows, VHA has made significant improvements over the past 8 years in many areas of HCV population management including patient identification, testing, and in quality of care indicators. These improvements coincide with the establishment of a National Hepatitis Clinical Program Office and the Hepatitis C Resource Centers. Programmatic efforts
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have included the development of educational materials, development and dissemination of successful models of care, various training programs and quality improvement initiatives. This document provides a descriptive report; it is not meant to be exhaustive nor is it to provide the type of statistical analyses that allow inferences to be drawn. The PHSHG uses these data to understand HCV prevalence, burden of disease, and care outcomes regionally and locally in order to design targeted interventions and identify topics requiring additional investigation, thus assisting in improving care for our nation‟s Veterans. Geographic variability across VISNs and local healthcare systems exists on all the quality indicators covered in this report, providing an opportunity for the PHSHG, administrators, local champions, and VHA researchers to identify gaps, barriers, and best practices to improve care.
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Chapter 1 – Background and Perspective
1.1 Department of Veterans Affairs, Veterans Health Administration
The Department of Veterans Affairs (VA) Veterans Health Administration (VHA) is a federal comprehensive healthcare system serving eligible, enrolled US Veterans. Organizationally, the VHA is divided into 21 geographic regions called Veteran Integrated Service Networks or VISNs, each of which encompasses a number of local healthcare systems. These 128 local healthcare systems include over 1,100 facilities consisting of medical centers, community based outpatient clinics (CBOCs), domiciliaries, extended care facilities, hospices, and specialty centers for mental health, blind rehabilitation, spinal cord injury, polytrauma and traumatic brain injury. In federal fiscal year 2008, there were 7.8 million VHA enrollees and 5.6 million (72%) of them received care at a VHA facility. Nationwide, VHA inpatient care involved 641,000 discharges (70% of which were for acute care) totaling 4.3 million bed days of care. That year, the average daily census in nursing homes was 33,782 Veterans. Over 67 million outpatient visits were provided by the VHA in fiscal year 2008, 13.7 million of which were at CBOCs. Additional information on the general Veteran population can be found at http://www1.va.gov/vetdata/.
1.2 Overview of Program Office and Quality Initiatives
The Office of Public Health and Environmental Hazards improves Veterans' health through prevention, outreach, treatment and surveillance. It focuses on specific populations of Veterans including women Veterans, Veterans with HIV/AIDS, Veterans with hepatitis C (HCV), and Veterans exposed to hazardous materials during military service. The Office also manages VHA‟s medical response to emergencies and protects the safety and health of VHA employees. Additional information on the Office of Public Health and Environmental Hazards is available at www.publichealth.va.gov.
Public Health Strategic Health Care Group
The Public Health Strategic Health Care Group (PHSHG) is an organizational unit within the Office of Public Health and Environmental Hazards. PHSHG's mission is to improve the health of Veterans through the development of sound policies and programs related to several
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major public health concerns including: HCV infection, HIV infection, seasonal influenza, smoking and tobacco use, and emerging infections of public health significance including healthcare associated infections. PHSHG strives to promote the highest quality, comprehensive care for Veterans and to have that care recognized as the standard by which all healthcare in the United States is measured. PHSHG efforts include patient care activities, clinician education, patient education, prevention activities, policy development, and research directed at continuous improvement of medical and preventive services delivered to Veterans. Additional information on the PHSHG is available at http://www.publichealth.va.gov/about/pubhealth/index.asp.
Clinical Public Health Programs Office
The Clinical Public Health Program Office (CPHP), a component of PHSHG, oversees the VA National Hepatitis C Program. The Hepatitis C Program works to ensure that patients with or at risk for HCV receive the highest quality healthcare services. Led by PHSHG and carried out by providers at VA medical facilities across the country, the program takes a comprehensive approach to HCV that includes:
Universal screening for risk of HCV infection Effective counseling and testing for those at risk Education for patients and their families Prevention and harm reduction
Clinician training on the latest information regarding the management of HCV including antiviral therapy Promotion of excellence in clinical care Proactive research to improve clinical care
Data-based quality improvement Hepatitis C Resource Centers
The Hepatitis C Resource Center (HCRC) network is an integral part of VA's National Hepatitis C Program and is overseen by CPHP. Initially funded in 2002, the four HCRCs,
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located in Minneapolis, San Francisco, Seattle/Portland, and West Haven, work closely with CPHP and other elements of PHSHG to develop best practices in HCV prevention, clinical care, patient and provider education, and program evaluation for use within VA as well as within other medical care systems. Projects of the HCRCs include:
Improving screening and testing methods Development of patient education materials Assessing impact of co-morbidities on chronic HCV treatment decisions (e.g. mental illness, substance abuse, or concurrent HIV infection) and piloting effective models of care to address these challenges Development and dissemination of models of interdisciplinary care to optimize effective management of chronic HCV Training of VA healthcare providers on hepatitis C diagnosis and care, including reduction of risk from co-morbidities and management of complications of chronic HCV infection Surveying HCV clinicians to better understand HCV care delivery in VHA Development and dissemination of clinical standards for managing patients with all stages of HCV Development of telehealth models of care to improve access to care for Veterans with chronic HCV
Over the period covered by this report, the HCRC program was instrumental in developing treatment guidelines, educational materials for Veterans and providers, and numerous products and staff educational programs with the goal of improving the quality of care for Veterans with chronic HCV. Additional information on the HCRC program including access to guidelines and educational materials for both Veterans and clinicians can be found on the internet at http://www.hepatitis.va.gov and within VHA at http://vaww.hepatitis.va.gov .
Center for Quality Management in Public Health
The Center for Quality Management in Public Health (CQMPH), also a component of the PHSHG, is based at the VA Palo Alto Health Care System. CQMPH oversees the Clinical Case
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Registry (CCR) for HCV. CQMPH‟s mission is to catalyze continual innovation and improvement in VHA clinical care via the use of quality management techniques and the strategic use of clinical information systems. This work is possible because of the unique VHA electronic medical record (EMR). Taking advantage of clinical data from the VHA‟s EMR, CQMPH develops centralized patient registries, and enhances local registry functions to provide clinicians useful information about their populations of Veterans with HCV. CQMPH staff members provide support to VHA clinicians and administrative staff to enhance their ability to use the CCR. CQMPH also provides other electronic tools such as optional Clinical Reminders. All these efforts are designed to enhance the quality of care delivered to Veterans.
1.3 Electronic Medical Records, the Clinical Case Registry, and CCR Reports
VHA has a state of the art electronic medical record (EMR) covering all aspects of healthcare delivery and documentation. Electronic tools use healthcare data to provide clinicians with patient-centric reminders and guidance related to care delivery including safety functions such as drug-drug interaction and allergy checks, reminders to provide vaccinations, laboratory tests and screenings, and alerts regarding abnormal results or procedures. The VHA EMR also includes population management tools, such as the Clinical Case Registry (CCR). The CCR software, deployed throughout VHA, provides a registry at every VHA facility to support local care delivery and populates a national clinical database. Staff members at VHA facilities serve as local registry coordinators, reviewing the medical records of Veterans with laboratory results and/or diagnosis codes reflecting potential infection with HCV and in cases of chronic infection, confirming their addition to the local CCR. Addition of a Veteran to a local registry triggers his or her addition to the national CCR, which is created through extraction of specific clinical data from the local EMR. Data elements extracted to the national CCR include information on allergies, demographics, diagnoses, inpatient stays, laboratory tests, outpatient visits, prescriptions, procedures, and radiology.
Using data from all VHA facilities, periodic summary reports are created on the population of Veterans with chronic HCV receiving care in the VHA. These reports use the latest available data and provide information at the national, VISN, and local healthcare system levels to VHA clinicians, administrators, and researchers. Each report is based on an extract of CCR data on a specific date. In each extract, CCR historical data is updated with current data for
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Veterans already in the CCR and with historical and current data for Veterans recently added to the CCR. Because CCR data collection is dynamic, reports covering the same period using extracts created on different dates are not necessarily identical. Nonetheless, comparison of information from reports created in different periods is useful for monitoring trends. The ultimate goal of these reports is to provide information to guide clinical, quality improvement, and administrative activities directed to assuring safe, effective and efficient care for Veterans with chronic HCV.
In addition, local healthcare system staff have access to population management reporting tools in their local CCR software. While such local reports are based only on data from the local healthcare system (as opposed to the national CCR) they permit the user to examine a variety of process and outcome related questions.
Examples of valuable ways the local and national CCR supports clinical practice include: Measurement of patient volume and disease severity to inform decisions about how care is delivered, allocation of staff and other resources Assessment of adherence to national guideline recommendations or medication criteria for use
Identification of trends over time, such as screening practices, hepatocellular carcinoma (HCC) diagnosis, vaccination, or monitoring of treatment Describing patient demographic characteristics and co-morbidities to assess types of services likely to be required, such as treatment for age-related issues or chronic conditions.
Measurement of treatment outcomes and effectiveness of current practices, protocols or guidelines including production of reports from the national CCR by PHSHG Performing ongoing comparison across VISNs or healthcare systems of like size to identify variation that may indicate quality issues or opportunities for improvement
Feedback reporting is a fundamental strategy that PHSHG employs to achieve its mission to assure the highest quality, comprehensive care to Veterans. This State of Care Report joins PHSHG's efforts in clinical surveillance, patient care activities, clinician education, patient education, prevention activities, and research directed at continuous improvement of medical and preventive services delivered to Veterans with chronic HCV.
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Chapter 2 – Veterans with Chronic 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.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.
2.1 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 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.
Figure 1. Number of Veterans with Chronic HCV in VHA Care by Year
160,000 140,000 120,000 100,000
80,000 60,000 40,000 20,000
0
Number of Veterans with Chronic HCV in VHA Care by Year
2000 2001 2002
2003 2004
Year
2005 2006 2007 2008
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Number of Veterans
2.2 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.
Figure 2. VHA VISN Map
Figure 3. Number of Veterans with Chronic HCV in VHA Care in 2008 by VISN
Number of Veterans with Chronic HCV in VHA Care in 2008 by VISN
16,000 14,000 12,000 10,000
8,000 6,000 4,000 2,000
0 219231101512517189 3114 62021722816
VISN Number
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Number of Veterans
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.
Figure 4. Percent of VHA Healthcare Systems by HCV Caseload in 2008
30% 25% 20% 15% 10%
5% 0%
Percent of VHA Healthcare Systems by HCV Caseload in 2008
Less than 501
501 - 1,000
1,001 - 1,500
1,501 - 2000
2,001 and over
Number of Veterans in Care
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
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Percent of Reporting Healthcare Systems
number of Veterans with chronic HCV at each local healthcare system can be found in Appendix A.
2.3 Demographics
Sex 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
Race/Ethnicity 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.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.
Figure 5. Race/Ethnicity for Veterans with Chronic HCV in VHA Care in 2008
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Age 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.
Figure 6. Veterans with Chronic HCV in VHA Care in 2000, 2004 and 2008 - Age by Decade of Life
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 year.4 According to the CDC, peak prevalence of acute HCV infection in the general US population in 2007 occurred among persons aged 40-492. 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.
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2.4 Deaths
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.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.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.
Methods:
  • 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.
References:
  • 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
    http://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:
    http://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.
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Chapter 3 – Services Provided to Veterans with Chronic HCV
The 147,352 Veterans with chronic HCV in VHA care in 2008 generated over 60,000 inpatient stays, over 5 million outpatient visits and over 5.3 million prescription fills. Compared to data from fiscal year 2008 for the overall VHA population, Veterans with chronic HCV had higher use of some VHA services including hospitalizations and outpatient visits (Table 1).
Table 1. Healthcare Utilization for Veterans with Chronic HCV and All Veterans
















Veterans with
All Veterans in Care FY 2008

Chronic HCV CY 2008

Number of Veterans147,3525.6 million
Inpatient Discharges (#/1000 Veterans)*410115
Outpatient Visits (#/1000 Veterans)33,93211,982
Prescription Fills (#/1000 Veterans)35,96843,661
* Includes acute and non-acute discharges. Abbreviations: CY calendar year; FY, federal fiscal year
Over twenty thousand (23,762) Veterans with chronic HCV had one or more of the 60,359 inpatient discharges in 2008. Their average length of stay was 17.9 days with a median of 5 days. Mental health diagnoses were the most common primary inpatient diagnosis at 19.5% for Veterans with chronic HCV and 14% for the general VHA population (Table 2). Compared with the overall VHA population, Veterans with chronic HCV had a higher percent of discharges for diseases of the digestive system (11.9% vs. 8.4%) and substance use disorders (14% vs. 6.1%). The general VHA population had a higher percentage of hospitalizations for diseases of the circulatory system than Veterans with chronic HCV at 18.7% versus 9.7%, respectively. The percentage of discharges with a primary diagnosis of cirrhosis was 4.4% in Veterans with chronic HCV compared to 0.9% of the general population of Veterans nationwide. With one exception, there was little difference in incidence of primary discharge diagnosis between 2005 and 2008 for Veterans with chronic HCV. The exception is that substance use disorder among Veterans with chronic HCV decreased from 18% of all primary discharges in 2005 to 14% in 2008.
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Table 2. Percent of Primary Discharge Diagnosis by VHA Major Diagnostic Group





































































Veterans with Chronic HCV CY 2005*Veterans with Chronic HCV CY 2008*
All Veterans FY 2008*
Major Diagnostic Group

Mental Disorders20.8%19.5%14.1%
Substance Use and Disorders18.0%14.0%6.1%
Diseases of the Digestive System11.3%11.9%8.4%
Diseases of the Circulatory System9.2%9.7%18.7%
Signs and Symptoms**6.9%6.7%7.0%
Diseases of the Respiratory System4.9%5.6%8.4%
Health Status Factors***3.2%4.9%5.2%
Injury, Poisoning, Drug Toxicity5.2%4.9%4.9%
Neoplasms3.6%4.6%6.4%
Diseases of the Musculoskeletal System and Connective Tissue2.8%3.2%4.2%
Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders3.3%3.2%3.5%
Diseases of the Skin and Subcutaneous Tissue3.2%2.8%2.5%
Kidney and Urinary Tract2.2%2.8%4.2%
Infectious and Parasitic Diseases2.2%2.6%1.6%
Diseases of the Nervous System and Sense Organs1.3%1.7%2.4%
Diseases of the Blood and Blood-Forming Organs0.9%1.3%1.4%
* Percent of all discharges in that year. Subgroups with at least 1% in any year are presented and ranked by Veterans with chronic HCV in CY 2008 ** Includes discharges for signs and symptoms including fever, shortness of breath, fainting and other symptoms requiring evaluation and observation. *** Includes discharges related to prosthetic or orthopedic aftercare and rehabilitation. Abbreviations: CY, calendar year; FY, fiscal year
With regard to outpatient care, depending on the local healthcare system, Veterans with chronic HCV may be seen for their HCV infection in Gastrointestinal (GI), Hepatology, Primary Care, or a combination of these clinics. Veterans with chronic HCV were actively engaged in VHA care; in 2008; 52% of Veterans had between 2 and 6 visits to GI clinic, Hepatology, or Primary Care, 20% had between 7 and 12 visits, 8% had 13 visits or more, while 20% had one visit or less (Figure 7).
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Figure 7. Percent of Veterans with Chronic HCV by Number of GI, Hepatology or Primary Clinic Visits in 2008
The numbers of prescription fills for Veterans with chronic HCV were lower than those without chronic HCV. The cost of antiviral therapy and the management of associated toxicities likely results in higher overall prescription costs per Veteran with chronic HCV. This increased cost is contrasted with the potential for cost avoidance associated with prevention of progression of liver disease and early death. With new, more effective treatments for chronic HCV on the near horizon, it will be important for healthcare administrators to understand the overall cost impact of chronic HCV care over the next two decades.
Methods:
  • VHA data. The data on the entire Veteran population can be found at http://www1.va.gov/vetdata.
  • Major Diagnostic Group. The distribution of admissions by major diagnostic group was determined using the
    primary discharge code for each hospitalization categorized by the 17 groups created by the Classification of Diseases and Injuries version ICD-9-CM. Distribution of discharges for the National VA population is based on data from the VA‟s Decision Support System.
  • Outpatient Visits. Only one visit is counted for a Veteran for each clinic and date of visit even if multiple practitioners (i.e. nurse practitioner and physician) saw a given patient.
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Chapter 4 – Other Diseases and Conditions
4.1 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 Section 6.5. 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.
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Table 3. Rates of Co-morbid Conditions for Veterans with Chronic HCV in VHA Care in 2008
Co-morbid Condition Group
Cardiovascular
Co-morbid Condition
Cardiomyopathy Cerebral Vascular Conditions
Conduction Disorders / Dysrhythmias
Congestive Heart Failure Hypertension Ischemic Heart Disease Esophageal Disease Pancreatic Disease Ulcers
Anemia Cirrhosis
Decompensated Liver Disease
Colon / Rectum Hepatocellular Carcinoma Kidney / Renal Pelvis Leukemia Lung / Bronchus Lymphoma Melanoma of the Skin Oral Cavity / Pharynx Pancreatic Prostate Urinary Bladder Bipolar Disorder Depression Neuroses and Anxiety States PTSD Schizophrenia
Percent with First VHA Diagnosis of Condition in 2008
0.3% 0.4%
1.2%
0.8% 4.1% 1.2% 2.6% 0.5% 0.4% 3.0% 1.9%
1.2%
0.2% 0.6% 0.1% 0.0% 0.3% 0.1% 0.0% 0.1% 0.1% 0.0% 0.1% 0.7% 3.1% 1.7% 1.5% 0.3%
Percent with VHA Diagnosis of Condition Ever*
2.2% 2.5%
10.3%
5.1% 63.0% 15.0% 30.4% 4.4% 5.9% 20.5% 12.0%
5.3%
0.9% 1.5% 0.6% 0.3% 1.0% 0.7% 0.4% 0.8% 0.1% 1.1% 0.5% 11.7% 56.0% 33.3% 25.8% 10.1%
Gastrointestinal
Hematologic Liver Disease
Malignancy
Mental Illness
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Percent with First VHA Diagnosis of Condition in 2008Percent with VHA Diagnosis of Condition Ever*
Co-morbid Condition GroupCo-morbid Condition

MetabolicDiabetes, Type I0.1%5.2%

Diabetes Type II and Unspecified2.1%25.5%

Dyslipidemias3.3%34.3%

Male Hypogonadism0.2%1.0%
PulmonaryAsthma0.4%6.5%

COPD1.8%18.4%

Emphysema0.2%2.6%
RenalRenal Failure, Acute1.6%5.4%

Renal Failure, Chronic1.2%6.1%
Substance UseAlcohol Use2.5%54.5%

Illicit Drug Use1.7%39.3%

Other and Unspecified Drug Use1.5%31.6%

Tobacco Use4.3%61.5%
Viral DiseasesHepatitis B0.5%7.7%

HIV Infection0.1%3.8%
* Refers to the percent of those Veterans with chronic HCV in care in 2008.
4.2 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.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
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survival is significantly reduced.2,3 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 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).
Figure 8. Number and Percent of Veterans with Chronic HCV with First and Existing Diagnosis of Cirrhosis in VHA care
20,000 18,000 16,000 14,000 12,000 10,000
8,000 6,000 4,000 2,000
0 2000
14% 12% 10% 8% 6% 4% 2% 0%
Number and Percent of Veterans with Chronic HCV with First and Existing Diagnosis of Cirrhosis in VHA care
2002
2004
Year
2006
2008
# First Diagnosed in VHA % First Diagnosed in VHA
# Ever Diagnosed in VHA % Ever Diagnosed in VHA
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%.
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Percent of Veterans
Table 4. Diagnoses of Cirrhosis in Veterans with Chronic HCV in VHA Care in 2008





# in VHA Care with First Diagnosis of Cirrhosis
Number in Care
147,3523,061
Nation
VISN (number)
# in VHA Care with Diagnosis of Cirrhosis Ever
19,012










































5,126107
2,48042
6,952128
7,745177
6,28187
8,164176
9,583205
13,392304
6,933136
5,170111
7,003141
5,913108
5,384100
14,019264
6,313218
6,703153
4,04682
8,607196
8,670173
10,899240
5,126107
VA New England Healthcare System (1) 778
VA Healthcare Network Upstate New York (2) 364
VA NY/NJ Veterans Healthcare Network (3) 808 VA Healthcare (4) 1,136
VA Capitol Health Care Network (5) 539
VA Mid-Atlantic Health Care Network (6) 1,164 VA Southeast Network (7) 1,231
VA Sunshine Healthcare Network (8) 1,950 VA Mid South Healthcare Network (9) 903
VA Healthcare System of Ohio (10) 689 Veterans in Partnership (11) 812 VA Great Lakes Health Care System (12) 751
VA Heartland Network (15) 700 South Central VA Health Care Network (16) 1,565
VA Heart of Texas Health Care Network(17) 1,207 VA Southwest Health Care Network (18) 999
Rocky Mountain Network (19) 490 Northwest Network (20) 1,282
Sierra Pacific Network (21) 1,194
Desert Pacific Healthcare Network (22) 1,296 VA Midwest Health Care Network (23) 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 Section 4.3) to
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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 .
4.3 Hepatocellular Carcinoma
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.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.
Figure 9. HCC Cases in Veterans with Chronic HCV in VHA Care
6,000 5,000 4,000 3,000 2,000 1,000
HCC Cases in Veterans with Chronic HCV in VHA Care
0
2000 2001 2002 2003
2006 2007 2008 In Care Diagnosed Ever in VHA
First Diagnosed in VHA Cumulative Cases Diagnosed Ever
Year
2004 2005
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%.6 Additional information on screening for HCC can be found in Section 6.6.
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
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Number of Veterans
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.
Methods:
  • 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).
References:
  • 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]
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Chapter 5 – Antiviral Therapy for Chronic HCV
The current standard of pharmacologic treatment of chronic HCV, which received Food and Drug Administration (FDA) approval in 2001, consists of weekly subcutaneous pegylated interferon injections in combination with daily oral ribavirin. This therapy is typically completed in 24 to 48 weeks, although shorter or longer durations are sometimes indicated. The duration of therapy is determined by the HCV genotype and, increasingly, by the patient‟s virologic response during therapy. Infections due to genotype 1 HCV strains (the most common genotype among Veterans with chronic HCV in VHA care) require longer durations of therapy and are associated with lower response rates. In cases where poor adherence, lack of tolerance, or early treatment failure is detected, Veterans may not complete a full treatment course. Therapy may need to be repeated in cases of virologic failure after treatment discontinuation or in the rare occurrence of re-infection with HCV.
Historically, the FDA-approved treatment options for chronic HCV have included interferon monotherapy, interferon plus ribavirin, pegylated interferon monotherapy, consensus interferon, and the current combination of pegylated interferon plus ribavirin. All FDA-approved alfa-interferon products, including pegylated interferon products, and ribavirin have been included on the national VHA formulary and are currently available to Veterans with chronic HCV. Figure 10 shows the cumulative use of these agents between 2000 and 2008.
Figure 10. Cumulative Number of Veterans with Chronic HCV with HCV Antivirals
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Through the end of 2008, over 31,500 Veterans with chronic HCV had received at least one
course of HCV treatment at VHA, including 21% of those in VHA care in 2008 (Figure 11). The
number of those in VHA care who received their first ever HCV antiviral treatment regimen
increased 2.5-fold from 1,367 in 2000 to 3,393 in 2008. The same magnitude of increase was
seen in overall caseload on therapy, which increased from 2,402 in 2000 to 6,325 in 2008.
Figure 11. Number and Percent of Veterans with Chronic HCV in VHA Care Treated with HCV Antivirals
35,000 30,000 25,000 20,000 15,000 10,000
5,000 0
35% 30% 25% 20% 15% 10% 5% 0%
Number and Percent of Veterans with Chronic HCV in VHA Care Treated with HCV Antivirals
2000
2002
2004
Year
2006
2008
# In Care Ever Treated
% In Care Ever Treated
Across VISNs, the percentage of Veterans with chronic HCV who ever received HCV antiviral therapy ranged from 16% to 31% (Table 5). Some Veterans with chronic HCV may not be candidates for antiviral treatment. Though general guidelines exist on treatment considerations for HCV infected patients, most treatment decisions continue to be individualized.1,2 Factors which may prevent Veterans from receiving HCV antiviral therapy include low blood cell counts, advanced cirrhosis, or the presence of certain medical conditions or mental health conditions, including ongoing substance abuse. Alternatively, because response rates to the currently available treatments are less than ideal (see Section 6.8) and because the medications are poorly tolerated, clinicians and patients may postpone treatment until newer, more effective agents become available. Newer agents for the treatment of HCV that significantly increase response rates are expected to become available in 2011 and will likely be used in combination with pegylated interferon and ribavirin. PHSHG is exploring various models of care delivery in anticipation of the increased demand for newer HCV antiviral treatments.
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Number of Veterans
Percent of Veterans
Table 5. Number of Veterans with Chronic HCV in VHA care in 2008, the Number Receiving HCV Antivirals in 2008, and the Number that Ever Received HCV Antivirals from VHA by VISN





Number Receiving HCV Antivirals In 2008
Number in Care
147,3526,325
Nation VISN (number) VA New England Healthcare System (1)
VA Healthcare Network Upstate New York (2) VA NY/NJ Veterans Healthcare Network (3) VA Healthcare (4) VA Capitol Health Care Network (5)
VA Mid-Atlantic Health Care Network (6) VA Southeast Network (7) VA Sunshine Healthcare Network (8) VA Mid South Healthcare Network (9) VA Healthcare System of Ohio (10) Veterans in Partnership (11)
VA Great Lakes Health Care System (12) VA Heartland Network (15) South Central VA Health Care Network (16) VA Heart of Texas Health Care Network (17) VA Southwest Health Care Network (18) Rocky Mountain Network (19)
Northwest Network (20) Sierra Pacific Network (21) Desert Pacific Healthcare Network (22) VA Midwest Health Care Network (23)
Number Ever Receiving HCV Antivirals from VHA
31,541
1,589 556 1,228 1,762 1,160 1,839 1,634 3,289 1,584 1,105 1,358 1,326 1,397 2,977 1,304 1,657 773 1,508 1,963 1,690 1,200










































5,126315
2,480115
6,952224
7,745404
6,281269
8,164422
9,583344
13,392517
6,933287
5,170223
7,003261
5,913190
5,384225
14,019596
6,313278
6,703317
4,046131
8,607353
8,670486
10,899472
4,235183
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Table 5 also shows the number and percent of Veterans with chronic HCV in VHA care by VISN who received antiviral therapy in 2008. Regardless of HCV caseload, in each VISN close to 4% of Veterans with chronic HCV were on antiviral therapy that year. In 2007, PHSHG led a survey of local healthcare system HCV providers that included questions to assess local antiviral treatment management. Findings from this VA-wide survey of HCV clinicians indicate that multiple issues related to patient characteristics (e.g., ongoing substance abuse), clinician and facility factors (e.g., staff turnover) may influence the numbers of patients on antiviral therapy. Information learned from this survey has and will be incorporated into educational and training initiatives that include expanding antiviral therapy where indicated and appropriate. Engaging and maintaining Veterans in HCV care and discussing available treatment options, including risks versus benefits, remain important objectives within VHA.
Methods:
1. HCV antiviral therapy – All FDA approved medications are included in this report. Medication use is reported from the VHA outpatient prescription files.
References:
  • 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.
  • Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, management, and treatment of hepatitis C:
    an update. Hepatology 2009. 49: 1335-1374.
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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.
6.1 Confirming Chronic HCV Infection.
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).
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Figure 12. Cumulative Number of Veterans in the CCR Tested for HCV Antibodies and Viral Load.
400,000 350,000 300,000 250,000 200,000 150,000 100,000
50,000 0
Cumulative Number of Veterans in the CCR Tested for HCV Antibodies and Viral Load
HCV antibody
HCV 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.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 Testing
100% 80% 60% 40% 20% 0%
Percent of Veterans in the CCR with a Positive HCV Antibody Test who had HCV Viral Load Testing
2000 2002
2004 2006 2008
Year
% with HCV Viral Load Testing
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Percent of Veterans
Number of Veterans
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
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.gov.
6.2 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).2,3 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.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).
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Figure 14. Rates of Hepatitis A Antibody Testing and Vaccination in Veterans with Chronic HCV
100% 80% 60% 40% 20% 0%
Rates of Hepatitis A Antibody Testing and Vaccination in Veterans with Chronic HCV
2000
2002
2004 2006 2008
Year
% Vaccinated with Antibody Testing % Immune or Vaccinated
% Tested for Antibodies % Vaccinated without Antibody Testing
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).
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Percent of Veterans
Figure 15. Rates of Hepatitis B Antibody Testing and Vaccination in Veterans with Chronic HCV
100% 80% 60% 40% 20% 0%
Rates of Hepatitis B Antibody Testing and Vaccination in Veterans with Chronic HCV
2000
2002
2004 2006 2008
% Tested for Antibodies % Vaccinated without Antibody Testing
% Vaccinated with Antibody Testing % Immune or Vaccinated
Year
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





































Percent with VHA HAV Immunity or VaccinePercent with VHA HBV Immunity or Vaccine*
Number in Care



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%
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Percent of Veterans

































































Percent with VHA HAV Immunity or VaccinePercent with VHA HBV Immunity or Vaccine*
Number in Care



Nation147,35265%70%
VISN (number)
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%
* 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
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
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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.
6.3 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.4,5 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 VISN
Maximum and Minimum HIV Testing Rates in Veterans with Chronic HCV
100% 80% 60% 40% 20% 0%
over Time by VISN
2003 2004 National Average
2001 2002 VISN Maximum
2005
2006 2007 2008 VISN Minimum
Year
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Percent of Veterans
Table 7. HIV Testing Rates in Veterans with Chronic HCV in VHA Care in 2008



Number in Care

147,352
Nation VISN (number)
Percent with VHA HIV Test Ever
56%
53% 56% 65% 53%





















5,126
2,480
6,952
7,745
6,281
8,164
9,583
13,392
6,933
5,170
7,003
5,913
5,384
14,019
6,313
6,703
4,046
8,607
8,670
10,899
4,235
VA New England Healthcare System (1) VA Healthcare Network Upstate New York (2) VA NY/NJ Veterans Healthcare Network (3) VA Healthcare (4) VA Capitol Health Care Network (5) 68% VA Mid-Atlantic Health Care Network (6) 71% VA Southeast Network (7) 53% VA Sunshine Healthcare Network (8) 60% VA Mid South Healthcare Network (9) 53% VA Healthcare System of Ohio (10) 53% Veterans in Partnership (11) 49% VA Great Lakes Health Care System (12) 52% VA Heartland Network (15) 46% South Central VA Health Care Network (16) 57% VA Heart of Texas Health Care Network (17) 66% VA Southwest Health Care Network (18) 47% Rocky Mountain Network (19) 45% Northwest Network (20) 46% Sierra Pacific Network (21) 58% Desert Pacific Healthcare Network (22) 64% VA Midwest Health Care Network (23) 48%
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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.
6.4 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 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



















Percent with VHA Influenza Vaccine during 2007/2008 Influenza Season
Number Eligible for Influenza Vaccination



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%
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Percent with VHA Influenza Vaccine during 2007/2008 Influenza Season
Number Eligible for Influenza Vaccination



Nation138,14646%
VISN (number)
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
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automated and manual electronic medical record audit performed at each local healthcare system and reports on Veterans in these groups.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.
6.5 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.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























Percent with VHA DiagnosisPercent with VHA Diagnosis ofPercent with VHA Pharmaco-Percent with VHA Pharmaco-
Number in Care


of Tobacco Use EverTobacco Use in 2008therapy Evertherapy in 2008

Nation147,35262%37%46%20%
VISN (number)
VA New England Healthcare System (1)5,12664%41%54%26%
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Percent with VHA Diagnosis of Tobacco Use EverPercent with VHA Diagnosis of Tobacco Use in 2008Percent with VHA Pharmaco- therapy Ever
Number in Care



Nation147,35262%37%46%
VISN (number)
Percent with VHA Pharmaco- therapy in 2008
20%
22% 19%
19% 22% 21%
22% 18%
20%
23% 20% 23%
22% 20%
18% 16%
23% 21% 18% 13%































































































VA Healthcare Network Upstate New York (2)2,48068%42%50%
VA NY/NJ Veterans Healthcare Network (3)6,95252%30%42%
VA Healthcare (4)7,74561%38%52%
VA Capitol Health Care Network (5)6,28156%32%51%
VA Mid-Atlantic Health Care Network (6)8,16461%38%46%
VA Southeast Network (7)9,58361%35%48%
VA Sunshine Healthcare Network (8)13,39259%36%41%
VA Mid South Healthcare Network (9)6,93363%38%45%
VA Healthcare System of Ohio (10)5,17076%50%53%
Veterans in Partnership (11)7,00365%41%48%
VA Great Lakes Health Care System (12)5,91366%42%50%
VA Heartland Network (15)5,38466%41%50%
South Central VA Health Care Network (16)14,01964%36%49%
VA Heart of Texas Health Care Network(17)6,31356%31%45%
VA Southwest Health Care Network (18)6,70365%38%41%
Rocky Mountain Network (19)4,04663%40%50%
Northwest Network (20)8,60766%41%52%
Sierra Pacific Network (21)8,67062%39%44%
Desert Pacific Healthcare Network (22)10,89955%31%35%
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Percent 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
Number in Care



Nation147,35262%37%46%20%
VISN (number)
VA Midwest Health Care Network (23)4,23568%44%60%29%
6.6 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.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
100% 80% 60% 40% 20% 0%
2000 2002 2004
Percent with AFP Only
2007 2008 Percent with Both
2005 2006
Year
Percent with Imaging Only
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Percent of Veterans
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 Care
Percent with Imaging Only
Percent with Either
Percent with AFP OnlyPercent with Both


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%
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Number with Cirrhosis in Care
Percent with Imaging Only
Percent with Either
Percent with AFP OnlyPercent with Both


Nation16,01411%12%45%67%
VISN (number)
Rocky Mountain Network (19)4137%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.
6.7 Use of Non-Selective Beta Blockers in Veterans with Chronic HCV Admitted with 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.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%.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
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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.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 EVH
100% 80% 60% 40% 20% 0%
Percent of Veterans with Chronic HCV Alive Following First Admission for EVH
% Alive at Discharge 2000 2002
% Alive at 180 Days Post Discharge 2004 2006
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Percent of Veterans
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 HCV
Rates of NSBB Use Prior to Admission, During Hospitalization, and Following a First Admission for EVH in Veterans with Chronic HCV
100% 80% 60% 40% 20% 0%
% on prior to Admission
% on during Admission
2000 2002 2004 2006
% on at Discharge
Year
% on 180 after Discharge
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).
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Percent of Veterans
Figure 20. Maximum and Minimum VISN Rates for NSBB Use by VISN in Veterans with Chronic HCV and First Admission for EVH in 2006
Maximum and Minimum VISN Rates for NSBB Use in Veterans with Chronic HCV and First Admission for EVH in 2006
100% 80% 60% 40% 20% 0%
Prior to Admission VISN Maximum National Average VISN Minimum
During Admission
At Discharge
180 Days After Discharge
Table 11. Use of Non-Selective Beta Blockers (NSBB) in Veterans with Chronic HCV Hospitalized with First Esophageal Variceal Hemorrhage (EVH) in 2006






























































Percent on NSBB on 180 Days after Discharge
Percent on NSBB During Admission
Number Alive 180 Days after Discharge
Number with EVH Admission
Percent on NSBB prior to Admission
Number Alive at Discharge
Percent on NSBB at Discharge
VISN Number







National
69029%55%62937%49246%
VISN Number*


Percent Receiving NSBB During 120 Days Before Admission
Percent Receiving NSBB During Inpatient Stay



Percent Receiving NSBB on Day 180 After Discharge
Percent Receiving NSBB Upon Discharge
Number Alive at Day 180 After Discharge
Number with EVH Admission
Number Alive at Discharge
VISN Number





12040%50%1937%1765%
27NRNRNRNRNRNR
32825%54%2631%1942%
43531%63%3339%3033%
51638%75%1540%1070%
62520%56%2344%1947%
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Percent of Veterans






































































































































Percent on NSBB on 180 Days after Discharge
Percent on NSBB During Admission
Number Alive 180 Days after Discharge
Number with EVH Admission
Percent on NSBB prior to Admission
Number Alive at Discharge
Percent on NSBB at Discharge
VISN Number







National
69029%55%62937%49246%
VISN Number*


Percent Receiving NSBB During
Percent Receiving NSBB



Percent Receiving NSBB on
Percent Receiving
Number Alive at Day
Number with EVH
Number Alive at
VISN
Number
120 Days Before Admission
During Inpatient Stay
NSBB Upon Discharge
180 After Discharge
Day 180 After Discharge
Admission
Discharge





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%
*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.
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-
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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.
6.8 Sustained Virologic Response after HCV Antiviral 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 3.11-13 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 treatment14,15 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.
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Figure 21. SVR Rates in Veterans with Chronic HCV after First VHA Course of Pegylated Interferon and Ribavirin Treatment Initiated between 2002 and 2006
100% 80% 60% 40% 20% 0%
SVR Rates in Veterans with Chronic HCV after First VHA Course of Pegylated Interferon and Ribavirin Treatment Initiated between 2002 and 2006
2002
HCVGT 1
2003
2004
Year of First Treatment
2005 2006
Combined
HCVGT 2 HCVGT 3
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 Healthcare1,64325%30659%19144%
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Percent of Veterans with SVR










































































































GT1 Number TreatedGT1 Percent with SVRGT2 Number TreatedGT2 Percent with SVRGT3 Number TreatedGT3 Percent with SVR


Nation15,42426%3,06262%1,96152%
VISN (Number)
Network (8)





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
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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.16,17
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:
  • 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.
  • 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.
  • 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.
  • 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.
  • 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,
  • 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).
  • 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.
  • 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.
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  • Centers for Disease Control and Prevention. Hepatitis A FAQ for health Professionals. http://www.cdc.gov/hepatitis/HAV/HAVfaq.htm#vaccine. Accessed March 23, 2010
  • Center for Disease Control and Prevention. Hepatitis B Virus FAQ. Http://www.cdc.gov/hepatitis/HBV/HBVFaq.htm#treatment. Accessed March 23, 2010
  • 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.
  • 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.
  • 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.
  • 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.
  • 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
  • Hepatitis C and Hepatocellular Carcinoma. http://hepatitis.va.gov/vahep?page=prtop08-02-kb-01 Accessed march 23, 2010
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
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Chapter 7 – Chronic HCV Quality Care in VHA and the Future
7.1 Quality
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
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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.
7.2 Future Initiatives
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 model1,2, while early detection of HCC can allow liver transplantation or other curative therapies.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
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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
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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.
References:
  • 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.
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Acknowledgements
This report would not have been possible without the dedicated network of local HCV Clinical Case Registry (CCR) coordinators. These VHA staff have the responsibility for reviewing potential cases of chronic HCV, confirming (or rejecting) the diagnosis and, if confirmed, entering the Veteran into the CCR. The entire staff at the VHA‟s Center for Quality Management in Public Health (CQMPH) is responsible for CCR training, local and national software development, testing, and validation, the design and completion of the data analyses, and the production of this report. The CQMPH staff involved with this work included:
Larry Mole, PharmD Director, CQMPH
Lisa Backus, MD PhD CCR Clinical Manager
James Halloran, MSN, RN, CNS National Quality Manager
Pam Belperio, PharmD National Public Health Clinical Pharmacist
Gale Yip, BA Health Scientist
Tim Loomis, PhD Project Manager, CCR
I-Chun Thomas, MS Statistician
Derek Boothroyd, PhD Statistician
Joanne McDay Administrative Officer
Vera Katseva, MS Data Manager/Statistician
Paula Edwards Program Assistant
Barbara Phillips, PhD Senior Health Science Specialist
The Hepatitis C Resource Centers (HCRC) have conducted a number of education and training initiatives covering HCV over the past 8 years including the publication of treatment recommendations and guidelines. The impact of their work is likely shown in the improvements in the quality of care indicators over the past 8 years. HCRC leadership was involved in the initial formulation of indicators for quality care contained in this report and provided review of this document:
Eric Dieperink, MD Co-Director, Minneapolis HCRC
Guadalupe Garcia-Tsao, MD Director, VA Connecticut HCRC
Christine Pocha, MD Co-Director, Minneapolis HCRC
Alexander Monto, MD Director, San Francisco HCRC
Jason A. Dominitz, MD, MHS Director, Pacific Northwest HCRC
We would like to thank Dr. Ronald Valdiserri for his comprehensive review and contributions to this work. PHSHG staff contributing extensively to this report including guidance on future directions of hepatitis C care included;
Janet Durfee, RN, MSN, APRN Acting Chief Consultant, PHSHG
David Ross, MD, PhD Director, Clinical Public Health Programs
Maggie Czarnogorski, MD Deputy Director, Clinical Public Health
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For additional copies of this report, please contact the Public Health Strategic Healthcare Group Center for Quality Management in Public Health at (650) 849-0365
Suggested citation for this Report:
Center for Quality Management in Public Health. The State of Care for Veterans with Chronic Hepatitis C. Palo Alto, California: U.S. Department of Veteran Affairs, Public Health Strategic Health Care Group, Center for Quality Management in Public Health, 2010.
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Appendix
Table A.1 and A.2 show the number of Veterans with chronic HCV in VHA care by VISN and local healthcare system, respectively, in three recent years. To be counted in a given year, a Veteran must:
Exist in the Clinical Case Registry for HCV and Have a history of measurable HCV viral load and Have a hospitalization, outpatient visit, or prescription filled in the VISN ( healthcare system) during the calendar year of interest. A Veteran was counted in each VISN (healthcare system) providing him or her care during the year.
Table A.1. Chronic HCV Caseload by VISN for 2000, 2004 and 2008
























































































200020042008
National111,521145,261147,352
VA New England Healthcare System (1)4,4885,2955,126
VA Healthcare Network Upstate New York (2)2,0902,6742,480
VA NY/NJ Veterans Healthcare Network (3)7,0767,6586,952
VA Healthcare (4)5,9717,5967,745
VA Capitol Health Care Network (5)5,3476,5486,281
VA Mid-Atlantic Health Care Network (6)5,1997,4478,164
VA Southeast Network (7)6,4708,8889,583
VA Sunshine Healthcare Network (8)9,37012,80813,392
VA Mid South Healthcare Network (9)4,8506,4926,933
VA Healthcare System of Ohio (10)3,8294,9565,170
Veterans in Partnership (11)5,2407,1687,003
VA Great Lakes Health Care System (12)5,0966,0345,913
VA Heartland Network (15)3,0735,2475,384
South Central VA Health Care Network (16)10,24314,30414,019
VA Heart of Texas Health Care Network(17)4,3636,2466,313
VA Southwest Health Care Network (18)5,0066,7156,703
Rocky Mountain Network (19)2,6903,8054,046
Northwest Network (20)6,2778,5118,607
Sierra Pacific Network (21)6,5638,5318,670
Desert Pacific Healthcare Network (22)9,34611,54010,899
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200020042008
National111,521145,261147,352
VA Midwest Health Care Network (23)3,1854,2844,235
Table A.2. Chronic HCV Caseload by Main Healthcare System City and State, 2000, 2004 and 2008
State Main Healthcare System City 2000 National 111,521
2004 2008
145,261 147,352
AL Birmingham
AL Montgomery
AL Tuscaloosa
AK Anchorage
AZ Phoenix
AZ Prescott
AZ Tucson
AR Fayetteville
AR Little Rock
CA Fresno
CA Loma Linda
CA Long Beach
CA Los Angeles
CA Martinez
CA Palo Alto
CA San Diego
CA San Francisco
CO Denver
CO Grand Junction
CT West Haven
DE Wilmington
DC District of Columbia
FL Bay Pines
1,350 770 248 473 1,676 418 818 603 1,390 580 1,207 1,490 4,335 2,219 1,617 1,524 1,636 1,260 135 1,153 639 1,930 1,498
1,616 1,117 327 546 2,218 646 1,055 1,033 1,731 758 1,742 1,861 4,947 2,955 2,146 1,948 2,007 1,794 190 1,354 836 2,498 2,117
1,701 1,116 244 552 2,110 644 1,100 1,114 1,603 798 1,733 1,800 4,319 3,008 2,222 1,890 1,967 1,861 235 1,319 835 2,392 2,170
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State Main Healthcare System City 2000 2004 2008 National 111,521 145,261 147,352 FL Gainesville 1,474 2,440 2,969 FL Miami 1,832 2,190 2,038 FL Tampa 2,954 4,263 4,476 FL West Palm Beach 762 1,049 1,050 GA Atlanta 1,701 2,442 2,663 GA Augusta 642 968 1,039 GA Dublin 393 582 670 HI Honolulu 329 465 478 ID Boise 372 502 580 IL Chicago 2,164 2,296 2,161 IL Danville 370 579 590 IL Hines 1,122 1,375 1,313 IL Marion 456 720 726 IL North Chicago 635 663 552 IN Indianapolis 1,455 1,907 1,793 KY Lexington 507 674 768 KY Louisville 824 951 1,006 LA Alexandria 475 737 698 LA New Orleans 1,251 1,659 1,278 LA Shreveport 826 1,160 1,230 ME Togus 328 491 526 MD Baltimore 2,842 3,357 3,105 MA Bedford 494 559 474 MA Boston 1,588 1,710 1,572 MA Northampton 351 443 478 MI Ann Arbor 733 1,080 978 MI Battle Creek 777 1,053 1,053 MI Detroit 1,633 2,169 1,963 MI Iron Mountain 152 188 185
MI Saginaw 364
539 576
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State Main Healthcare System City 2000 2004 2008 National 111,521 145,261 147,352 MN Minneapolis 1,087 1,510 1,506 MN St. Cloud 418 483 482 MS Jackson 552 777 814 MS Biloxi 1,302 1,922 1,696 MO Kansas City 1,768 3,096 3,071 MO St. Louis 1,313 2,178 2,347 MT Fort Harrison 364 588 605 NE Omaha 1,342 1,844 1,738 NV Las Vegas 1,184 1,595 1,552 NV Reno 684 828 784 NH Manchester 261 353 307 NJ East Orange 1,670 1,918 1,805 NM Albuquerque 1,197 1,503 1,405 NY Buffalo 2,090 2,674 2,480 NY Bronx 1,508 1,574 1,400 NY Montrose 746 819 781 NY Northport 634 711 654 NY New York City (Manhattan, Brooklyn) 3,047 3,215 2,891 NC Asheville 515 723 864 NC Durham 999 1,395 1,463 NC Fayetteville 718 1,103 1,184
  • NC  Salisbury 704 1,209 1,445
  • ND  Fargo 170 251 275
OH Columbus 416 589 645 OH Chillicothe 406 555 523 OH Cincinnati 910 1,167 1,173 OH Dayton 637 812 825 OH Cleveland 1,689 2,183 2,259 OK Muskogee 595 919 925 OK Oklahoma City 1,188 1,613 1,611
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State Main Healthcare System City 2000 National 111,521 OR Portland 1,528 OR Roseburg 542 OR White City 552 PA Altoona 161 PA Butler 142 PA Coatesville 898 PA Erie 134 PA Lebanon 668 PA Philadelphia 2,417 PA Pittsburgh 1,011 PA Wilkes-Barre 502 PI Manila 7 PR San Juan 1,190 RI Providence 593 SC Charleston 792
  • SC  Columbia 1,023
  • SD  Fort Meade 249
SD Sioux Falls 193 TN Memphis 1,063 TN Mountain Home 686 TN Nashville 1,408 TX Amarillo 565 TX Big Spring 340 TX Dallas 1,097 TX El Paso 323 TX Houston 2,496 TX San Antonio 1,798 TX Temple 1,657 UT Salt Lake City 689 VT White River Junction 289
2004 2008
145,261 147,352 2,401 2,600 786 779 878 887 257 279 235 259 1,166 909 167 203 838 883 2,819 2,639 1,505 1,614 689 732 18 26 1,271 1,213 708 716 1,088 1,192 1,537 1,643 364 317 244 264 1,399 1,365 954 1,323 2,088 2,132 768 771 497 529 1,548 1,475 480 488 3,456 3,585 2,551 2,672 2,421 2,356 936 964 362 345
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StateMain Healthcare System City200020042008
National
111,521145,261147,352
VAHampton9951,3621,387
VARichmond1,0381,4611,556
VASalem487687666
WASeattle2,4142,9032,754
WASpokane564776744
WAWalla Walla304424417
WVBeckley173210207
WVClarksburg208288331
WVHuntington477603586
WVMartinsburg8721,1111,111
WIMadison420629656
WIMilwaukee9571,2551,261
WITomah229326313
WYCheyenne168218229
WYSheridan169272324
Please note that the geographic coverage of a given VISN or main healthcare system can cross state lines and that a Veteran can be seen in multiple VISNs and/or healthcare systems.
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HCV State of Care Report IB 10-381 P96452 November 2010
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