In the second intervention, opportunities for switching those who completed treatment from face-to-face clinic visits to telephone were identified. These patients historically were seen in clinic for a brief interview and for a blood test used to determine end-of-treatment viral load. Improving access for new patients in the clinic involved moving more existing patients from in-clinic visits to telephone. At the end of the treatment plan, existing patients received an order for laboratory tests that included viral load. When all laboratory results were ready, patients were contacted by telephone. Recruiting a registered nurse to the treatment team who assisted with telephone visits further improved clinic efficiency.
The third intervention was inspired by successful results at other VA sites and launched a group treatment clinic for patients who were starting ribavirin-free DAA regimens .7 Group visits were run by 2 pharmacists and accommodated up to 10 veterans. Patients underwent testing for HCV genotype and viral load before the initial group visit. At check-in, patients received a short questionnaire and consent form for group participation. The questionnaire reviewed patient history of drug and alcohol use and potential barriers to medication adherence. Patients also were encouraged to write down any questions they had about the treatment. During the initial group visit, pharmacists provided general education about the medications, potential adverse effects, treatment expectations, and the monitoring plan. Follow-up visits were conducted in a group setting as well.
Phase 2: Increase Recruitment
The records of 534 patients with advanced liver disease (F3-F4 fibrosis on the Fibrosis-4 Index for Liver Fibrosis) and HCV infection were identified in the CCR database for the period August 2015 to December 2015 (Figure 1). 8 Patients were excluded if they were deceased, were receiving palliative care (n = 45), or if they had transferred their care to another VA facility (n = 69). Of the 420 patients in the study reviewed, 234 (56%) had not previously been referred to an HCV clinic or been started on treatment because of a variety of social issues, including active substance use (Figure 2).
Many of the patients were difficult to engage because the clinic could not effectively assist them in achieving sobriety and lacked support personnel who could address their complex social issues. Given the availability of all-oral HCV treatments, the VA Public Health Department issued guidance allowing all HCV-infected patients to receive DAA treatment regardless of ongoing drug or alcohol use disorders. 9 Substance use was not to be considered a contraindication to therapy. It was suggested that health care providers determine these patients’ treatment eligibility on a case-by-case basis. An official VA memorandum supporting this initiative was released in September 2016. 10
Interventions
In an effort to engage all HCV-infected patients, the CCR review was expanded to include patients without advanced liver disease. All patients were contacted by mail. Any patient registered for secure messaging through MyHealtheVet also received a secure message. Patients were informed about the newly approved DAA therapies and were connected directly with specialized HCV clinic schedulers at RLRVAMC. Patients who responded were scheduled for a group education class facilitated by 2 members of the HCV treatment team.