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.
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.
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.
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.
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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