Clinical Review

Screening and Treating Hepatitis C in the VA: Achieving Excellence Using Lean and System Redesign

Fed Pract. 2018 July;35(7):24-29

Author(s):

Angela Park, PharmD

Rachel Gonzalez, MPH

Maggie Chartier, PsyD, MPH

Shari Rogal, MD

Vera Yakovchenko, MPH

David Ross, MD, PhD, MBI

Timothy R. Morgan, MD

The national effort to redesign care using Lean management strategies, develop local and regional teams, and to centralize support allowed VA to maximize available resources to achieve higher rates of testing and treatment of patients with hepatitis C virus than that of any other health care system in the US.

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References

1. Colvin HM, Mitchell AE, eds; and the Committee on the Prevention and Control of Viral Hepatitis Infections Board on Population Health and Public Health Practice. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. Washington, DC: The National Academies Press; 2010.

2. US Department of Health and Human Services. Combating the silent epidemic of viral hepatitis: action plan for the prevention, care and treatment of viral hepatitis. https://www.hhs.gov/sites/default/files/action-plan-viral-hepatitis-2011.pdf. Accessed April 27, 2018.

3. Wolitski R. National viral hepatitis action plan: 2017-2020. https://www.hhs.gov/hepatitis/action-plan/national-viralhepatitis-action-plan-overview/index.html. Updated February
21, 2018. Accessed May 8, 2018.

4. National Academies of Sciences, Engineering, and Medicine. A National Strategy for the Elimination of Hepatitis B and C: Phase Two Report. Washington, DC: The National Academies Press; 2017.

5. Belperio PS, Chartier M, Ross DB, Alaigh P, Shulkin D. Curing hepatitis C infection: best practices from the Department of Veterans Affairs. Ann of Intern Med. 2017;167(7):499-504.

6. Kushner T, Serper M, Kaplan DE. Delta hepatitis within the Veterans Affairs medical system in the United States: prevalence, risk factors, and outcomes. J Hepatol. 2015;63(3):586-592.

7. US Department of Veterans Affairs, Veteran Health Administration. National Clinical Preventive Service Guidance Statements: Screening for Hepatitis C. http://www.prevention.va.gov/CPS/Screening_for_Hepatitis_C.asp. Published on June 20, 2017. [Nonpubic document; source not verified.]

8. Moyer VA; US 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(5):349-357.

9. Smith BD, Morgan RL, Beckett GA, 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(RR-4):1-32.

10. Garrard J, Choudary V, Groom H, et al. Organizational change in management of hepatitis C: evaluation of a CME program. J Contin Educ Health Prof. 2006;26(2):145-160.

11. Shook J. Managing to Learn: Using the A3 Management Process to Solve Problems, Gain Agreement, Mentor, and Lead. Cambridge, MA: Lean Enterprise Institute; 2010.

12. Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21.

13. Rogal SS, Yakovchenko V, Waltz TJ, et al. The association between implementation strategy use and the uptake of hepatitis C treatment in a national sample. Implement Sci.
2017;12(1):60.

14. Mellinger JL, Moser S, Welsh DE, et al. Access to subspecialty care and survival among patients with liver disease. Am J Gastroenterol. 2016;111(6):838-844.

15. Beste LA, Leipertz SL, Green PK, Dominitz JA, Ross D, Ioannou GN. Trends in the burden of cirrhosis and hepatocellular carcinoma by underlying liver disease in US Veterans from 2001-2013. Gastroenterology. 2015;149(6):1471-1482.e5.

16. Kaplan DE, Chapko MK, Mehta R, et al; VOCAL Study Group. Healthcare costs related to treatment of hepatocellular carcinoma among veterans with cirrhosis in the United States. Clin Gastroenterol Hepatol. 2018;16(1):106-114.

Hepatitis C virus (HCV) infection is a major public health problem in the US. Following the 2010 report of the Institute of Medicine/National Academies of Sciences, Engineering, and Medicine (NASEM) on hepatitis and liver cancer, the US Department of Health and Human Services (HHS) released the first National Viral Hepatitis Action Plan in 2011 with subsequent action plan updates for 2014-2016 and 2017-2020. ^1-3 A NASEM phase 2 report and the 2017-2020 HHS action plan outline a national strategy to prevent new viral hepatitis infections; reduce deaths and improve the health of people living with viral hepatitis; reduce viral hepatitis health disparities; and coordinate, monitor, and report on implementation of viral hepatitis activities. ^3,4 The Department of Veterans Affairs (VA) is the single largest HCV care provider in the US with about 165,000 veterans in care diagnosed with HCV in the beginning of 2014 and is a national leader in the testing and treatment of HCV. ^5,6

The VA’s recommendations for screening for HCV infection are in alignment with the United States Preventive Services Task Force (USPSTF) and Centers for Disease Control and Prevention (CDC) recommendations to test all veterans born between 1945 and 1965 and anyone with risk factors such as injection drug use.7-9 As of January 1, 2018, the VA had screened more than 80% of veterans in care within this highest risk birth cohort. As of January 1, 2018, more than 100,000 veterans in VA care have initiated treatment for HCV with direct-acting antivirals (DAAs) (Figure 1).

To date, more than 77,000 veterans have a documented sustained virologic response (SVR) with DAAs 12 weeks after treatment completion (SVR12) (VHA Population Health Service, personal communication, February 15, 2018).

Several critical factors contributed to the VA success with HCV testing and treatment, including congressional appropriation of funding from fiscal year (FY) 2016 through FY 2018, unrestricted access to interferon-free DAA HCV treatments, and dedicated resources from the VA National Viral Hepatitis Program within the HIV, Hepatitis, and Related Conditions Programs (HHRC) in the Office of Specialty Care Services. ⁵ In 2014, HHRC created and supported the Hepatitis Innovation Team (HIT) Collaborative, a VA process improvement initiative enabling
Veterans Integrated Service Network (VISN) -based, multidisciplinary teams to increase veterans’ access to HCV testing and treatment.

As the VA makes consistent progress toward eliminating HCV in veterans in VA care, it has become clear that achieving a cure is only a starting point in improving HCV care. Many patients with HCV infection also have advanced liver disease (ALD), or cirrhosis, which is a condition of permanent liver fibrosis that remains after the patient has been cured of HCV infection. In addition to hepatitis C, ALD also can be caused by excessive alcohol use, hepatitis B virus (HBV) infection, nonalcoholic fatty liver diseases, and several other inherited diseases. Advanced liver disease affects more than 80,000 veterans in VA care, and the HIT infrastructure provides an excellent framework to better understand and address facility-level and systemwide challenges in diagnosing, caring for, and treating veterans with ALD across the Veterans Health Administration (VHA) system.

References

4. National Academies of Sciences, Engineering, and Medicine. A National Strategy for the Elimination of Hepatitis B and C: Phase Two Report. Washington, DC: The National Academies Press; 2017.

5. Belperio PS, Chartier M, Ross DB, Alaigh P, Shulkin D. Curing hepatitis C infection: best practices from the Department of Veterans Affairs. Ann of Intern Med. 2017;167(7):499-504.

6. Kushner T, Serper M, Kaplan DE. Delta hepatitis within the Veterans Affairs medical system in the United States: prevalence, risk factors, and outcomes. J Hepatol. 2015;63(3):586-592.

10. Garrard J, Choudary V, Groom H, et al. Organizational change in management of hepatitis C: evaluation of a CME program. J Contin Educ Health Prof. 2006;26(2):145-160.

11. Shook J. Managing to Learn: Using the A3 Management Process to Solve Problems, Gain Agreement, Mentor, and Lead. Cambridge, MA: Lean Enterprise Institute; 2010.

13. Rogal SS, Yakovchenko V, Waltz TJ, et al. The association between implementation strategy use and the uptake of hepatitis C treatment in a national sample. Implement Sci.
2017;12(1):60.

14. Mellinger JL, Moser S, Welsh DE, et al. Access to subspecialty care and survival among patients with liver disease. Am J Gastroenterol. 2016;111(6):838-844.

Screening and Treating Hepatitis C in the VA: Achieving Excellence Using Lean and System Redesign

References

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