EP741 - Characterizing the Use of Community Care for Anal Cancer Screening Among Veterans with HIV

Purpose/Background: The incidence of anal squamous cell carcinoma and precursor anal squamous cell intraepithelial lesions (ASIL) is rising, particularly in high-risk groups such as people with HIV (PWH). Treatment of ASIL reduces the risk of developing anal cancer, highlighting the value of screening programs. The Department of Veterans Affairs (VA) is the largest health care system in the United States providing care to PWH. When services are unavailable through the VA, care is purchased through community providers to provide timely access to care. We sought to describe the use of VA-funded community care for anal cancer screening and treatment among a national VA population of PWH.

Methods/Interventions: We conducted a retrospective analysis of anal evaluations among PWH from 2019 to 2024, utilizing the VA Corporate Data Warehouse. PWH were identified by ICD-9/10 codes for HIV diagnoses and antiretroviral medications. We identified PWH and anal evaluations within the VA using rule-based text analysis of anal pathology reports. We identified PWH who received community care using ICD-9/10 codes. We described the utilization of community care for anal cancer screening among PWH and collected patient demographics and system level variables for the referrals. We describe regional geographic utilization of community care by Veterans Integrated Service Network (VISN).

Results/Outcomes: A total of 42,422 PWH were identified, and 8,476 (20.0%) underwent anal evaluations within VA. The percentage of anal evaluations varied by region, ranging from 9.5% to 39.3% (Fig. 1). Among the 8,476 patients with anal evaluations, 22% utilized community care. There were a total of 4,046 community care referrals placed, an average of 2.2 referrals per patient. Patients with anal evaluations within the VA versus community care were similar in age, sex, and ethnicity. Community care patients were more likely to live in a rural location (23.6% vs. 11.8%, p < 0.01). Most community care visits, however, occurred in urban areas (95.9%). Community care patients were more likely to have a history of anal condyloma than those treated in the VA alone, 39.9% vs. 31.1% (p < 0.01). Community care utilization for anal evaluation also varied by geographic location by ranging from 10.7% to 42.7%, and the average number of visits ranged from 1.3 to 4.9 per patient (Fig. 1). By region, the highest number of community care referrals for anal evaluation were 4.9, 3.4, and 3.3 referrals per patient (Fig. 1). Access issues (34.0%) and wait time (10.9%) were the most identified reasons for qualifying for community care, and surgery was the most common specialty associated with referrals (22.8%). The total annual cost of community care for anal evaluations increased significantly over the study period, from $358,842 in 2020 to $3,707,548 in 2024 (Fig. 2).

Conclusion/Discussion: We found that 22% of PWH with anal evaluations utilized community care, which cost the VA system over $3.7 million in 2024. Patients with condyloma were more likely to use community care, which may reflect more complex disease. Surgical services were the most common specialty utilized for community care referral, reflecting their important role in anal evaluation programs in VA. Patients in rural areas were more likely to utilize community care; however, their visits occurred primarily in urban settings, reflecting a possible lost opportunity to keep care within the VA. Further investigation into our observed VISN-level heterogeneity may provide insight for future interventions aimed at optimizing anal cancer screening in PWH.

Figure 1. A) Percentage of patients with anal evaluations, B) Percentage of patients with anal evaluations and community care referrals, C) Number of referrals per patient for anal evaluations by Veterans Integrated Service Network (VISN)
Figure 2. Total annual cost of VA-funded community care for anal evaluations among PWH