Healthcare Quality in HCV Is Suboptimum, Based on Medicare Criteria

Laurie Barclay, MD

August 18, 2010 — Healthcare quality in chronic hepatitis C virus (HCV) infection is suboptimum based on Medicare criteria, according to the results of a retrospective cohort study reported in the August 17 issue of the Annals of Internal Medicine.

"Medicare has proposed quality-of-care indicators for chronic [HCV] infection," write Fasiha Kanwal, MD, MSHS, from the John Cochran Veterans Affairs Medical Center and Saint Louis University School of Medicine, Missouri, and colleagues. "The extent to which these standards are met in practice is largely unknown."

Using a nationwide US health insurance company research database, the investigators aimed to assess the quality of healthcare received by patients with HCV, as well as factors linked to receipt of quality care. Between 2003 and 2006, 10,385 patients with HCV were enrolled in the database. Those patients eligible for at least 1 of 7 explicit quality indicators included in Medicare's 2009 Physician Quality Reporting Initiative were included in the analysis.

All recommended care was received by only 18.5% of patients (95% confidence interval [CI], 18% - 19%). The proportions of patients who met quality indicators varied considerably, from 21.5% for vaccination to 79% for the HCV genotype testing indicator.

Factors associated with lower quality of care were older age and presence of comorbid conditions, whereas elevated liver enzyme levels, cirrhosis, and HIV infection predicted higher quality of care. The best care was received by patients who saw both generalists and specialists. Compared with collaborative care (ie, from both specialist and primary care physician), the odds ratio of receiving care for which a patient was eligible was 0.79 (95% CI, 0.66 - 0.95) when specialists alone were involved in the patient's care, and 0.44 (95% CI, 0.40 - 0.48) when the primary care physician alone was involved in the patient's healthcare.

Limitations of this study include observational retrospective design, use of a convenience sample, lack of data on patient ethnicity, and the possibility that the indicators or the reporting of the indicators of HCV care are suboptimal, rather than the care itself. In addition, some of the findings may reflect differential ascertainment and coding.

"Healthcare quality, based on Medicare criteria, is suboptimum for HCV," the study authors write. "Care that included both specialists and generalists is associated with the best quality. Our results support the development of specialist and primary care collaboration to improve the quality of HCV care."

The Saint Louis University Liver Center supported this study. Some of the study authors report various financial relationships with Veterans Affairs Health Services, Saint Louis University Liver Center, Merck/Schering-Plough, Valeant, Gilead Sciences, Three Rivers Pharma, Vertex, Human Genome Sciences, and/or Up-To-Date.

Ann Intern Med. 2010;153:231-239.

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Also See: Quality of Care in Patients With Chronic Hepatitis C Virus Infection