The Veteran's Administration (VA) healthcare system is the largest single provider of medical care to people with hepatitis C (HCV) in the US. With a prevalence rate (5.4 percent) far exceeding that in the general US population (1.6 percent), 208,000 veterans with chronic HCV sought care in the VA in 2007. Although recognized as an "expensive condition", little is known about the cost of the care provided.
In this pilot study, our main aim was to obtain a reliable estimate of the cost of caring for HCV patients in the VA, and to examine variations by disease complication and comorbid conditions. In this cost-identification analysis we aggregated costs for VA from inpatient stays, outpatient clinic visits and pharmacy use. Our specific aims were to: 1) Estimate average annual VA cost per HCV patient of a) overall healthcare, and b) care for HCV infection and complications; 2) Compare differences by facility in average annual VA cost per HCV patient; and 3) Estimate average annual VA cost per HCV patient by HCV complications and comorbid conditions.
For this pilot study, we limited focus to only on patients in the VA Southern California and Nevada Network (VISN 22). Using the VA HCV Clinical Case Registry (CCR), we identified all VISN22 HCV viremic cases and obtained a matched cohort (up to 4 controls per case) of non-HCV controls, also from VISN22. Matching criteria were sex, age, race/ethnicity and indication of HIV, alcohol abuse and substance abuse during baseline period (CY 2005-06). Merging administrative data for inpatient, outpatient and pharmacy use we compared annual VA costs during CY 2007-08, and also compared the source of cost differences in terms of diagnoses and setting of care (inpatient/outpatient).
We identified 8,029 HCV viremic VISN22 patients (cases) and obtained 30,608 matched VISN22 patients (controls). During CY 2007-08, the annualized utilization costs for the cases were $14,099 and for controls $4,975, difference of $9,125 (p<0.001). Adjusting for differences in baseline comorbid conditions, this difference is reduced to $6,647 (p<0.001). Across all five facilities (VAMCs), costs for cases are 250% to 330% higher than for matched controls. Examination of costs by the principal diagnosis for which care was obtained indicates that cases have higher rates of utilization not only for liver-related diagnosis but also a range of other diagnoses, including mental health conditions, alcohol and substance abuse, pneumonia, CHF, hypertension and diabetes.
These cost estimates -- overall cost and its breakdown by type of care (inpatient, outpatient and pharmacy) and diagnostic condition (liver-related and other conditions) -- will offer valuable information in planning resource allocation to improve overall HCV disease management as well as equity in access to appropriate care. Findings from this study will also offer valuable timely information as treatment for HCV is on the verge of a dramatic improvement with the introduction of the newly-approved protease-based HCV therapies (Boceprevir and Telaprevir), and for which decisions relating to adoption into VA formularies and prescription guidelines need to be made.
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