veterans & hepatitis c: test, treat, curevel/sof (jul 2016) n=1987 population health services...

Veterans & Hepatitis C: Test, Treat, Cure November 10, 2016

VETERANS HEALTH ADMINISTRATION

Faculty Presenters

Lisa I. Backus MD PhD

Patient Care Services/Population Health

Department of Veterans Affairs

Rachel Gonzalez, MPH

Program Manager, National Hepatitis C Resource Center

Elizabeth Maguire, MSW

Communications Lead, HIV, Hepatitis, and Public Health Pathogens Program

Center for Healthcare Organization and Implementation Research (CHOIR)

Bedford VA Medical Center

2


VA Structure

• Organized into 18 regions called Veteran Integrated Service Networks (VISNs)

• 151 VA Medical Centers (VAMCs), with 6-8 per VISN

– A VAMC generally consists of an acute care hospital, outpatient clinics, diagnostic facilities, and support services

• ~1000 community-based outpatient clinics (CBOCs), with 3-8 per VAMC

- provide primary care and mental health services

• HCV recognized as a priority by VA leadership

• VA is the largest single provider of HCV care in the United States

3


Cascade of HCV Care Veterans in VHA Care

4

250,000

200,000

150,000

100,000

50,000 220,605 65,742 174,027 161,955 47,919

(100%) (30%) (79%) (73%) (22%)

232,001 180,489 160,794 43,544 22,159 (100%) (78%) (69%) (19%) (10%) 0

Chronic HCV Diagnosed with Linked to HCV care‡ Treated with HCV Achieved SVR● (estimated)* chronic HCV† antivirals◊

2014 2015

79% 93% 41% 73%

78% 89% 27% 51%

*Estimated from diagnosed+ratio of prevalence in sex, race/ethnicity, birth cohort strata in those tested in prior two years applied to those still untested †Diagnosed with chronic HCV defined as ever had a detectable HCV RNA or genotype. ‡Linked to HCV care required an outpatient visit in 2014, entry in the VHA’s HCV registry and HCV entered on the patient's medical record problem list. ◊Treated with HCV antivirals defined as ever received HCV antivirals from VHA as of 31 December 2014/2015. ●Achieved SVR defined as undetectable HCV RNA on all tests after end of treatment including at least one test at least 12 weeks after the end of treatment with the SVR rate among those evaluable for SVR applied to those without definitive SVR status.


HCV Testing

5

Lisa I. Backus MD PhD Patient Care Services/Population Health Department of Veterans Affairs


Background

• Nationally an estimated 2.7 to 3.9 million Americans have chronic HCV infection

– 45% to 85% do not know they are infected

– Disproportionately high prevalence of HCV in those born 1945-1965

• CDC (2012) and USPSTF (2013) recommend one-time HCV screening for anyone born 1945-1965

6 Denniston et al, Ann Inter Med 2014;160:293-300 Armstrong et al, Ann Inter Med 2006;144:705-714

HCV Ab+ prevalence by birth year from two NHANES periods: 1988-1994 and 1999-2002


Background

• HCV disproportionately affects Veterans

– HCV prevalence in veterans in VA care in 2011 was elevated at 6.2% compared to national estimate of 1.0%

– HCV prevalence in veterans in VA care in 2011 was highest in the 1945-1965 birth cohort

• Born <1945 prevalence 1.7%

• Born 1945-1965 prevalence 10.3%

• Born >1965 prevalence 1.1%

• VA (2014) also recommends one-time HCV

screening for anyone born 1945-1965

• ~220,000 veterans with HCV in VA care

7 Backus et al, JAMA Inter Med 2013;173(16):1549-1552

20.0%18.4%

18.0%

16.0%

14.0%

12.0%

10.0%

8.0%

6.0%

3.8% 4.0%2.5%

2.0%

0.0%


VHA HCV Testing National

8

,000,000

2,753,017

,500,000

,000,000 1,924,778 (69.9%)

,500,0001,350,882

,000,000828,239 817,621 (30.1%)

500,000533,261 (39.5%)

02002 2004 2006 2008 2009 2010 2011 2012 2013 2014 2015

Born 1945-1965 in care in year HCV tested in VHA Need testing

1

1

2

2

3


HCV Testing of Female Veterans in Care in 2015

[VALUE] 72.9%

67.0% 72.1% 73.7% 71.5% 68.8%

51.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

National AmericanIndian/AlaskaNative

Asian Black Hispanic NativeHawaiian/

PacificIslander

White Mixed/Other/

Unknown

Born <1945 Born 1945-1965 Born > 1965Females

Population Health Services Data Source: CDW as of 7 January 2016

9


HCV Testing of Male Veterans in Care in 2015

70.0% 72.8%

66.9%

77.5% 76.2% 72.6%

69.0%

55.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



PacificIslander

White Mixed/Other/

Unknown

Born <1945 Born 1945-1965 Born > 1965Males


10


HCV Prevalence in Female Veterans in Care in 2015

3.9%

4.8%

1.5%

4.4%

3.3%

5.0%

3.7%

2.8%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

Total American Indian/Alaska Native

Asian Black Hispanic Native Hawaiian/Pacific Islander

White Mixed/Other/

Unknown

Born <1945 Born 1945-1965 Born >1965


11


HCV Prevalence in Male Veterans in Care in 2015


8.4% 8.4%

2.2%

14.8%

8.6%

7.4% 6.6% 6.5%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%



PacificIslander

White Mixed/Other/

Unknown

Born <1945 Born 1945-1965 Born >1965

12


Homeless Veterans • VA provides care to over 200,000 homeless veterans each year

– HCV prevalence presumed elevated in homeless veterans

– Prior prevalence estimates for HCV antibody positivity ranging from 6.6%-44.0%

13

Cheung et al, J Clin Gastro 2002;34(4):476-480; Desai et al, Soc Psych Pysch Epi 2003;38(7):396-401; Gish et al, Clin Gastro Hep 2005;3(4):311-318.

Homeless veterans in VA care in 2015, N=242,740

Non-homeless veterans in VA care in 2015, N=5,424,685

Female Male

26,966 (11.1%) 215,774 (88.9)

408,481 (7.5%) 5,016,204 (92.5%)

American Indian/Alaskan Native Asian Black Native Hawaiian/Pacific Islander Hispanic White Mixed/Other/Unknown

3,465 (1.4%) 1,653 (0.7%)

94,166 (38.8%) 2,058 (0.8%)

16,601 (6.8%) 112,137 (46.2%)

12,660 (5.2%)

45,599 (0.8%) 54,000 (1.0%)

824,828 (15.2%) 47,095 (0.9%)

316,125 (5.8%) 3,655,678 (67.4%)

481,360 (8.9%)

Born <1945 Born 1945-1965 Born >1965

11,200 (4.6%) 143,617 (59.2%) 87,923 (36.2%)

1,659,796 (30.6%) 2,609,717 (48.1%) 1,155,172 (21.3%)

Backus LI, APHA Oct 2016


HCV Testing in Homeless Veterans in VA Care in 2015

59.5%

44.0%

69.2% 60.0%

78.1%

64.9%

83.6%

70.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Total Born <1945 Born 1945-1965

Born>1965

Non-homeless Homeless

189,508 242,740

3,277,550 5,424,685

7,264 11,200

729,840 1,659,796

1,804,687 2,609,717

693,023 1,155,172

62,153 87,923

120,091 143,617

14



HCV Prevalence in Homeless Veterans in VA Care in 2015

4.5%

1.3%

7.2%

0.9%

15.4%

8.4%

21.4%

4.6%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Total Born <1945 Born 1945-1965

Born>1965


29,063 188,581

144,964 3,216,967

610 7,228

9,696 727,309

129,163 1,797,664

6,105 691,972

2,876 62,045

25,577 119,308

15



HCV Testing - Strategies

• National electronic Clinical Reminder for providers

– “pop-up” that notifies provider that patient is in 1945-1965 birth cohort

– HCV RNA reflex testing for positive antibody

• Automated invitation letter for at-risk veterans to get tested – automation of result notification

• Focus on at-risk groups by educating and partnering with providers in MH, SUD

• Partner with homeless stand-downs and HUD/VASH programs

• Performance measure for VISN Network Directors

– Increase in screening rates by 7-8% nationwide in FY15+FY16 (vs. 1% in years prior)

• Social Marketing

– Multimedia

– Stimulate patients to ask for the test

16


VA Electronic HCV Testing Reminders

• Birth Cohort testing: Born 1945-1965

• Documented HCV risk factor

• If a patient has a positive anti-HCV antibody but no HCV RNA result in the local VISTA system, the reminder will provide options for ordering HCV RNA or recording outside HCV RNA results

₋ IDU ₋ Blood transfusion or organ transplantation

prior to 1992 ₋ Hemodialysis ₋ Vietnam-era service (1964-1975) ₋ Tattoos or body piercing ₋ Intranasal drug use ₋ 20+ lifetime sexual partners ₋ Sexual exposure to HCV-infected persons

₋ HIV infection ₋ Hemophilia and received clotting factors

prior to 1987 ₋ Unexplained liver disease or abnormal liver

function test ₋ Alcoholic hepatitis ₋ Alcohol abuse/dependence ₋ Born to mother with HCV ₋ Incarceration

17


HCV Treatment & Cure

18

Lisa I. Backus MD PhD Patient Care Services/Population Health Department of Veterans Affairs


Treatment of HCV-Infected Veterans in VA

70,000

io

nt 60,000

ipcr

es 50,000

pr

tfi

rs 40,000

h

wit

s 30,000

ane

rte 20,000

Ve

ivta 10,000

Cu

mu

l

01/1/14 1/1/15 1/1/16

SOF (Jan 2014) n=7892

SOF+SMV (Jan 2014) n=3697

LDV/SOF (Nov 2014) n=46,000

OPrD (Jan 2015) n=8174

DAC+SOF (Aug 2015) n=1406

OPr (Aug 2015) n=35

ELB/GRZ (Feb 2016) n=4493

Uptake of HCV Antiviral Regimens in VA in 2014/2015/2016

VEL/SOF (Jul 2016) n=1987

Population Health Services Release dates through 9/30/2016

Regimen (first available) n Cumulative Veterans n=71,586

FY15 29,129 FY14 5,445 FY16 37,012

19


Number of Veterans with HCV in VA care Requiring Anti-viral Treatment

168,708

71,811

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

10/1/2013 10/1/2014 10/1/2015 10/1/2016

Vet

era

ns

awai

tin

g tr

eat

me

nt

Population Health Services Data Source: CCR as of 7 October 2016

20


Demographics of HCV-Infected Veterans in VA care in 2015

21

Veterans with HCV in VA care in 2015

Female Male

3.5% 96.5%

American Indian/Alaskan Native Asian Black Native Hawaiian/Pacific Islander Hispanic White Mixed/Other/Unknown

1.0% 0.2%

35.2% 0.8% 6.0%

52.2% 4.6%

Born <1945 Born 1945-1965 Born >1965

5.9% 88.9% 5.2%

Population Health Services Data Source: CCR as of 27 March 2016


Characteristics of 21,142 Genotype 1 Veterans Initiating HCV Treatment in VA

Age (years)

< 55

55-64

≥ 65

61.7±6.4 (23.4-90.8)

2,040 (9.6%)

12,841 (60.5%)

6,361 (29.9%)

Sex Male 20,529 (96.6%)

Race/ethnicity

African-American

Caucasian

Hispanic

Other/multiple

8,276 (39.0%)

10,447 (49.2%)

1,143 (5.4%)

1,376 (6.5%)

Diabetes 6,883 (32.4%)

HIV co-infected 1,092 (5.1%)

Mental health diagnosis, ever 15,102 (71.1%)

Mental health diagnosis, ever

Anxiety

Bipolar

Depression

PTSD

Schizophrenia

9,529 (44.9%)

2,708 (12.7%)

13,338 (62.8%)

6,740 (31.7%)

1,968 (9.3%)

Mental health diagnosis in the past year

Anxiety

Bipolar

Depression

PTSD

Schizophrenia

3,632 (17.1%)

1,115 (5.2%)

7,379 (34.7%)

4,351 (20.5%)

838 (3.9%)

Population Health Services Backus et al, AASLD 2016 poster 2011

22


SVR Rates Among GT-1 HCV-infected Veterans

Population Health Service Backus et al, AASLD 2016 poster 2011

% (n/N)

Overall SVR 90.3 (17,609/19,504)

Age < 55

55-64

≥ 65

90.8 (1,634/1,800)

90.1 (10,620/11,782)

90.4 (5,355/5,922)

Sex: Male

Female

90.2 (16,996/18,848)

93.4 (613/656)

Race/ethnicity

African-American

Caucasian

Hispanic

Other/multiple/unknown

89.6 (6,789/7,575)

91.0 (8,730/9,595)

89.7 (9,54/1,063)

89.4 (1,136/1,271)

HIV coinfection: No

Yes

90.3 (16,701/18,495)

90.0 (908/1,009)

FIB-4: ≤3.25

>3.25

91.7 (12,372/13,488)

87.1 (5,187/5,952)

HCV subtype: 1a

1b

89.6 (12,589/14,047)

92.0 (5,020/5,457)

23


SVR Rates Among GT-1 HCV-infected Veterans: Impact of Mental Health

Population Health Services Backus et al, AASLD 2016 poster 2011

24

% n/N

Mental health diagnosis

No

Yes

91.6 (5,201/5,679)

89.8 (12,408/13,825)

Mental health diagnosis, ever

Anxiety

Bipolar

Depression

PTSD

Schizophrenia

89.6 (7,787/8,695)

89.6 (2,182/2,434)

89.7 (10,959/12,216)

89.7 (5,522/6,158)

89.7 (1,606/1,791)

Mental health diagnosis in past year

Anxiety

Bipolar

Depression

PTSD

Schizophrenia

90.3 (2,983/3,305)

90.3 (908/1,006)

89.8 (6,046/6,734)

89.3 (3,558/3,985)

89.7 (689/768)

HCV Care Cascade in Homeless and Non-homeless Veterans in VHA Care in 2015

100.0%

77.0% 72.4%

31.0%

22.8%

100.0%

89.6%

79.5%

22.9%

15.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Chronic HCV(estimated)*

n=188,156|32,449

Diagnosed with chronic HCV†

n=144,964 |29,063

Linked to HCV care‡ n=136,169|25,786

Treated with HCV antivirals◊

n=58,321|7,421

Achieved SVR●

n=42,878|5,041

% o

f to

tal c

hro

nic

HC

V p

op

ula

tio

n


77.0% 93.9% 42.8% 73.5%

89.6% 88.7% 28.8% 67.9%

4,012 homeless Ve terans received all-oral regimens in 2015

Noska A, et al. Pub Health Rep , in press

25

VETERANS HEALTH ADMINISTRATION 26

Data Reports to Identify Patients Locally


VA Strategies to Address HCV

Timothy Morgan MD Chief of Hepatology, VA Long Beach Director, National Hepatitis C Resource Center

27


VA National Strategy for Curing HCV

• Active identification and outreach (registry, dashboards)

• Data analysis and feedback to track and monitor continuum of caremetrics, outcomes, and cost

• Increase capacity – make it easy for patients to get treated

– Midlevel providers (PharmD’s, NP’s, PA’s to treat), SCAN-ECHO, telehealth,shared medical appointments

• Integrated care – case management, psychosocial support, primary care,pharmacy

• Targeted Outreach to patients – multimedia, letters, Veteran ServiceOrganizations

• Regional HCV Innovation Teams (HITs)- education and dissemination ofbest practices, redesign care based on local process and clinical outcomes

28

National Hepatitis C Resource Center/VISN HCV Innovation Team (HIT) Collaborative

National Hepatitis C Resource Center

• Provider and Patient Education• Regional (VISN) Innovation Teams• System Redesign• Monitoring and Evaluation of HCV care

Collaborating within VISNs and across VISNs HIT Collaborative

• Multi-disciplinary teams guided by Lean/process improvement methods Physicians, nursing, pharmacy, psychology, case management Lean experts, Population Health, IT

• Make-up of teams and activities guided by local needs

VETERANS HEALTH ADMINISTRATION 29


System Redesign Definition and Process

30

• Improving care by redesigning the processes of care

delivery

• Assess how we deliver care now (current state map)

• Identify problems with care delivery (problem statement)

• Propose solutions (future state map)

• Measure change in care (monitoring and evaluation)

– Assess improvements


Linkage to Care - Strategies

• Active outreach vs. dependency on passive referral

• Treatment offered to all – emphasis on patients with most severe liver disease

• Optimizing use of electronic health records to create electronic population health management tools for hep c (registry, dashboards)

• Multi-disciplinary team coordinators

• Patient education classes

31


Evaluation and Treatment

• Ongoing Provider education – vaww.hepatitis.va.gov, educational materials

– Teleconferences, webinars, clinical updates, email communication to providers

• System-wide guidelines and VA treatment considerations for evaluation for treatment

• Primary care providers, mid-level and specialty care providers engaged in evaluation and treatment

• Group treatment clinics

32


Increasing Capacity

• Expanding role of mid-level providers

– PharmD, NP, PA as treaters and to conduct monitoring and follow-up

• Engage Primary Care

– Testing

– Identification of HCV patients

– Co-management / Treatment

• SCAN-ECHO

• Telehealth

• Mental Health / Substance Use Disorder integration

• Education

– Produce high-quality providers

– Mini-sabbaticals, train-the-trainer, Bootcamps

33


Integrated Care

34

• Integrated multi-disciplinary

HCV care: use of PharmD,

NP, PA as “treaters”

• Screening protocols for

psychiatric, alcohol use, and

substance use disorders

• Motivational interviewing to

reduce alcohol use and allow

anti-viral treatment of HCV

patients

• Liver tumor boards to

coordinate HCC care

Liver

Specialty

Social

Work

Pharmacy Substance Use

Disorder Therapy

Mental

Health Care

Coordination

Primary

Care


Barriers

• Patient Level – Unable or unwilling to receive HCV treatment

– Other comorbidities (Mental health, substance use)

– Extensive, multi-pronged outreach approaches necessary

• System Level – Funding

– Efficient linkage to care

– Geographic location / convenience

– Provider knowledge / experience / comfort

– Infrastructure

• Lab resources, case management, psychosocial support

35


Patient-level Barriers to Treatment

36

Source: Based on VA data collected from VISNs 3, 7, 8, 17, 19, 21, 22, & 23; July 2016

Deceased 3%

Psychosocial Needs 16%

Unstable Comorbidity

31%

Patient Determinant

50%

Deceased

Psychosocial Needs

Unstable Comorbidity

Patient Determinant


Outreach and Education

Elizabeth Maguire, MSW Communications Lead, HIV, Hepatitis, and Public Health Pathogens Program Center for Healthcare Organization and Implementation Research (CHOIR) Bedford VA Medical Center

37


Veteran Outreach

• Awareness campaigns, including social media

• Advertising campaigns

• Partnerships with Veteran Service Organizations (VSOs)

• Direct outreach to Veterans

38


Promotional Campaign with Veterans Cured of Hepatitis C

39


Provider Resources

– AUDIT-C scoring cards

– Hepatitis A/B immunization

– Hepatitis C Support Groups

– Liver Telehealth Guide

– Brief Alcohol Intervention Teaching Guide

• Web

– LiveMeeting Webcasts on HCV

• Conferences

– SCAN/ECHO

– Clinical Pharmacist HCV Boot Camps

– Hot Topics in Liver Disease at AASLD

– HCV Protease inhibitor training

– Liver Disease for Primary Care Physicians

– Mini-sabbaticals/mini-residencies

• Published guidelines

– VA HCV Treatment Considerations

– HCV Testing

Patient Resources • Patient Guides

– Cirrhosis

– Liver Cancer

– New HCV Drugs “Taking Your Therapy”

– Liver Transplant

– Alcohol

– Managing Treatment Side-effects

• Patient tools

– Drinking diaries

– Triple therapy workbooks

– Education classes

40

Training and Education www.hepatitis.va.gov

www.hepatitis.va.gov

41

http://www.hepatitis.va.gov/

veterans & hepatitis c: test, treat, curevel/sof (jul 2016) n=1987 population health services...

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