November 16, 2011

Rural Vets Unlikely to Receive Specialist HCV Care

Neil Canavan

November 16, 2011 (San Francisco, California) — An analysis performed by the Veterans Health Administration (VHA) suggests that not only are a surprising number of veterans infected with hepatitis C virus (HCV) living in rural areas, but less than half of these individuals have ever been seen by an HCV specialty provider. This finding was presented here at The Liver Meeting 2011: American Association for the Study of Liver Diseases 62nd Annual Meeting.

"What makes the VHA so unique in examining rural differences and access to care is the way in which the VHA is set up," said Catherine Rongey, MD, MSHS, assistant professor, gastroenterology and hepatology, San Francisco Veterans Affairs Medical Center and the University of San Francisco, California.

The VHA is the largest integrated healthcare system in the country. For specialist care, it is required that veterans be treated at one of the urban-based VHA centers where specialists reside. Any specialist care involves an electronic record, and because the VHA has embraced electronic health records, detailed records are easily obtained.

The first aim of this study was to determine the geographic distribution of HCV-infected patients; the second was to determine how a rural setting affects access to specialty HCV care. Data on viremic-confirmed patients, collected from 2005 to 2009, were obtained from the HCV Clinical Case Registry, a national VHA registry (n = 185,978). These data were analyzed for the distribution of HCV patients in rural and urban sites, the severity of liver disease, medical comorbidities, and HCV quality-of-care indicators.

Overall, the data showed that 40% of all VA patients reside in rural areas. What is interesting, Dr. Rongey said, "is that 32% of our veterans in rural areas are infected with hepatitis C. This is quite different than HIV or any other infectious disease. It's much higher than anticipated."

Perhaps as expected, these rural patients are receiving less specialist care than those in urban settings. This analysis shows that only 45% of rural veterans with HCV had ever seen an HCV specialist, compared with 50% of urban veterans. In addition, only 82.6% of rural veterans have ever undergone an HCV screening, compared with 85.2% of urban veterans.

In the multivariate analysis, after adjustment for cirrhosis and comorbidities, rural patients were 33% less likely to access hepatology care than urban patients (P ≤ .05). "Less than half of VHA patients with liver disease have accessed a gastroenterologist/liver physician," said Dr. Rongey, "and only 20% have been treated. Our response rates [to treatment] are lower than other healthcare systems, and our patients have more comorbidities."

Getting rural patients to the specialist is not the answer to improving care, she explained. In California, veterans can travel up to 8 hours round trip to seek specialty care. "Many of our patients also have PTSD or are anxiety disordered, so traveling 8 hours in a shuttle bus that goes through tunnels and over bridges may not be the best approach." The solution is to bring the specialist to the patient.

"One such initiative is focusing on leveraging telemedicine — doing provider-based telemedicine care as part of Project ECHO [Extension for Community Healthcare Outcomes], in which providers such as myself in San Francisco connect with multiple providers simultaneously at these outlying clinics." The idea is to transfer specialists' skills to the providers in a way that can actually benefit the patients.

"Our program is being designed to build specialty-level knowledge among primary care providers, and often to mid-levels," said Dr. Rongey. Her interest is not tutoring just on standards of care, but on recent changes in treatment paradigms. "While we're excited by all these new HCV treatments that are coming out, what could also be useful is training our primary care providers and mid-levels in the management of chronic liver disease."

Now that effective drugs are available, veterans who have failed treatment or who have been waiting for the new agents to be approved will be coming back and seeking specialist care.

Because this analysis showed that veterans living an any setting are being undertreated for HCV, the ECHO initiative will also provide opportunities to urban-based healthcare providers.

Project ECHO

"For the VA, all the incentives are perfectly aligned to do a project like ECHO," said founder and current director of Project ECHO, Sanjeev Arora, MD, professor of medicine, executive vice chair of the Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque.

In brief, ECHO is a telemedicine case-based approach that connects the urban-based specialist to the remotely located provider using the Internet. The program costs nothing to the remote participant, and Internet access is funded by the program. ECHO participants who complete educational modules related to specialty care for the HCV patient can earn CME credits.

Dr. Arora pointed out that the VHA has long waits for specialty consultation across its entire system, and that lack of access is actually driving up costs. "For example, in 2009, the VA paid $8 million in travel expenses to transport vets for specialty care from outlying areas to the VA center in Albuquerque. These are massive costs that are not likely adding to the patient's care experience," and are possibly causing discomfort.

The VHA hopes expand access to specialty care by using the blueprints from Project ECHO.

"The VA is a very thoughtful and large organization, and it involves a significant amount of dialog," Dr. Arora said with a smile when reporting on the progress made with so far Project ECHO. "They've been extraordinarily responsive to the need, and they are rolling out ECHO at an absolutely rapid speed all across the VA system."

Dr. Rongey and Dr. Arora have disclosed no relevant financial relationships.

The Liver Meeting 2011: American Association for the Study of Liver Diseases (AASLD) 62nd Annual Meeting: Abstract 102. Presented November 6, 2011.