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Simi T. Hurst, PhD 1 ; Teresa S. Marshall 1 ; Barry Patel, PharmD 2 ; Catherine C. Capparelli, CHCP 1 1 Medscape Education, New York, NY; 2 Indegene Total Therapeutic Management, Kennesaw, GA QUALITY IMPROVEMENT IN HCV: ENHANCING PROVIDER PERFORMANCE; IMPROVING PATIENT CARE HEALTHCARE PROBLEM EDUCATIONAL INTERVENTIONS AND OUTCOMES ASSESSMENT STRATEGY ■ Hepatitis C virus (HCV) infection is the most common chronic blood-borne infection in the United States and a leading cause of liver-related morbidity and mortality 1 ■ As “baby boomers” are identified and linked to care, more patients than ever before will require HCV treatment. 2 Unfortunately, traditional HCV care models are inadequate 3,4 ■ Advances in HCV treatment now make it possible to expand HCV care responsibilities to non-hepatologists and thereby increase patients’ access to care 5,6 ■ Medscape, LLC; Indegene; and Aetna formed a strategic partnership to address the need for additional HCV care providers and to improve HCV care ■ The partnership incorporated a multipronged strategy comprising healthcare provider (HCP) interventions for both closed (Aetna provider practices) and open (Medscape) systems; and a patient engagement intervention (WebMD Education) ■ Thirteen performance measures were developed based on the American Association for the Study of Liver Diseases/Infectious Diseases Society of America Guidelines, 7 Physician Consortium for Performance Improvement, 8 and Physician Quality Reporting System 9 measures HCP INTERVENTION–CLOSED SYSTEM ■ The physician study cohort was drawn from 30 Aetna HCP practices and comprised 28 general gastroenterologists and 2 primary care providers who met the specified study inclusion/exclusion criteria (Figure 1) ■ Gaps in knowledge and competence were assessed using a multiple-choice survey instrument; gaps in performance were measured using baseline patient chart review (300 charts) ■ Virtual mentoring sessions provided performance feedback to physicians based on results of baseline chart review ■ Each physician was directed to 1 or more CME-certified educational activities (described below) based on individual gaps ■ Approximately 6 months after CME completion, each clinician was re-assessed using patient chart review (300 charts), allowing for measurement of performance changes and patient impact. FIGURE 2. Alignment of Online Educational Activities With HCP Performance Measures FIGURE 3. Patient Engagement http://www.medscape.org/viewarticle/843910 http://www.medscape.org/viewarticle/843910 http://www.medscape.org/viewarticle/842682 http://www.medscape.org/viewarticle/843912 http://www.medscape.org/viewarticle/842683 PERFORMANCE MEASURES % of HCV patients who have: • Documented comprehensive treatment plan • Evaluation of HAV, HIV HBV • HAV, HBV vaccines • Evaluation for advanced fibrosis • Counseling on alcohol consumption, prevention of transmission % of HCV patients prescribed antiviral treatment who prior to treatment receive: • RNA testing • HCV genotype testing • Counseling on use of contraception • Assessment of comorbidities % of HCV patients who are prescribed antiviral treatment who receive the following during/ following treatment: • Antiviral treatment selection • Completed or discontinued treatment regimen • RNA testing for evaluation of end of treatment and SVR 12 HCP INTERVENTION–OPEN SYSTEM ■ Four multimedia, CME-certified activities were developed and launched online between August 20, 2015, and August 24, 2015 (Figure 2) ■ Two activities featured video-based discussions between 2 expert faculty that provided guidance on initial patient evaluation and provision of preventive care for patients entering, or re-entering, HCV care ■ Two activities featured interactive case-based learning that provided education on individualizing HCV management ■ Each HCP activity also included a link to the patient engagement interventions (described below). These links offered HCPs the opportunity to direct their patients to online activities as a follow-up to the clinical encounter or as preparation for the next clinical encounter. ■ Each online activity measured practice changes via a case-based survey instrument administered immediately prior to and following the educational intervention. Change was measured at both aggregate and per-learner levels PATIENT ENGAGEMENT INTERVENTION ■ Four multimedia patient education/engagement modules addressed the fundamentals of HCV infection and available treatment options (Figure 3) ■ Each module included a linked pre-/post-activity question to measure changes in knowledge/attitudes PATIENT-LEVEL OUTCOMES HCP INTERVENTION–CLOSED SYSTEM Comparison of pre- vs post-intervention chart abstracted data revealed that participation in this initiative resulted in an increased number of patients ■ Who were assessed for liver disease (Figure 4) ■ Who were evaluated for coinfection (Figure 5) ■ Who were evaluated for comorbid conditions (Figure 6) ■ For whom baseline labs were ordered prior to treatment initiation (Figure 7) ■ Who were treated for chronic HCV infection (Figure 8) HCP INTERVENTION–OPEN SYSTEM ■ As of November 17, 2015, a total of 17,384 learners had engaged in the online educational activities, including • 3316 general gastroenterologists • 3348 primary care physicians • 1583 ID specialists • 303 nurse practitioners ■ Following participation in the online activities, providers had significantly ( P <.05) improved their ability to • Select an HCV antiviral regimen based on laboratory assessment and prior treatment history • Provide timely monitoring of patients receiving treatment • Provide appropriate follow-up for a patient who has completed treatment (Data not shown) PATIENT ENGAGEMENT INTERVENTION ■ The patient engagement modules launched in May 2015 and pre- vs post- activity question data were collected through November 2015 ■ A total of 7710 patients and/or caregivers engaged in the online educational activities as of November 2016 ■ Following participation in the patient engagement modules, patients were better able to • Determine when it is appropriate to begin HCV treatment ( P <.001) • Recognize what HCV treatment might entail ( P <.001) • Identify when they will know if they have been cured ( P <.001) (Figure 9) Disclosures The authors have nothing to disclose. References 1. Razavi H, Elkhoury AC, Elbasha E, et al. Chronic hepatitis C virus (HCV) disease burden and cost in the United States. Hepatology. 2013;57:2164-2170. 2. Centers for Disease Control and Prevention (CDC). Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rep. 2012;61:1-32. 3. Shiffman ML. A balancing view: we cannot do it alone. Am J Gastroenterol. 2007;102:1841-1843. 4. McGowan CE, Fried MW. Barriers to hepatitis C treatment. Liver Int. 2012;32:151-156. 5. Afdhal N, Zeuzem S, Kwo P, et al; ION-1 Investigators. Ledipasvir and sofosbuvir for untreated HCV genotype 1 infection. N Engl J Med. 2014;370:1889-1898. 6. Lawitz E, Poordad FF, Pang PS, et al. Sofosbuvir and ledipasvir fixed- dose combination with and without ribavirin in treatment-naive and previously treated patients with genotype 1 hepatitis C virus infection (LONESTAR): an open-label, randomised, phase 2 trial. Lancet. 2014;383:515-523. 7. American Association for the Study of Liver Diseases (AASLD)/ Infectious Diseases Society of America (IDSA). HCV guidance: recommendations for testing, managing, and treating hepatitis C. Updated February 24, 2016. http://www.hcvguidelines.org/full- report-view. Accessed March 28, 2016. 8. American Association for the Study of Liver Diseases/American Gastroenterological Association Institute/ American Medical Association-convened Physician Consortium for Performance Improvement. Hepatitis C Performance Measurement Set. PCPI Approved August 2013. https://download.ama-assn.org/resources/ doc/pcpi/hepatitis-c-worksheets.pdf. Accessed November 15, 2016. 9. Centers for Medicare & Medicaid Services. Physician Quality Reporting System. Modified December 23, 2015. https://www.cms. gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ PQRS/index.html. Accessed March 28, 2016. Support This quality improvement initiative was funded through independent medical educational grants from Gilead Sciences Medical Affairs. For additional information, please contact Simi T. Hurst, PhD, Director of Clinical Strategy, Medscape, LLC, at [email protected]. CONCLUSIONS ■ Baseline chart review and online survey data identified a variety of performance gaps in the care of patients with chronic HCV infection ■ This quality improvement initiative focused on expanding the HCV provider base as a means to increase patient access to HCV care ■ For HCPs, significant improvements were observed in both the open and closed systems ■ For patients and/or caregivers, significant improvements were observed on various aspects of HCV infection and its treatment ■ Through strategic partnership, Medscape, LLC; Indegene Inc., and Aetna developed and implemented a multipronged strategy that has helped close provider performance gaps, improve patient care, increase patient knowledge, and bring about meaningful change within this cohort of providers and patients FIGURE 1. Closed System Study Design 30 Physicians IRB-Approved Protocol Chart Review 28 Gastroenterologists 2 PCPs 300 Patient Charts One-on-One Mentoring Chart review benchmarking 6-Month Follow-Up Chart review to assess performance changes Education Recommendations Targeted recommendations for up to 4 online CME activities based on identified performance gaps PHYSICIAN INCLUSION CRITERIA • Specialize or practice in one of the following areas: gastroenterology, infectious diseases, internal medicine, general medicine, primary care, or family medicine • Have had at least 10 patients with an established diagnosis of chronic HCV within the past year • Affiliated with Aetna • Commitment to participate in the QI initiative, including education, and to provide 10 patient charts meeting inclusion criteria for abstraction prior to and following education PATIENT INCLUSION CRITERIA • Age ≥18 years • Established diagnosis of chronic HCV infection ― 070.54 Chronic hepatitis C without hepatic coma ― 070.70 Unspecified viral hepatitis C without hepatic coma • ≥1 visit with physician in previous 24 months • Have chronic HCV genotype 1a, 1b, 2 or 3 ASSESSMENT PERIOD • Baseline: March 1, 2013 and February 28, 2015 • Follow-up: January 4, 2016 – April 11, 2016 FIGURE 4. Increased Assessment of Liver Status FIGURE 6. Increased Evaluation for Comorbid Conditions FIGURE 7. Increased Baseline Laboratory Evaluations FIGURE 5. Increased Evaluation for Coinfection 0 50 100 150 200 250 300 27% 23% 22% Number of Patient Charts Assessed Liver Disease Cirrhosis HCC/Liver Cancer Patients Assessed at Baseline (n) 176 196 196 Patients Assessed at Follow-Up (n) 224 240 237 0 50 100 150 200 250 300 12% 17% 7% 18% Number of Patient Charts Assessed Hypertension Hypercholesterolemia Renal Impairment History of Mental Illness or Depression Patients Assessed at Baseline (n) 202 177 182 200 Patients Assessed at Follow-Up (n) 225 206 194 237 0 50 100 150 200 250 300 11% 8% 13% 17% Number of Patient Charts Assessed CBC LFT Serum Albumin T Protein Patients Assessed at Baseline (n) 192 198 186 173 Patients Assessed at Follow-Up (n) 214 215 209 203 0 50 100 150 200 250 300 64% 35% 37% Number of Patient Charts Assessed HIV HAV HBV Patients Assessed at Baseline (n) 125 153 157 Patients Assessed at Follow-Up (n) 207 207 213 FIGURE 8. Increased Treatment for Chronic HCV Infection 0 50 100 150 200 250 300 51% Number of Patient Charts Assessed Patients Assessed at Baseline (n) 159 Patients Assessed at Follow-Up (n) 240 FIGURE 9. Increased Comprehension Among Patient/Caregiver Learners 0 20 40 60 80 100 133% 42% 90% % of Patient Learners Who Selected the Correct Response Identify when it’s appropriate to begin HCV treatment (n=485) Recognize what HCV treatment might entail (n=550) Identify what they will know if they have been cured (n=516) Pre-Intervention 27% 59% 42% Post-Intervention 63% 85% 80% P <.001 ABBREVIATIONS CBC: Complete Blood Count HAV: Hepatitis A Virus HBV: Hepatitis B Virus HCC: Hepatocellular Carcinoma HCV: Hepatitis C Virus HIV: Human Immunodeficiency Virus LFT: Liver Function Tests
