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Beydoun HA, Tsai J. Screening rates for hepatitis B and C among low-income US veterans: Data from the National Veteran Homeless and Other Poverty Experiences Study. J Viral Hepat 2024. [PMID: 38984865 DOI: 10.1111/jvh.13981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/25/2024] [Accepted: 06/22/2024] [Indexed: 07/11/2024]
Abstract
Screening for viral hepatitis is considered a high-priority area in the Veterans Health Administration (VHA). Yet, few studies have examined viral hepatitis screening test use among low-income veterans who are considered high-risk with limited healthcare access. Using cross-sectional data from 933 participants in the 2021-2022 National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study, we examined rates and correlates of lifetime screening for hepatitis B (HBV) and hepatitis C (HCV) infections. Multivariable logistic regression models evaluated characteristics associated with HBV/HCV screening. Nearly 16% and 21% reported lifetime HBV and HCV screening, respectively. These rates are considerably lower than HBV (47.3%) and HCV (92.9%) screening rates documented among contemporaneous veterans in VHA electronic health records. In the NV-HOPE data, veterans 50-79 years were more likely than those ≥80 years of age to ever-screen for HBV/HCV. Whereas, household income was inversely related to lifetime screening behaviours, veterans reporting 'other' employment types (vs. full-time/part-time employment) were more likely to ever-screen for HBV/HCV. Ever-screening for HBV was more likely among veterans reporting non-Hispanic 'other' (vs. non-Hispanic 'white') race, housing instability, Medicaid insurance, as well as drug use and cognitive disorder histories. Living with ≥5 members (vs. alone), histories of alcohol use, cancer, and liver disorders were also correlated with ever-screening for HCV. HIV/AIDS history correlated with ever-screening for HBV/HCV. In conclusion, fewer than one-third of low-income US veterans ever-screened for HBV/HCV, with lower screening rates among those less likely to be exposed to viral hepatitis, thereby informing interventions aimed at promoting available screening, treatment and vaccinations for HBV/HCV.
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Affiliation(s)
- Hind A Beydoun
- National Center on Homelessness among Veterans (NCHAV), Veterans Health Administration, Washington, DC, USA
- School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jack Tsai
- National Center on Homelessness among Veterans (NCHAV), Veterans Health Administration, Washington, DC, USA
- School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
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Varley CD, Lowy E, Cartwright EJ, Morgan TR, Ross DB, Rozenberg-Ben-Dror K, Beste LA, Maier MM. Success of the US Veterans Health Administration's Hepatitis C Virus Care Continuum in the Direct-acting Antiviral Era. Clin Infect Dis 2024; 78:1571-1579. [PMID: 38279939 DOI: 10.1093/cid/ciae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/17/2023] [Accepted: 01/23/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND Estimated hepatitis C prevalence within the Veterans Health Administration is higher than the general population and is a risk factor for advanced liver disease and subsequent complications. We describe the hepatitis C care continuum within the Veterans Health Administration 1 January 2014 to 31 December 2022. METHODS We included individuals in Veterans Health Administration care 2021-2022 who were eligible for direct-acting antiviral treatment 1 January 2014 to 31 December 2022. We evaluated the proportion of Veterans who progressed through each step of the hepatitis C care continuum, and identified factors associated with initiating direct-acting antivirals, achieving sustained virologic response, and repeat hepatitis C viremia. RESULTS We identified 133 732 Veterans with hepatitis C viremia. Hepatitis C treatment was initiated in 107 134 (80.1%), with sustained virologic response achieved in 98 136 (91.6%). In those who achieved sustained virologic response, 1097 (1.1%) had repeat viremia and 579 (52.8%) were retreated for hepatitis C. Veterans of younger ages were less likely to initiate treatment and achieve sustained virologic response, and more likely to have repeat viremia. Stimulant use and unstable housing were negatively associated with each step of the hepatitis C care continuum. CONCLUSIONS The Veterans Health Administration has treated 80% of Veterans with hepatitis C in care 2021-2022 and achieved sustained virologic response in more than 90% of those treated. Repeat viremia is rare and is associated with younger age, unstable housing, opioid use, and stimulant use. Ongoing efforts are needed to reach younger Veterans, and Veterans with unstable housing or substance use disorders.
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Affiliation(s)
- Cara D Varley
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon, USA
| | - Elliott Lowy
- Health Systems Research, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
| | - Emily J Cartwright
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Medicine, Veteran Affairs Atlanta Health Care System, Atlanta, Georgia, USA
| | - Timothy R Morgan
- Gastroenterology Section, Veterans Affairs Long Beach Healthcare System, Long Beach, California, USA
| | - David B Ross
- Department of Veterans Affairs, HIV, Hepatitis, and Public Health Pathogens Programs, Washington, District of Columbia, USA
| | | | - Lauren A Beste
- Division of General Internal Medicine, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA
| | - Marissa M Maier
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
- Infectious Diseases Section, Veteran Affairs Portland Health Care System, Portland, Oregon, USA
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3
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Martin MT, Pham AN, Wagner JS. A cross-sectional survey of viral hepatitis education within pharmacy curricula in the United States. Int J Clin Pharm 2024; 46:648-655. [PMID: 38353914 DOI: 10.1007/s11096-023-01691-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/11/2023] [Indexed: 05/30/2024]
Abstract
BACKGROUND The Viral Hepatitis National Strategic Plan emphasizes the importance of a collaborative provider workforce trained in hepatitis prevention and treatment to eliminate viral hepatitis in the United States by 2030. Although pharmacists play a key role in hepatitis management, literature lacks documentation of the amount of viral hepatitis education provided to pharmacy students. AIM Our study goal was to describe viral hepatitis education provided at United States pharmacy schools. METHOD In this cross-sectional survey study, investigators developed a 19-item Qualtrics questionnaire, sent questionnaire links to curricula content experts at 140 accredited pharmacy colleges/schools in May-June 2022, and allotted 28 days for completion. Questions assessed the viral hepatitis instruction provided to students and hepatitis instructors' training/experience. We used descriptive statistics for analysis. RESULTS Forty-eight pharmacy institutions across 29 states/territories responded; 44% had 50-99 students/class, and 58% used lecture and discussion to provide required hepatitis education. Students received more lecture (average = 3.4 h, range 0.8-1.6 h/hepatitis topic) than discussion (average = 1.7 h, range 0.6-0.9 h/hepatitis topic), with the most time spent on hepatitis C, followed by hepatitis B virus. Respondents reported 93% of their instructors had post-graduate training/certifications and 67% worked in clinical settings with hepatitis patients. CONCLUSION Survey results demonstrate variability in hepatitis education across United States pharmacy curricula. Data offer stakeholders in hepatitis elimination efforts knowledge about the viral hepatitis education provided to Doctor of Pharmacy students. Future directions include consideration of implementation of minimum hepatitis education standards to further support work toward national hepatitis elimination.
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Affiliation(s)
- Michelle T Martin
- University of Illinois Chicago (UIC) College of Pharmacy, Chicago, IL, 60612, USA.
- University of Illinois Hospital and Health Sciences System (UI Health), 833 South Wood Street, Suite 164, M/C 886, Chicago, IL, 60612, USA.
| | - Aileen N Pham
- University of Illinois Chicago (UIC) College of Pharmacy, Chicago, IL, 60612, USA
| | - Jessica S Wagner
- University of Illinois Chicago (UIC) College of Pharmacy, Chicago, IL, 60612, USA
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Cartwright EJ, Pierret C, Minassian C, Esserman DA, Tate JP, Goetz MB, Bhattacharya D, Fiellin DA, Justice AC, Lo Re V, Rentsch CT. Alcohol Use and Sustained Virologic Response to Hepatitis C Virus Direct-Acting Antiviral Therapy. JAMA Netw Open 2023; 6:e2335715. [PMID: 37751206 PMCID: PMC10523171 DOI: 10.1001/jamanetworkopen.2023.35715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023] Open
Abstract
Importance Some payers and clinicians require alcohol abstinence to receive direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) infection. Objective To evaluate whether alcohol use at DAA treatment initiation is associated with decreased likelihood of sustained virologic response (SVR). Design, Setting, and Participants This retrospective cohort study used electronic health records from the US Department of Veterans Affairs (VA), the largest integrated national health care system that provides unrestricted access to HCV treatment. Participants included all patients born between 1945 and 1965 who were dispensed DAA therapy between January 1, 2014, and June 30, 2018. Data analysis was completed in November 2020 with updated sensitivity analyses performed in 2023. Exposure Alcohol use categories were generated using responses to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnoses for alcohol use disorder (AUD): abstinent without history of AUD, abstinent with history of AUD, lower-risk consumption, moderate-risk consumption, and high-risk consumption or AUD. Main Outcomes and Measures The primary outcome was SVR, which was defined as undetectable HCV RNA for 12 weeks or longer after completion of DAA therapy. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% CIs of SVR associated with alcohol category. Results Among 69 229 patients who initiated DAA therapy (mean [SD] age, 62.6 [4.5] years; 67 150 men [97.0%]; 34 655 non-Hispanic White individuals [50.1%]; 28 094 non-Hispanic Black individuals [40.6%]; 58 477 individuals [84.5%] with HCV genotype 1), 65 355 (94.4%) achieved SVR. A total of 32 290 individuals (46.6%) were abstinent without AUD, 9192 (13.3%) were abstinent with AUD, 13 415 (19.4%) had lower-risk consumption, 3117 (4.5%) had moderate-risk consumption, and 11 215 (16.2%) had high-risk consumption or AUD. After adjustment for potential confounding variables, there was no difference in SVR across alcohol use categories, even for patients with high-risk consumption or AUD (OR, 0.95; 95% CI, 0.85-1.07). There was no evidence of interaction by stage of hepatic fibrosis measured by fibrosis-4 score (P for interaction = .30). Conclusions and Relevance In this cohort study, alcohol use and AUD were not associated with lower odds of SVR. Restricting access to DAA therapy according to alcohol use creates an unnecessary barrier to patients and challenges HCV elimination goals.
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Affiliation(s)
- Emily J. Cartwright
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
- Atlanta Veterans Affairs Medical Center, Decatur, Georgia
| | - Chloe Pierret
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Caroline Minassian
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Denise A. Esserman
- Veterans Affairs Connecticut Healthcare System, US Department of Veterans Affairs, West Haven
| | - Janet P. Tate
- Veterans Affairs Connecticut Healthcare System, US Department of Veterans Affairs, West Haven
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Matthew B. Goetz
- Department of Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles
- Veterans Affairs Greater Los Angeles Health Care System, US Department of Veterans Affairs, Los Angeles, California
| | - Debika Bhattacharya
- Department of Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles
- Veterans Affairs Greater Los Angeles Health Care System, US Department of Veterans Affairs, Los Angeles, California
| | - David A. Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
| | - Amy C. Justice
- Veterans Affairs Connecticut Healthcare System, US Department of Veterans Affairs, West Haven
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Christopher T. Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Veterans Affairs Connecticut Healthcare System, US Department of Veterans Affairs, West Haven
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Nakayama J, Hertzberg VS, Ho JC, Simpson RL, Cartwright EJ. Hepatitis C care cascade in a large academic healthcare system, 2012 to 2018. Medicine (Baltimore) 2023; 102:e32859. [PMID: 36897716 PMCID: PMC9997763 DOI: 10.1097/md.0000000000032859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/17/2023] [Indexed: 03/11/2023] Open
Abstract
To determine the hepatitis C virus (HCV) care cascade among persons who were born during 1945 to 1965 and received outpatient care on or after January 2014 at a large academic healthcare system. Deidentified electronic health record data in an existing research database were analyzed for this study. Laboratory test results for HCV antibody and HCV ribonucleic acid (RNA) indicated seropositivity and confirmatory testing. HCV genotyping was used as a proxy for linkage to care. A direct-acting antiviral (DAA) prescription indicated treatment initiation, an undetectable HCV RNA at least 20 weeks after initiation of antiviral treatment indicated a sustained virologic response. Of the 121,807 patients in the 1945 to 1965 birth cohort who received outpatient care between January 1, 2014 and June 30, 2017, 3399 (3%) patients were screened for HCV; 540 (16%) were seropositive. Among the seropositive, 442 (82%) had detectable HCV RNA, 68 (13%) had undetectable HCV RNA, and 30 (6%) lacked HCV RNA testing. Of the 442 viremic patients, 237 (54%) were linked to care, 65 (15%) initiated DAA treatment, and 32 (7%) achieved sustained virologic response. While only 3% were screened for HCV, the seroprevalence was high in the screened sample. Despite the established safety and efficacy of DAAs, only 15% initiated treatment during the study period. To achieve HCV elimination, improved HCV screening and linkage to HCV care and DAA treatment are needed.
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Affiliation(s)
- Jasmine Nakayama
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA
| | - Vicki S. Hertzberg
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA
- Emory University Department of Computer Science, Atlanta, GA
| | - Joyce C. Ho
- Emory University Department of Computer Science, Atlanta, GA
| | - Roy L. Simpson
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA
| | - Emily J. Cartwright
- Emory University School of Medicine, Atlanta, GA
- Atlanta VA Medical Center, Atlanta, GA
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Hawks L, Wang EA, Butt AA, Crystal S, Keith McInnes D, Re VL, Cartwright EJ, Puglisi LB, Haque LYK, Lim JK, Justice AC, McGinnis KA. Treating Hepatitis C in Individuals With Previous Incarceration: The Veterans Health Administration, 2012-2019. Am J Public Health 2023; 113:162-165. [PMID: 36480765 PMCID: PMC9850617 DOI: 10.2105/ajph.2022.307152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 12/14/2022]
Abstract
To determine whether the Veterans Health Administration's (VHA) hepatitis C (HCV) treatment campaign reached marginalized populations, we compared HCV care by previous incarceration status with Veterans Aging Cohort Study data. Of those with and those without previous incarceration, respectively, 40% and 21% had detectable HCV, 59% and 65% underwent treatment (P = .07); 92% and 94% of those who completed treatment achieved sustained virologic response. The VHA HCV treatment effort was successful and other systems should replicate those efforts. (Am J Public Health. 2023;113(2):162-165. https://doi.org/10.2105/AJPH.2022.307152).
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Affiliation(s)
- Laura Hawks
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
| | - Emily A Wang
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
| | - Adeel A Butt
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
| | - Stephen Crystal
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
| | - D Keith McInnes
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
| | - Vincent Lo Re
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
| | - Emily J Cartwright
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
| | - Lisa B Puglisi
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
| | - Lamia Y K Haque
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
| | - Joseph K Lim
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
| | - Amy C Justice
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
| | - Kathleen A McGinnis
- Laura Hawks is with the Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee. Emily A. Wang and Lisa B. Puglisi are with the SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT. Adeel A. Butt is with the Department of Medicine, Weill Cornell Medical College, New York, NY. Stephen Crystal is with the Center for Health Services Research, Rutgers University, New Brunswick, NJ. D. Keith McInnes is with the Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA. Vincent Lo Re III is with the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Emily J. Cartwright is with the Department of Medicine, Emory University School of Medicine, Atlanta, GA. Lamia Y. K. Haque and Joseph K. Lim are with the Department of Medicine, Yale School of Medicine, New Haven, CT. Amy C. Justice and Kathleen A. McGinnis are with the VA Connecticut Healthcare System, West Haven
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7
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Yakovchenko V, Jacob DA, Rogal SS, Morgan TR, Rozenberg-Ben-Dror K. User experience of a hepatitis c population management dashboard in the Department of Veterans Affairs. PLoS One 2023; 18:e0285044. [PMID: 37130107 PMCID: PMC10153746 DOI: 10.1371/journal.pone.0285044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/13/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The Veterans Health Administration (VA) is the largest integrated healthcare organization in the US and cares for the largest cohort of individuals with hepatitis C (HCV). A national HCV population management dashboard enabled rapid identification and treatment uptake with direct acting antiviral agents across VA hospitals. We describe the HCV dashboard (HCVDB) and evaluate its use and user experience. METHODS A user-centered design approach created the HCVDB to include reports based on the HCV care continuum: 1) 1945-1965 birth cohort high-risk screening, 2) linkage to care and treatment of chronic HCV, 3) treatment monitoring, 4) post-treatment to confirm cure (i.e., sustained virologic response), and 5) special populations of unstably housed Veterans. We evaluated frequency of usage and user experience with the System Usability Score (SUS) and Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) instruments. RESULTS Between November 2016 and July 2021, 1302 unique users accessed the HCVDB a total of 163,836 times. The linkage report was used most frequently (71%), followed by screening (13%), sustained virologic response (11%), on-treatment (4%), and special populations (<1%). Based on user feedback (n = 105), the mean SUS score was 73±16, indicating a good user experience. Overall acceptability was high with the following UTAUT2 rated from highest to least: Price Value, Performance Expectancy, Social Influence, and Facilitating Conditions. CONCLUSIONS The HCVDB had rapid and widespread uptake, met provider needs, and scored highly on user experience measures. Collaboration between clinicians, clinical informatics, and population health experts was essential for dashboard design and sustained use. Population health management tools have the potential for large-scale impacts on care timeliness and efficiency.
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Affiliation(s)
- Vera Yakovchenko
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States of America
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - David A Jacob
- Veteran Affairs Heart of Texas Health Care Network, Temple, TX, United States of America
| | - Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
- Departments of Medicine and Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Timothy R Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, CA, United States of America
- Department of Medicine, Division of Gastroenterology, University of California, Irvine, CA, United States of America
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Rotenstein LS, Holmgren AJ, Healey MJ, Horn DM, Ting DY, Lipsitz S, Salmasian H, Gitomer R, Bates DW. Association Between Electronic Health Record Time and Quality of Care Metrics in Primary Care. JAMA Netw Open 2022; 5:e2237086. [PMID: 36255725 PMCID: PMC9579903 DOI: 10.1001/jamanetworkopen.2022.37086] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Physicians across the US spend substantial time working in the electronic health record (EHR), with primary care physicians (PCPs) spending the most time. The association between EHR time and ambulatory care quality outcomes is unclear. OBJECTIVE To characterize measures of EHR use and ambulatory care quality performance among PCPs. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of PCPs with longitudinal patient panels using a single EHR vendor was conducted at Brigham and Women's Hospital and Massachusetts General Hospital during calendar year 2021. EXPOSURES Independent variables included PCPs demographic and practice characteristics and EHR time measures (PCP-level mean of daily total EHR time, after-hours time, time from 5:30 pm to 7:00 am and time on weekends, and daily EHR time on notes, sending and receiving patient, staff, results, prescription, or system messages [in-basket], and clinical review). MAIN OUTCOMES AND MEASURES Outcome variables were ambulatory quality measures (year-end, PCP panel-level achievement of targets for hemoglobin A1c level control, lipid management, hypertension control, diabetes screening, and breast cancer screening). RESULTS The sample included 291 physicians (174 [59.8%] women). Median panel size was 829 (IQR, 476-1157) patients and mean (SD) clinical full-time equivalent was 0.54 (0.27). The PCPs spent a mean (SD) of 145.9 (64.6) daily minutes on the EHR. There were significant associations between EHR time and panel-level achievement of hemoglobin A1c control, hypertension control, and breast cancer screening targets. In adjusted analyses, each additional 15 minutes of total daily EHR time was associated with 0.58 (95% CI, 0.32-0.84) percentage point greater panel-level hemoglobin A1c control, 0.52 (95% CI, 0.33-0.71) percentage point greater hypertension control, and 0.28 (95% CI, 0.05-0.52) higher breast cancer screening rates. Each daily additional 15 minutes of in-basket time was associated with 2.26 (95% CI, 1.05-3.48) greater panel-wide hemoglobin A1c control, 1.65 (95% CI, 0.83-2.47) percentage point greater hypertension control, and 1.26 (95% CI, 0.51-2.02) percentage point higher breast cancer screening rates. Associations were largely concentrated among PCPs with 0.5 clinical full-time equivalent or less. There were no associations between EHR use metrics and diabetes screening or lipid management in patients with cardiovascular disease. CONCLUSIONS AND RELEVANCE This cross-sectional study found an association between EHR time and some measures of ambulatory care quality. Although increased EHR time is associated with burnout, it may represent a level of thoroughness or communication that enhances certain outcomes. It may be useful for future studies to characterize payment models, workflows, and technologies that enable high-quality ambulatory care delivery while minimizing EHR burden.
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Affiliation(s)
- Lisa S Rotenstein
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - A Jay Holmgren
- Division of Hospital Medicine, Department of Medicine, University of California at San Francisco
| | - Michael J Healey
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Daniel M Horn
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - David Y Ting
- Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics, Massachusetts General Hospital, Boston
| | - Stuart Lipsitz
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hojjat Salmasian
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Richard Gitomer
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - David W Bates
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
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Kaplan DE, Serper M, Kaushik A, Durkin C, Raad A, El-Moustaid F, Smith N, Yehoshua A. Cost-effectiveness of direct-acting antivirals for chronic hepatitis C virus in the United States from a payer perspective. J Manag Care Spec Pharm 2022; 28:1138-1148. [PMID: 36125059 PMCID: PMC10373042 DOI: 10.18553/jmcp.2022.28.10.1138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Direct-acting antivirals (DAAs) have been a breakthrough therapeutic innovation in the treatment of chronic hepatitis C virus (HCV) with significantly improved efficacy, safety, and tolerability. OBJECTIVE: To evaluate the cost-effectiveness of treating patients with HCV with DAAs compared with pre-DAAs or no treatment over a lifetime horizon from the perspective of the US Veterans Affairs (VA) health care system. METHODS: A hybrid decision-tree and Markov model simulated the health outcomes of a cohort of 142,147 patients with HCV with an average age of 63 years. Demographic data, treatment rates and distribution, treatment efficacy by subpopulation, and health state costs were sourced from VA data. Treatment costs and utility values were sourced from publicly available databases and prior publications for older regimens. RESULTS: Over a lifetime horizon, the use of DAAs results in a significant reduction in advanced liver disease events compared with pre-DAA and no treatment. Total cost savings of $7 and $9 billion over a lifetime horizon (50 years) were predicted for patients who received DAA treatments compared with patients treated with pre-DAA treatments and those who were untreated, respectively. Cost savings were achieved quickly after treatment, with DAAs being inexpensive when compared with both the pre-DAA and untreated scenarios within 5 years. The DAA intervention dominated (ie, more effective and less costly) for both the pre-DAA and untreated strategies on both a per-patient and cohort basis. CONCLUSIONS: The use of DAA-based treatments in patients with HCV in the VA system significantly reduced long-term HCV-related morbidity and mortality, while providing cost savings within only 5 years of treatment. DISCLOSURES: This work was supported by Gilead Inc. Health Economic Outcomes Research group, grant number GS-US-18-HCV003. Drs Yehoshua and Kaushik are employees of Gilead in the Health Economic Outcome Research group. These individuals reviewed the manuscript but did not contribute to input or output of the Markov model. Maple Health Group (Dr El-Moustaid, Ms Raad, and Dr Smith) are consultants hired by Gilead for Markov modeling expertise. The model used in this study was previously published and peer reviewed. Data inputted into the model related to patient demographic, treatment outcomes, clinical outcomes, and costs were completely independent in derivation by Drs Kaplan, Serper, and Durkin and were not influenced by the funding sponsor. Dr Kaplan reports grants from Gilead Inc. during the conduct of the study and grants from Gilead Inc., other from Glycotest Inc., other from AstraZeneca, other from Exact Sciences, and other from Bayer outside the submitted work.
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Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Gastroenterology Section, Philadelphia VA Medical Center, PA
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Gastroenterology Section, Philadelphia VA Medical Center, PA
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, PA
| | | | - Claire Durkin
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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10
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Christy SM, Reich RR, Rathwell JA, Vadaparampil ST, Isaacs-Soriano KA, Friedman MS, Roetzheim RG, Giuliano AR. Using the Electronic Health Record to Characterize the Hepatitis C Virus Care Cascade. Public Health Rep 2022; 137:498-505. [PMID: 33831316 PMCID: PMC9109542 DOI: 10.1177/00333549211005812] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Chronic hepatitis C virus (HCV) infection is one of the main causes of hepatocellular carcinoma. Before initiating a multilevel HCV screening intervention, we sought to (1) describe concordance between the electronic health record (EHR) data warehouse and manual medical record review in recording aspects of HCV testing and treatment and (2) estimate the percentage of patients with chronic HCV infection who initiated and completed HCV treatment using manual medical record review. METHODS We examined the medical records for 177 patients (100 randomly selected patients born during 1945-1965 without evidence of HCV testing and 77 adult patients of any birth cohort who had completed HCV testing) with a primary care or relevant specialist visit at an academic health care system in Tampa, Florida, from 2015 through 2018. We used the Cohen κ coefficient to examine the degree of concordance between the searchable data warehouse and the medical record review abstractions. Descriptive statistics characterized referral to and receipt of treatment among patients with chronic HCV infection from medical record review. RESULTS We found generally good concordance between the data warehouse abstraction and medical record review for HCV testing data (κ ranged from 0.66 to 0.87). However, the data warehouse failed to capture data on HCV treatment variables. According to medical record review, 28 patients had chronic HCV infection; 16 patients were prescribed treatment, 14 initiated treatment, and 9 achieved and had a reported posttreatment undetected HCV viral load. CONCLUSIONS Using data warehouse data provides generally reliable HCV testing information. However, without the use of natural language processing and purposeful EHR design, manual medical record reviews will likely be required to characterize treatment initiation and completion.
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Affiliation(s)
- Shannon M. Christy
- Department of Health Outcomes and Behavior, Division of
Population Science, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL,
USA
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer
Center and Research Institute, Tampa, FL, USA
- Center for Immunization and Infection Research in Cancer, H. Lee
Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine,
University of South Florida, Tampa, FL, USA
| | - Richard R. Reich
- Biostatistics and Bioinformatics Shared Resource, H. Lee Moffitt
Cancer Center and Research Institute, Tampa, FL, USA
| | - Julie A. Rathwell
- Center for Immunization and Infection Research in Cancer, H. Lee
Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Cancer Epidemiology, Division of Population Science,
H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Susan T. Vadaparampil
- Department of Health Outcomes and Behavior, Division of
Population Science, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL,
USA
- Center for Immunization and Infection Research in Cancer, H. Lee
Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine,
University of South Florida, Tampa, FL, USA
| | - Kimberly A. Isaacs-Soriano
- Center for Immunization and Infection Research in Cancer, H. Lee
Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Cancer Epidemiology, Division of Population Science,
H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Mark S. Friedman
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer
Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine,
University of South Florida, Tampa, FL, USA
| | - Richard G. Roetzheim
- Department of Health Outcomes and Behavior, Division of
Population Science, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL,
USA
- Center for Immunization and Infection Research in Cancer, H. Lee
Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Family Medicine, Morsani College of Medicine,
University of South Florida, Tampa, FL, USA
| | - Anna R. Giuliano
- Center for Immunization and Infection Research in Cancer, H. Lee
Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine,
University of South Florida, Tampa, FL, USA
- Department of Cancer Epidemiology, Division of Population Science,
H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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11
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Tien A, Sahota A, Yang SJ, Balbuena R, Chang M, Lim C, Fong TL. Prevalence and Characteristics of Chronic Hepatitis C Among Asian Americans Are Distinct From Other Ethnic Groups. J Clin Gastroenterol 2021; 55:884-890. [PMID: 33074947 DOI: 10.1097/mcg.0000000000001447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/12/2020] [Indexed: 01/22/2023]
Abstract
GOAL The goal of this study was to determine the prevalence and characteristics of chronic hepatitis C (CHC) among Asian Americans compared with other ethnicities. BACKGROUND Chronic hepatitis C virus (HCV) affects an estimated 2.7 million in the United States, but there are limited data on HCV among Asian Americans. STUDY A total of 3,369,881 adults over the age of 18 who were patients of the integrated health care system in Southern California and 4903 Asian participants at community hepatitis screenings were included in a cross-sectional study. Variables included HCV serology, HCV genotype, comorbidities, and coinfections. RESULTS The prevalence of CHC was 1.3% in the general population (8271 adults) and 0.6% among Asians. The prevalence of CHC was significantly higher in the 1945-1965 birth cohort with 2.7% (5876) in the general population and 1.0% (313) among Asians (P<0.001). Asians had the highest rates of hepatitis B coinfection (2.9% vs. 0.2%, P<0.001). The distribution of genotypes among Asians differed from the general population with the most common genotype being 1b (27.5%) and a higher presence of genotype 6 (9.5%) (P<0.001). The presence of cirrhosis was 17.6% in Asians. Disaggregated Asian data showed that CHC was highest among Vietnamese and Cambodian and that genotype 6 was predominant among these 2 subgroups. CONCLUSIONS The prevalence of chronic HCV was significantly lower in Asians compared with other ethnicities. However, disaggregated data among Asians showed the highest prevalence rates among adults from Vietnam and Cambodia.
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Affiliation(s)
| | - Amandeep Sahota
- Gastroenterology, Kaiser Permanente Los Angeles Medical Center
| | - Su-Jau Yang
- Department of Research and Evaluation, Southern California Kaiser Permanente, Pasadena, CA
| | - Ronald Balbuena
- Department of Research and Evaluation, Southern California Kaiser Permanente, Pasadena, CA
| | - Mimi Chang
- Asian Pacific Liver Center, St. Vincent Medical Center
| | - Carolina Lim
- Asian Pacific Liver Center, St. Vincent Medical Center
| | - Tse-Ling Fong
- Asian Pacific Liver Center, St. Vincent Medical Center
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine at University of Southern California, Los Angeles
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You Can't Have One Without the Other: Innovation and Ethical Dilemmas in Gastroenterology and Hepatology. Clin Gastroenterol Hepatol 2021; 19:2015-2019. [PMID: 32445954 DOI: 10.1016/j.cgh.2020.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/08/2020] [Accepted: 05/13/2020] [Indexed: 02/07/2023]
Abstract
Medical innovation and ethical dilemmas are intertwined in gastroenterology and hepatology. This narrative review explores direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) as a touchstone example of how medical innovation breeds ethical dilemmas. A few quandaries-informed consent as well as informed deferral during the first wave of DAA approvals, sobriety restrictions from payors, and high DAA costs for patients-are addressed through the lens of the foundational principles of clinical medical ethics: autonomy, beneficence, non-maleficence, justice, and utility. By placing these issues within a medical ethics framework, we hope not only to focus on the solutions that the gastroenterology and hepatology community developed in the advent of DAA therapy, but to highlight an ethical paradigm that can be applied to similar dilemmas that will be faced as new therapies for other gastrointestinal diseases are approved.
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Abstract
Purpose of review This review provides an overview of the current state of research around improving healthcare delivery for patients with cirrhosis in the outpatient, inpatient, and transitional care settings. Recent findings Recent studies have broadly employed changes to the model of care delivery, team composition, and technology to improve cirrhosis care. In the outpatient setting, approaches have included engaging caregivers, patient navigators, and non-physicians and using virtual care, smartphone applications, and wearables. Inpatient care approaches have focused on the role of interdisciplinary teams, education interventions, and changes to the medical record system, while post-discharge interventions have included day hospitals and care coordinator interventions. This review also describes the Veterans Health Administration’s novel, population-level approach to delivery of cirrhosis care, and addressed how the pandemic has impacted the delivery of cirrhosis care. Summary Comprehensive, evidence-based approaches to delivering high-quality cirrhosis care continue to evolve to meet the needs of a growing population in an ever-changing healthcare environment.
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14
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Rogal SS, Yakovchenko V, Gonzalez R, Park A, Beste LA, Rozenberg-Ben-Dror K, Bajaj JS, Scott D, McCurdy H, Comstock E, Sidorovic M, Gibson S, Lamorte C, Nobbe A, Chartier M, Ross D, Dominitz JA, Morgan TR. The Hepatic Innovation Team Collaborative: A Successful Population-Based Approach to Hepatocellular Carcinoma Surveillance. Cancers (Basel) 2021; 13:cancers13092251. [PMID: 34067177 PMCID: PMC8125814 DOI: 10.3390/cancers13092251] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Liver cancer is a growing problem that largely impacts people with cirrhosis. This article describes the Veterans Health Administration’s national cirrhosis quality improvement program and its focus on early detection of liver cancer. Abstract After implementing a successful hepatitis C elimination program, the Veterans Health Administration’s (VHA) Hepatic Innovation Team (HIT) Collaborative pivoted to focus on improving cirrhosis care. This national program developed teams of providers across the country and engaged them in using systems redesign methods and population health approaches to improve care. The HIT Collaborative developed an Advanced Liver Disease (ALD) Dashboard to identify Veterans with cirrhosis who were due for surveillance for hepatocellular carcinoma (HCC) and other liver care, promoted the use of an HCC Clinical Reminder in the electronic health record, and provided training and networking opportunities. This evaluation aimed to describe the VHA’s approach to improving cirrhosis care and identify the facility factors and HIT activities associated with HCC surveillance rates, using a quasi-experimental design. Across all VHA facilities, as the HIT focused on cirrhosis between 2018–2019, HCC surveillance rates increased from 46% (IQR 37–53%) to 51% (IQR 42–60%, p < 0.001). The median HCC surveillance rate was 57% in facilities with high ALD Dashboard utilization compared with 45% in facilities with lower utilization (p < 0.001) and 58% in facilities using the HCC Clinical Reminder compared with 47% in facilities not using this tool (p < 0.001) in FY19. Increased use of the ALD Dashboard and adoption of the HCC Clinical Reminder were independently, significantly associated with HCC surveillance rates in multivariate models, controlling for other facility characteristics. In conclusion, the VHA’s HIT Collaborative is a national healthcare initiative associated with significant improvement in HCC surveillance rates.
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Affiliation(s)
- Shari S. Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA 15240, USA; (S.G.); (C.L.)
- Departments of Medicine and Surgery, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15240, USA
- Correspondence: ; Tel.: +1-412-360-6177
| | - Vera Yakovchenko
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Building 70, Bedford, MA 01730, USA;
| | - Rachel Gonzalez
- Department of Veterans Affairs, Sierra Pacific Veterans Integrated Service Network, Pharmacy Benefits Management, Mather, CA 94523, USA;
| | - Angela Park
- Office of Healthcare Transformation, Department of Veterans Affairs, 810 Vermont Avenue, Washington, DC 20420, USA;
| | - Lauren A. Beste
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA;
- General Medicine Service, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Karine Rozenberg-Ben-Dror
- Veteran Affairs Great Lakes Health Care System, VISN 12 PBM, 11301 W Cermak Road, Ste 810, Westchester, IL 60154, USA;
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, 1200 E Broad Street, West Hospital, 14th Floor, Box 980341, Richmond, VA 23298, USA;
- Division of Gastroenterology, Central Virginia Veterans Affairs Healthcare System, 1201 Broad Rock Blvd, Richmond, VA 23249, USA
| | - Dawn Scott
- Department of Medicine, Central Texas Veterans Healthcare System, 1901 Veterans Memorial Drive, Temple, TX 76504, USA;
| | - Heather McCurdy
- VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI 48105, USA;
| | - Emily Comstock
- Department of Infectious Diseases, Baltimore VA Medical Center, 10 N Greene Street, Baltimore, MD 21201, USA;
| | - Michael Sidorovic
- Salisbury VA Medical Center, 1601 Brenner Avenue, Salisbury, NC 28144, USA;
| | - Sandra Gibson
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA 15240, USA; (S.G.); (C.L.)
| | - Carolyn Lamorte
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA 15240, USA; (S.G.); (C.L.)
| | - Anna Nobbe
- Digestive Disease Section, Cincinnati VA Medical Center, 3200 Vine Street, Cincinnati, OH 45220, USA;
| | - Maggie Chartier
- HIV, Hepatitis, and Related Conditions, Office of Specialty Care Services (10P11I), Department of Veterans Affairs, 810 Vermont Avenue, Washington, DC 20420, USA; (M.C.); (D.R.)
| | - David Ross
- HIV, Hepatitis, and Related Conditions, Office of Specialty Care Services (10P11I), Department of Veterans Affairs, 810 Vermont Avenue, Washington, DC 20420, USA; (M.C.); (D.R.)
| | - Jason A. Dominitz
- Gastroenterology Section, Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA;
- Division of Gastroenterology, Department of Medicine, RR-512, Health Sciences Building, University of Washington School of Medicine, Box 356420, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Timothy R. Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, 5901 E 7th Street, Long Beach, CA 90822, USA;
- Division of Gastroenterology, Department of Medicine, University of California, 333 City Blvd. West, Suite 400, Orange, CA 92868, USA
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Patel AA, Bui A, Prohl E, Bhattacharya D, Wang S, Branch AD, Perumalswami PV. Innovations in Hepatitis C Screening and Treatment. Hepatol Commun 2021; 5:371-386. [PMID: 33681673 PMCID: PMC7917266 DOI: 10.1002/hep4.1646] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/20/2020] [Accepted: 11/01/2020] [Indexed: 12/11/2022] Open
Abstract
New therapies offer hope for a cure to millions of persons living with hepatitis C virus (HCV) infection. HCV elimination is a global goal that will be difficult to achieve using the traditional paradigms of diagnosis and care. The current standard has evolved toward universal HCV screening and treatment, to achieve elimination goals. There are several steps between HCV diagnosis and cure with major barriers along the way. Innovative models of care can address barriers to better serve hardly reached populations and scale national efforts in the United States and abroad. Herein, we highlight innovative models of HCV care that aid in our progress toward HCV elimination.
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Affiliation(s)
- Arpan A. Patel
- Division of Digestive DiseasesDavid Geffen School of Medicine at UCLALos AngelesCAUSA
- Greater Los Angeles Veterans Affairs Medical CenterLos AngelesCAUSA
| | - Aileen Bui
- Division of General Internal MedicineDavid Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Eian Prohl
- Division of General Internal MedicineDavid Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Debika Bhattacharya
- Greater Los Angeles Veterans Affairs Medical CenterLos AngelesCAUSA
- Division of Infectious DiseasesDavid Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Su Wang
- Saint Barnabas Medical CenterLivingstonNJUSA
- World Hepatitis AllianceLondonUnited Kingdom
| | - Andrea D. Branch
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Ponni V. Perumalswami
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
- Veterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
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Rates and Predictors of Undergoing Different Hepatocellular Carcinoma Screening Tests in Patients With Cirrhosis. Am J Gastroenterol 2021; 116:411-415. [PMID: 33252455 DOI: 10.14309/ajg.0000000000001000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 09/16/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION We aimed to assess rates and predictors of hepatocellular carcinoma (HCC) screening among patients with cirrhosis. METHODS We reviewed electronic health records of 11,361 patients with cirrhosis from 11 U.S. Veterans Health Administration facilities for receipt of HCC screening in the 6 months preceding October 1, 2019. RESULTS Nearly half of the cohort (46%) received HCC screening over a 6-month period. Screening rates and modalities (ultrasound, computed tomography, magnetic resonance imaging, serum alpha fetoprotein) varied by facility. Screening was associated with race/ethnicity, body mass index ≥ 25, cirrhosis etiology, thrombocytopenia, Fibrosis-4 ≥ 3.25, and lower Model for End-Stage Liver Disease-Sodium. DISCUSSION HCC screening rates varied by facility. Higher risk patients were more likely to receive screening.
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Habchi J, Thomas AM, Sprecht-Walsh S, Arias E, Bratberg J, Hurley L, Hart S, Taylor LE. Optimizing Hepatitis C Virus (HCV) Treatment in a US Colocated HCV/Opioid Agonist Therapy Program. Open Forum Infect Dis 2020; 7:ofaa310. [PMID: 33072802 PMCID: PMC7550646 DOI: 10.1093/ofid/ofaa310] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023] Open
Abstract
Background A minority of patients with opioid use disorder are treated for hepatitis C virus infection (HCV). While colocated HCV and opioid agonist therapy (OAT) along with harm reduction can facilitate prevention and cascade to cure, there are few real-world examples of such embedded care models in the United States in the direct-acting antiviral (DAA) era. Methods We conducted a retrospective chart review to determine sustained virologic response (SVR) and reinfection rates during the first 5-year period of DAA availability among individuals tested and treated on-site at Rhode Island’s only nonprofit methadone maintenance program. Results Of 275 who initiated DAAs, the mean age (range) was 43 (22–71) years, 34.5% were female, 57.5% had genotype 1a, 23.3% had cirrhosis, and 92% were Medicaid recipients. SVR was 85.0% (232/273), while modified intent-to-treat SVR was 93.2% (232/249); 17 patients did not achieve SVR, 2 awaited SVR 12 weeks post-end-of-treatment, and 24 were lost to follow-up. Thirty reinfections were identified over 375.5 person-years of follow-up (rate, 7.99/100 person-years). The median time to first reinfection (interquartile range) was 128 (85.25–202.5) days. Before July 1, 2018, 72 patients accessed DAAs over 3.7 years; after Medicaid DAA restrictions were lifted, 109 patients accessed DAAs over 1.3 years. The Prior Authorization (PA) process requires many steps, differing across 11 RI insurers, taking 45–120 minutes per patient. Conclusions DAA treatment was effective among a marginalized population in an urban colocated OAT/HCV program. Removing DAA restrictions facilitates treatment initiation. The PA process remains a modifiable barrier to expanding capacity in the United States.
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Affiliation(s)
- Jackie Habchi
- CODAC Behavioral Healthcare, Providence, Rhode Island, USA
| | | | | | - Elenita Arias
- CODAC Behavioral Healthcare, Providence, Rhode Island, USA
| | | | - Linda Hurley
- CODAC Behavioral Healthcare, Providence, Rhode Island, USA
| | - Susan Hart
- CODAC Behavioral Healthcare, Providence, Rhode Island, USA
| | - Lynn E Taylor
- CODAC Behavioral Healthcare and University of Rhode Island, Providence, Rhode Island, USA
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18
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Strategy Configurations Directly Linked to Higher Hepatitis C Virus Treatment Starts: An Applied Use of Configurational Comparative Methods. Med Care 2020; 58:e31-e38. [PMID: 32187105 DOI: 10.1097/mlr.0000000000001319] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Department of Veterans Affairs (VA) cares for more patients with hepatitis C virus (HCV) than any other US health care system. We tracked the implementation strategies that VA sites used to implement highly effective new treatments for HCV with the aim of uncovering how combinations of implementation strategies influenced the uptake of the HCV treatment innovation. We applied Configurational Comparative Methods (CCMs) to uncover causal dependencies and identify difference-making strategy configurations, and to distinguish higher from lower HCV treating sites. METHODS We surveyed providers to assess VA sites' use of 73 implementation strategies to promote HCV treatment in the fiscal year 2015. CCMs were used to identify strategy configurations that uniquely distinguished higher HCV from lower HCV treating sites. RESULTS From the 73 possible implementation strategies, CCMs identified 5 distinct strategy configurations, or "solution paths." These were comprised of 10 individual strategies that collectively explained 80% of the sites with higher HCV treatment starts with 100% consistency. Using any one of the following 5 solution paths was sufficient to produce higher treatment starts: (1) technical assistance; (2) engaging in a learning collaborative AND designating leaders; (3) site visits AND outreach to patients to promote uptake and adherence; (4) developing resource sharing agreements AND an implementation blueprint; OR (5) creating new clinical teams AND sharing quality improvement knowledge with other sites AND engaging patients. There was equifinality in that the presence of any one of the 5 solution paths was sufficient for higher treatment starts. CONCLUSIONS Five strategy configurations distinguished higher HCV from lower HCV treating sites with 100% consistency. CCMs represent a methodological advancement that can help inform high-yield implementation strategy selection and increase the efficiency and effectiveness of future implementation efforts.
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Turner BJ, Rochat A, Lill S, Bobadilla R, Hernandez L, Choi A, Guerrero JA. Hepatitis C Virus Screening and Care: Complexity of Implementation in Primary Care Practices Serving Disadvantaged Populations. Ann Intern Med 2019; 171:865-874. [PMID: 31791065 DOI: 10.7326/m18-3573] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) disproportionately affects disadvantaged communities. OBJECTIVE To examine processes and outcomes of Screen, Treat, Or Prevent Hepatocellular Carcinoma (STOP HCC), a multicomponent intervention for HCV screening and care in safety-net primary care practices. DESIGN Mixed-methods retrospective analysis. SETTING 5 federally qualified health centers (FQHCs) and 1 family medicine residency program serving low-income communities in diverse locations with largely Hispanic populations. PATIENTS Persons born in 1945 through 1965 (baby boomers) who had never been tested for HCV and were followed through May 2018. INTERVENTION The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model guided implementation and evaluation. Test costs were covered for uninsured patients. MEASUREMENTS All practices tested patients for anti-HCV antibody (anti-HCV) and HCV RNA. For uninsured patients with chronic HCV in 4 practices, quantitative data also enabled assessment of HCV staging, specialist teleconsultation, direct-acting antiviral (DAA) treatment, and sustained virologic response (SVR). Implementation fidelity and adaptation were assessed qualitatively. RESULTS Anti-HCV screening was done in 13 334 of 27 700 baby boomers (48.1%, varying by practice from 19.8% to 71.3%). Of 695 anti-HCV-positive patients, HCV RNA was tested in 520 (74.8%; 48.9% to 92.9% by practice), and 349 persons (2.6% of those screened) were diagnosed with chronic HCV. In 4 FQHCs, 174 (84.9%) of 205 uninsured patients with chronic HCV had disease staging, 145 (70.7%) had teleconsultation review, 119 (58.0%) were recommended to start DAA therapy, 82 (40.0%) initiated free DAA therapy, 74 (36.1%) completed therapy (27.8% to 60.0% by practice), and 70 (94.6% of DAA completers) achieved SVR. Implementation was promoted by multilevel practice engagement, patient navigation, and anti-HCV screening with reflex HCV RNA testing. LIMITATION No control practices were included, and data were missing for some variables. CONCLUSION Despite a similar framework for STOP HCC implementation, performance varied widely across safety-net practices, which may reflect practice engagement as well as infrastructure or cost challenges beyond practice control. PRIMARY FUNDING SOURCE Cancer Prevention & Research Institute of Texas and Centers for Medicare & Medicaid Services.
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Affiliation(s)
- Barbara J Turner
- Joe R. and Teresa Lozano Long School of Medicine and Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas, and Keck Medical Center and Gehr Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, California (B.J.T.)
| | - Andrea Rochat
- Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas (A.R., S.L., R.B., L.H.)
| | - Sarah Lill
- Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas (A.R., S.L., R.B., L.H.)
| | - Raudel Bobadilla
- Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas (A.R., S.L., R.B., L.H.)
| | - Ludivina Hernandez
- Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas (A.R., S.L., R.B., L.H.)
| | - Aro Choi
- Joe R. and Teresa Lozano Long School of Medicine and Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas (A.C.)
| | - Juan A Guerrero
- Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas (J.A.G.)
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20
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Dunn SH, Rogal SS, Maier MM, Chartier M, Morgan TR, Beste LA. Access to Comprehensive Services for Advanced Liver Disease in the Veterans Health Administration. Dig Dis Sci 2019; 64:3471-3479. [PMID: 31432344 DOI: 10.1007/s10620-019-05785-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 08/07/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND The Veterans Health Administration (VHA) provides care to the one of the largest cohorts of patients with advanced liver disease (ALD) in the USA. AIMS We performed a national survey to assess system-wide strengths and barriers to care for Veterans with ALD in this national integrated healthcare setting. METHODS A 52-item survey was developed to assess access and barriers to care in Veterans with ALD. The survey was distributed to all VHA medical centers in 2015. Results were analyzed using descriptive statistics. RESULTS One hundred and fifty-three sites responded to this survey. Multidisciplinary services were available on-site at > 80% of sites. Ninety-five percent of sites had mental health and addictions treatment available, with 14% co-locating these services within the liver clinic. Few sites (< 25%) provided pharmacologic treatment for alcohol use disorder in primary care or hepatology settings. Seventy-two percent of sites reported at least one barrier to liver-related care. Of the sites reporting at least one barrier, 53% reported barriers to liver transplant referral, citing complex processes and lack of staff/resources to coordinate referrals. Palliative care was widely available, but 61% of sites reported referring < 25% of their patients with ALD for palliative services. CONCLUSION Multidisciplinary services for Veterans with ALD are widely available at VHA sites, though barriers to optimal care remain. Opportunities for improvement include the expansion of providers with hepatology expertise, integrating pharmacotherapy for alcohol use disorder into hepatology and primary care, streamlining the transplant referral process, and expanding palliative care referrals for patients with ALD.
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Affiliation(s)
- S Hunter Dunn
- Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
| | - Shari S Rogal
- Departments of Surgery and Medicine, VA Pittsburgh Healthcare System, 1 University Drive, Pittsburgh, PA, 15240, USA
| | - Marissa M Maier
- Division of Infectious Diseases, VA Portland Health Care System, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA
| | - Maggie Chartier
- HIV, Hepatitis, and Related Conditions Programs Office of Specialty Care Services, U.S. Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC, 20571, USA
| | - Timothy R Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, 5901 E. Seventh Street, Long Beach, CA, 90822, USA
| | - Lauren A Beste
- General Medicine Service, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA
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21
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Davis BC, Gilles H, Fuchs M. Hooray for the VHA! A Survey of Access and Barriers to Liver Care Among Veterans. Dig Dis Sci 2019; 64:3361-3362. [PMID: 31591680 DOI: 10.1007/s10620-019-05874-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Brian C Davis
- Hepatology Section, McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA, 23249, USA.
| | - HoChong Gilles
- Hepatology Section, McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA, 23249, USA
| | - Michael Fuchs
- Hepatology Section, McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA, 23249, USA
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22
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Taye BW. A Path to Ending Hepatitis C in Ethiopia: A Phased Public Health Approach to Achieve Micro-Elimination. Am J Trop Med Hyg 2019; 101:963-972. [PMID: 31516107 PMCID: PMC6838594 DOI: 10.4269/ajtmh.19-0295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/20/2019] [Indexed: 12/12/2022] Open
Abstract
Ethiopia's hepatitis C virus (HCV) prevalence is predicted to rise by 2030. To halt this increasing trend, a suitable approach to the elimination of HCV is needed. This review explores the current status, challenges, and opportunities and outlines a strategy for the micro-elimination approach in Ethiopia. I searched PubMed and EMBASE using combined Medical Subject Heading databases for the literature on HCV micro-elimination. A phased public health approach to HCV micro-elimination, including preparation/capacity building (phase I), implementation (phase II), and rollout and scale-up (phase III), targeting people living with HIV, prisoners, chronic hepatitis and cancer patients, blood donors, and pregnant women is a pragmatic strategy to Ethiopia. This can be implemented at general and tertiary care referral hospitals with a future scale-up to district hospitals through task-shifting by training general practitioners, nurses, laboratory technologists, and pharmacists. Availability of the highly effective direct-acting antivirals (DAAs) can be ensured by expanding the existing program that provides highly subsidized DAAs through an agreement with Gilead Sciences, Inc. and eventually aiming at domestic generic manufacturing. The significant enablers to HCV micro-elimination in Ethiopia include the control of healthcare-associated HCV infection, blood safety, access to affordable testing and pan-genotypic DAAs, task-shifting, multisectoral partnership, and regulatory support. General population-based HCV screening and treatment are not cost-effective for Ethiopia because of high cost, program complexity, and disease epidemiology.
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Affiliation(s)
- Belaynew Wasie Taye
- Address correspondence to Belaynew Wasie Taye, Faculty of Medicine, The University of Queensland, Herston Rd., Brisbane 4006, Australia. E-mails: or
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23
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Koren DE, Zuckerman A, Teply R, Nabulsi NA, Lee TA, Martin MT. Expanding Hepatitis C Virus Care and Cure: National Experience Using a Clinical Pharmacist-Driven Model. Open Forum Infect Dis 2019; 6:5528030. [PMID: 31363775 PMCID: PMC6667715 DOI: 10.1093/ofid/ofz316] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/02/2019] [Indexed: 12/25/2022] Open
Abstract
Background The US National Viral Hepatitis Action Plan depends on additional providers to expand hepatitis C virus (HCV) treatment capacity in order to achieve elimination goals. Clinical pharmacists manage treatment and medication within interdisciplinary teams. The study’s objective was to determine sustained virologic response (SVR) rates for clinical pharmacist–delivered HCV therapy in an open medical system. Methods Investigators conducted a multicenter retrospective cohort study of patients initiating direct-acting antivirals from January 1, 2014, through March 12, 2018. Data included demographics, comorbidities, treatment, and clinical outcomes. The primary outcome of SVR was determined for patients initiating (intent-to-treat) and those who completed (per-protocol) treatment. Chi-square tests were conducted to identify associations between SVR and adverse reactions, drug–drug interactions, and adherence. Results A total of 1253 patients initiated treatment; 95 were lost to follow-up, and 24 discontinued therapy. SVR rates were 95.1% (1079/1134) per protocol and 86.1% (1079/1253) intent to treat. The mean age (SD) was 57.4 (10.1) years, the mean body mass index (SD) was 28.7 (6.2) kg/m2, 63.9% were male, 53.7% were black, 40.3% were cirrhotic, 88.4% were genotype 1, and 81.6% were treatment-naïve. Patients missing ≥1 dose had an SVR of 74.9%; full adherence yielded 90% (P < .0001). Conclusions HCV treatment by clinical pharmacists in an open medical system resulted in high SVR rates comparable to real-world studies with specialists and nonspecialists. These findings demonstrate the success of a clinical pharmacist–delivered method for HCV treatment expansion and elimination.
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Affiliation(s)
- David E Koren
- Temple University Health System, Philadelphia, Pennsylvania
| | - Autumn Zuckerman
- Specialty Pharmacy Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robyn Teply
- Creighton University School of Pharmacy & Health Professions, Omaha, Nebraska
| | - Nadia A Nabulsi
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Michelle T Martin
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois.,University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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Houck KK, Ifeachor AP, Fleming BS, Andres AM, O'Donovan KN, Johnson AJ, Liangpunsakul S. Pharmacist-driven multidisciplinary pretreatment workup process for hepatitis C care: A novel model for same-day pretreatment workup. J Am Pharm Assoc (2003) 2019; 59:710-716. [PMID: 31227418 DOI: 10.1016/j.japh.2019.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/07/2019] [Accepted: 05/12/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The objective is to describe and quantify the impact of a novel practice model for pharmacist involvement in care coordination and patient education in hepatitis C virus (HCV) care. SETTING This practice model was implemented in the gastroenterology clinic at the Richard L. Roudebush Veterans Affairs Medical Center in Indianapolis, Indiana. PRACTICE DESCRIPTION Traditional pretreatment workup for HCV requires multiple on-site appointments to complete imaging and laboratory assessments and for provider and social work appointments. High pretreatment time burden and increasing psychosocial complexity of the patient population present significant barriers to HCV eradication. Patients frequently miss appointments, and each on-site visit creates a separate opportunity for patients to be lost to follow-up. PRACTICE INNOVATION The pharmacist-driven multidisciplinary pretreatment workup process was launched by HCV pharmacists to mitigate barriers. Patients complete the pretreatment evaluation process, which includes same-day pharmacy education, provider visit, social work assessment, FibroScan, and laboratory assessments, in approximately 2.5 hours. EVALUATION Forty-six patients who completed the pharmacist-driven multidisciplinary pretreatment workup process versus 235 patients who completed traditional workup were analyzed for time from date of HCV consultation placement to treatment start and time from most recent HCV provider visit to treatment start. RESULTS From time of HCV consult entry to date of treatment start, patients were initiated on HCV treatment in an average of 42.2 ± 7.5 days and 184.1 ± 27.6 days (P = 0.0001) within the intervention and traditional workup groups, respectively. A decreased time from most recent HCV provider visit to treatment initiation was noted between groups with 38.2 ± 7.1 days and 54.7 ± 3.6 days (P = 0.04) in the intervention and traditional workup groups, respectively. CONCLUSION The pharmacist-driven multidisciplinary pretreatment workup process is an effective way to engage patients and decrease time to treatment initiation. This model could be replicated in other practice settings, especially those challenged by multi-step care coordination.
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Yakovchenko V, Bolton RE, Drainoni ML, Gifford AL. Primary care provider perceptions and experiences of implementing hepatitis C virus birth cohort testing: a qualitative formative evaluation. BMC Health Serv Res 2019; 19:236. [PMID: 31014322 PMCID: PMC6480846 DOI: 10.1186/s12913-019-4043-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/27/2019] [Indexed: 11/23/2022] Open
Abstract
Background In 2014, the Department of Veterans Affairs (VA) adopted a screening test policy for hepatitis C virus (HCV) in all “Baby Boomers” - those born between 1945 and 1965. About 1 in 12 Veterans were estimated to be infected with HCV yet approximately 34% of the birth cohort remained untested. Early HCV diagnosis and successful antiviral treatment decrease the risk of onward transmission, cirrhosis, hepatocellular carcinoma, liver transplant, and death. Implementing evidence-based HCV screening in primary care has great potential to reduce morbidity and mortality. To inform design and implementation of a quality improvement intervention, we studied primary care provider (PCP) perceptions of and experiences with HCV birth cohort testing. Methods We conducted a formative evaluation using qualitative semi-structured interviews guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Twenty-two PCPs in six states across a large integrated US healthcare system were interviewed. Content analysis with a priori and emergent codes was performed on verbatim interview transcripts. Results We identified three themes related to primary care provider HCV testing and linkage practices, as mapped to i-PARIHS constructs: 1) evaluating cues to HCV testing (innovation/evidence), 2) framing HCV testing decisions (recipients), and 3) HCV testing and linkage to care in the new treatment era (context). The most frequently reported HCV testing cue was an electronic clinical reminder alert, followed by clinical markers and the presence of behavioral risk factors. Most PCPs saw testing as routine, but less urgent, leading to some reluctance. Providers largely saw themselves as performing guideline-concordant testing, yet no performance data were available to assess performance. Given the recent availability of new HCV medications, many PCPs were highly motivated to test and link patients to specialty care for treatment. Conclusions Our results suggest a multi-component intervention around awareness and education, feedback of performance data, clinical reminder updates, and leadership support, would address both a significant need, and be deemed acceptable and feasible to primary care providers. Electronic supplementary material The online version of this article (10.1186/s12913-019-4043-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vera Yakovchenko
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road (152), Building 70, Bedford, MA, 01730, USA.
| | - Rendelle E Bolton
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road (152), Building 70, Bedford, MA, 01730, USA.,Brandeis University, Heller School for Social Policy and Management, Waltham, MA, USA
| | - Mari-Lynn Drainoni
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road (152), Building 70, Bedford, MA, 01730, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Public Health, Boston, MA, USA
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Public Health, Boston, MA, USA
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