Diffusion of innovation: case study of hepatitis C in the VA
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BACKGROUND: The VA is the nation’s largest hepatitis C virus treatment provider with a large cadre of HCV specialty care providers. Nevertheless, when highly effective, but expensive all-oral interferon-free medications (directly-acting antivirals, DAAs) for HCV were released, the unanticipated high demand created a VA pharmacy funding shortfall. As this shortfall became apparent, the Veterans Choice Program’s “Choice First” (Choice) initiative emerged. Through Choice, veterans could seek HCV care from non-VA community providers in lieu of waiting for VA care, which in turn complicated access and adoption of DAAs. This study examined VA patient and providers’ experience of and reactions to new DAAs and the implementation of Choice for HCV care. METHODS: A qualitative study informed by grounded theory methodology was conducted involving semi-structured interviews with 38 veteran patients and 10 of their HCV providers at three VA medical centers in New England. Patient and provider interviews focused on their experiences with the new HCV treatment, and the processes of care in the VA and through Choice. RESULTS: Five themes emerged: 1) the VA’s implementation was considerably more reactive than planned, 2) adopting highly effective HCV medication and Choice were both symbiotic and reciprocally confounding, 3) patient demand and provider awareness were attributed to direct-to-consumer-advertising, 4) the VA organizational structure was not perceived as conducive to rapid implementation of highly effective, demanded, yet costly medication, and 5) veterans and providers had similar perceptions of treatment candidacy. CONCLUSIONS: The VA initially achieved a rapid pace of treating veterans with the DAAs, but eventually could not keep up with demand, leading to a largely unsuccessful attempt to refer patients to non-VA care for HCV treatment. The VA acted as a complex adaptive system and responded to implementation difficulties by applying new policies, which were often opaque, disrupted provider heuristics and practices, and impaired patient autonomy. Patients and providers embraced the HCV treatment innovation, but their experiences navigating community HCV care through Choice indicated a number of flaws in the execution of that program. Choice could have been implemented more effectively with proper recognition and measurement of system antecedents.