J-101 Diagnosis and treatment of HCV in the VA healthcare system
Authors: Gonzalez Rachel , Park Angela , Belperio Pamela , Ross David , Chartier Maggie , Morgan Timothy 
Published: April 2019

More than 145,000 Veterans were known to be HCV viremic and approximately 66% of the 1945–1965 birth cohort had been screened for HCV when all-oral direct acting antivirals (DAAs) were placed on the VA formulary in January 2015. Although the VA had addressed HCV screening and treatment for more than 15 years, the availability of highly effective treatments heightened the focus on HCV. Beginning in FY15, Congress appropriated additional funds for DAAs. VA negotiated favorable pricing for DAAs and wrote guidelines that allowed treatment of patients with and without cirrhosis as well as those with ongoing substance use disorders or mental health conditions. Training nurse practitioners (NP), physician assistants (PA), and clinical pharmacists (PharmD) resulted in more than 60% of patients being treated by non-physicians, with excellent success. In anticipation of the availability of DAAs, the VA created the National Hepatitis C Resource Center (NHCRC) to oversee HCV care in VHA in 2014. In collaboration with the VA's New England Veteran Engineering Resource Center (VERC), the NHCRC created VISN-based Hepatitis Innovation.

Teams (HITs). Composed of HCV providers and system redesign (process improvement) experts, HITs were coached in the use of Lean methodology to identify gaps in current care, develop solutions and implement changes, and measure improvement in care. Annually, each HIT prepared an A3 (plan) describing their goals for improving HCV diagnosis and treatment. HITs reported activities towards their annual goals and shared their successful practices (“best practices”) on monthly conference calls with HIT leadership coaches and other VISNs. Data on HCV screening and treatment starts, by facility, was updated monthly on the VA website, and was critical for implementing change. Annually, HIT leadership established goals for screening, treatment, and sustained virologic response (SVR) (steps in the HCV care cascade). Progress towards those goals was reviewed monthly with the HITs. The NHCRC's evaluation team assessed implementation strategies used by the most successful HIT's, as measured by treatment starts at the facility. Change infrastructure, develop stakeholder relationships, and use evaluative/iterative strategies were 3 of strategies used by the most successful HITs.

As of summer 2018, HCV screening of the 1945–1965 birth cohort had increased above 80%. The VA had treated more than 110,000 patients with DAAs, which included many with older age (>60), and/or substance use disorders/mental health diagnoses. Approximately 88% of treated patients had been tested for SVR12, and among those tested, SVR12 rates exceeded 95%. Of the approximately 28,000 patients remaining to be treated, it is estimated that between 10 and 15,000 are currently not candidates because of patient preference for non-treatment or treatment-limiting co-morbidities. The number of patients starting treatment each month continues to decline, as it has since ∼6/2016, although >1000 patients still start treatment each month.

In summary, VA has screened > 80% of the 1945–1965 birth cohort in current VA care and treated approximately 75% of the known viremic patients in current VA care. Many of the remaining untreated patients have barriers to HCV treatment that VA is addressing. The VA has a goal of 90-90-90 (screening, treated, documented SVR) by 2020. Sufficient funding for medications, support from leadership, real-time data, and creating and sustaining teams on the ground trained in Lean management and system redesign were critical to VA's successes.