In the U.S., 2.7 to 3.9 million people are chronically infected with the hepatitis C virus (HCV). 1 Survey data suggest that HCV infection is more prevalent in patients enrolled in the VA health care system than it is in civilian health care systems. 2 Studies have shown that Vietnam veterans, veterans with mental health and substance abuse disorders, and veterans without stable housing are more likely to be infected with HCV. 3 Data from the VA HCV Clinical Case Registry (CCR) for 2015 showed that 174,842 veterans with chronic HCV infection receieved care within the VHA, which makes the VA the single largest HCV care provider in the nation. 4
The VA is dedicated to providing treatment to veterans with HCV infection. For fiscal year (FY) 2016, the VA allocated $1 billion to HCV care,and in February 2016 it began offering treatment to all veterans with HCV, regardless of degree of fibrosis or severity of underlying liver disease. 3,5 Each VAMC was tasked with improving veterans’ access to HCV treatment.
In an effort to engage patients in HCV care, the multidisciplinary HCV team at the Richard L. Roudebush VAMC (RLRVAMC) in Indianapolis, Indiana, launched a 2-phase improvement process in 2016. The goal in phase 1 was to increase patient access to HCV clinics, and the goal in phase 2 was to recruit patients for direct-acting antiviral (DAA) therapy for HCV. These efforts were designed to increase screening, identification, and linkage to care for HCV and to expand clinic access for the treatment and cure of all identified veterans who pursued treatment.
Patients with HCV infection, referred from primary care clinics, initially were evaluated by HCV clinic providers (hepatologists, infectious disease specialists, gastroenterology fellows, or nurse practitioners) for eligibility to receive DAA therapy for HCV. Eligible patients then were referred to a pharmacist-run HCV clinic, which had been established at RLRVAMC in 2011. At the start of FY 2016, the clinic, staffed by 3 pharmacists, operated 5 half-days per week and accommodated up to 35 weekly patient appointments.
In this clinic, patients received initial education and medication reconciliation for potential drug interactions with DAAs. Once the HCV treatment was initiated, patients were evaluated in the clinic every 2 weeks for medication refills and assessment for tolerability, adherence, and laboratory abnormalities until end of treatment (8-24 weeks, depending on HCV genotype, experiences with prior HCV treatment, and presence/absence of cirrhosis). Twelve weeks after completion of treatment, viral load was obtained to determine sustained virologic response (SVR12).
Methods
Phase 1: Improve Clinic Access
During FY 2016, methods for expanding clinic access to accommodate a large influx of treatment-eligible patients were reviewed and implemented.
In the first intervention, unneeded follow-up visits were eliminated to make room for additional new patient appointments. In general, patients treated with ribavirin require close monitoring, given the risk for anemia. 6 With the release of newer DAAs, however, more patients became eligible for treatment with ribavirin-free regimens. 7 As a result, follow-up appointments for these patients were extended to 4-week intervals instead of every 2 weeks. A patient with a history of nonadherence to medication use or clinic visits was still maintained on a 2-week schedule of follow-up for close monitoring.