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FORUM - Translating research into quality health care for Veterans

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Research Highlight

Hepatitis C virus (HCV) infection is a leading cause of cirrhosis and liver cancer in both the U.S and Veterans Health Administration (VHA). A new generation of treatment regimens (Direct Acting Agents) has increased rates of sustained viral response (SVR) with fewer side effects than previous treatments.1 Approximately 9 out of 10 patients who complete treatment achieve SVR12, indicating that the virus is no longer detectable 12 weeks after treatment completion.2 With previous regimens, only 5 or 6 out of 10 patients achieved SVR, with much longer treatment durations and more frequent side effects such as extreme fatigue, depression, skin rash, and anemia. This efficacy increased demand, without a corresponding increase in clinic resources. To address this imbalance, the Hepatitis C Innovation Team (HIT) Collaborative committed to timely identification and treatment of patients with HCV, and reorganization of care in the most patient-centered manner.

In 2014, VA's HIV, Hepatitis and Related Conditions program (formerly the HIV, Hepatitis, and Public Health Pathogens Program), chartered the HIT Collaborative to improve access and quality of care for approximately 200,000 Veterans affected by HCV. The National Hepatitis C Resource Center partnered with the New England Veterans Engineering Resource Center to launch the HIT Collaborative and provide a clinically focused Lean foundation to Veterans Integrated Service Network (VISN)-based HITs. These multi-disciplinary teams apply Lean process improvement principles to identify barriers, implement strategies to address them, and improve health care delivery from testing through treatment.

All teams receive centralized Lean training, data, coaching, and financial support from the HIT Collaborative. In the first year of the program, each of the twenty VISN HITs identified three priority issues in care delivery and designed corresponding interventions. HITs then selected and implemented strategies best suited to address local needs. The HIT Collaborative reviewed clinical quality measures and defined system-wide metrics to track changes in outcomes. While HITs identified opportunities for improvement across the care cascade (from screening to linkage to care, treatment and testing for SVR), HITs singled out the treatment initiation step as an area of critical importance. With growing treatment demand, most sites identified increasing treatment capacity and treatment starts as a top priority. Since the launch of the HIT Collaborative over 80,000 Veterans have initiated HCV treatment.

The HIT Collaborative Evaluation Team applied implementation science methodologies to evaluate the impact of a multitude of strategies employed by the HITs. The Expert Recommendations for Implementing Change (ERIC) provided a structured approach to identify and assess the use of discrete implementation strategies to increase HCV treatment initiation.3 ERIC enumerates 73 implementation strategies in nine clusters: changing infrastructure, utilizing financial strategies, supporting clinicians, providing interactive assistance, training and educating stakeholders, adapting to the context, developing stakeholder interrelationships, using evaluative and iterative strategies, and engaging consumers (patients). The evaluation team's VA medical center survey identified which of the 73 implementation strategies were used at each site.

The evaluation team found that the number of strategies used by a medical center was positively correlated with treatment starts. Of the 73 strategies, 28 were associated with treatment starts. The most frequent strategies implemented included using data warehousing techniques (e.g., using a population health management tool), and intervening with patients to promote uptake and adherence to HCV treatment.

Data from a prior survey of medical centers about the number and types of providers on the HCV care team also provided insight. The number of providers was neither significantly associated with number of patients treated nor the number of strategies used. This finding underscored a core element of the HIT Collaborative coaching, which emphasizes improving the processes of care, despite the size or composition of the HCV care team.

By using a Lean and team approach to identify barriers and design tailored solutions with the Veteran in mind, any care team, large or small, can work towards improving health care delivery and patient experiences. The results drawn from this evaluation support HITs to continue exploring which strategies lead to increased treatment. This information is invaluable to the work of the HIT Collaborative and helps drive the work of continuous improvement in health care delivery.

  1. Naghavi M WH, et al. "Global, Regional, and National Age-Sex Specific All-Cause and Cause- Specific Mortality for 240 Causes of Death, 1990- 2013: A Systematic Analysis for the Global Burden of Disease Study 2013," Lancet 2015; 385:117-71.
  2. Backus LI, et al. "Real-world Effectiveness and Predictors of Sustained Virological Response with All-oral Therapy in 21,242 Hepatitis C Genotype-1 Patients," Antiviral Therapy December 2016 [Epub ahead of print].
  3. Powell BJ, et al. "A Refined Compilation of Implementation Strategies: Results from the Expert Recommendations for Implementing Change (ERIC) Project" Implementation Science 2015; 10(1):1.

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