FROM ANNALS OF INTERNAL MEDICINE
The U.S. Department of Veterans Affairs (VA) cares for more patients with hepatitis C virus than any other care provider in the country, and has achieved a rapid and sharp reduction in hepatitis C virus (HCV) infection among veterans over the past 3 years.
The VA has treated more than 92,000 HCV-infected individuals since the advent of oral direct-acting antiviral (DAA) therapy in 2014. The number of veterans with HCV who were eligible for treatment was 168,000 in 2014 and 51,000 in July 2017, according to an article in Annals of Internal Medicine (2017 Sep 26. doi: 10.7326/M17-1073 ).
Given that success in HCV treatment, with a cure rate that exceeds 90% for those prescribed DAAs, the VA is well positioned to share best practices with other organizations, according to Pamela S. Belperio, PharmD, and her coauthors. The best practices harmonize with the recently outlined national strategy to eliminate hepatitis B and C from the National Academies of Sciences, Engineering, and Medicine.
The VA’s strategy begins with population health management practices that enable it to identify and track veterans with HCV, monitor their care, and use population-level data to inform practice. The VA’s National Hepatitis C Clinical Case Registry is a database that aggregates patient-level data about patients and their disease characteristics; the registry also tracks where patients are receiving care, what treatment they are receiving, and treatment outcomes. That registry is coupled with a data warehouse that contains real-time electronic medical record data.
“The leveraging of health systems data transforms numbers into knowledge” that is used both by individual providers and the VA as a whole, wrote Dr. Belperio , national public health pharmacist in the VA’s public health division, and her coauthors.
Identifying veterans who were infected with HCV is simplified by means of electronic point-of-care reminders that prompt providers to conduct HCV risk assessment and testing. Veterans eligible for testing also receive automated letters that serve as a laboratory order form for HCV testing at a VA laboratory.
Adding HCV birth cohort screening as a performance measure and recommending reflex confirmatory HCV RNA testing for positive antibody tests were additional initiatives that contributed to the 3%-4% annual increase in veterans receiving HCV testing, “substantially higher than in other health care systems,” wrote Dr. Belperio and her colleagues.
To respect regional variations in practice within the VA system, multidisciplinary innovation teams meet in each region to identify opportunities for improving and streamlining HCV testing and treatment, using lean process improvement techniques. Regions also share innovations with each other.
The VA used a multipronged approach to raise awareness about HCV testing and treatment among VA health care providers and veterans. Provider reach has been expanded by extensive use of telemedicine, including real-time video calls between providers and patients or other providers at remote locations. Those telemedicine initiatives allow pharmacists and mental health providers to lend their expertise to physicians and other providers, who are themselves directly caring for HCV-infected individuals.
Patients at more than half of VA facilities receive care from physician assistants, nurse practitioners, and clinical pharmacy specialists, “who have been recognized as delivering the same quality of care and providing more timely access to HCV treatment,” wrote Dr. Belperio and her collaborators. Expanding the use of advanced practice providers allows more targeted use of specialists, and “is an important practice that can be adapted into other health care systems,” they noted.
Non–evidence-based criteria for HCV treatment eligibility remain a major barrier for HCV-infected individuals nationwide, despite VA studies showing “cure rates among veterans with alcohol, substance use, and mental health disorders that are similar to cure rates in those without these conditions,” said Dr. Belperio and her colleagues.
Within the VA, involving alcohol and substance use specialists, mental health providers, case managers, and social workers in the patient’s care team is an approach that can increase adherence and up the chance for a cure among the most vulnerable veterans.
The VA has been able to negotiate reduced pricing for the expensive DAAs, and has continued to receive additional appropriations to fund DAAs and other HCV-related resources. “Financing for HCV treatment and infrastructure resources, coupled with reduced drug prices, has been paramount to the VA’s success in curing HCV infection,” said Dr. Belperio and her colleagues.
However, they added, individual private insurers may not reap the benefits of achieving sweeping HCV cures within their particular patient panel, because patients frequently switch insurers. Still, “consistent leveraging of drug prices and removal of restrictions to HCV treatment among all insurers would help assuage this gap,” they wrote.
Dr. Belperio described the VA’s vision of a “hepatitis C cascade of cure” that occurs when individuals with chronic HCV are identified, linked to care, treated with DAAs, and achieve sustained viral response. The comprehensive strategies employed by the VA have meant that, from 2014 to 2016, the percentage of HCV-infected individuals who have been linked to care and treatment increased from 27% to 59%. Of those treated, SVR rates have risen from 51% to 84% during the same period, said Dr. Belperio and her coauthors.
It will not be easy to extend that success into the nongovernment sector, the article’s authors acknowledged. Still, “the VA recognizes the resources necessary to realize this goal and the innovations that could make it possible, and is poised to extend best practices to other health care organizations and providers delivering HCV care.”
None of the study authors reported conflicts of interest.
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