The virus causes a chronic  infection in 85 percent of cases. Thousands of Veterans Identified as At Risk Remain Untested for Hepatitis C Despite VA Exceeding Its Testing Goal

Even though VA’s fiscal year 2002 performance measurement results show  that it tested 62 percent of veterans identified to be at risk for hepatitis C,  exceeding its national goal of 55 percent, thousands of veterans in the  sample who were identified as at risk were not tested. For example, when we excluded  veterans from the sample who were tested for hepatitis C prior to fiscal  year 2002, and included in the performance measurement sample only  those veterans who were seen by VA in fiscal year 2002 and needed to be  tested for hepatitis C, we found Network 5 tested 38 percent of these  veterans as compared to Network 5’s cumulative performance  measurement result of 60 percent. Several Factors Impeded One Network’s Efforts to Test Veterans Identified as At Risk

We identified three factors that impeded the process used by our case  study network, VA’s Network 5 (Baltimore), for testing veterans identified  as at risk for hepatitis C. The factors were tests not being ordered by the  provider, ordered tests not being completed, and providers being unaware  that needed tests had not been ordered or completed. 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. 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. Officials in two networks modified VA’s required hepatitis C  testing clinical reminder, which is satisfied when a hepatitis C test is  ordered, to continue to alert the provider until a hepatitis C test result is in  the medical record. Some Facilities Developed a Safety Net for Veterans Identified as At Risk Who Have Not Been Tested

Officials at two facilities in our review searched all records in their  facilities’ computerized medical record systems and found several  thousand untested veterans identified as at risk for hepatitis C. The  process, referred to as a “look back,” involves searching all medical  records to identify veterans who have risk factors for hepatitis C but have  not been tested either because the providers did not order the tests or  ordered tests were not completed. 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. Such a system appears to have  merit, but neither the networks nor VA has evaluated its effectiveness. 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.
Why GAO Did This Study

Hepatitis C is a chronic disease caused by a blood-borne virus that can lead to potentially fatal liverrelated conditions. In 2001, GAO reported that the VA missed opportunities to test about 50 percent of veterans identified as at risk for hepatitis C. GAO was asked to (1) review VA's fiscal year 2002 performance measurement results in testing veterans at risk for hepatitis C, (2) identify factors that impede VA's efforts to test veterans for hepatitis C, and (3) identify actions taken by VA networks and medical facilities to improve the testing rate of veterans at risk for hepatitis C. GAO reviewed VA's fiscal year 2002 hepatitis C performance results and compared them against VA's national performance goals, interviewed headquarters and field officials in three networks, and conducted a case study in one network.

What GAO Found

VA's performance measurement result shows that it tested, in fiscal year 2002 or earlier, 5,232 (62 percent) of the 8,501 veterans identified as at risk for hepatitis C in VA's performance measurement sample, exceeding its fiscal year 2002 national goal of 55 percent. Thousands of veterans (about one-third) of those identified as at risk for hepatitis C infection in VA's performance measurement sample were not tested. VA's hepatitis C testing result is a cumulative measure of performance over time and does not only reflect current fiscal year performance. GAO found Network 5 (Baltimore) tested 38 percent of veterans in fiscal year 2002 as compared to Network 5's cumulative performance result of 60 percent. In its case study of Network 5, which was one of the networks to exceed VA's fiscal year 2002 performance goal, GAO identified several factors that impeded the hepatitis C testing process. These factors were tests not being ordered by the provider, ordered tests not being completed, and providers being unaware that needed tests had not been ordered or completed. For more than two-thirds of the veterans identified as at risk but not tested for hepatitis C, the testing process failed because hepatitis C tests were not ordered, mostly due to poor communication between clinicians. For the remaining veterans, the testing process was not completed because orders had expired by the time veterans visited the laboratory or test orders were overlooked because laboratory staff had to scroll back and forth through daily lists, a cumbersome process, to identify active orders. Moreover, during subsequent primary care visits by these untested veterans, providers often did not recognize that hepatitis C tests had not been ordered nor had their results been obtained. Consequently, undiagnosed veterans risk unknowingly transmitting the disease as well as potential complications resulting from delayed treatment. The three networks GAO looked at--5 (Baltimore), 2 (Albany), and 9 (Nashville)--have taken steps intended to improve the testing rate of veterans identified as at risk for hepatitis C. To do this, in two networks officials modified clinical reminders in the computerized medical record to alert providers that for ordered hepatitis C tests, results were unavailable. Officials at two facilities developed a "look back" method to search computerized medical records to identify all at-risk veterans who had not yet been tested and identified approximately 3,500 untested veterans. The look back serves as a safety net for veterans identified as at risk for hepatitis C who have not been tested. The modified clinical reminder and look back method of searching medical records appear promising, but neither the networks nor VA has evaluated their effectiveness.