The U.S. Department of Veterans Affairs (VA) is a leader in its ability to reach hepatitis C virus (HCV)-infected patients and engage them in care. Here, the secrets to its success are laid bare.
According to a recent paper in the Annals of Internal Medicine, the VA is the country’s largest care-provider for HCV-infected patients and is well on its way to eliminating the disease in its population. As of July 2017, a total of 51,000 veterans remain potentially eligible for treatment, a significant drop from more than 168,000 only 3 years ago. The number of people infected is decreasing by an estimated 30,000 per year.
The paper, titled “Curing Hepatitis C Virus Infection: Best Practices From the U.S. Department of Veterans Affairs,” outlines how the VA has managed to have so much success treating HCV. Authors include the VA’s Pamela Belperio, PharmD; David Shulkin, MD, the U.S. Secretary of the Department of the VA; and colleagues.
The VA is uniquely suited to inform national efforts to eliminate HCV, the authors wrote. The VA is the largest integrated healthcare system in the US and includes 154 medical centers, plus 875 ambulatory care and community-based outpatient clinics throughout the country. In 2013 alone, over 5.7-million veterans received healthcare.
The paper noted that the “National Strategy for the Elimination of Viral Hepatitis” from the National Academies of Sciences, Engineering, and Medicine emphasizes prevention, screening, and universal treatment — areas that already sit at the core of what the VA does.
The Strategy presents specific actions to reduce the burden of HCV infection, with five distinct areas: information, interventions, service delivery, financing, and research.
With information, the VA had a head start in terms of having extensive data on its population in the form of a single comprehensive electronic medical record system. Such data are important for research as well as for continual quality improvement. In addition is the VA’s National Hepatitis C Clinical Case Registry, developed largely to help link HCV-infected veterans to care.
Such data allow for comprehensive monitoring of incidence, prevalence, and disease course at the national, regional, and individual-facility levels — enabling “providers, teams, and leadership to assess progress and goals.”
The VA identified several at-risk populations for screening, including the baby boomer cohort; African American males (who have double the prevalence of white males, at 17.7% versus 8.3%, respectively); homeless people (who have triple the risk of non-homeless individuals, at 13% prevalence versus 3.5%); and persons who inject drugs (PWID).
As of the fall of 2017, the VA had screened an impressive 79.5% of its 2.7-million strong boomer cohort and 89.6% of its homeless population.
Once at-risk patients were identified, getting people in for testing was the next big thing, said George Ioannou, MD, of the University of Washington and director of Hepatology at the VA’s Affairs Puget Sound Health Care System. He was not an author of the recent study but has studied related areas.
The VA had multiple ways to reach people, he told MedPage Today. One lay in the VA’s capacity to generate lists of all untreated HCV patients and their relevant clinical characteristics. Each VA clinic used this to contact patients and invite them for screening and treatment.
“We used many methods,” Ioannou said. “We sent multiple letters to all patients, and we contacted each patient by phone — often more than once. For patients in remote locations who had a hard time coming to the main facility, we set up hepatitis C clinics at our community-outreach clinics as well as using teleconsultation … For outreach to homeless patients we partnered with homeless shelters and with the VA’s homeless patient access care teams.”
Studies show that the VA has a substantially higher rate of screening of at-risk patients than other large healthcare systems in the U.S.
The VA created teams of 15 to 30 people to figure out how to cater care-delivery to different settings. These Integrated Service Network Hepatitis C Innovation Teams (HITs) collaboratives included healthcare providers, administrators, and information technology and system redesign specialists.
HCV care went beyond specialty physician providers, with some care being done by mid-level providers and primary care doctors, and in community clinics. This made treatment accessible to people living in remote regions or small towns. “At more than half of VA facilities, treatment is delivered by clinical pharmacy specialists, nurse practitioners, and physician assistants,” Belperio et al wrote.
Telemedicine and real-time clinical video teleconferencing helped significantly. The VA telemedicine program includes pharmacist-led provider programs as well as mental health and substance use programs. The program had a 20% higher HCV treatment initiation rate than sites without this technology.
“Multiple patients were treated ‘remotely’ and had medications mailed out,” Ioannou said.
Addressing barriers to care, such as addiction, homelessness, mental health issues, and medical comorbidities, are a focus in the VA’s approach. “The VA took aggressive steps to eliminate non–evidence-based abstinence policies for HCV treatment and provided clinical guidance on effectively assessing alcohol and substance use,” the authors said. Integrated care teams should include mental health and addiction specialists, care coordinators, case managers, and social workers. Studies show excellent cure rates in these populations.
Of course, money helps. A recent editorial in the New England Journal of Medicine comparing the Indian Health Services and the VA system in the battle against HCV noted that the VA budget is $59 billion, supplemented by more than $2 billion earmarked for HCV.
The VA was able to place DAAs on its National Core Formulary, plus lifted treatment restrictions. As a result, treatment rates increased more than 20-fold.
“All of the above [steps] could translate to other systems,” said Ioannou.
Belperio and colleagues agree, concluding: “The VA is poised to share and extend best practices to other healthcare organizations and providers delivering HCV care, contributing to a concerted effort to reduce the overall burden of HCV infection.”