Kanwal F (Saint Louis VAMC), Kramer J
(Michael E. DeBakey VAMC and Baylor College of Medicine), Hoang T
(VA Greater Los Angeles Healthcare System), El-Serag H
(Michael E. DeBakey VAMC and Baylor College of Medicine), Eisen T
(Saint Louis VAMC), Asch S
(VA Greater Los Angeles Healthcare System)
Chronic hepatitis C virus infection (HCV) is a prevalent, burdensome, and expensive condition within VA. Congress has mandated a screening program for HCV among VA users, which has been widely implemented. However, how well VA does in caring for patients after they are diagnosed with HCV is less clear. We sought to determine the level and determinants of the initial evaluation process of patients with HCV.
Using a national VA HCV Registry from 1/1/2000 to 12/30/2006, we evaluated 3 modified Delphi-panel derived quality indicators (QIs): confirmation of HCV viremia, specialty evaluation after confirmation, and testing for HCV genotype. We derived the aggregate score as the proportion of QIs satisfied among those for which patients were eligible. Using logistic regression multivariable analysis, we evaluated patient demographic, clinical, and comorbidity-related factors potentially associated with the receipt of evaluation-related care in HCV.
Of 165,599 patients with positive HCV antibody, 65% received a confirmatory PCR test within a year of follow-up after HCV diagnosis. Of those with confirmed infection, 52% were evaluated by a specialist, and 50% received a genotype test within the following year. Overall, patients received 52% of the recommended care, with fewer than 15% of patients receiving all indicated QIs. In the multivariable analysis, African American race (RR = 0.67, p < 0.0001), older age ( > 65 y vs. < 65 y, RR = 0.63), alcohol or drug use (RR = 0.84), bipolar disorder (RR = 0.83), psychosis (RR = 0.64), and end-stage renal disease (RR = 0.84) were associated with poor adherence to aggregate measures of quality. In contrast, patients with a diagnosis of cirrhosis (RR = 1.3) and those with HIV (RR = 1.06) were more likely to receive higher quality care. All p-values < 0.001.
We found low overall adherence to evidence-based QIs. Several demographic, clinical, and comorbidity-related factors explain part of the variation in the receipt of indicated care.
Although VA has made targeted efforts to improve rates of testing and specialty evaluation of HCV patients, these efforts have not been very successful thus far. Future research will attempt to measure the role of non-patient factors in explaining the difference between expected and observed care. These data may ultimately assist researchers and policy-makers in focusing quality improvement efforts in HCV.