Background: Veterans in care at Veterans Affairs (VA) medical centers have a higher prevalence of Hepatitis C (HCV) antibody positivity than the general population1,2. Despite high tolerability and cure rates approaching 95% with new direct-acting antiviral (DAA) drugs, a significant proportion of veterans have not been initiated on treatment due to barriers including active substance use, serious mental illness, documented non-adherence, and an inability to be contacted3.
Purpose: This project sought to use the inpatient admission as an opportunity to initiate hepatitis C treatment for those unable to participate in traditional outpatient treatment. These patients were deemed the hardest to treat due to unstable mental health and substance use issues, and the hardest to reach due to marginal housing and difficulty with follow-up. With this in mind, a program was created to identify and initiate HCV treatment for appropriate patients on the inpatient psychiatry wards. A secondary group of patients, identified via passive referral on the med/surg wards, was also evaluated and if appropriate, initiated on inpatient treatment.
Description: This project primarily took place on the Palo Alto Veterans Affairs (VA) inpatient psychiatric wards. Initially, patients with chronic untreated HCV were referred for treatment by the inpatient psychiatry teams. Due to a low volume of referrals, the program was transitioned into a 12-month comprehensive screening effort to screen all patients admitted to the inpatient psychiatry wards. Treatment candidates were identified and if appropriate, treatment was initiated during the inpatient stay. A secondary group of patients from the Palo Alto VA med/surg wards was generated via passive referrals from inpatient med/surg teams and outpatient Liver Clinic providers.
During this project, over 800 psychiatric admissions were screened for HCV. Between 5 and 7% were found to have chronic untreated HCV, far exceeding the latest population estimate of active HCV infection in 1% of adults in the United States4. Of 43 patients eligible for and amenable to treatment, 12 were ultimately initiated on treatment while on the inpatient psychiatry wards. A secondary group of 24 patients with chronic untreated HCV was identified via passive referral from the med/surg wards. Of these, 8 were started on treatment while inpatient. At the time of writing, all patients initiated on treatment have either attained or are projected to attain SVR.
Conclusions: Breakthroughs in Hepatitis C treatment have resulted in high rates of cure with minimal reported side effects. Despite this, significant patient specific barriers have precluded participation in treatment for many veterans. This project suggests the strategy of using the inpatient admission as an opportunity to identify, stabilize and initiate treatment for patients with chronic untreated HCV is not only feasible, but can also yield final outcomes comparable to the general population.