VA Health Care:

Improvements Needed in Hepatitis C Disease Management Practices

GAO-03-136: Published: Jan 31, 2003. Publicly Released: Mar 4, 2003.

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In 1998, the Department of Veterans Affairs (VA) launched an initiative to screen and test veterans for hepatitis C--a chronic blood-borne virus that can cause potentially fatal liver-related conditions. Since 2001, GAO has been monitoring VA's hepatitis C program. This year GAO was asked to report on VA's hepatitis C disease management practices. GAO surveyed 141 VA medical facilities about their processes for notifying veterans concerning hepatitis C test results and evaluating veterans' medical conditions regarding potential treatment options. In addition, GAO reviewed medical records of 100 hepatitis C patients at 1 facility and visited 4 other facilities that used unique hepatitis C disease management processes.

There is considerable variation among VA facilities in the time it takes to notify veterans that they have hepatitis C. For example, 29 VA medical facilities estimated that veterans were typically notified within 7 days of testing while 16 estimated that notification times exceeded 60 days. At facilities with longer notification times, primary care providers generally notified veterans at their next regularly scheduled appointments--sometimes more than 4 months away. In contrast, facilities with shorter notification times generally scheduled special appointments focused on hepatitis C notification or notified veterans by telephone or mail. Longer notification times increase the risk that veterans may unknowingly infect others or continue to engage in behaviors, such as alcohol use, that could accelerate the damaging effects of hepatitis C on their livers. VA medical facilities also varied considerably in the time that veterans must wait before physician specialists evaluate their medical conditions concerning hepatitis C treatment recommendations. For example, 23 facilities estimated that veterans waited 30 days or less for appointments with physician specialists while 52 facilities estimated that veterans waited over 60 days. At facilities with longer waiting times, primary care providers frequently referred all veterans to physician specialists for evaluations. In contrast, facilities with shorter waiting times often relied on nonspecialists, such as primary care providers, to conduct initial hepatitis C evaluations, referring only those with certain conditions, such as liver injury, to specialists for additional evaluations.

Recommendations for Executive Action

  1. Status: Closed - Not Implemented

    Comments: Although VA has not directed facilities to use special arrangements to notify veterans, it has given facilities guidance (IL 10-2002-019) for notifying veterans of hepatitis C test results. The guidance includes designating one individual in the facility to be responsible for receiving test results and subsequently notifying the veterans. VA has also implemented an electronic system--HealtheVet--that permits veterans to obtain test results, among other information, via the computer. VA's hepatitis C Case Registry has been implemented and includes an enhancement that permits facilities to identify and track veterans who need to be notified of test results.

    Recommendation: To continue to improve the management of hepatitis C, the Secretary of Veterans Affairs should direct the Under Secretary for Health to direct facilities to use special arrangements, such as mail or telephone when appropriate, to notify a veteran rather than waiting until the next regularly scheduled visit if it is more than 30 days away.

    Agency Affected: Department of Veterans Affairs

  2. Status: Closed - Not Implemented

    Comments: This recommendation is being closed without being implemented because VA states that it has given sufficient guidance on testing and notification to its facilities. VA issued guidance in the form of an Information Letter (IL 10-2002-019) and facility clinicians are notified promptly of hepatitis C test results through use of the view/alert in the electronic medical record or the critical value alert from the laboratory. VA is reluctant to use the critical value alert to immediately notify clinicians because hepatitis C test results are not thought to be critical. VA believes that any changes to its electronic medical record system would not be cost effective without national level data indicating problems with hepatitis C result notification.

    Recommendation: To continue to improve the management of hepatitis C, the Secretary of Veterans Affairs should direct the Under Secretary for Health to direct facilities to modify their computerized patient record systems so that providers are alerted to positive hepatitis C test results as soon as possible.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: VA has provided medical facilities with tools to improve timeliness of evaluations for veterans diagnosed with hepatitis C. These tools are educational activities for clinicians that include: (1) distribution of a pocket reference and training materials concerning evaluation of hepatitis C veterans, specifically targeted to non-specialists; (2) an update of VA's hepatitis C treatment recommendations to reflect current knowledge and latest drug approval information; (3) three satellite TV broadcasts that address evaluation and care of veterans with hepatitis C; (4) web-based learning tools developed and available by end of calendar year 2003; (5) development of a hepatitis C template for clinicians' documentation of treatment; and (6) restructuring of a preceptorship program to broaden the scope of hepatitis C training and encourage collaborative care between clinicians. Data on timeliness of evaluation and assessment of candidacy for antiviral therapy are being collected through the External Peer Review Program to further guide development of performance improvement initiatives.

    Recommendation: To continue to improve the management of hepatitis C, the Secretary of Veterans Affairs should direct the Under Secretary for Health to help facilities improve the timeliness of evaluations for veterans diagnosed with hepatitis C by encouraging facilities to use nonspecialists to conduct initial evaluations, and develop clinical guidelines for when to refer veterans to physician specialists for additional consultations.

    Agency Affected: Department of Veterans Affairs

 

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