VA Health Care: Further Efforts Needed to Improve Hepatitis C Testing for At-Risk Veterans
Published: 2003-12-12T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Hepatitis C is a chronic disease caused by a blood-borne virus that can lead to potentially fatal liverrelated conditions. In 2001, GAO reported that the VA missed opportunities to test about 50 percent of veterans identified as at risk for hepatitis C. GAO was asked to (1) review VA's fiscal year 2002 performance measurement results in testing veterans at risk for hepatitis C, (2) identify factors that impede VA's efforts to test veterans for hepatitis C, and (3) identify actions taken by VA networks and medical facilities to improve the testing rate of veterans at risk for hepatitis C. GAO reviewed VA's fiscal year 2002 hepatitis C performance results and compared them against VA's national performance goals, interviewed headquarters and field officials in three networks, and conducted a case study in one network.
section_title: What GAO Found
paragraphs: VA's performance measurement result shows that it tested, in fiscal year 2002 or earlier, 5,232 (62 percent) of the 8,501 veterans identified as at risk for hepatitis C in VA's performance measurement sample, exceeding its fiscal year 2002 national goal of 55 percent. Thousands of veterans (about one-third) of those identified as at risk for hepatitis C infection in VA's performance measurement sample were not tested. VA's hepatitis C testing result is a cumulative measure of performance over time and does not only reflect current fiscal year performance. GAO found Network 5 (Baltimore) tested 38 percent of veterans in fiscal year 2002 as compared to Network 5's cumulative performance result of 60 percent. In its case study of Network 5, which was one of the networks to exceed VA's fiscal year 2002 performance goal, GAO identified several factors that impeded the hepatitis C testing process. These factors were tests not being ordered by the provider, ordered tests not being completed, and providers being unaware that needed tests had not been ordered or completed. For more than two-thirds of the veterans identified as at risk but not tested for hepatitis C, the testing process failed because hepatitis C tests were not ordered, mostly due to poor communication between clinicians. For the remaining veterans, the testing process was not completed because orders had expired by the time veterans visited the laboratory or test orders were overlooked because laboratory staff had to scroll back and forth through daily lists, a cumbersome process, to identify active orders. Moreover, during subsequent primary care visits by these untested veterans, providers often did not recognize that hepatitis C tests had not been ordered nor had their results been obtained. Consequently, undiagnosed veterans risk unknowingly transmitting the disease as well as potential complications resulting from delayed treatment. The three networks GAO looked at--5 (Baltimore), 2 (Albany), and 9 (Nashville)--have taken steps intended to improve the testing rate of veterans identified as at risk for hepatitis C. To do this, in two networks officials modified clinical reminders in the computerized medical record to alert providers that for ordered hepatitis C tests, results were unavailable. Officials at two facilities developed a "look back" method to search computerized medical records to identify all at-risk veterans who had not yet been tested and identified approximately 3,500 untested veterans. The look back serves as a safety net for veterans identified as at risk for hepatitis C who have not been tested. The modified clinical reminder and look back method of searching medical records appear promising, but neither the networks nor VA has evaluated their effectiveness.

section_title: Letter
paragraphs: In 1998, the Department of Veterans Affairs (VA) launched a major  initiative to screen all veterans treated at VA facilities by asking them a  series of questions about possible risk factors for hepatitis C and  performing blood tests for those veterans identified as being at risk for  contracting the disease. Hepatitis C is a chronic disease caused by a  blood-borne virus that can lead to potentially fatal liver-related conditions.  This initiative represents a major undertaking for VA, which provided  health care services to approximately 4.7 million veterans and identified  over 180,000 veterans with hepatitis C infections in fiscal year 2002.
In June 2001, we testified before your subcommittee that VA was not  conducting hepatitis C risk factor screening for about 80 percent of  veterans making outpatient clinic visits to VA facilities and not testing, on  average, about half of the veterans it identified with at least one risk factor  at four VA facilities we visited. We concluded and VA agreed that for VA  to identify undiagnosed veterans, it would need to establish early  detection as a standard of care and hold managers accountable for the  testing of identified at-risk veterans who receive care in VA’s outpatient  clinics. As a result, VA implemented a hepatitis C screening and testing  process and, in fiscal year 2002, included both screening and testing of  veterans for hepatitis C in its performance measurement system. VA’s  hepatitis C screening and testing performance is measured by reviewing a  sample of veterans’ medical records to determine the percentage of  veterans screened against a list of risk factors for the disease and the  percentage of at-risk veterans who are subsequently tested. To be included  in the hepatitis C testing performance measure, the veteran does not have  to have been tested in fiscal year 2002; testing may have occurred in a  prior fiscal year. VA established its fiscal year 2002 national hepatitis C  testing performance goal at 55 percent. For the veterans’ medical records  to be included in the performance measurement sample, veterans must  have been enrolled to receive VA health care for 2 continuous years and  been seen at least once during the current fiscal year in one of VA’s  primary care clinics.
VA’s hepatitis C screening performance result for fiscal year 2002 was 85  percent, a significant improvement from its baseline result of 51 percent in  fiscal year 2001. As a result, you asked us to focus our work on testing  performance and we (1) reviewed VA’s fiscal year 2002 performance  measurement results in testing veterans it identified as at risk for hepatitis  C, (2) identified factors that impede VA’s efforts to test veterans for  hepatitis C in one VA health care network, and (3) identified actions taken  by VA networks and medical facilities intended to improve the testing rate  of veterans identified as at risk for hepatitis C.
We reviewed VA’s fiscal year 2002 performance measurement process  results in testing veterans it identified as at risk for hepatitis C, the most  recently available data at the time we conducted our work. Specifically, to  assess VA’s fiscal year 2002 performance measurement results, we  compared VA’s national and individual network performance results for  testing veterans in fiscal year 2002 or earlier against VA’s national goal and  analyzed VA’s method for calculating performance results. In addition, we  looked at one VA health care network’s testing rate for at-risk veterans  visiting its clinics in fiscal year 2002. We identified factors that impede  VA’s efforts to test veterans for hepatitis C through a case study of VA’s  Network 5 (Baltimore), which included interviews with network and  facility officials and clinical staff. From the medical record review we were  able to determine if a hepatitis C test was ordered, if the ordered test was  completed, if the veteran visited the laboratory and provider after the test  was ordered, and if a test result was present in the medical record.  Network 5 was chosen for the case study because its rate of hepatitis C  testing was comparable to VA’s national performance results. To identify  actions taken by networks and medical facilities intended to improve the  rate of hepatitis C testing, we expanded our interviews of VA officials and  clinical staff beyond Network 5 (Baltimore) to include staff in Network 2  (Albany) and Network 9 (Nashville). For a complete description of our  scope and methodology, see appendix I. Our review was conducted from  April 2002 through November 2003 and in accordance with generally  accepted government auditing standards.
subsections: section_title: Background
paragraphs: Hepatitis C was first recognized as a unique disease in 1989. It is the most  common chronic blood-borne infection in the United States and is a  leading cause of chronic liver disease. The virus causes a chronic  infection in 85 percent of cases. Hepatitis C, which is the leading  indication for liver transplantation, can lead to liver cancer, cirrhosis  (scarring of the liver), or end-stage liver disease. Most people infected with  hepatitis C are relatively free of physical symptoms. While hepatitis C  antibodies generally appear in the blood within 3 months of infection, it  can take 15 years or longer for the infection to develop into cirrhosis.  Blood tests to detect the hepatitis C antibody, which became available in  1992, have helped to virtually eliminate the risk of infection through blood  transfusions and have helped curb the spread of the virus. Many  individuals were already infected, however, and because many of them  have no symptoms, they are unaware of their infection. Hepatitis C  continues to be spread through blood exposure, such as inadvertent  needle-stick injuries in health care workers and through the sharing of  needles by intravenous drug abusers.
Early detection of hepatitis C is important because undiagnosed persons  miss opportunities to safeguard their health by unknowingly behaving in  ways that could speed the progression of the disease. For example,  alcohol use can hasten the onset of cirrhosis and liver failure in those  infected with the hepatitis C virus. In addition, persons carrying the virus  pose a public health threat because they can infect others.
The Centers for Disease Control and Prevention estimates that nearly 4  million Americans are infected with the hepatitis C virus. Approximately  30,000 new infections occur annually. The prevalence of hepatitis C  infection among veterans is unknown, but limited survey data suggest that  hepatitis C has a higher prevalence among veterans who are currently  using VA’s health care system than among the general population because  of veterans’ higher frequency of risk factors. A 6 year study—1992–1998—  of veterans who received health care at the VA Palo Alto Health Care  System in Northern California reported that hepatitis C infection was  much more common among veterans within a very narrow age  distribution—41 to 60 years of age—and intravenous drug use was the  major risk factor. VA began a national study of the prevalence of hepatitis  C in the veteran population in October 2001. Data collection for the study  has been completed but results have not been approved for release. The  prevalence of hepatitis C among veterans could have a significant impact  on current and future VA health care resources, because hepatitis C  accounts for over half of the liver transplants needed by VA  patientscosting as much as $140,000 per transplantand the drug  therapy to treat hepatitis C is costlyabout $13,000 for a 48-week  treatment regimen.
In the last few years, considerable research has been done concerning  hepatitis C. The National Institutes of Health (NIH) held a consensus  development conference on hepatitis C in 1997 to assess the methods used  to diagnose, treat, and manage hepatitis C infections. In June 2002, NIH  convened a second hepatitis C consensus development conference to  review developments in management and treatment of the disease and  identify directions for future research. This second panel concluded that  substantial advances had been made in the effectiveness of drug therapy  for chronic hepatitis C infection.
VA’s Public Health Strategic Healthcare Group is responsible for VA’s  hepatitis C program, which mandates universal screening of veterans to  identify at-risk veterans when they visit VA facilities for routine medical  care and testing of those with identified risk factors, or those who simply  want to be tested. VA has developed guidelines intended to assist health  care providers who screen, test, and counsel veterans for hepatitis C.  Providers are to educate veterans about their risk of acquiring hepatitis C,  notify veterans of hepatitis C test results, counsel those infected with the  virus, help facilitate behavior changes to reduce veterans’ risk of  transmitting hepatitis C, and recommend a course of action. In January  2003, we reported that VA medical facilities varied considerably in the time  that veterans must wait before physician specialists evaluate their medical  conditions concerning hepatitis C treatment recommendations.
To assess the effectiveness of VA’s implementation of its universal  screening and testing policy, VA included performance measures in the  fiscal year 2002 network performance plan. Network performance  measures are used by VA to hold managers accountable for the quality of  health care provided to veterans. For fiscal year 2002, the national goal for  testing veterans identified as at risk for hepatitis C was established at 55  percent based on preliminary performance results obtained by VA. To  measure compliance with the hepatitis C performance measures, VA uses  data collected monthly through its External Peer Review Program, a  performance measurement process under which medical record reviewers  collect data from a sample of veterans’ computerized medical records.
Development of VA’s computerized medical record began in the mid-1990s  when VA integrated a set of clinical applications that work together to  provide clinicians with comprehensive medical information about the  veterans they treat. Clinical information is readily accessible to health care  providers at the point of care because the veteran’s medical record is  always available in VA’s computer system. All VA medical facilities have  computerized medical record systems.
Clinical reminders are electronic alerts in veterans’ computerized medical  records that remind providers to address specific health issues. For  example, a clinical reminder would alert the provider that a veteran needs  to be screened for certain types of cancer or other disease risk factors,  such as hepatitis C. In July 2000, VA required the installation of hepatitis C  clinical reminder software in the computerized medical record at all  facilities. This reminder alerted providers when they opened a veteran’s  computerized medical record that the veteran needed to be screened for  hepatitis C. In fiscal year 2002, VA required medical facilities to install an  enhanced version of the July 2000 clinical reminder. The enhanced version  alerts the provider to at-risk veterans who need hepatitis C testing, is  linked directly to the entry of laboratory orders for the test, and is satisfied  once the hepatitis C test is ordered.
section_title: Thousands of Veterans Identified as At Risk Remain Untested for Hepatitis C Despite VA Exceeding Its Testing Goal
paragraphs: Even though VA’s fiscal year 2002 performance measurement results show  that it tested 62 percent of veterans identified to be at risk for hepatitis C,  exceeding its national goal of 55 percent, thousands of veterans in the  sample who were identified as at risk were not tested. Moreover, the  percentage of veterans identified as at risk who were tested varied widely  among VA’s 21 health care networks. Specifically, we found that VA  identified in its performance measurement sample 8,501 veterans  nationwide who had hepatitis C risk factors out of a sample of 40,489  veterans visiting VA medical facilities during fiscal year 2002. VA  determined that tests were completed, in fiscal year 2002 or earlier, for 62  percent of the 8,501 veterans based on a review of each veteran’s medical  record through its performance measurement process. For the remaining  38 percent (3,269 veterans), VA did not complete hepatitis C tests when  the veterans visited VA facilities. The percentage of identified at-risk  veterans tested for hepatitis C ranged, as table 1 shows, from 45 to 80  percent for individual networks. Fourteen of VA’s 21 health care networks  exceeded VA’s national testing performance goal of 55 percent, with 7  networks exceeding VA’s national testing performance level of 62 percent.  The remaining 7 networks that did not meet VA’s national performance  goal tested from 45 percent to 54 percent of at-risk veterans.
VA’s fiscal year 2002 testing rate for veterans identified as at risk for  hepatitis C reflects tests performed in fiscal year 2002 and in prior fiscal  years. Thus, a veteran who was identified as at risk and tested for hepatitis  C in fiscal year 1998 and whose medical record was reviewed as part of the  fiscal year 2002 sample would be counted as tested in VA’s fiscal year 2002  performance measurement result. As a result of using this cumulative  measurement, VA’s fiscal year 2002 performance result for testing at-risk  veterans who visited VA facilities in fiscal year 2002 and need hepatitis C  tests is unknown. To determine if the testing rate is improving for veterans  needing hepatitis C tests when they were seen at VA in fiscal year 2002, VA  would also need to look at a subset of the sample of veterans currently  included in its performance measure. For example, when we excluded  veterans from the sample who were tested for hepatitis C prior to fiscal  year 2002, and included in the performance measurement sample only  those veterans who were seen by VA in fiscal year 2002 and needed to be  tested for hepatitis C, we found Network 5 tested 38 percent of these  veterans as compared to Network 5’s cumulative performance  measurement result of 60 percent.
section_title: Several Factors Impeded One Network’s Efforts to Test Veterans Identified as At Risk
paragraphs: We identified three factors that impeded the process used by our case  study network, VA’s Network 5 (Baltimore), for testing veterans identified  as at risk for hepatitis C. The factors were tests not being ordered by the  provider, ordered tests not being completed, and providers being unaware  that needed tests had not been ordered or completed. More than two- thirds of the time, veterans identified as at risk were not tested because  providers did not order the test, a crucial step in the process. The  remainder of these untested veterans had tests ordered by providers, but  the actual laboratory testing process was not completed. Moreover,  veterans in need of hepatitis C testing had not been tested because  providers did not always recognize during subsequent clinic visits that the  hepatitis C testing process had not been completed. These factors are  similar to those we identified and reported in our testimony in June 2001.
subsections: section_title: Hepatitis C Tests Were Not Always Ordered for Veterans Identified as At Risk
paragraphs: Primary care providers and clinicians in Network 5’s three facilities  offered two reasons that hepatitis C tests were not ordered for over two- thirds of the veterans identified as at risk but not tested for hepatitis C in  the Network 5 fiscal year 2002 performance measurement sample. First,  facilities lacked a method for clear communication between nurses who  identified veterans’ risk factors and providers who ordered hepatitis C  tests. For example, in two facilities, nurses identified veterans’ need for  testing but providers were not alerted through a reminder in the  computerized medical record to order a hepatitis C test. In one of these  facilities, because nursing staff were at times delayed in entering a note in  the computerized medical record after screening a veteran for hepatitis C  risk factors, the provider was unaware of the need to order a test for a  veteran identified as at risk. The three network facilities have changed  their practices for ordering tests, and as of late 2002, nursing staff in each  of the facilities are ordering hepatitis C tests for at-risk veterans. The  second reason for tests not being ordered, which was offered by a  clinician in another one of the three Network 5 facilities, was that nursing  staff did not properly complete the ordering procedure in the computer.  Although nurses identified at-risk veterans using the hepatitis C screening  clinical reminder in the medical record, they sometimes overlooked the  chance the reminder gave them to place a test order. To correct this,  nursing staff were retrained on the proper use of the reminder.
section_title: Hepatitis C Test Orders Were Not Always Completed
paragraphs: For the remaining 30 percent of untested veterans in Network 5, tests were  not completed for veterans who visited laboratories to have blood drawn  after hepatitis C tests were ordered. One reason that laboratory staff did  not obtain blood samples for tests was because more than two-thirds of  the veterans’ test orders had expired by the time they visited the  laboratory. VA medical facilities consider an ordered test to be expired or  inactive if the veteran’s visit to the laboratory falls outside the number of  days designated by the facility. For example, at two Network 5 facilities,  laboratory staff considered a test order to be expired or inactive if the date  of the order was more than 30 days before or after the veteran visited the  laboratory. If the veteran’s hepatitis C test was ordered and the veteran  visited the laboratory to have the test completed 31 days later, the test  would not be completed because the order would have exceeded the 30- day period and would have expired. Providers can also select future dates  as effective dates. If the provider had designated a future date for the  order and the veteran visited the laboratory within 30 days of that future  date, the order would be considered active.
Another reason for incomplete tests was that laboratory staff overlooked  some active test orders when veterans visited the laboratory. VA facility  officials told us that laboratory staff could miss test orders, given the many  test orders some veterans have in their computerized medical records. The  computer package used by laboratory staff to identify active test orders  differs from the computer package used by providers to order tests. The  laboratory package does not allow staff to easily identify all active test  orders for a specific veteran by creating a summary of active test orders.  According to a laboratory supervisor at one facility, the process for  identifying active test orders is cumbersome because staff must scroll  back and forth through a list of orders to find active laboratory test orders.  Further complicating the identification of active orders for laboratory  staff, veterans may have multiple laboratory test orders submitted on  different dates from several providers. As a result, when the veteran visits  the laboratory to have tests completed, instead of having a summary of  active test orders, staff must scroll through a daily list of ordered testsin  two facilities up to 60 days of ordersto identify the laboratory tests that  need to be completed. Network and facility officials are aware of, but have  not successfully addressed, this problem. VA plans to upgrade the  computer package used by laboratory staff during fiscal year 2005.
section_title: Providers Often Unaware That Hepatitis C Tests Were Not Ordered or Completed
paragraphs: Hepatitis C tests that were not ordered or completed sometimes went  undetected for long periods in Network 5, even though veterans often  made multiple visits to primary care providers after their hepatitis C risk  factors were identified. Our review of medical records showed that nearly  two-thirds of the at-risk veterans in Network 5’s performance  measurement sample who did not have ordered or completed hepatitis C  tests had risk factors identified primarily in fiscal years 2002 and 2001.
All veterans identified as at risk but who did not have hepatitis C test  orders visited VA primary care providers at least once after having a risk  factor identified during a previous primary care visit, including nearly 70  percent who visited more than three times. Further, almost all of the at- risk veterans who had hepatitis C tests ordered but not completed  returned for follow-up visits for medical care. Even when the first follow- up visits were made to the same providers who originally identified these  veterans as being at risk for hepatitis C, providers did not recognize that  hepatitis C tests had not been ordered or completed. Providers did not  follow up by checking for hepatitis C test results in the computerized  medical records of these veterans. Most of these veterans subsequently  visited the laboratory to have blood drawn for other tests and, therefore,  could have had the hepatitis C test completed if the providers had  recognized that test results were not available and reordered the hepatitis  C tests.
section_title: Some VA Networks and Facilities Have Taken Action Intended to Improve Hepatitis C Testing of Veterans Identified as At Risk
paragraphs: Steps intended to improve the testing rate of veterans identified as at risk  for hepatitis C have been taken in three of VA’s 21 health care networks.  VA network and facility officials in the three networks we reviewed— Network 5 (Baltimore), Network 2 (Albany), and Network 9 (Nashville)— identified similar factors that impede hepatitis C testing and most often  focused on getting tests ordered immediately following risk factor  identification. Officials in two networks modified VA’s required hepatitis C  testing clinical reminder, which is satisfied when a hepatitis C test is  ordered, to continue to alert the provider until a hepatitis C test result is in  the medical record. Officials at two facilitiesone in Network 5 and the  other in Network 9created a safety net for veterans at risk for hepatitis  C who remain untested by developing a method that looks back through  computerized medical records to identify these veterans. The method has  been adopted in all six facilities in Network 9; the other two facilities in  Network 5 have not adopted it.
subsections: section_title: Some Networks and Facilities Took Steps Intended to Improve Hepatitis C Test Ordering and Completion
paragraphs: VA network and facility managers in two networks we reviewed  Networks 2 and 9instituted networkwide changes intended to improve  the ordering of hepatitis C tests for veterans identified as at risk. Facility  officials recognized that VA’s enhanced clinical reminder that facilities  were required to install by the end of fiscal year 2002 only alerted  providers to veterans without ordered hepatitis C tests and did not alert  providers to veterans with ordered but incomplete tests.
These two networks independently changed this reminder to improve  compliance with the testing of veterans at risk for hepatitis C. In both  networks, the clinical reminder was modified to continue to alert the  provider, even after a hepatitis C test was ordered. Thus, if the laboratory  has not completed the order, the reminder is intended to act as a backup  system to alert the provider that a hepatitis C test still needs to be  completed. Providers continue to receive alerts until a hepatitis C test  result is placed in the medical record, ensuring that providers are aware  that a hepatitis C test might need to be reordered. The new clinical  reminder was implemented in Network 2 in January 2002, and Network 9  piloted the reminder at one facility and then implemented it in all six  network facilities in November 2002.
section_title: Some Facilities Developed a Safety Net for Veterans Identified as At Risk Who Have Not Been Tested
paragraphs: Officials at two facilities in our review searched all records in their  facilities’ computerized medical record systems and found several  thousand untested veterans identified as at risk for hepatitis C. The  process, referred to as a “look back,” involves searching all medical  records to identify veterans who have risk factors for hepatitis C but have  not been tested either because the providers did not order the tests or  ordered tests were not completed. The look back serves as a safety net for  these veterans. The network or facility can perform the look back with any  chosen frequency and over any period of time. The population searched in  a look back includes all veteran users of the VA facility and is more  inclusive than the population that is sampled monthly in VA’s performance  measurement process.
As a result of a look back, one facility manager in Network 5 identified  2,000 veterans who had hepatitis C risk factors identified since January  2001 but had not been tested as of August 2002. Facility staff began  contacting the identified veterans in October 2002 to offer them the  opportunity to be tested. Although officials in the other two Network 5  facilities have the technical capability to identify and contact all untested  veterans determined to be at risk for hepatitis C, they have not done so. An  official at one facility not currently conducting look back searches stated  that the facility would need support from those with computer expertise to  conduct a look back search.
A facility manager in Network 9 identified, through a look back, more than  1,500 veterans who had identified risk factors for hepatitis C but were not  tested from January 2001 to September 2002. The manager in this facility  began identifying untested, at-risk veterans in late March 2003 and  providers subsequently began contacting these veterans to arrange testing  opportunities. Other Network 9 facility managers have also begun to  identify untested, at-risk veterans. Given that two facilities in our review  have identified over 3,000 at-risk veterans in need of testing through look  back searches, it is likely that similar situations exist at other VA facilities.
section_title: Conclusions
paragraphs: Although VA met its goal for fiscal year 2002, thousands of veterans at risk  for hepatitis C remained untested. Problems persisted with obtaining and  completing hepatitis C test orders. As a result, many veterans identified as  at risk did not know if they have hepatitis C. These undiagnosed veterans  risk unknowingly transmitting the disease as well as potentially developing  complications resulting from delayed treatment.
Some networks and facilities have upgraded VA’s required hepatitis C  clinical reminder to continue to alert providers until a hepatitis C test  result is present in the medical record. Such a system appears to have  merit, but neither the networks nor VA has evaluated its effectiveness.  Network and facility managers would benefit from knowing, in addition to  the cumulative results, current fiscal year performance results for hepatitis  C testing to determine the effectiveness of actions taken to improve  hepatitis C testing rates. Some facilities have compensated for weaknesses  in hepatitis C test ordering and completion processes by conducting look  backs through computerized medical record systems to identify all at-risk  veterans in need of testing. If all facilities were to conduct look back  searches, potentially thousands more untested, at-risk veterans would be  identified.
section_title: Recommendations for Executive Action
paragraphs: To improve VA’s testing of veterans identified as at risk of hepatitis C  infection, we recommend that the Secretary of Veterans Affairs direct the  Under Secretary for Health to    determine the effectiveness of actions taken by networks and facilities to  improve the hepatitis C testing rates for veterans and, where actions have  been successful, consider applying these improvements systemwide and    provide local managers with information on current fiscal year  performance results using a subset of the performance measurement  sample of veterans in order for them to determine the effectiveness of  actions taken to improve hepatitis C testing processes.
section_title: Agency Comments and Our Evaluation
paragraphs: In commenting on a draft of this report VA concurred with our  recommendations. VA said its agreement with the report’s findings was  somewhat qualified because it was based on fiscal year 2002 performance  measurement results. VA stated that the use of fiscal year 2002 results  does not accurately reflect the significant improvement in VA’s hepatitis C  testing performanceup from 62 percent in fiscal year 2002 to 86 percent  in fiscal year 2003, results that became available recently. VA, however,  did not include its fiscal year 2003 hepatitis C testing performance results  by individual network, and as a result, we do not know if the wide  variation in network results, which we found in fiscal year 2002, still exists  in fiscal year 2003. We incorporated updated performance information  provided by VA where appropriate.
VA did report that it has, as part of its fiscal year 2003 hepatitis C  performance measurement system, provided local facility managers with a  tool to assess real-time performance in addition to cumulative  performance. Because this tool was not available at the time we conducted  our audit work, we were unable to assess its effectiveness. VA’s written  comments are reprinted in appendix II.
We are sending copies of this report to the Secretary of Veterans Affairs  and other interested parties. We also will make copies available to others  upon request. In addition, the report is available at no charge on the GAO  Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please call me at  (202) 512-7101. Another contact and key contributors are listed in  appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: To follow up on the Department of Veterans Affairs’ (VA) implementation  of performance measures for hepatitis C we (1) reviewed VA’s fiscal year  2002 performance measurement results of testing veterans it identified as  at risk for hepatitis C, (2) identified factors that impede VA’s efforts to test  veterans for hepatitis C in one VA health care network, and (3) identified  actions taken by VA networks and medical facilities intended to improve  the testing rate of veterans identified as at risk for hepatitis C.
We reviewed VA’s fiscal year 2002 hepatitis C testing performance results,  the most recently available data at the time we conducted our work, for a  sample of 8,501 veterans identified as at risk and compared VA’s national  and network results for fiscal year 2002 against VA’s performance goal for  hepatitis C testing. The sample of veterans identified as at risk for hepatitis  C was selected from VA’s performance measurement process—also  referred to as the External Peer Review Process—that is based on data  abstracted from medical records by a contractor. In addition, we looked at  one VA health care network’s testing rate for at-risk veterans visiting its  clinics in fiscal year 2002. To test the reliability of VA’s hepatitis C  performance measurement data, we reviewed 288 medical records in  Network 5 (Baltimore) and compared the results against the contractor’s  results for the same medical records and found that VA’s data were  sufficiently reliable for our purposes. To augment our understanding of  VA’s performance measurement process for hepatitis C testing, we  reviewed VA documents and interviewed officials in VA’s Office of Quality  and Performance and Public Health Strategic Health Care Group.
To identify the factors that impede VA’s efforts to test veterans for  hepatitis C, we conducted a case study of the three medical facilities  located in VA’s Network 5Martinsburg, West Virginia; Washington, D.C.;  and the VA Maryland Health Care System. We chose Network 5 for our  case study because its hepatitis C testing performance, at 60 percent, was  comparable to VA’s national performance of 62 percent.
As part of the case study of Network 5, we reviewed medical records for  all 288 veterans identified as at risk for hepatitis C who were included in  that network’s sample for VA’s fiscal year 2002 performance measurement  process. Of the 288 veterans identified as at risk who needed hepatitis C  testing, VA’s performance results found that 115 veterans in VA’s Network  5 were untested. We reviewed the medical records for these 115 veterans  and found hepatitis C testing results or indications that the veterans  refused testing in 21 cases. Eleven veterans had hepatitis C tests  performed subsequent to VA’s fiscal year 2002 performance measurement  data collection. Hepatitis C test results or test refusals for 10 veterans  were overlooked during VA’s data collection. As such, we consider  hepatitis C testing opportunities to have been missed for 94 veterans.
On the basis of our medical record review, we determined if the provider  ordered a hepatitis C test and, if the test was ordered, why the test was not  completed. For example, if a hepatitis C test had been ordered but a test  result was not available in the computerized medical record, we  determined whether the veteran visited the laboratory after the test was  ordered. If the veteran had visited the laboratory, we determined if the test  order was active at the time of the visit and was overlooked by laboratory  staff. Based on interviews with providers, we identified the reason why  hepatitis C tests were not ordered. We also analyzed medical records to  determine how many times veterans with identified risk factors and no  hepatitis C test orders returned for primary care visits.
To determine actions taken by networks and medical facilities intended to  improve the testing rate of veterans identified as at risk for hepatitis C, we  expanded our review beyond Network 5 to include Network 2 and  Network 9. We reviewed network and facility documents and conducted  interviews with network quality managers and medical facility staff— primary care providers, nurses, quality managers, laboratory chiefs and  supervisors, and information management staff. Our review was  conducted from April 2002 through November 2003 in accordance with  generally accepted government auditing standards.
section_title: Appendix II: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Carl S. Barden, Irene J. Barnett,  Martha A. Fisher, Daniel M. Montinez, and Paul R. Reynolds made key  contributions to this report.
section_title: Related GAO Products
paragraphs: VA Health Care: Improvements Needed in Hepatitis C Disease  Management Practices. GAO-03-136. Washington, D.C.: January 31, 2003.
Major Management Challenges and Program Risks: Department of  Veterans Affairs. GAO-03-110. Washington, D.C.: January 2003.
Veterans’ Health Care: Standards and Accountability Could Improve  Hepatitis C Screening and Testing Performance. GAO-01-807T.  Washington, D.C.: June 14, 2001.
Veterans’ Health Care: Observations on VA’s Assessment of Hepatitis C  Budgeting and Funding. GAO-01-661T. Washington, D.C.: April 25, 2001.