VA Health Care
Further Efforts Needed to Improve Hepatitis C Testing for At-Risk Veterans Gao ID: GAO-04-106 December 12, 2003Hepatitis C is a chronic disease caused by a blood-borne virus that can lead to potentially fatal liverrelated conditions. In 2001, GAO reported that the VA missed opportunities to test about 50 percent of veterans identified as at risk for hepatitis C. GAO was asked to (1) review VA's fiscal year 2002 performance measurement results in testing veterans at risk for hepatitis C, (2) identify factors that impede VA's efforts to test veterans for hepatitis C, and (3) identify actions taken by VA networks and medical facilities to improve the testing rate of veterans at risk for hepatitis C. GAO reviewed VA's fiscal year 2002 hepatitis C performance results and compared them against VA's national performance goals, interviewed headquarters and field officials in three networks, and conducted a case study in one network.
VA's performance measurement result shows that it tested, in fiscal year 2002 or earlier, 5,232 (62 percent) of the 8,501 veterans identified as at risk for hepatitis C in VA's performance measurement sample, exceeding its fiscal year 2002 national goal of 55 percent. Thousands of veterans (about one-third) of those identified as at risk for hepatitis C infection in VA's performance measurement sample were not tested. VA's hepatitis C testing result is a cumulative measure of performance over time and does not only reflect current fiscal year performance. GAO found Network 5 (Baltimore) tested 38 percent of veterans in fiscal year 2002 as compared to Network 5's cumulative performance result of 60 percent. In its case study of Network 5, which was one of the networks to exceed VA's fiscal year 2002 performance goal, GAO identified several factors that impeded the hepatitis C testing process. These factors were tests not being ordered by the provider, ordered tests not being completed, and providers being unaware that needed tests had not been ordered or completed. For more than two-thirds of the veterans identified as at risk but not tested for hepatitis C, the testing process failed because hepatitis C tests were not ordered, mostly due to poor communication between clinicians. For the remaining veterans, the testing process was not completed because orders had expired by the time veterans visited the laboratory or test orders were overlooked because laboratory staff had to scroll back and forth through daily lists, a cumbersome process, to identify active orders. Moreover, during subsequent primary care visits by these untested veterans, providers often did not recognize that hepatitis C tests had not been ordered nor had their results been obtained. Consequently, undiagnosed veterans risk unknowingly transmitting the disease as well as potential complications resulting from delayed treatment. The three networks GAO looked at--5 (Baltimore), 2 (Albany), and 9 (Nashville)--have taken steps intended to improve the testing rate of veterans identified as at risk for hepatitis C. To do this, in two networks officials modified clinical reminders in the computerized medical record to alert providers that for ordered hepatitis C tests, results were unavailable. Officials at two facilities developed a "look back" method to search computerized medical records to identify all at-risk veterans who had not yet been tested and identified approximately 3,500 untested veterans. The look back serves as a safety net for veterans identified as at risk for hepatitis C who have not been tested. The modified clinical reminder and look back method of searching medical records appear promising, but neither the networks nor VA has evaluated their effectiveness.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-04-106, VA Health Care: Further Efforts Needed to Improve Hepatitis C Testing for At-Risk Veterans
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Report to the Chairman, Subcommittee on National Security, Emerging
Threats, and International Relations, Committee on Government Reform,
House of Representatives:
United States General Accounting Office:
GAO:
December 2003:
VA Health Care:
Further Efforts Needed to Improve Hepatitis C Testing for At-Risk
Veterans:
GAO-04-106:
GAO Highlights:
Highlights of GAO-04-106, a report to the Chairman, Subcommittee on
National Security, Emerging Threats, and International Relations,
Committee on Government Reform, House of Representatives
Why GAO Did This Study:
Hepatitis C is a chronic disease caused by a blood-borne virus that
can lead to potentially fatal liver-related conditions. In 2001, GAO
reported that the VA missed opportunities to test about 50 percent of
veterans identified as at risk for hepatitis C. GAO was asked to (1)
review VA‘s fiscal year 2002 performance measurement results in
testing veterans at risk for hepatitis C, (2) identify factors that
impede VA‘s efforts to test veterans for hepatitis C, and (3)
identify actions taken by VA networks and medical facilities to
improve the testing rate of veterans at risk for hepatitis C. GAO
reviewed VA‘s fiscal year 2002 hepatitis C performance results and
compared them against VA‘s national performance goals, interviewed
headquarters and field officials in three networks, and conducted a
case study in one network.
What GAO Found:
VA‘s performance measurement result shows that it tested, in fiscal
year 2002 or earlier, 5,232 (62 percent) of the 8,501 veterans
identified as at risk for hepatitis C in VA‘s performance measurement
sample, exceeding its fiscal year 2002 national goal of 55 percent.
Thousands of veterans (about one-third) of those identified as at risk
for hepatitis C infection in VA‘s performance measurement sample were
not tested. VA‘s hepatitis C testing result is a cumulative measure
of performance over time and does not only reflect current fiscal
year performance. GAO found Network 5 (Baltimore) tested 38 percent of
veterans in fiscal year 2002 as compared to Network 5‘s cumulative
performance result of 60 percent.
In its case study of Network 5, which was one of the networks to
exceed VA‘s fiscal year 2002 performance goal, GAO identified several
factors that impeded the hepatitis C testing process. These factors
were tests not being ordered by the provider, ordered tests not being
completed, and providers being unaware that needed tests had not been
ordered or completed. For more than two-thirds of the veterans
identified as at risk but not tested for hepatitis C, the testing
process failed because hepatitis C tests were not ordered, mostly due
to poor communication between clinicians. For the remaining veterans,
the testing process was not completed because orders had expired by
the time veterans visited the laboratory or test orders were
overlooked because laboratory staff had to scroll back and forth
through daily lists, a cumbersome process, to identify active orders.
Moreover, during subsequent primary care visits by these untested
veterans, providers often did not recognize that hepatitis C tests
had not been ordered nor had their results been obtained.
Consequently, undiagnosed veterans risk unknowingly transmitting the
disease as well as potential complications resulting from delayed
treatment.
The three networks GAO looked at”5 (Baltimore), 2 (Albany), and 9
(Nashville)”have taken steps intended to improve the testing rate of
veterans identified as at risk for hepatitis C. To do this, in two
networks officials modified clinical reminders in the computerized
medical record to alert providers that for ordered hepatitis C tests,
results were unavailable. Officials at two facilities developed a
’look back“ method to search computerized medical records to identify
all at-risk veterans who had not yet been tested and identified
approximately 3,500 untested veterans. The look back serves as a
safety net for veterans identified as at risk for hepatitis C who
have not been tested. The modified clinical reminder and look back
method of searching medical records appear promising, but neither the
networks nor VA has evaluated their effectiveness.
What GAO Recommends:
To improve testing performance, GAO recommends that VA determine the
effectiveness of actions taken by networks and facilities to improve
the hepatitis C testing rates for veterans and consider applying such
actions systemwide. GAO also recommends VA provide local managers
with information on current fiscal year performance results in order
for them to determine the effectiveness of actions taken to improve
hepatitis C testing processes. VA concurred with these
recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-04-106.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Cynthia A. Bascetta
at (202) 512-7101.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Thousands of Veterans Identified as At Risk Remain Untested for
Hepatitis C Despite VA Exceeding Its Testing Goal:
Several Factors Impeded One Network's Efforts to Test Veterans
Identified as At Risk:
Some VA Networks and Facilities Have Taken Action Intended to Improve
Hepatitis C Testing of Veterans Identified as At Risk:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Veterans Affairs:
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Acknowledgments:
Related GAO Products:
Table:
Table 1: Veterans in VA Performance Measurement Sample Identified as At
Risk and Tested for Hepatitis C-VA National and Network Results, Fiscal
Year 2002:
Abbreviations:
NIH: National Institutes of Health:
VA: Department of Veterans Affairs:
United States General Accounting Office:
Washington, DC 20548:
December 12, 2003:
The Honorable Christopher Shays:
Chairman:
Subcommittee on National Security, Emerging Threats, and
International Relations:
Committee on Government Reform:
House of Representatives:
Dear Mr. Chairman:
In 1998, the Department of Veterans Affairs (VA) launched a major
initiative to screen all veterans treated at VA facilities by asking
them a series of questions about possible risk factors for hepatitis C
and performing blood tests for those veterans identified as being at
risk for contracting the disease.[Footnote 1] Hepatitis C is a chronic
disease caused by a blood-borne virus that can lead to potentially
fatal liver-related conditions. This initiative represents a major
undertaking for VA, which provided health care services to
approximately 4.7 million veterans and identified over 180,000 veterans
with hepatitis C infections in fiscal year 2002.
In June 2001, we testified before your subcommittee that VA was not
conducting hepatitis C risk factor screening for about 80 percent of
veterans making outpatient clinic visits to VA facilities and not
testing, on average, about half of the veterans it identified with at
least one risk factor at four VA facilities we visited.[Footnote 2] We
concluded and VA agreed that for VA to identify undiagnosed veterans,
it would need to establish early detection as a standard of care and
hold managers accountable for the testing of identified at-risk
veterans who receive care in VA's outpatient clinics. As a result, VA
implemented a hepatitis C screening and testing process and, in fiscal
year 2002, included both screening and testing of veterans for
hepatitis C in its performance measurement system.[Footnote 3] VA's
hepatitis C screening and testing performance is measured by reviewing
a sample of veterans' medical records to determine the percentage of
veterans screened against a list of risk factors for the disease and
the percentage of at-risk veterans who are subsequently tested. To be
included in the hepatitis C testing performance measure, the veteran
does not have to have been tested in fiscal year 2002; testing may have
occurred in a prior fiscal year. VA established its fiscal year 2002
national hepatitis C testing performance goal at 55 percent. For the
veterans' medical records to be included in the performance measurement
sample, veterans must have been enrolled to receive VA health care for
2 continuous years and been seen at least once during the current
fiscal year in one of VA's primary care clinics.[Footnote 4]
VA's hepatitis C screening performance result for fiscal year 2002 was
85 percent, a significant improvement from its baseline result of 51
percent in fiscal year 2001. As a result, you asked us to focus our
work on testing performance and we (1) reviewed VA's fiscal year 2002
performance measurement results in testing veterans it identified as at
risk for hepatitis C, (2) identified factors that impede VA's efforts
to test veterans for hepatitis C in one VA health care network, and (3)
identified actions taken by VA networks and medical facilities intended
to improve the testing rate of veterans identified as at risk for
hepatitis C.
We reviewed VA's fiscal year 2002 performance measurement process
results in testing veterans it identified as at risk for hepatitis C,
the most recently available data at the time we conducted our work.
Specifically, to assess VA's fiscal year 2002 performance measurement
results, we compared VA's national and individual network performance
results for testing veterans in fiscal year 2002 or earlier against
VA's national goal and analyzed VA's method for calculating performance
results. In addition, we looked at one VA health care network's testing
rate for at-risk veterans visiting its clinics in fiscal year 2002. We
identified factors that impede VA's efforts to test veterans for
hepatitis C through a case study of VA's Network 5 (Baltimore), which
included interviews with network and facility officials and clinical
staff. From the medical record review we were able to determine if a
hepatitis C test was ordered, if the ordered test was completed, if the
veteran visited the laboratory and provider after the test was ordered,
and if a test result was present in the medical record. Network 5 was
chosen for the case study because its rate of hepatitis C testing was
comparable to VA's national performance results. To identify actions
taken by networks and medical facilities intended to improve the rate
of hepatitis C testing, we expanded our interviews of VA officials and
clinical staff beyond Network 5 (Baltimore) to include staff in Network
2 (Albany) and Network 9 (Nashville). For a complete description of our
scope and methodology, see appendix I. Our review was conducted from
April 2002 through November 2003 and in accordance with generally
accepted government auditing standards.
Results in Brief:
VA's performance measurement results show that it tested, in fiscal
year 2002 or earlier, 5,232 (62 percent) of the 8,501 veterans
identified as at risk for hepatitis C in VA's performance measurement
sample, exceeding its fiscal year 2002 national goal of 55 percent.
Thousands of veterans, about one-third of those identified as at risk
for hepatitis C infection in VA's performance measurement sample, were
not tested. Moreover, the percentage of veterans identified as at risk
who were tested for hepatitis C varied widely among VA's 21 health care
networks, with 14 networks meeting or exceeding VA's national goal of
55 percent and 7 networks falling from 1 to 10 percent below the goal.
VA's hepatitis C testing results are a cumulative measure of
performance over time and do not reflect only the current fiscal year
performance. When we looked at Network 5's testing performance for
fiscal year 2002, we found that 38 percent of veterans who needed to be
tested in fiscal year 2002 were tested as compared to the Network's
cumulative performance result of 60 percent.
We identified three factors that impeded the hepatitis C testing
process used by Network 5 (Baltimore), our case study, which was one of
the networks to exceed VA's national goal. These factors were tests not
being ordered by the provider, ordered tests not being completed, and
providers being unaware that needed tests had not been ordered or
completed. For more than two-thirds of the untested, at-risk veterans,
providers did not order tests, a crucial step in the testing process,
mostly due to poor communication between clinicians that a hepatitis C
test was needed. For the remaining veterans, tests were ordered but the
testing process was not completed. Tests were not completed primarily
because orders were expired by the time veterans visited the laboratory
or test orders were overlooked due to the cumbersome process used by
laboratory staff. Instead of being able to view a summary of active
test orders, laboratory staff must scroll back and forth through a
daily list of ordered testsæin two Network 5 facilities up to 60 days
of ordersæto identify laboratory tests that need to be completed.
Moreover, during subsequent primary care visits by these untested, at-
risk veterans, providers often failed to recognize that hepatitis C
tests either had not been ordered or the results of tests had not been
obtained. Consequently, neither the at-risk veterans nor their
providers know whether the veterans have hepatitis C. These undiagnosed
veterans unknowingly risk transmitting the disease as well as
potentially developing complications as a result of delayed treatment.
Some networks and facilities have made changes intended to improve
their hepatitis C testing processes. VA network and facility officials
in the three networks we reviewed--Network 5 (Baltimore), Network 2
(Albany), and Network 9 (Nashville)--identified similar factors that
impede hepatitis C testing and focused on getting test results
immediately following risk factor identification. Officials at two
networks modified clinical reminders in the computerized medical record
to alert providers that for ordered hepatitis C tests, results were
unavailable. Thus, if the laboratory has not completed the order, the
reminder acts as a backup system to alert the provider that a hepatitis
C test may need to be reordered. Officials at two facilities in
different networks created a safety net for veterans identified as at
risk for hepatitis C who remain untested. Officials developed a method
that electronically looks back through computerized medical records,
for any time frame specified, to identify at-risk veterans in need of
testing and identified approximately 3,500 untested veterans.
To improve testing performance, we recommend that VA determine the
effectiveness of actions taken by networks and facilities intended to
improve the hepatitis C testing rates for veterans and, where actions
have been successful, consider applying these improvements systemwide.
Also, because VA's cumulative measurement looks at performance over
time, VA should select a subset of the performance measurement sample
of veterans to determine current fiscal year performance and provide
managers with a tool for improving testing processes. In commenting on
a draft of this report, VA concurred with our recommendations and noted
that its fiscal year 2003 cumulative hepatitis C testing performance
showed improvement. We incorporated updated performance information
provided by VA where appropriate. However, because VA did not include
its fiscal year 2003 hepatitis C testing performance results by
individual network, we do not know if the wide variation in network
results, which we found in fiscal year 2002, still exists in fiscal
year 2003.
Background:
Hepatitis C was first recognized as a unique disease in 1989. It is the
most common chronic blood-borne infection in the United States and is a
leading cause of chronic liver disease.[Footnote 5] The virus causes a
chronic infection in 85 percent of cases. Hepatitis C, which is the
leading indication for liver transplantation, can lead to liver cancer,
cirrhosis (scarring of the liver), or end-stage liver disease. Most
people infected with hepatitis C are relatively free of physical
symptoms. While hepatitis C antibodies generally appear in the blood
within 3 months of infection, it can take 15 years or longer for the
infection to develop into cirrhosis. Blood tests to detect the
hepatitis C antibody, which became available in 1992, have helped to
virtually eliminate the risk of infection through blood transfusions
and have helped curb the spread of the virus. Many individuals were
already infected, however, and because many of them have no symptoms,
they are unaware of their infection. Hepatitis C continues to be spread
through blood exposure, such as inadvertent needle-stick injuries in
health care workers and through the sharing of needles by intravenous
drug abusers.
Early detection of hepatitis C is important because undiagnosed persons
miss opportunities to safeguard their health by unknowingly behaving in
ways that could speed the progression of the disease. For example,
alcohol use can hasten the onset of cirrhosis and liver failure in
those infected with the hepatitis C virus. In addition, persons
carrying the virus pose a public health threat because they can infect
others.
The Centers for Disease Control and Prevention estimates that nearly 4
million Americans are infected with the hepatitis C virus.
Approximately 30,000 new infections occur annually. The prevalence of
hepatitis C infection among veterans is unknown, but limited survey
data suggest that hepatitis C has a higher prevalence among veterans
who are currently using VA's health care system than among the general
population because of veterans' higher frequency of risk factors. A 6
year study--1992-1998--of veterans who received health care at the VA
Palo Alto Health Care System in Northern California reported that
hepatitis C infection was much more common among veterans within a very
narrow age distribution--41 to 60 years of age--and intravenous drug
use was the major risk factor.[Footnote 6] VA began a national study of
the prevalence of hepatitis C in the veteran population in October
2001. Data collection for the study has been completed but results have
not been approved for release. The prevalence of hepatitis C among
veterans could have a significant impact on current and future VA
health care resources, because hepatitis C accounts for over half of
the liver transplants needed by VA patientsæcosting as much as $140,000
per transplantæand the drug therapy to treat hepatitis C is
costlyæabout $13,000 for a 48-week treatment regimen.[Footnote 7]
In the last few years, considerable research has been done concerning
hepatitis C. The National Institutes of Health (NIH) held a consensus
development conference on hepatitis C in 1997 to assess the methods
used to diagnose, treat, and manage hepatitis C infections. In June
2002, NIH convened a second hepatitis C consensus development
conference to review developments in management and treatment of the
disease and identify directions for future research.[Footnote 8] This
second panel concluded that substantial advances had been made in the
effectiveness of drug therapy for chronic hepatitis C infection.
VA's Public Health Strategic Healthcare Group is responsible for VA's
hepatitis C program, which mandates universal screening of veterans to
identify at-risk veterans when they visit VA facilities for routine
medical care and testing of those with identified risk factors, or
those who simply want to be tested. VA has developed guidelines
intended to assist health care providers who screen, test, and counsel
veterans for hepatitis C. Providers are to educate veterans about their
risk of acquiring hepatitis C, notify veterans of hepatitis C test
results, counsel those infected with the virus, help facilitate
behavior changes to reduce veterans' risk of transmitting hepatitis C,
and recommend a course of action. In January 2003, we reported that VA
medical facilities varied considerably in the time that veterans must
wait before physician specialists evaluate their medical conditions
concerning hepatitis C treatment recommendations.[Footnote 9]
To assess the effectiveness of VA's implementation of its universal
screening and testing policy, VA included performance measures in the
fiscal year 2002 network performance plan. Network performance measures
are used by VA to hold managers accountable for the quality of health
care provided to veterans. For fiscal year 2002, the national goal for
testing veterans identified as at risk for hepatitis C was established
at 55 percent based on preliminary performance results obtained by
VA.[Footnote 10] To measure compliance with the hepatitis C performance
measures, VA uses data collected monthly through its External Peer
Review Program, a performance measurement process under which medical
record reviewers collect data from a sample of veterans' computerized
medical records.[Footnote 11]
Development of VA's computerized medical record began in the mid-1990s
when VA integrated a set of clinical applications that work together to
provide clinicians with comprehensive medical information about the
veterans they treat. Clinical information is readily accessible to
health care providers at the point of care because the veteran's
medical record is always available in VA's computer system. All VA
medical facilities have computerized medical record systems.
Clinical reminders are electronic alerts in veterans' computerized
medical records that remind providers to address specific health
issues. For example, a clinical reminder would alert the provider that
a veteran needs to be screened for certain types of cancer or other
disease risk factors, such as hepatitis C. In July 2000, VA required
the installation of hepatitis C clinical reminder software in the
computerized medical record at all facilities. This reminder alerted
providers when they opened a veteran's computerized medical record that
the veteran needed to be screened for hepatitis C. In fiscal year 2002,
VA required medical facilities to install an enhanced version of the
July 2000 clinical reminder. The enhanced version alerts the provider
to at-risk veterans who need hepatitis C testing, is linked directly to
the entry of laboratory orders for the test, and is satisfied once the
hepatitis C test is ordered.
Thousands of Veterans Identified as At Risk Remain Untested for
Hepatitis C Despite VA Exceeding Its Testing Goal:
Even though VA's fiscal year 2002 performance measurement results show
that it tested 62 percent of veterans identified to be at risk for
hepatitis C, exceeding its national goal of 55 percent, thousands of
veterans in the sample who were identified as at risk were not tested.
Moreover, the percentage of veterans identified as at risk who were
tested varied widely among VA's 21 health care networks. Specifically,
we found that VA identified in its performance measurement sample 8,501
veterans nationwide who had hepatitis C risk factors out of a sample of
40,489 veterans visiting VA medical facilities during fiscal year
2002.[Footnote 12] VA determined that tests were completed, in fiscal
year 2002 or earlier, for 62 percent of the 8,501 veterans based on a
review of each veteran's medical record through its performance
measurement process.[Footnote 13] For the remaining 38 percent (3,269
veterans), VA did not complete hepatitis C tests when the veterans
visited VA facilities. The percentage of identified at-risk veterans
tested for hepatitis C ranged, as table 1 shows, from 45 to 80 percent
for individual networks. Fourteen of VA's 21 health care networks
exceeded VA's national testing performance goal of 55 percent, with 7
networks exceeding VA's national testing performance level of 62
percent. The remaining 7 networks that did not meet VA's national
performance goal tested from 45 percent to 54 percent of at-risk
veterans.
Table 1: Veterans in VA Performance Measurement Sample Identified as At
Risk and Tested for Hepatitis C-VA National and Network Results, Fiscal
Year 2002:
VA network (location): 1 (Boston); Number of veterans identified as at
risk for hepatitis C: 548; Number of at-risk veterans tested for
hepatitis C[A]: 381; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 69.
VA network (location): 2 (Albany); Number of veterans identified as at
risk for hepatitis C: 308; Number of at-risk veterans tested for
hepatitis C[A]: 181; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 59.
VA network (location): 3 (Bronx); Number of veterans identified as at
risk for hepatitis C: 284; Number of at-risk veterans tested for
hepatitis C[A]: 226; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 80.
VA network (location): 4 (Pittsburgh); Number of veterans identified as
at risk for hepatitis C: 528; Number of at-risk veterans tested for
hepatitis C[A]: 315; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 60.
VA network (location): 5 (Baltimore); Number of veterans identified as
at risk for hepatitis C: 288; Number of at-risk veterans tested for
hepatitis C[A]: 173; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 60.
VA network (location): 6 (Durham); Number of veterans identified as at
risk for hepatitis C: 424; Number of at-risk veterans tested for
hepatitis C[A]: 288; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 68.
VA network (location): 7 (Atlanta); Number of veterans identified as at
risk for hepatitis C: 539; Number of at-risk veterans tested for
hepatitis C[A]: 289; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 54.
VA network (location): 8 (Bay Pines); Number of veterans identified as
at risk for hepatitis C: 375; Number of at-risk veterans tested for
hepatitis C[A]: 214; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 57.
VA network (location): 9 (Nashville); Number of veterans identified as
at risk for hepatitis C: 436; Number of at-risk veterans tested for
hepatitis C[A]: 219; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 50.
VA network (location): 10 (Cincinnati); Number of veterans identified
as at risk for hepatitis C: 277; Number of at-risk veterans tested for
hepatitis C[A]: 165; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 60.
VA network (location): 11 (Ann Arbor); Number of veterans identified as
at risk for hepatitis C: 429; Number of at-risk veterans tested for
hepatitis C[A]: 229; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 53.
VA network (location): 12 (Chicago); Number of veterans identified as
at risk for hepatitis C: 327; Number of at-risk veterans tested for
hepatitis C[A]: 169; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 52.
VA network (location): 15 (Kansas City); Number of veterans identified
as at risk for hepatitis C: 392; Number of at-risk veterans tested for
hepatitis C[A]: 231; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 59.
VA network (location): 16 (Jackson); Number of veterans identified as
at risk for hepatitis C: 566; Number of at-risk veterans tested for
hepatitis C[A]: 348; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 61.
VA network (location): 17 (Dallas); Number of veterans identified as at
risk for hepatitis C: 198; Number of at-risk veterans tested for
hepatitis C[A]: 90; Percentage of veterans identified as at risk tested
for hepatitis C[B]: 45.
VA network (location): 18 (Phoenix); Number of veterans identified as
at risk for hepatitis C: 428; Number of at-risk veterans tested for
hepatitis C[A]: 224; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 52.
VA network (location): 19 (Denver); Number of veterans identified as at
risk for hepatitis C: 303; Number of at-risk veterans tested for
hepatitis C[A]: 208; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 69.
VA network (location): 20 (Portland); Number of veterans identified as
at risk for hepatitis C: 505; Number of at-risk veterans tested for
hepatitis C[A]: 327; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 65.
VA network (location): 21 (San Francisco); Number of veterans
identified as at risk for hepatitis C: 590; Number of at-risk veterans
tested for hepatitis C[A]: 472; Percentage of veterans identified as at
risk tested for hepatitis C[B]: 80.
VA network (location): 22 (Long Beach); Number of veterans identified
as at risk for hepatitis C: 353; Number of at-risk veterans tested for
hepatitis C[A]: 187; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 53.
VA network (location): 23 (Minneapolis); Number of veterans identified
as at risk for hepatitis C: 403; Number of at-risk veterans tested for
hepatitis C[A]: 294; Percentage of veterans identified as at risk
tested for hepatitis C[B]: 73.
VA network (location): Total; Number of veterans identified as at risk
for hepatitis C: 8,501; Number of at-risk veterans tested for hepatitis
C[A]: 5,232; Percentage of veterans identified as at risk tested for
hepatitis C[B]: 62.
Source: VA.
Note: In January 2002, VA merged Networks 13 and 14 to create Network
23.
[A] These numbers include veterans tested for hepatitis C prior to
fiscal year 2002.
[B] These percentages are rounded.
[End of table]
VA's fiscal year 2002 testing rate for veterans identified as at risk
for hepatitis C reflects tests performed in fiscal year 2002 and in
prior fiscal years. Thus, a veteran who was identified as at risk and
tested for hepatitis C in fiscal year 1998 and whose medical record was
reviewed as part of the fiscal year 2002 sample would be counted as
tested in VA's fiscal year 2002 performance measurement result. As a
result of using this cumulative measurement, VA's fiscal year 2002
performance result for testing at-risk veterans who visited VA
facilities in fiscal year 2002 and need hepatitis C tests is unknown.
To determine if the testing rate is improving for veterans needing
hepatitis C tests when they were seen at VA in fiscal year 2002, VA
would also need to look at a subset of the sample of veterans currently
included in its performance measure. For example, when we excluded
veterans from the sample who were tested for hepatitis C prior to
fiscal year 2002, and included in the performance measurement sample
only those veterans who were seen by VA in fiscal year 2002 and needed
to be tested for hepatitis C, we found Network 5 tested 38 percent of
these veterans as compared to Network 5's cumulative performance
measurement result of 60 percent.
Several Factors Impeded One Network's Efforts to Test Veterans
Identified as At Risk:
We identified three factors that impeded the process used by our case
study network, VA's Network 5 (Baltimore), for testing veterans
identified as at risk for hepatitis C. The factors were tests not being
ordered by the provider, ordered tests not being completed, and
providers being unaware that needed tests had not been ordered or
completed. More than two-thirds of the time, veterans identified as at
risk were not tested because providers did not order the test, a
crucial step in the process. The remainder of these untested veterans
had tests ordered by providers, but the actual laboratory testing
process was not completed. Moreover, veterans in need of hepatitis C
testing had not been tested because providers did not always recognize
during subsequent clinic visits that the hepatitis C testing process
had not been completed. These factors are similar to those we
identified and reported in our testimony in June 2001.[Footnote 14]
Hepatitis C Tests Were Not Always Ordered for Veterans Identified as At
Risk:
Primary care providers and clinicians in Network 5's three facilities
offered two reasons that hepatitis C tests were not ordered for over
two-thirds of the veterans identified as at risk but not tested for
hepatitis C in the Network 5 fiscal year 2002 performance measurement
sample. First, facilities lacked a method for clear communication
between nurses who identified veterans' risk factors and providers who
ordered hepatitis C tests. For example, in two facilities, nurses
identified veterans' need for testing but providers were not alerted
through a reminder in the computerized medical record to order a
hepatitis C test. In one of these facilities, because nursing staff
were at times delayed in entering a note in the computerized medical
record after screening a veteran for hepatitis C risk factors, the
provider was unaware of the need to order a test for a veteran
identified as at risk. The three network facilities have changed their
practices for ordering tests, and as of late 2002, nursing staff in
each of the facilities are ordering hepatitis C tests for at-risk
veterans. The second reason for tests not being ordered, which was
offered by a clinician in another one of the three Network 5
facilities, was that nursing staff did not properly complete the
ordering procedure in the computer. Although nurses identified at-risk
veterans using the hepatitis C screening clinical reminder in the
medical record, they sometimes overlooked the chance the reminder gave
them to place a test order. To correct this, nursing staff were
retrained on the proper use of the reminder.
Hepatitis C Test Orders Were Not Always Completed:
For the remaining 30 percent of untested veterans in Network 5, tests
were not completed for veterans who visited laboratories to have blood
drawn after hepatitis C tests were ordered. One reason that laboratory
staff did not obtain blood samples for tests was because more than two-
thirds of the veterans' test orders had expired by the time they
visited the laboratory. VA medical facilities consider an ordered test
to be expired or inactive if the veteran's visit to the laboratory
falls outside the number of days designated by the facility. For
example, at two Network 5 facilities, laboratory staff considered a
test order to be expired or inactive if the date of the order was more
than 30 days before or after the veteran visited the laboratory. If the
veteran's hepatitis C test was ordered and the veteran visited the
laboratory to have the test completed 31 days later, the test would not
be completed because the order would have exceeded the 30-day period
and would have expired. Providers can also select future dates as
effective dates. If the provider had designated a future date for the
order and the veteran visited the laboratory within 30 days of that
future date, the order would be considered active.
Another reason for incomplete tests was that laboratory staff
overlooked some active test orders when veterans visited the
laboratory. VA facility officials told us that laboratory staff could
miss test orders, given the many test orders some veterans have in
their computerized medical records. The computer package used by
laboratory staff to identify active test orders differs from the
computer package used by providers to order tests. The laboratory
package does not allow staff to easily identify all active test orders
for a specific veteran by creating a summary of active test orders.
According to a laboratory supervisor at one facility, the process for
identifying active test orders is cumbersome because staff must scroll
back and forth through a list of orders to find active laboratory test
orders. Further complicating the identification of active orders for
laboratory staff, veterans may have multiple laboratory test orders
submitted on different dates from several providers. As a result, when
the veteran visits the laboratory to have tests completed, instead of
having a summary of active test orders, staff must scroll through a
daily list of ordered testsæin two facilities up to 60 days of
ordersæto identify the laboratory tests that need to be completed.
Network and facility officials are aware of, but have not successfully
addressed, this problem. VA plans to upgrade the computer package used
by laboratory staff during fiscal year 2005.
Providers Often Unaware That Hepatitis C Tests Were Not Ordered or
Completed:
Hepatitis C tests that were not ordered or completed sometimes went
undetected for long periods in Network 5, even though veterans often
made multiple visits to primary care providers after their hepatitis C
risk factors were identified. Our review of medical records showed that
nearly two-thirds of the at-risk veterans in Network 5's performance
measurement sample who did not have ordered or completed hepatitis C
tests had risk factors identified primarily in fiscal years 2002 and
2001.
All veterans identified as at risk but who did not have hepatitis C
test orders visited VA primary care providers at least once after
having a risk factor identified during a previous primary care visit,
including nearly 70 percent who visited more than three times. Further,
almost all of the at-risk veterans who had hepatitis C tests ordered
but not completed returned for follow-up visits for medical care. Even
when the first follow-up visits were made to the same providers who
originally identified these veterans as being at risk for hepatitis C,
providers did not recognize that hepatitis C tests had not been ordered
or completed. Providers did not follow up by checking for hepatitis C
test results in the computerized medical records of these veterans.
Most of these veterans subsequently visited the laboratory to have
blood drawn for other tests and, therefore, could have had the
hepatitis C test completed if the providers had recognized that test
results were not available and reordered the hepatitis C tests.
Some VA Networks and Facilities Have Taken Action Intended to Improve
Hepatitis C Testing of Veterans Identified as At Risk:
Steps intended to improve the testing rate of veterans identified as at
risk for hepatitis C have been taken in three of VA's 21 health care
networks. VA network and facility officials in the three networks we
reviewed--Network 5 (Baltimore), Network 2 (Albany), and Network 9
(Nashville)--identified similar factors that impede hepatitis C testing
and most often focused on getting tests ordered immediately following
risk factor identification. Officials in two networks modified VA's
required hepatitis C testing clinical reminder, which is satisfied when
a hepatitis C test is ordered, to continue to alert the provider until
a hepatitis C test result is in the medical record. Officials at two
facilitiesæone in Network 5 and the other in Network 9æcreated a safety
net for veterans at risk for hepatitis C who remain untested by
developing a method that looks back through computerized medical
records to identify these veterans. The method has been adopted in all
six facilities in Network 9; the other two facilities in Network 5 have
not adopted it.
Some Networks and Facilities Took Steps Intended to Improve Hepatitis C
Test Ordering and Completion:
VA network and facility managers in two networks we reviewedæ Networks
2 and 9æinstituted networkwide changes intended to improve the ordering
of hepatitis C tests for veterans identified as at risk. Facility
officials recognized that VA's enhanced clinical reminder that
facilities were required to install by the end of fiscal year 2002 only
alerted providers to veterans without ordered hepatitis C tests and did
not alert providers to veterans with ordered but incomplete tests.
These two networks independently changed this reminder to improve
compliance with the testing of veterans at risk for hepatitis C. In
both networks, the clinical reminder was modified to continue to alert
the provider, even after a hepatitis C test was ordered. Thus, if the
laboratory has not completed the order, the reminder is intended to act
as a backup system to alert the provider that a hepatitis C test still
needs to be completed. Providers continue to receive alerts until a
hepatitis C test result is placed in the medical record, ensuring that
providers are aware that a hepatitis C test might need to be reordered.
The new clinical reminder was implemented in Network 2 in January 2002,
and Network 9 piloted the reminder at one facility and then implemented
it in all six network facilities in November 2002.
Some Facilities Developed a Safety Net for Veterans Identified as At
Risk Who Have Not Been Tested:
Officials at two facilities in our review searched all records in their
facilities' computerized medical record systems and found several
thousand untested veterans identified as at risk for hepatitis C. The
process, referred to as a "look back," involves searching all medical
records to identify veterans who have risk factors for hepatitis C but
have not been tested either because the providers did not order the
tests or ordered tests were not completed. The look back serves as a
safety net for these veterans. The network or facility can perform the
look back with any chosen frequency and over any period of time. The
population searched in a look back includes all veteran users of the VA
facility and is more inclusive than the population that is sampled
monthly in VA's performance measurement process.
As a result of a look back, one facility manager in Network 5
identified 2,000 veterans who had hepatitis C risk factors identified
since January 2001 but had not been tested as of August 2002. Facility
staff began contacting the identified veterans in October 2002 to offer
them the opportunity to be tested. Although officials in the other two
Network 5 facilities have the technical capability to identify and
contact all untested veterans determined to be at risk for hepatitis C,
they have not done so. An official at one facility not currently
conducting look back searches stated that the facility would need
support from those with computer expertise to conduct a look back
search.
A facility manager in Network 9 identified, through a look back, more
than 1,500 veterans who had identified risk factors for hepatitis C but
were not tested from January 2001 to September 2002. The manager in
this facility began identifying untested, at-risk veterans in late
March 2003 and providers subsequently began contacting these veterans
to arrange testing opportunities. Other Network 9 facility managers
have also begun to identify untested, at-risk veterans. Given that two
facilities in our review have identified over 3,000 at-risk veterans in
need of testing through look back searches, it is likely that similar
situations exist at other VA facilities.
Conclusions:
Although VA met its goal for fiscal year 2002, thousands of veterans at
risk for hepatitis C remained untested. Problems persisted with
obtaining and completing hepatitis C test orders. As a result, many
veterans identified as at risk did not know if they have hepatitis C.
These undiagnosed veterans risk unknowingly transmitting the disease as
well as potentially developing complications resulting from delayed
treatment.
Some networks and facilities have upgraded VA's required hepatitis C
clinical reminder to continue to alert providers until a hepatitis C
test result is present in the medical record. Such a system appears to
have merit, but neither the networks nor VA has evaluated its
effectiveness. Network and facility managers would benefit from
knowing, in addition to the cumulative results, current fiscal year
performance results for hepatitis C testing to determine the
effectiveness of actions taken to improve hepatitis C testing rates.
Some facilities have compensated for weaknesses in hepatitis C test
ordering and completion processes by conducting look backs through
computerized medical record systems to identify all at-risk veterans in
need of testing. If all facilities were to conduct look back searches,
potentially thousands more untested, at-risk veterans would be
identified.
Recommendations for Executive Action:
To improve VA's testing of veterans identified as at risk of hepatitis
C infection, we recommend that the Secretary of Veterans Affairs direct
the Under Secretary for Health to:
* determine the effectiveness of actions taken by networks and
facilities to improve the hepatitis C testing rates for veterans and,
where actions have been successful, consider applying these
improvements systemwide and:
* provide local managers with information on current fiscal year
performance results using a subset of the performance measurement
sample of veterans in order for them to determine the effectiveness of
actions taken to improve hepatitis C testing processes.
Agency Comments and Our Evaluation:
In commenting on a draft of this report VA concurred with our
recommendations. VA said its agreement with the report's findings was
somewhat qualified because it was based on fiscal year 2002 performance
measurement results. VA stated that the use of fiscal year 2002 results
does not accurately reflect the significant improvement in VA's
hepatitis C testing performanceæup from 62 percent in fiscal year 2002
to 86 percent in fiscal year 2003, results that became available
recently. VA, however, did not include its fiscal year 2003 hepatitis C
testing performance results by individual network, and as a result, we
do not know if the wide variation in network results, which we found in
fiscal year 2002, still exists in fiscal year 2003. We incorporated
updated performance information provided by VA where appropriate.
VA did report that it has, as part of its fiscal year 2003 hepatitis C
performance measurement system, provided local facility managers with a
tool to assess real-time performance in addition to cumulative
performance. Because this tool was not available at the time we
conducted our audit work, we were unable to assess its effectiveness.
VA's written comments are reprinted in appendix II.
We are sending copies of this report to the Secretary of Veterans
Affairs and other interested parties. We also will make copies
available to others upon request. In addition, the report is available
at no charge on the GAO Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please call
me at (202) 512-7101. Another contact and key contributors are listed
in appendix III.
Sincerely yours,
Cynthia A. Bascetta:
Director, Health Care--Veterans' Health and Benefits Issues:
Signed by Cynthia A. Bascetta:
[End of section]
Appendix I: Scope and Methodology:
To follow up on the Department of Veterans Affairs' (VA) implementation
of performance measures for hepatitis C we (1) reviewed VA's fiscal
year 2002 performance measurement results of testing veterans it
identified as at risk for hepatitis C, (2) identified factors that
impede VA's efforts to test veterans for hepatitis C in one VA health
care network, and (3) identified actions taken by VA networks and
medical facilities intended to improve the testing rate of veterans
identified as at risk for hepatitis C.
We reviewed VA's fiscal year 2002 hepatitis C testing performance
results, the most recently available data at the time we conducted our
work, for a sample of 8,501 veterans identified as at risk and compared
VA's national and network results for fiscal year 2002 against VA's
performance goal for hepatitis C testing. The sample of veterans
identified as at risk for hepatitis C was selected from VA's
performance measurement process--also referred to as the External Peer
Review Process--that is based on data abstracted from medical records
by a contractor. In addition, we looked at one VA health care network's
testing rate for at-risk veterans visiting its clinics in fiscal year
2002. To test the reliability of VA's hepatitis C performance
measurement data, we reviewed 288 medical records in Network 5
(Baltimore) and compared the results against the contractor's results
for the same medical records and found that VA's data were sufficiently
reliable for our purposes.[Footnote 15] To augment our understanding of
VA's performance measurement process for hepatitis C testing, we
reviewed VA documents and interviewed officials in VA's Office of
Quality and Performance and Public Health Strategic Health Care Group.
To identify the factors that impede VA's efforts to test veterans for
hepatitis C, we conducted a case study of the three medical facilities
located in VA's Network 5æMartinsburg, West Virginia; Washington, D.C.;
and the VA Maryland Health Care System. We chose Network 5 for our case
study because its hepatitis C testing performance, at 60 percent, was
comparable to VA's national performance of 62 percent.
As part of the case study of Network 5, we reviewed medical records for
all 288 veterans identified as at risk for hepatitis C who were
included in that network's sample for VA's fiscal year 2002 performance
measurement process. Of the 288 veterans identified as at risk who
needed hepatitis C testing, VA's performance results found that 115
veterans in VA's Network 5 were untested. We reviewed the medical
records for these 115 veterans and found hepatitis C testing results or
indications that the veterans refused testing in 21 cases. Eleven
veterans had hepatitis C tests performed subsequent to VA's fiscal year
2002 performance measurement data collection. Hepatitis C test results
or test refusals for 10 veterans were overlooked during VA's data
collection.[Footnote 16] As such, we consider hepatitis C testing
opportunities to have been missed for 94 veterans.
On the basis of our medical record review, we determined if the
provider ordered a hepatitis C test and, if the test was ordered, why
the test was not completed. For example, if a hepatitis C test had been
ordered but a test result was not available in the computerized medical
record, we determined whether the veteran visited the laboratory after
the test was ordered. If the veteran had visited the laboratory, we
determined if the test order was active at the time of the visit and
was overlooked by laboratory staff. Based on interviews with providers,
we identified the reason why hepatitis C tests were not ordered. We
also analyzed medical records to determine how many times veterans with
identified risk factors and no hepatitis C test orders returned for
primary care visits.
To determine actions taken by networks and medical facilities intended
to improve the testing rate of veterans identified as at risk for
hepatitis C, we expanded our review beyond Network 5 to include Network
2 and Network 9. We reviewed network and facility documents and
conducted interviews with network quality managers and medical facility
staff--primary care providers, nurses, quality managers, laboratory
chiefs and supervisors, and information management staff. Our review
was conducted from April 2002 through November 2003 in accordance with
generally accepted government auditing standards.
[End of section]
Appendix II: Comments from the Department of Veterans Affairs:
THE SECRETARY OF VETERANS AFFAIRS
WASHINGTON:
November 17, 2003:
Ms. Cynthia A. Bascetta
Director, Health Care Team
U. S. General Accounting Office
441 G Street, NW Washington, DC 20548:
Dear Ms. Bascetta:
The Department of Veterans Affairs (VA) has read your draft report, VA
HEALTH CARE: Further Efforts Needed to Improve Hepatitis C Testing for
At-Risk Veterans (GAO-04-106) and concurs with your recommendations.
However, VA's agreement with the report's findings is somewhat
qualified since they are based on outdated (FY 2002) information. VA is
pleased to report that the Veterans Health Administration (VHA) has
made great strides this past fiscal year in its efforts to improve both
hepatitis C screening and testing for at-risk veterans. VHA is fully
committed to ensuring ongoing improvement in all aspects of hepatitis C
care management and is already taking concrete steps to ensure that
best practices are systematically applied throughout all VA's health
care facilities.
VA has established what is arguably the largest and most comprehensive
hepatitis C screening and testing program of any health care
organization. In fact, VA is recognized to have set the standard in the
health care community. VHA's Office of Quality and Performance's
External Peer Review Program (EPRP) reports that 95 percent of 52,427
patient charts that were reviewed during FY 2003 showed evidence of
screening, testing or diagnosis of the disease. Such findings, when
extrapolated systemwide, indicate remarkable compliance in potentially
screening all veteran patients, yet GAO's report focuses only on
testing data. However, in this arena, too, FY 2003 EPRP data confirm
that 86 percent of the 24,196 veterans identified as at-risk were
tested for, or diagnosed with, hepatitis C. These numbers strongly
suggest that significant improvement in testing has occurred since the
initial GAO data collection. The 2003 EPRP review process includes a
supporting indicator (non-performance measure data element) that
reports the number and percentage of veterans with identified risk
prior to the study interval who were not tested during the study
interval. This supporting indicator provides managers with a tool to
assess real time performance as opposed to cumulative performance. In
addition, VHA has taken steps to broadly promote hepatitis C education
and awareness and has retained performance measures with high numerical
standards for success. The
impressive gains in performance in FY 2003 demonstrate and further
encourage the adoption of best practices in hepatitis C screening
throughout the system.
In conclusion, VA believes that the report's lack of current FY 2003
data showing the significant improvements in VA's hepatitis C screening
and testing performance leads to an incomplete and inaccurate
understanding of the
breadth, scope and progress of the program. In this rapidly changing
health care field, it is not sufficient to base conclusions and
recommendations solely on data that are more than a year old, now that
more timely data are available. VA requests that GAO update its report
to include current screening and testing statistics. VA also encourages
GAO to assess the hepatitis C screening and testing activities of any
large health care organization, health maintenance organization or
health plan as a comparison to VA's program and progress.
Due to the limited amount of time to comment on GAO's draft report, VHA
is still developing an action plan to implement GAO's recommendations.
VA will provide the action plan in its comments to GAO's final report.
Sincerely yours,
Signed by:
Anthony J. Principi:
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Marcia A. Mann, (202) 512-9526:
Acknowledgments:
In addition to the contact named above, Carl S. Barden, Irene J.
Barnett, Martha A. Fisher, Daniel M. Montinez, and Paul R. Reynolds
made key contributions to this report.
[End of section]
Related GAO Products:
VA Health Care: Improvements Needed in Hepatitis C Disease Management
Practices. GAO-03-136. Washington, D.C.: January 31, 2003.
Major Management Challenges and Program Risks: Department of Veterans
Affairs. GAO-03-110. Washington, D.C.: January 2003.
Veterans' Health Care: Standards and Accountability Could Improve
Hepatitis C Screening and Testing Performance. GAO-01-807T. Washington,
D.C.: June 14, 2001.
Veterans' Health Care: Observations on VA's Assessment of Hepatitis C
Budgeting and Funding. GAO-01-661T. Washington, D.C.: April 25, 2001.
FOOTNOTES
[1] VA identifies veterans at risk for hepatitis C infection as those
who have one or more of the following 11 risk factors: Vietnam-era
veteran; blood transfusion before 1992; past or present intravenous
drug use; unequivocal blood exposure of skin or mucous membranes;
history of multiple sexual partners; history of hemodialysis; tattoo or
repeated body piercing; history of intranasal cocaine use; unexplained
liver disease; unexplained/abnormal alanine aminotransferase, which is
an enzyme that is present in high concentration in the liver and other
organs; and intemperate or immoderate use of alcohol.
[2] U.S. General Accounting Office, Veterans' Health Care: Standards
and Accountability Could Improve Hepatitis C Screening and Testing
Performance, GAO-01-807T (Washington, D.C.: June 14, 2001).
[3] VA's performance measurement process is based on the External Peer
Review Program, which is a contracted program designed to measure
quality of patient care provided in VA medical facilities. VA officials
select a monthly sample of medical records, based on specific criteria,
to be reviewed for its performance measurement process. Criteria
include a visit to VA 2 years prior to the current year and a visit in
the study year. Contractors from the West Virginia Medical Institute
conducted the medical record reviews.
[4] VA's measurement of its performance in testing veterans identified
as at risk for hepatitis C cannot be generalized to the entire
population of veterans who seek health care at VA's medical facilities
because of limitations in VA's sample selection.
[5] W. Ray Kim, MD M.Sc, MBA, "The Burden of Hepatitis C in the United
States," NIH Consensus Development Conference: Management of Hepatitis
C: 2002 (Bethesda, Md.: National Institutes of Health, 2002).
[6] Ramsey C. Cheung, MD, "Epidemiology of Hepatitis C Virus Infection
in American Veterans," The American Journal of Gastroenterology, vol.
95, no. 3 (March 2000).
[7] See Samuel B. Ho, MD, "Managing the HCV Veteran," The HCV Advocate
Medical Writers' Circle (April 2002), and GAO-01-807T.
[8] NIH Consensus Development Conference, Management of Hepatitis C:
2002, June 2002. The 12-member consensus panel is an independent,
nonadvocacy, and nonfederal panel including representatives from
internal medicine, gastroenterology, infectious diseases, family
practice, and the public. The panel heard presentations from 28
hepatitis C experts and reviewed an extensive body of medical
literature and a report prepared by the Johns Hopkins University School
of Medicine Evidence-based Practice Center.
[9] U.S. General Accounting Office, VA Health Care: Improvements Needed
in Hepatitis C Disease Management Practices, GAO-03-136 (Washington,
D.C.: Jan. 31, 2003).
[10] For fiscal year 2003, VA increased its hepatitis C testing
performance goal to 82 percent.
[11] The sample includes veterans with 2 years of continuous enrollment
in VA who have been seen at least once in one of VA's eight primary
care clinics during the current fiscal year. The eight clinics are
primary care, general medicine, cardiology, endocrinology/ metabolism,
diabetes, hypertension, pulmonary/chest, and women's. A veteran's
medical record can only be included in the performance measurement
sample once during any fiscal year.
[12] Of the 40,489 veterans selected as part of VA's performance
measurement sample, VA providers had completed hepatitis C risk
assessment screenings for 34,310 of them. Thus, the prevalence of risk
factors among those assessed was approximately 25 percent (8,501 of
34,310).
[13] At the time of our audit work, testing data for fiscal year 2003
were unavailable. In commenting on a draft of this report, VA stated
that its testing rate for fiscal year 2003 was 86 percent.
[14] GAO-01-807T.
[15] In May 2003, VA's Office of Inspector General reported that
differences in VA's performance measurement results collected by its
contractor and the results found by the Inspector General were
immaterial. See U.S. Department of Veterans Affairs, Office of
Inspector General, Accuracy of Data Used to Compute VA's Chronic
Disease Care and Prevention Indices for FY 2001, 01-01544-88
(Washington, D.C.: May 1, 2003).
[16] Our review for hepatitis C test results was extended to November
30, 2002, in order to allow time for testing of veterans who had tests
ordered in September 2002.
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