Implementation strategies associated with improved cirrhosis care during COVID-19 in the veterans health administration

Background: The COVID-19 pandemic has presented tremendous hurdles to the continuation of preventative services worldwide, including surveillance for HCC for patients with cirrhosis. The Veterans Health Administration (VA) Hepatic Innovation Team Learning Collaborative (HIT) aims to improve care for Veterans with cirrhosis nationally. This evaluation aimed to assess 1) the approaches that sites used to providing cirrhosis care (implementation strategies) during the pandemic and 2) the implementation strategies associated with improved HCC surveillance rates during the pandemic. Methods: VA hepatology clinicians were surveyed about the use of 73 implementation strategies used to improve cirrhosis care in fiscal year (FY) 2020 and whether strategy use was affected by COVID-19. Descriptive and bivariate statistics defined frequencies and associations with HCC surveillance in the year. Results: Survey responses were received from 72 (55%) VA sites caring for over 42,000 Veterans with cirrhosis. Over the course of the pandemic in FY20, the HCC surveillance rate nationally declined from 51% to a nadir of 39%, with an overall rate of 40% at the end of FY20. Sites reported using a median of 10 (IQR 4-20) of 73 implementation strategies to improve cirrhosis care in FY20. Implementation strategy use shifted during the pandemic such that, relative to pre-COVID, sites engaged in more academic collaborations, local technical assistance, and networking to problem solve and less outreach to patients, clinical performance data, site visits, and external facilitation. Implementation strategy selection was associated with HCC surveillance;sites using more implementation strategies had significantly higher HCC surveillance rates (p=.046). Six of 73 individual implementation strategies were significantly associated with increased HCC surveillance: 1) use clinical reminders or note templates, 2) create new clinical teams, 3) use data experts, 4) tailor care to meet local needs, 5) learn from experts in cirrhosis care, and 6) use interdisciplinary workgroups to provide input into cirrhosis policies and practices. Conclusion: While VA experienced an expected national decline in HCC surveillance during FY20, sites used a variety of shifting strategies to adapt to the changing environment. A subset of implementation strategies, including interdisciplinary team formation and using medical record tools and data, was associated with higher surveillance rates during the pandemic.