Cascade of Care for Hepatitis C Virus Infection Within the US Veterans Health Administration

Abstract

Objectives: We measured the quality of HCV care using a cascade of HCV care model.

Methods: We estimated the number of patients diagnosed with chronic HCV, linked to HCV care, treated with HCV antivirals, and having achieved a sustained virologic response (SVR) in the electronic medical record data from the Veterans Health Administration's Corporate Data Warehouse and the HCV Clinical Case Registry in 2013.

Results: Of the estimated 233,898 patients with chronic HCV, 77% (181,168) were diagnosed, 69% (160,794) were linked to HCV care, 17% (39,388) were treated with HCV antivirals, and 7% (15,983) had achieved SVR.

Conclusions: This Cascade of HCV Care provides a clinically relevant model to measure the quality of HCV care within a health care system and to compare HCV care across health systems.

FIGURE 1—

Cascade of HCV care in the Veterans Health Administration (VHA) in 2013 (n = 233 898). Note. SVR = sustained virologic response. The proportion of patients in each step of the cascade from the patients in the preceding step is presented in the arrows between each bar. ^aChronic HCV was estimated from the sum of those already identified with chronic HCV plus estimated additional cases from projected prevalence among HCV antibody-positive patients who had not had RNA testing plus estimated additional cases from projected prevalence among the untested population. ^b“Diagnosed with chronic HCV” was defined as ever had a detectable HCV RNA or genotype. ^c“Linked to HCV care” required an outpatient visit in 2013, entry in the VHA’s HCV registry, and HCV entered on the patient’s medical record problem list. ^d“Treated with HCV antivirals” was defined as ever received HCV antivirals from the VHA as of December 31, 2013. ^e“Achieved SVR” was defined as undetectable HCV RNA on all tests after end of treatment, including at least 1 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.

FIGURE 2—

Cascade of HCV care within the Veterans Health Administration (VHA) and relative to national US estimates in 2013. Note. SVR = sustained virologic response. Total estimated chronic HCV population in the VHA in 2013 was 233 898. Source. National US estimates were derived from the following sources: diagnosed with chronic HCV, linked to HCV care, treated with HCV antivirals and achieved SVR. VHA estimates were derived from the VHA Corporate Data Warehouse and the HCV Clinical Case Registry. ^a“Diagnosed with chronic HCV” was defined as ever had a detectable HCV RNA or genotype. ^b“Linked to HCV care” required an outpatient visit in 2013, entry in the VHA’s HCV registry, and HCV entered on the patient’s medical record problem list. ^c“Treated with HCV antivirals” was defined as ever received HCV antivirals from the VHA as of December 31, 2013. ^d“Achieved SVR” was defined as undetectable HCV RNA on all tests after end of treatment, including at least 1 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. *P < .001.