oversight

VA Health Care: Further Efforts Needed to Improve Hepatitis C Testing for At-Risk Veterans

Published by the Government Accountability Office on 2003-12-12.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                United States General Accounting Office

GAO             Report to the Chairman, Subcommittee
                on National Security, Emerging
                Threats, and International Relations,
                Committee on Government Reform,
                House of Representatives
December 2003
                VA HEALTH CARE

                Further Efforts
                Needed to Improve
                Hepatitis C Testing for
                At-Risk Veterans




GAO-04-106
                                                December 2003


                                                VA HEALTH CARE

                                                Further Efforts Needed to Improve
Highlights of GAO-04-106, a report to the       Hepatitis C Testing for At-Risk Veterans
Chairman, Subcommittee on National
Security, Emerging Threats, and
International Relations, Committee on
Government Reform, House of
Representatives




Hepatitis C is a chronic disease                VA’s performance measurement result shows that it tested, in fiscal year
caused by a blood-borne virus that              2002 or earlier, 5,232 (62 percent) of the 8,501 veterans identified as at risk
can lead to potentially fatal liver-            for hepatitis C in VA’s performance measurement sample, exceeding its
related conditions. In 2001, GAO                fiscal year 2002 national goal of 55 percent. Thousands of veterans (about
reported that the VA missed                     one-third) of those identified as at risk for hepatitis C infection in VA’s
opportunities to test about 50
percent of veterans identified as at
                                                performance measurement sample were not tested. VA’s hepatitis C testing
risk for hepatitis C. GAO was                   result is a cumulative measure of performance over time and does not only
asked to (1) review VA’s fiscal year            reflect current fiscal year performance. GAO found Network 5 (Baltimore)
2002 performance measurement                    tested 38 percent of veterans in fiscal year 2002 as compared to Network 5’s
results in testing veterans at risk             cumulative performance result of 60 percent.
for hepatitis C, (2) identify factors
that impede VA’s efforts to test                In its case study of Network 5, which was one of the networks to exceed
veterans for hepatitis C, and                   VA’s fiscal year 2002 performance goal, GAO identified several factors that
(3) identify actions taken by VA                impeded the hepatitis C testing process. These factors were tests not being
networks and medical facilities to              ordered by the provider, ordered tests not being completed, and providers
improve the testing rate of veterans            being unaware that needed tests had not been ordered or completed. For
at risk for hepatitis C. GAO
reviewed VA’s fiscal year 2002
                                                more than two-thirds of the veterans identified as at risk but not tested for
hepatitis C performance results and             hepatitis C, the testing process failed because hepatitis C tests were not
compared them against VA’s                      ordered, mostly due to poor communication between clinicians. For the
national performance goals,                     remaining veterans, the testing process was not completed because orders
interviewed headquarters and field              had expired by the time veterans visited the laboratory or test orders were
officials in three networks, and                overlooked because laboratory staff had to scroll back and forth through
conducted a case study in one                   daily lists, a cumbersome process, to identify active orders. Moreover,
network.                                        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
To improve testing performance,                 unknowingly transmitting the disease as well as potential complications
GAO recommends that VA                          resulting from delayed treatment.
determine the effectiveness of
actions taken by networks and                   The three networks GAO looked at—5 (Baltimore), 2 (Albany), and 9
facilities to improve the hepatitis C           (Nashville)—have taken steps intended to improve the testing rate of
testing rates for veterans and                  veterans identified as at risk for hepatitis C. To do this, in two networks
consider applying such actions                  officials modified clinical reminders in the computerized medical record to
systemwide. GAO also                            alert providers that for ordered hepatitis C tests, results were unavailable.
recommends VA provide local                     Officials at two facilities developed a “look back” method to search
managers with information on
                                                computerized medical records to identify all at-risk veterans who had not yet
current fiscal year performance
results in order for them to                    been tested and identified approximately 3,500 untested veterans. The look
determine the effectiveness of                  back serves as a safety net for veterans identified as at risk for hepatitis C
actions taken to improve hepatitis              who have not been tested. The modified clinical reminder and look back
C testing processes. VA concurred               method of searching medical records appear promising, but neither the
with these recommendations.                     networks nor VA has evaluated their effectiveness.
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.
Contents


Letter                                                                                               1
                       Results in Brief                                                              3
                       Background                                                                    5
                       Thousands of Veterans Identified as At Risk Remain Untested for
                         Hepatitis C Despite VA Exceeding Its Testing Goal                           8
                       Several Factors Impeded One Network’s Efforts to Test Veterans
                         Identified as At Risk                                                     10
                       Some VA Networks and Facilities Have Taken Action Intended to
                         Improve Hepatitis C Testing of Veterans Identified as At Risk             13
                       Conclusions                                                                 14
                       Recommendations for Executive Action                                        15
                       Agency Comments and Our Evaluation                                          15

Appendix I             Scope and Methodology                                                       17



Appendix II            Comments from the Department of Veterans Affairs                            19



Appendix III           GAO Contact and Staff Acknowledgments                                       21
                       GAO Contact                                                                 21
                       Acknowledgments                                                             21

Related GAO Products                                                                               22



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                       9




                       Page i                            GAO-04-106 VA Hepatitis C Testing Performance
Abbreviations

NIH                        National Institutes of Health
VA                         Department of Veterans Affairs




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Page ii                                  GAO-04-106 VA Hepatitis C Testing Performance
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.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.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



                                   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).



                                   Page 1                                   GAO-04-106 VA Hepatitis C Testing Performance
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.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.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



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.




Page 2                                     GAO-04-106 VA Hepatitis C Testing Performance
                   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.


                   VA’s performance measurement results show that it tested, in fiscal year
Results in Brief   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


                   Page 3                             GAO-04-106 VA Hepatitis C Testing Performance
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 testsin
two Network 5 facilities up to 60 days of ordersto 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


Page 4                             GAO-04-106 VA Hepatitis C Testing Performance
             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.


             Hepatitis C was first recognized as a unique disease in 1989. It is the most
Background   common chronic blood-borne infection in the United States and is a
             leading cause of chronic liver disease.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



             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).




             Page 5                                GAO-04-106 VA Hepatitis C Testing Performance
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.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
patientscosting as much as $140,000 per transplantand the drug
therapy to treat hepatitis C is costlyabout $13,000 for a 48-week
treatment regimen.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.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


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.




Page 6                                   GAO-04-106 VA Hepatitis C Testing Performance
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.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.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.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


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.




Page 7                                        GAO-04-106 VA Hepatitis C Testing Performance
                      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.


                      Even though VA’s fiscal year 2002 performance measurement results show
Thousands of          that it tested 62 percent of veterans identified to be at risk for hepatitis C,
Veterans Identified   exceeding its national goal of 55 percent, thousands of veterans in the
                      sample who were identified as at risk were not tested. Moreover, the
as At Risk Remain     percentage of veterans identified as at risk who were tested varied widely
Untested for          among VA’s 21 health care networks. Specifically, we found that VA
                      identified in its performance measurement sample 8,501 veterans
Hepatitis C Despite   nationwide who had hepatitis C risk factors out of a sample of 40,489
VA Exceeding Its      veterans visiting VA medical facilities during fiscal year 2002.12 VA
Testing Goal          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.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.




                      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.




                      Page 8                                     GAO-04-106 VA Hepatitis C Testing Performance
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

                                     Number of                           Percentage of
                                       veterans Number of at-risk veterans identified
    VA network              identified as at risk veterans tested for  as at risk tested
                                                                     a
    (location)                   for hepatitis C         hepatitis C    for hepatitis Cb
    1 (Boston)                                 548                      381             69
    2 (Albany)                                 308                      181             59
    3 (Bronx)                                  284                      226             80
    4 (Pittsburgh)                             528                      315             60
    5 (Baltimore)                              288                      173             60
    6 (Durham)                                 424                      288             68
    7 (Atlanta)                                539                      289             54
    8 (Bay Pines)                              375                      214             57
    9 (Nashville)                              436                      219             50
    10 (Cincinnati)                            277                      165             60
    11 (Ann Arbor)                             429                      229             53
    12 (Chicago)                               327                      169             52
    15 (Kansas City)                           392                      231             59
    16 (Jackson)                               566                      348             61
    17 (Dallas)                                198                       90             45
    18 (Phoenix)                               428                      224             52
    19 (Denver)                                303                      208             69
    20 (Portland)                              505                      327             65
    21 (San Francisco)                         590                      472             80
    22 (Long Beach)                            353                      187             53
    23 (Minneapolis)                           403                      294             73
    Total                                    8,501                   5,232              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.


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



Page 9                                        GAO-04-106 VA Hepatitis C Testing Performance
                             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.


                             We identified three factors that impeded the process used by our case
Several Factors              study network, VA’s Network 5 (Baltimore), for testing veterans identified
Impeded One                  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
Network’s Efforts to         that needed tests had not been ordered or completed. More than two-
Test Veterans                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
Identified as At Risk        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 2001.14


Hepatitis C Tests Were Not   Primary care providers and clinicians in Network 5’s three facilities
Always Ordered for           offered two reasons that hepatitis C tests were not ordered for over two-
Veterans Identified as At    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,
Risk                         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


                             14
                                  GAO-01-807T.




                             Page 10                             GAO-04-106 VA Hepatitis C Testing Performance
                          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   For the remaining 30 percent of untested veterans in Network 5, tests were
Were Not Always           not completed for veterans who visited laboratories to have blood drawn
Completed                 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


                          Page 11                             GAO-04-106 VA Hepatitis C Testing Performance
                          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 testsin
                          two facilities up to 60 days of ordersto 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   Hepatitis C tests that were not ordered or completed sometimes went
That Hepatitis C Tests    undetected for long periods in Network 5, even though veterans often
Were Not Ordered or       made multiple visits to primary care providers after their hepatitis C risk
                          factors were identified. Our review of medical records showed that nearly
Completed                 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.




                          Page 12                            GAO-04-106 VA Hepatitis C Testing Performance
                            Steps intended to improve the testing rate of veterans identified as at risk
Some VA Networks            for hepatitis C have been taken in three of VA’s 21 health care networks.
and Facilities Have         VA network and facility officials in the three networks we reviewed—
                            Network 5 (Baltimore), Network 2 (Albany), and Network 9 (Nashville)—
Taken Action                identified similar factors that impede hepatitis C testing and most often
Intended to Improve         focused on getting tests ordered immediately following risk factor
                            identification. Officials in two networks modified VA’s required hepatitis C
Hepatitis C Testing of      testing clinical reminder, which is satisfied when a hepatitis C test is
Veterans Identified as      ordered, to continue to alert the provider until a hepatitis C test result is in
At Risk                     the medical record. Officials at two facilitiesone in Network 5 and the
                            other in Network 9created 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           VA network and facility managers in two networks we reviewed
Facilities Took Steps       Networks 2 and 9instituted networkwide changes intended to improve
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
Hepatitis C Test Ordering   were required to install by the end of fiscal year 2002 only alerted
and Completion              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.




                            Page 13                             GAO-04-106 VA Hepatitis C Testing Performance
Some Facilities Developed   Officials at two facilities in our review searched all records in their
a Safety Net for Veterans   facilities’ computerized medical record systems and found several
Identified as At Risk Who   thousand untested veterans identified as at risk for hepatitis C. The
                            process, referred to as a “look back,” involves searching all medical
Have Not Been Tested        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.


                            Although VA met its goal for fiscal year 2002, thousands of veterans at risk
Conclusions                 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.




                            Page 14                              GAO-04-106 VA Hepatitis C Testing Performance
                         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.


                         To improve VA’s testing of veterans identified as at risk of hepatitis C
Recommendations for      infection, we recommend that the Secretary of Veterans Affairs direct the
Executive Action         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.


                         In commenting on a draft of this report VA concurred with our
Agency Comments          recommendations. VA said its agreement with the report’s findings was
and Our Evaluation       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 performanceup 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.




                         Page 15                            GAO-04-106 VA Hepatitis C Testing Performance
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




Page 16                            GAO-04-106 VA Hepatitis C Testing Performance
             Appendix I: Scope and Methodology
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.1 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 5Martinsburg, 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.




             1
               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).




             Page 17                                 GAO-04-106 VA Hepatitis C Testing Performance
Appendix I: Scope and Methodology




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.2 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.




2
 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.




Page 18                                  GAO-04-106 VA Hepatitis C Testing Performance
             Appendix II: Comments from the Department of Veterans Affairs
Appendix II: Comments from the Department
of Veterans Affairs




             Page 19                                GAO-04-106 VA Hepatitis C Testing Performance
Appendix II: Comments from the Department of Veterans Affairs




Page 20                                GAO-04-106 VA Hepatitis C Testing Performance
                  Appendix III: GAO Contact and Staff
Appendix III: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Marcia A. Mann, (202) 512-9526
GAO Contact
                  In addition to the contact named above, Carl S. Barden, Irene J. Barnett,
Acknowledgments   Martha A. Fisher, Daniel M. Montinez, and Paul R. Reynolds made key
                  contributions to this report.




                  Page 21                               GAO-04-106 VA Hepatitis C Testing Performance
             Related GAO Products
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.




(290175)
             Page 22                         GAO-04-106 VA Hepatitis C Testing Performance
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