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Publication Briefs

Veterans Advocate Treating "Sickest First" When Discussing Limited Resources for Hepatitis C Treatment

Like other healthcare providers, VA grapples with the problem of finding ways to provide new and costly medications to its patients. An example is direct-acting antiviral treatment for chronic hepatitis C virus (CHC) infection. One approach for such costly medications is to target treatments to the patients most likely to benefit. The use of this strategy for the allocation of treatment benefit seems promising, but to maximize the fair use of this approach and likely acceptance of its implementation, the values and beliefs of patients should be considered. Investigators in this study used Democratic Deliberation (DD) methods as a proof of concept for informing policy decisions related to the allocation of scarce resources for treatment of CHC in VA. They recruited 30 VA patients to attend a DD session. Following educational presentations from content experts, Veterans engaged in facilitated small group discussions to: 1) identify strategies to overcome CHC treatment barriers, and 2) evaluate, vote on, and modify/improve two CHC treatment policies – “first come, first served” (FCFS) and “sickest first” (SF). Study participants also completed pre- and post-DD surveys.


  • Most Veterans endorsed the sickest-first policy over the first-come-first-served policy, emphasizing the ethical and medical appropriateness of treating the sickest Veterans first. When given the option, almost two-thirds of participants insisted that all Veterans be treated without delay regardless of symptoms or degree of disease severity (note: this is currently VA policy but not common outside of VA). Only when required to choose between the two policies did a majority opt for the SF policy (86% before DD session; 93% after DD session).
  • Veterans also suggested modifications to the “sickest first” policy: 1) need to consider additional health factors, 2) taking behavior and lifestyle into account, 3) offering education and support to overcome barriers to treatment, 4) improving access to testing/treatment, and 5) improving how allocation decisions are made.


  • This study confirms the value of Democratic Deliberation (DD) for eliciting the informed preferences of Veterans regarding the allocation of limited treatment resources. The approach of using DD to incorporate the opinions of patients may have implications for how to develop policies around allocation of limited healthcare resources during the current COVID-19 pandemic.


  • Investigators could not thoroughly educate study participants on every issue of importance to this topic, e.g., the wide range of VA expenditures that compete with CHC treatments for limited funds.

This study was partly funded by HSR&D. Drs. Waljee, Saini (Director), Su, Arasim, Roman, and Nallamothu are part of HSR&D’s Center for Clinical Management Research (CCMR) in Ann Arbor, MI.

Waljee A, Ryan K, Krenz C, Ioannou G, Beste L, Tincopa M, Saini S, Su G, Arasim M, Roman P, Nallamothu B, and De Vries R. Eliciting Patient Views on the Allocation of Limited Healthcare Resources: A Deliberation on Hepatitis C Treatment in the Veterans Health Administration. BMC Health Services Research. May 1, 2020;20(1):369.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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