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Quality of Care in Chronic Hepatitis C Virus (HCV) Infection
Kanwal F, Hoang T, Spiegel BM, Eisen SE, Goetz M, Dominitz J, Asch SM. Quality of Care in Chronic Hepatitis C Virus (HCV) Infection. Paper presented at: VA HSR&D National Meeting; 2007 Feb 23; Arlington, VA.
Chronic HCV is a prevalent and expensive condition with a large burden of illness. Despite this, there are limited data evaluating the quality of care in HCV. We sought to measure quality of care in HCV by determining adherence to an explicit set of quality indicators (QIs) in the VA Healthcare System.
Using published quality measurement criteria and assessment from 3 experienced hepatologists, we converted the VA and AASLD guidelines into a preliminary set of 7 QIs grouped into 3 domains—diagnosis [if positive HCV antibody then HCV RNA testing; if active viremia then ALT testing], prevention [if no HIV then HIV testing; if no hepatitis A immunity then hepatitis A vaccination]; and treatment-related care [if active viremia and no treatment contra-indications (CI) then specialty referral; genotype testing; and treatment]. We then measured adherence with the QIs in a demographically diverse group of patients from 5 VA facilities in VISN-22. We defined an HCV patient as a subject with an ICD9-code or positive HCV test, and active viremia as positive HCV PCR or genotype test. To account for continuity of care, we included patients if they had = 2 visits/year to the treating facility from 1/1/2000-12/30/2005. We calculated QI scores as number of patients receiving the indicated process divided by number of patients eligible for QIx100.
We identified 25,715 HCV patients. Of these, 14,275 had active viremia. Quality scores in the diagnosis domain exceeded 70%. However, there were significant deficits in the prevention and treatment domains. For example, among patients with active viremia and no HIV, only 12% received HIV testing within the first year of HCV diagnosis. Similarly, among patients with active viremia and no CI, 48% were referred to specialty care and 14% received treatment.
We found low overall adherence to evidence-based QIs in a large secondary analysis of HCV patients, and observed significant variation in overall care. Low treatment rates may be due to provider perceptions related to HCV treatment efficacy.
Future research will identify sources of the observed variation in care processes. These data may ultimately assist researchers and policy-makers in focusing quality improvement efforts in HCV.