SUPPLEMENTARY FILES (APPENDIX)
Appendix Table 1. Operational definitions of Hepatitis C Virus Infection Specific Process Measures
Quality Indicator
Numerator
Denominator
Rate, %
(N
eligible)
Pre-treatment Domain
1. Confirmation of HCV
viremia
Patients who received hepatitis C hepatitis
C ribonucleic acid (RNA) test before or
within 12 months after (+) antibody test
Patients with (+) hepatitis C antibody
test
90.2
(31,193)
2. Specialty referral
Patients who saw a specialist# before or
within 12 months after (+) RNA date
Patients with (+) hepatitis RNA test
53.6
(34,212)
3. HCV genotype testing
Patients who received HCV genotype test
before or within 12 months after seeing a
specialist.
Patients with confirmed viremia who
saw a specialist
75.9
(21,640)
4. Liver biopsy in genotype 1
patients
Patients who received a liver biopsy before
or within 12 months after seeing a
specialist.
Patients with genotype 1 HCV who
saw a specialist
26.3
(13,268)
5. Autoimmune liver disease
testing
Patients who received testing to rule out
autoimmune liver disease before or within
12 months after seeing a specialist.
Patients with confirmed viremia who
saw a specialist
53.8
(22,022)
6. Iron overload testing
Patients who received testing to rule out
iron overload before or within 12 months
after seeing a specialist.
Patients with confirmed viremia who
saw a specialist
71.3
(22,022)
7. Hepatitis B testing
Patients who received testing to rule out
hepatitis B virus co-infection before or
within 12 months after seeing a specialist.
Patients with confirmed viremia who
saw a specialist
91.2
(22,022)
Preventive and Comorbid Care Domain
8. HIV testing
Patients who received a HIV test within 12
months before or after (+) HCV test date
Patients without a previous HIV
diagnosis
27.7
(34,265)
9. Hepatitis A serology
testing
Patients who received a hepatitis A serology
test within 12 months after (+) HCV test
date
Patients with no prior hepatitis A
serology test or hepatitis A vaccination
66.5
(32,881)
10. Hepatitis B serology testing
Patients who received a hepatitis B serology
test within 12 months after (+) HCV test
date
Patients with no prior hepatitis B
serology test or hepatitis B vaccination
81.6
(31,257)
11. Hepatitis A vaccination
Patients who received at-least 1 hepatitis A
vaccination‡ within 12 months after (+)
HCV test
Patients with no prior hepatitis A
vaccination or documented immunity
within 1 year after HCV test date
25.1
(26,171)
12. Hepatitis B vaccination
Patients who received at-least 1 hepatitis B
vaccination‡ within 12 months after (+)
HCV test
Patients with no prior hepatitis B
vaccination or documented immunity
within 1 year after HCV test date
30.1
(22,863)
13. Referral for depression
management
Patients who received >1 of the following
treatments for depression: psychotherapy,
Patients with HCV and a diagnosis of
depression†
65.6
(13,326)
antidepressant prescription, visit to mental
health clinic within 28 days of depression
diagnosis
14. Referral for substance
abuse disorder (SUD)
Patients who received > 1 of the following
treatments for SUD: psychotherapy,
aversion therapy, visit to mental health
clinic within 28 days of SUD diagnosis
Patients with HCV and a diagnosis of
SUD†
48.7
(18,637)
Patients who received at-least 1 prescription
of interferon within 12 months of seeing a
specialist
Patients with genotype 1 or 4 HCV
who saw a specialist
Patients who received at-least 1 prescription
of interferon within 12 months of seeing a
specialist
Patients with genotype 2 or 3 HCV
who saw a specialist
17. Ribonucleic acid (RNA)
testing prior to treatment
Patients who received quantitative RNA test
within 6 months prior to start of anti-viral
therapy or 2 weeks after
Patients who received first interferon
prescription,§ and at-least 6 months of
follow up before interferon start date
69.8
(5588)
18. RNA testing at treatment
week 12
Patients who received RNA test between 10
– 14 weeks after start of anti-viral therapy
Patients who received first interferon
prescription before 9/24/2006,§ and atleast 12 weeks of ongoing treatment^
62.3
(4696)
19. RNA testing at treatment
week 24
Patients who received RNA test between 20
– 28 weeks after start of anti-viral therapy
Patients who received first interferon
prescription before 6/18/2006,§ and atleast 24 weeks of ongoing treatment^
62.6
(3427)
20. RNA testing at treatment
week 48
Patients who received RNA test between 44
– 56 weeks after start of anti-viral therapy
Patients who received first interferon
prescription before 12/4/2005,§ and atleast 48 weeks of ongoing treatment^
80.3
(1024)
21. RNA testing at 24 weeks
after end of treatment
Patients who received RNA test anytime
after post treatment week 22
Patients who received first interferon
prescription§ before 1/1/2005 and had
a negative RNA test at the end of
treatment^
90.5
22. Lowering ribavirin dose for
anemia
Patients who had a dose reduction or
discontinuation of ribavirin within 35 days
of hemoglobin test date
Patients with hemoglobin < 10g/dl
after first interferon start date and on
ribavirin
22.2 (942)
23. No stimulating factors for
low neutrophil count
Patients who did not receive any
prescription for colony stimulating growth
factor after the low neutrophil count date
Patients with neutrophil count of 500 700/mm3 after interferon start date
72.0 (579)
Antiviral Treatment
15. Antiviral treatment in
genotype 1/ 4
16. Antiviral treatment in
genotype 2 or 3
22.9
(33,076)
26.7
(10,838)
Treatment Monitoring Domain
(2040)
Appendix Table 1. Hepatitis C Specific Process Measures and their Operational Definitions
For all laboratory tests (HCV antibody, HCV RNA, HCV genotype, hepatitis A and B serology, and HIV), we used LOINC
codes in combination with laboratory test names to identify relevant tests. We then used laboratory test names and test results to
limit to specific tests of interest. HCV medications were identified using medication name in the pharmacy data.
#Anti-viral
treatment is rendered by gastroenterologists (clinic stop code 307), infectious disease (310), and (in some VA
facilities) by primary care providers (323). To ascertain which of these 3 clinics served as a specialty clinic for each VA facility,
we used pharmacy data and selected the clinic responsible for writing majority of the first interferon prescriptions for HCV
patients in a given facility. We classified a patient as having seen the specialists if s/he had a clinic visit to the specialty clinic
which was accompanied with diagnostic codes for HCV, cirrhosis, or chronic liver disease not specified.
§We included only those patients who received first course of interferon. All patients had > 3 months of follow up prior to first
interferon prescription, ensuring that we did not include patients who might have entered the VA while on treatment, thus
compromising the ascertainment of treatment initiation date.
^We defined treatment duration by calculating the cumulative days of supply of interferon prescriptions, as previously described
by Backus et al. (1) We identified gaps in treatment as the difference between the last date covered by previous prescriptions and
the fill date for the next prescription, and classified patients to have received sequential treatment if they had gaps greater than 45
days.
&RNA
testing at 24 weeks after end of treatment is used to assess sustained virologic response. In a sensitivity analysis, we
restricted the time window for the test to include only those RNA tests that were performed between 20 and 28 week after end of
treatment. We found that 57% of patients with a negative test at the end of treatment had at least 1 RNA test during this time
frame.
† Depression
defined as 1 inpatient or 2 outpatient ICD-9 codes within 1 year.
inpatient visit or outpatient ICD-9 code within 1 year
‡CPT
6 Substance
use disorder (SUD) defined as 1
codes. hepatitis A vaccination: 90632, 90633, 90634,90636, 90730; hepatitis B vaccination: 90636, 90740, 90743, 90744,
90746, 90747, 90748, G0010. These codes have been reported to be highly predictive of presence of vaccination in patients’
medical records (positive and negative predictive values >90%) (2)
Appendix Table 2. Sensitivity Analyses. Association of facility factors with overall care in patients with
hepatitis C virus infection. The first column (Model 1) presents the results of the regression analysis limiting
to patients without evidence of treatment contraindications. The second column (Model 2) presents the results
in a subsample with cirrhosis.
Variables
Age (reference 66 yrs and older
56-65 yrs
46-55 yrs
< 45 yrs
Race (reference white)
Black
Other
Number of visits/quarter
Cirrhosis
Depression
Drug or alcohol use
>1 medical comorbidity
Weekly ½ day clinics1
No dedicated clinic
1-3
4-7
8-12
13 or more
HCV quality improvement efforts
<3
4 or more
HCV patient load
Lowest load (lowest quartile, <430 patients)
Higher load
Region
West
Mid-Atlantic
Midwest
1
Odds ratio
(95% confidence interval
Model 1
Model 2
1.39 (1.09-1.79)
1.36 (1.09-1.70)
1.22 (0.92-1.62)
1.76 (1.24-2.49)
1.75 (1.26-2.44)
1.95 (1.30-2.9)
1.25 (1.03-1.51)
1.8 (0.99-3.28)
1.11 (1.08-1.14)
1.11 (0.78-1.59)
NA
NA
NA
1.13 (0.92-1.39)
0.73 (0.42-1.26)
1.07 (1.05-1.09)
NA
1.03 (0.87-1.21)
0.87 (0.75-1.01)
0.91 (0.76-1.09)
-1.52 (0.70-3.27)
1.51 (0.77-2.97)
1.36 (0.66-2.77)
3.58 (1.81-7.05)
-0.82 (0.52-1.29)
1.00 (0.68-1.48)
1.31 (0.87-1.96)
1.49 (1.00-2.23)
-1.38 (0.84-2.28)
-1.12 (0.82-1.53)
-1.1 (0.64-1.9)
-0.85 (0.60-1.21)
Northeast
-0.80 (0.46-1.37)
0.61 (0.35-1.07)
0.32 (0.15-0.69)
South
0.68 (0.39-1.20)
-1.22 (0.88-1.69)
0.99 (0.71-1.38)
1.11 (0.72-1.7)
1.33 (0.96-1.85)
Standardized per 1000 HCV patients
We removed patients with severe depression, drug and alcohol use, and severe medical comorbidity from Model 1.
As a result, these variables are not included in the regression model. All patients in Model 2 had evidence of
cirrhosis. As a result, Model 2 does not include a variable for cirrhosis.
References
1. Backus LI, Boothroyd DB, Phillips BR, Mole LA. Predictors of response of US veterans to treatment for
the hepatitis C virus. Hepatology. 2007;46:37-47.
2. Hachem CY, Kramer JR, Kanwal F, El-Serag HB. Hepatitis vaccination in patients with hepatitis C:
practice and validation of codes at a large Veterans Administration Medical Centre. Aliment Pharmacol
Ther. 2008;28:1078-87