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RRP 12-454 – HSR&D Study

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RRP 12-454
Increasing Access to HCV Self-Management Via the Internet
Erik J. Groessl PhD BA BS
VA San Diego Healthcare System, San Diego, CA
San Diego, CA
Funding Period: April 2013 - September 2015

BACKGROUND/RATIONALE:
Thousands of VA patients with chronic hepatitis C viral infection (HCV) are at risk for severe medical consequences because HCV causes liver damage over time. Despite the higher treatment success rates of new antiviral medications, some VA patients may not be optimally prepared to adhere to the expensive treatments. Efforts to better prepare HCV-infected patients for antiviral therapy may improve treatment success at a time when resource conservation is important. The HCV Self-Management Program (HCV-SMP) has been shown to improve health outcomes and was recently adapted to focus on preparation for HCV antiviral treatment. While in-person self-management programs can improve the health of Veterans, they may not be easily accessible to some people with HCV. Internet-based self-management programs have been effective with other chronic illnesses.

OBJECTIVE(S):
The study objective was to adapt the HCV-SMP content for the Internet, program the new web content, and build web content into an existing online platform. In addition, the study will pilot the Internet-based HCV-SMP with VA patients and examine the feasibility of recruitment, participation, assessment, and measurement of health outcomes in a single group design.

METHODS:
In Phase 1 of this study, investigators adapted content from the new HCV Treatment Preparation Program so that it could be effectively delivered via the Internet. the PI conducted work sessions at the Stanford University Patient Education Research Center. Center experts had previously converted multiple programs and assisted with outlining the approach for converting in-person self-management programs for Internet delivery. The PI then worked with the National Council on Aging (NCOA) to program and integrate the adapted HCV content into the existing IT web platform used to deliver the CDSMP, a similar self-management program. Newly programmed content was reviewed and revised iteratively before being piloted and fully tested as a web-based system.
In Phase 2 of this study, VA patients with HCV were recruited to participate in the new Internet-based program. To be eligible, Veterans had to be 18+ years of age, diagnosed with HCV, and be willing to participate in Internet treatment preparation sessions. Exclusion criteria were a) ongoing or planning to start HCV antiviral treatment within 6 months; b) life expectancy < 6 months; c) medical contraindication for antiviral treatment (not including substance use or psychological conditions); d) lack of reliable Internet access. Because the study was web-based, VA patients could participate from anywhere in the US. Patients were told about the research study by HCV clinicians at VA facilities in San Diego, Palo Alto, Cleveland, Seattle, Bedford, MA. In addition, flyers were posted at the VA San Diego Medical Center.
Interested VA patients contacted the project coordinator at VA San Diego for more information and screening. They were then mailed informed consent forms to sign and return. Eligible participants were given a login ID and temporary password for the online program. Upon logging in, participants completed baseline questionnaires (HCV Knowledge, Energy/Fatigue, Depression, Health Distress, Quality of Life, and Program Satisfaction), before being directed to the program website where they registered and signed additional consent forms for the NCOA site administration. Questionnaires were completed again after the 6-week program.
Participation in the program consisted of logging into the program on a weekly (or more frequent) basis and clicking through a series of 20-30 webpages that provided information on HCV, HCV antiviral treatment, and health behavior change principles. Participants completed interactive modules including quizzes, goal setting, self-monitoring, and discussion/feedback via a secure discussion board. New content was added each week. A facilitator moderated the workshop and monitored the discussion board for appropriate content.

FINDINGS/RESULTS:
Twenty eligible patients were recruited in 5 months. 16/20 completed the pre- assessment. 11/16 participants also completed the post- assessment. 9/16 participated in 1 or more online sessions. Of the 9 active participants, the mean # of sessions attended was 3.11.
Participants (n = 16) were 100% male, 63 years old on average, 38% non-White, 81% not employed, 63% not married, 88% attended some college, 25% were homeless in last 5 yrs. 44% lived 30 minutes or more from their local VA.
HCV Knowledge scores increased from 9.6/15 correct to 10.5. Energy scores increased from 2.7 to 2.8. Depression scores decreased from 11.2 to 10.1. Health distress scores increased from 1.5 to 1.6. SF12-Mental Component scores increased from 47.9 to 51.3. SF12-Physical Component scores decreased from 39.6 to 37.2. The only statistically significant difference was the decrease in SF12-PCS scores (p =0.036).
On the Program Satisfaction questionnaire, 8/11 or 73% "enjoyed participating" (agreed or strongly agreed), 73% felt the "level of computer skill required was OK", 6/11 or 55% felt they derived "health benefit" from the program, 55% felt a "positive connection" with other online participants, but only 3/11 or 27% felt the "got to know" other online participants.

IMPACT:
Recruitment for the study was slower than expected, suggesting that interest in the program may not be widespread and may have slowed since the emergence of very effective antiviral treatments with fewer requirements.
Participants had more difficulty than expected logging onto the website and online program. Part of the barrier was the multiple steps required to log into the assessment system, complete baseline questionnaires, register for the online program, log into the program, and then complete additional consent forms. In assisting participants with the process, the project coordinator reported that many participants seemed to lack adequate computer skills. It is likely that this contributed to 31% not completing the follow-up questionnaires despite repeated requests and the opportunity to be compensated $25 for their time.
Most health outcomes improved or changed in the expected direction. It was unexpected that that physical QOL would decrease significantly. There is no reason to expect the program could decrease physical QOL, but it is possible that learning about the severity of HCV could increase attention to physical symptoms and increase concern about having HCV.
For the future, it will be important to gauge how many Veterans with HCV are interested in attending the HCV Self-management Program via in-person groups or over the Internet. Some Veterans remain interested, but new clinical trials are indicating very high cure rates among subgroups that were previously hard to treat. If this trend continues, self-management programs may be of lesser value to Veterans and the VHA system.

PUBLICATIONS:
None at this time.


DRA: Brain and Spinal Cord Injuries and Disorders
DRE: Epidemiology
Keywords: QUERI Implementation
MeSH Terms: none

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