Abstract
The U.S. Department of Veterans Affairs (VA) is the nation's largest care provider for hepatitis C virus (HCV)–infected patients and is uniquely suited to inform national efforts to eliminate HCV. An extensive array of delivery of services, policy guidance, outreach efforts, and funding has broadened the reach and capacity of the VA to deliver direct-acting antiviral (DAA) HCV therapy, supported by an infrastructure to effectively implement change and informed by extensive population health data analysis. The VA has treated more than 92 000 HCV-infected veterans since all-oral DAAs became available in January 2014, with cure rates exceeding 90%; only 51 000 veterans in VA care are known to remain potentially eligible for treatment. Key actions advancing the VA's aggressive treatment of HCV infection that are germane to non-VA settings include expansion of treatment capacity through the use of nonphysician providers, video telehealth, and electronic technologies; expansion of integrated care to address psychiatric and substance use comorbidities; and electronic data tools for patient tracking and outreach. A critical component of effective implementation has been building infrastructure through the creation of regional multidisciplinary HCV Innovation Teams, whose system redesign efforts have produced innovative HCV practice models addressing gaps in care while providing more efficient and effective HCV management for the populations they serve. Financing for HCV treatment and infrastructure resources coupled with reduced drug prices has been paramount to the VA's success in curing HCV infection. The VA is poised to share and extend best practices to other health care organizations and providers delivering HCV care, contributing to a concerted effort to reduce the overall burden of HCV infection.
References
- 1.
National Academies of Sciences, Engineering,and Medicine . A National Strategy for the Elimination of Hepatitis B and C: Phase Two Report Phase Two ReportPhase Two Report. Washington, DC: National Academies Pr; 2017. [PMID: 28737845] doi:10.17226/24731 CrossrefMedlineGoogle Scholar - 2.
Buckley GJ ,Strom BL . A national strategy for the elimination of viral hepatitis emphasizes prevention, screening, and universal treatment of hepatitis C. Ann Intern Med. 2017;166:895-6. [PMID: 28384754]. doi:10.7326/M17-0766 LinkGoogle Scholar - 3.
Beste LA ,Ioannou GN . Prevalence and treatment of chronic hepatitis C virus infection in the US Department of Veterans Affairs. Epidemiol Rev. 2015;37:131-43. [PMID: 25600415] doi:10.1093/epirev/mxu002 CrossrefMedlineGoogle Scholar - 4. Surface Transportation and Veterans Health Care Choice Improvement Act of 2015, H.R. 3236, 114th Cong. (2015–2016). Google Scholar
- 5. U.S. Department of Veterans Affairs. Viral Hepatitis. Updated 20 July 2017. Accessed at www.hepatitis.va.gov on 20 April 2017. Google Scholar
- 6.
Backus LI ,Belperio PS ,Shahoumian TA ,Loomis TP ,Mole LA . Real-world effectiveness and predictors of sustained virological response with all-oral therapy in 21,242 hepatitis C genotype-1 patients. Antivir Ther. 2016. [PMID: 27934775] doi:10.3851/IMP3117 CrossrefMedlineGoogle Scholar - 7.
Ioannou GN ,Beste LA ,Chang MF ,Green PK ,Lowy E ,Tsui JI ,et al . Effectiveness of sofosbuvir, ledipasvir/sofosbuvir, or paritaprevir/ritonavir/ombitasvir and dasabuvir regimens for treatment of patients with hepatitis C in the Veterans Affairs national health care system. Gastroenterology. 2016;151:457-71. [PMID: 27267053] doi:10.1053/j.gastro.2016.05.049 CrossrefMedlineGoogle Scholar - 8.
Maier MM ,Ross DB ,Chartier M ,Belperio PS ,Backus LI . Cascade of care for hepatitis C virus infection within the US Veterans Health Administration. Am J Public Health. 2016;106:353-8. [PMID: 26562129] doi:10.2105/AJPH.2015.302927 CrossrefMedlineGoogle Scholar - 9.
Backus LI ,Gavrilov S ,Loomis TP ,Halloran JP ,Phillips BR ,Belperio PS ,et al . Clinical case registries: simultaneous local and national disease registries for population quality management. J Am Med Inform Assoc. 2009;16:775-83. [PMID: 19717794] doi:10.1197/jamia.M3203 CrossrefMedlineGoogle Scholar - 10.
Smith BD ,Morgan RL ,Beckett GA ,Falck-Ytter Y ,Holtzman D ,Teo CG ,et al ;Centers for Disease Control and Prevention . Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965. MMWR Recomm Rep. 2012;61:1-32. [PMID: 22895429] MedlineGoogle Scholar - 11.
Moyer VA ,U.S. Preventive Services Task Force . Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159:349-57. [PMID: 23798026]. doi:10.7326/0003-4819-159-5-201309030-00672 LinkGoogle Scholar - 12.
Backus LI ,Belperio PS ,Loomis TP ,Mole LA . Impact of race/ethnicity and gender on HCV screening and prevalence among U.S. veterans in Department of Veterans Affairs Care. Am J Public Health. 2014;104 Suppl 4:S555-61. [PMID: 25100421] doi:10.2105/AJPH.2014.302090 CrossrefMedlineGoogle Scholar - 13.
Noska AJ ,Belperio PS ,Loomis TP ,O'Toole TP ,Backus LI . Engagement in the hepatitis C care cascade among homeless veterans, 2015. Public Health Rep. 2017;132:136-9. [PMID: 28135425] doi:10.1177/0033354916689610 CrossrefMedlineGoogle Scholar - 14.
Jonas MC ,Rodriguez CV ,Redd J ,Sloane DA ,Winston BJ ,Loftus BC . Streamlining screening to treatment: the hepatitis C cascade of care at Kaiser Permanente Mid-Atlantic states. Clin Infect Dis. 2016;62:1290-6. [PMID: 26908812] doi:10.1093/cid/ciw086 CrossrefMedlineGoogle Scholar - 15. Ross DB, Gonzalez R, Morgan T, Park A. Best practices in screening, diagnosis, and treatment along the Veteran Health Administration's cascade of HCV care. In: Addressing the Unique Needs of Military Veterans With Chronic HCV Infection. Federal Practitioner Supplement. 1 February 2017. Google Scholar
- 16.
Toussaint JS ,Berry LL . The promise of Lean in health care. Mayo Clin Proc. 2013;88:74-82. [PMID: 23274021] doi:10.1016/j.mayocp.2012.07.025 CrossrefMedlineGoogle Scholar - 17.
Rogal SS ,Yakovchenko V ,Waltz TJ ,Powell BJ ,Kirchner JE ,Proctor EK ,et al . The association between implementation strategy use and the uptake of hepatitis C treatment in a national sample. Implement Sci. 2017;12:60. [PMID: 28494811] doi:10.1186/s13012-017-0588-6 CrossrefMedlineGoogle Scholar - 18.
Arora S ,Kalishman S ,Thornton K ,Dion D ,Murata G ,Deming P ,et al . Expanding access to hepatitis C virus treatment—Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52:1124-33. [PMID: 20607688] doi:10.1002/hep.23802 CrossrefMedlineGoogle Scholar - 19.
Beste LA ,Glorioso TJ ,Ho PM ,Au DH ,Kirsh SR ,Todd-Stenberg J ,et al . Telemedicine specialty support promotes hepatitis C treatment by primary care providers in the Department of Veterans Affairs. Am J Med. 2017;130:432-8. [PMID: 27998682] doi:10.1016/j.amjmed.2016.11.019 CrossrefMedlineGoogle Scholar - 20.
Rongey C ,Shen H ,Hamilton N ,Backus LI ,Asch SM ,Knight S . Impact of rural residence and health system structure on quality of liver care. PLoS One. 2013;8:e84826. [PMID: 24386420] doi:10.1371/journal.pone.0084826 CrossrefMedlineGoogle Scholar - 21.
Backus LI ,Belperio PS ,Shahoumian TA ,Mole LA . Impact of provider type on hepatitis C outcomes with boceprevir-based and telaprevir-based regimens. J Clin Gastroenterol. 2015;49:329-35. [PMID: 24667591] doi:10.1097/MCG.0000000000000124 CrossrefMedlineGoogle Scholar - 22.
Ourth H ,Groppi J ,Morreale AP ,Quicci-Roberts K . Clinical pharmacist prescribing activities in the Veterans Health Administration. Am J Health Syst Pharm. 2016;73:1406-15. [PMID: 27605319] doi:10.2146/ajhp150778 CrossrefMedlineGoogle Scholar - 23.
Tsui JI ,Williams EC ,Green PK ,Berry K ,Su F ,Ioannou GN . Alcohol use and hepatitis C virus treatment outcomes among patients receiving direct antiviral agents. Drug Alcohol Depend. 2016;169:101-9. [PMID: 27810652] doi:10.1016/j.drugalcdep.2016.10.021 CrossrefMedlineGoogle Scholar - 24. U.S. Department of Veterans Affairs. VA expands hepatitis C drug treatment [press release]. Washington, DC: U.S. Department of Veterans Affairs; 9 March 2016. Accessed at www.va.gov/opa/pressrel/pressrelease.cfm?id=2762 on 10 April 2017. Google Scholar
- 25.
Bhattacharya D ,Belperio PS ,Shahoumian TA ,Loomis TP ,Goetz MB ,Mole LA ,et al . Effectiveness of all-oral antiviral regimens in 996 human immunodeficiency virus/hepatitis C virus genotype 1-coinfected patients treated in routine practice. Clin Infect Dis. 2017;64:1711-20. [PMID: 28199525] doi:10.1093/cid/cix111 CrossrefMedlineGoogle Scholar - 26.
El-Serag HB ,Kramer J ,Duan Z ,Kanwal F . Epidemiology and outcomes of hepatitis C infection in elderly US Veterans. J Viral Hepat. 2016;23:687-96. [PMID: 27040447] doi:10.1111/jvh.12533 CrossrefMedlineGoogle Scholar - 27.
Yehia BR ,Schranz AJ ,Umscheid CA ,Lo Re V . The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis. PLoS One. 2014;9:e101554. [PMID: 24988388] doi:10.1371/journal.pone.0101554 CrossrefMedlineGoogle Scholar - 28.
Spradling PR ,Rupp L ,Moorman AC ,Lu M ,Teshale EH ,Gordon SC ,et al ;Chronic Hepatitis Cohort Study Investigators . Hepatitis B and C virus infection among 1.2 million persons with access to care: factors associated with testing and infection prevalence. Clin Infect Dis. 2012;55:1047-55. [PMID: 22875876] CrossrefMedlineGoogle Scholar - 29.
Holmberg SD ,Spradling PR ,Moorman AC ,Denniston MM . Hepatitis C in the United States. N Engl J Med. 2013;368:1859-61. [PMID: 23675657] doi:10.1056/NEJMp1302973 CrossrefMedlineGoogle Scholar
Author, Article, and Disclosure Information
Pamela S. Belperio,
From VA Palo Alto Health Care System, Palo Alto, California; San Francisco VA Medical Center, San Francisco, California; and U.S. Department of Veterans Affairs, Washington, DC.
Acknowledgment: The authors thank Dr. Lisa Backus for her contributions related to the generation of data used for reporting HCV testing rates, treatment rates, and cascade-of-care steps.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-1073.
Corresponding Author: Pamela S. Belperio, PharmD, Patient Care Services/Population Health Services, VA Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304; e-mail, pamela.
Current Author Addresses: Dr. Belperio: Patient Care Services/Population Health Services (10P4V), Department of Veterans Affairs, VA Palo Alto Health Care System, 3801 Miranda Avenue (M/C 132), Palo Alto, CA 94304.
Dr. Chartier: HIV, Hepatitis and Related Conditions, Office of Specialty Care Services (10P11I), Department of Veterans Affairs, San Francisco VA Medical Center, 4150 Clement Street (116B), San Francisco, CA 94121.
Dr. Ross: HIV, Hepatitis and Related Conditions, Office of Specialty Care Services (10P11I), Department of Veterans Affairs, 810 Vermont Avenue, Washington, DC 20420.
Dr. Alaigh: Office of the Under Secretary for Health, Department of Veterans Affairs, 810 Vermont Avenue, Washington, DC 20420.
Dr. Shulkin: Secretary of Veterans Affairs, Office of the Secretary for Health, Department of Veterans Affairs, 810 Vermont Avenue, Washington, DC 20420.
Author Contributions: Conception and design: P.S. Belperio, D.B. Ross, P. Alaigh, D. Shulkin.
Analysis and interpretation of the data: P.S. Belperio, M. Chartier, P. Alaigh, D. Shulkin.
Drafting of the article: P.S. Belperio, M. Chartier, D. Shulkin.
Critical revision of the article for important intellectual content: P.S. Belperio, M. Chartier, P. Alaigh.
Final approval of the article: P.S. Belperio, M. Chartier, D.B. Ross, P. Alaigh, D. Shulkin.
Obtaining of funding: D.B. Ross, D. Shulkin.
Administrative, technical, or logistic support: M. Chartier, D.B. Ross.
Collection and assembly of data: P.S. Belperio.
This article was published at Annals.org on 26 September 2017.
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