BACKGROUND/RATIONALE:
Chronic hepatitis C (HCV) is a major health concern that disproportionately affects U.S. veterans. Veterans with HCV experience impaired quality of life as a result of HCV infection and other co-morbid disorders; namely substance abuse and mental health problems. Only a small proportion of these patients currently receive and are cured of HCV with Interferon-based treatments. Treatment recommendations for HCV-infected veterans not scheduled for Interferon-based treatment include additional evaluations/procedures and adherence to behavioral/lifestyle guidelines. However, many patients with HCV and commonly occurring co-morbidities have difficulty following these recommendations without additional assistance. HCV self-management programs are one option for helping these patients adhere to treatment recommendations while improving their quality of life. Patient self-management programs augment traditional information-oriented patient education with problem-solving skills and cognitive-behavioral techniques that enable patients to manage chronic illness and their lives as a whole.

OBJECTIVE(S):
Our primary objective was to assess the efficacy of a 6-session self-management workshop designed to improve health outcomes for veterans with HCV who were not receiving Interferon-based treatment.

METHODS:
Participants were 134 Veterans with HCV who receive health care through the VA San Diego Healthcare System. They were randomized to either the HCV Self-Management Workshop (HCV-SMW) or to the Information-only intervention group. The self-management intervention included six 2-hour weekly workshop sessions in addition to the basic information provided to the comparison group. The HCV-SMW was co-led by a health educator and a peer-leader, and has been adapted from an existing self-management program that has been effective for patients with other chronic illnesses. The primary outcome for the study is health-related quality of life. Secondary outcome variables include HCV Knowledge, HCV Self-Efficacy, depression, health distress, attendance/no-shows at health care visits, health behaviors, substance use/abuse, and patient-provider communication. Questionnaire data was collected at baseline, 6-weeks, 6-months, and 12-months using self-report questionnaires. Clinical data was abstracted from the medical record for the 12 months before and after the baseline assessment. Data was analyzed using correlations, t-tests, and repeated-measures ANCOVA. An exploratory cost analysis was conducted.

FINDINGS/RESULTS:
134 VA patients with HCV were recruited with the following characteristics: mean age of 54.6, 95% male, 41% ethnic minority, 83% unmarried, 72% unemployed or disabled, 48% reported homelessness in last 5 years. Data were available for 132 participants at 6-weeks and 93 patients at 12-month follow-up, which was added after initial consent was obtained. At 6-weeks, participants attending the self-management workshop had better HCV knowledge (p<.001), HCV self-efficacy (p=.011), and SF-36 energy/vitality (p=.040) than the comparison group. Similar trends were found for other outcomes. At 12- months, attrition rates were not significantly different between groups. When compared to the information-only group, participants attending the self-management workshop improved more on HCV knowledge (p = .001), SF-36 energy/vitality (p = .038), and total Quality of Well-being score (p = .044). Similar non-significant trends were found for depression (p = .091). Using QWB scores, preliminary cost-effectiveness analysis found an incremental cost-effectiveness ratio of about $3500/QALY for the workshop.

IMPACT:
Study results indicate that the HCV Self-management Program can improve health outcomes in veterans with HCV. The self-management intervention appears to offer a cost-effective approach for treating HCV-infected VA patients who are not currently deemed ready for antiviral therapy. Future research should establish additional evidence of the intervention's effectiveness in other VA sites before widespread implementation. Modifying a few minor aspects of the study, such as adding booster sessions, may enhance effectiveness for a minimal cost.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Groessl EJ, Weingart KR, Gifford AL, Asch SM, Ho SB. Development of the hepatitis C self-management program. Patient education and counseling. 2011 May 1; 83(2):252-5. [view]
2. Groessl EJ, Weingart KR, Kaplan RM, Clark JA, Gifford AL, Ho SB. Living with hepatitis C: qualitative interviews with hepatitis C-infected veterans. Journal of general internal medicine. 2008 Dec 1; 23(12):1959-65. [view]
3. Pichetshote N, Groessl E, Yee H, Ho SB. Optimizing the dose and duration of therapy for chronic hepatitis C. Gut and Liver. 2009 Mar 31; 3(1):1-13. [view]
4. Groessl EJ, Ho SB, Asch SM, Stepnowsky CJ, Laurent D, Gifford AL. The hepatitis C self-management program: sustainability of primary outcomes at 1 year. Health education & behavior : the official publication of the Society for Public Health Education. 2013 Dec 1; 40(6):730-40. [view]
5. Groessl EJ, Weingart KR, Stepnowsky CJ, Gifford AL, Asch SM, Ho SB. The hepatitis C self-management programme: a randomized controlled trial. Journal of Viral Hepatitis. 2011 May 1; 18(5):358-68. [view]

Conference Presentations

1. Groessl EJ, Weingart KR, Gifford AL, Asch SM, Ho SB. A self-management intervention for veterans with Hepatitis C: Preliminary Data. Paper presented at: VA QUERI Career Development Annual Meeting; 2008 Oct 1; Phoenix, AZ. [view]
2. Groessl EJ. Self-management interventions for patients with Hepatitis C. Paper presented at: University of California San Diego Department of Medicine Division of Gastroenterology Research Retreat; 2006 Oct 7; La Jolla, CA. [view]
3. Groessl EJ, Weingart KR, Stepnowsky CJ, Gifford AL, Asch S, Ho SB. The Hepatitis C Self-Management Program. Paper presented at: American Association for the Study of Liver Diseases Annual Meeting; 2009 Oct 30; Boston, MA. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Prevention
Keywords: Behavior (patient), Quality of life, Self-care
MeSH Terms: none