Liver biopsy is the standard method for assessing liver damage resulting from chronic Hepatitis C infection. The VA and NIH recommend its use for managing and making treatment decisions for most HCV-infected patients. However, there is little consensus on which HCV-infected patients should be biopsied and when the biopsies should occur. Thus, there may be significant variability in how liver biopsy is used in the national VA Healthcare System, which could impact the health of VA patients with HCV.
Our objective was to examine patterns of liver biopsy use over time and among the geographic regions of VA Healthcare System. We also examined co-morbid diagnoses, demographic data, and clinical data as correlates of receiving a liver biopsy.
The study was a retrospective database analysis of over 300,000 VA patients who had data in the VA Hepatitis C Case registry. The HCV registry data was cleaned, coded, transformed, and analyzed for all registry patients with documented confirmatory viral testing. Data fields were reviewed for consistency and quality of data. Differences in the recording of tests and procedure were resolved in meetings with the PI, clinicians, and co-investigators. The primary outcome was the confirmation of 1 or more liver biopsies. Logistic regression was used to explore correlates of liver biopsy.
Our results suggest that the number of liver biopsies being performed in the national VA Healthcare System peaked in 2004 and has begun to decline. There is considerable variability in biopsy rates among the 23 geographic regions (VISNs) in the VA Healthcare System. Some VISNs biopsied 16-17% of their HCV-infected patients while other biopsied only 5-7%. Regression analyses suggest that patients with contraindications for antiviral treatment, HCV genotype 2 and 3, Hispanics, Asian/Pacific Islanders, and patients of Other/Unknown race/ethnicity were less likely to be biopsied. Initiation of antiviral treatment was associated with a much higher rate of biopsy.
The results suggest that liver biopsy may be underutilized, especially in some geographic areas of the VA Healthcare system. The reasons for fewer biopsies in some ethnic minority groups should be explored. Once the reasons for variability are understood, guidelines or training could help optimize the use of liver biopsy in the VA.
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