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What to cover:

Liver disease in primary care Stephen Willott – GP Clinical lead Alcohol misuse & BBV’s Nottingham City PLT 20/27 Sept 2016. What to cover:. P rimary care well placed Multi-morbidity and health inequality agendas Problems Possible solutions Potential barriers. Primary Care.

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What to cover:

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  1. Liver disease in primary careStephen Willott – GP Clinical lead Alcohol misuse & BBV’s Nottingham CityPLT 20/27 Sept 2016

  2. What to cover: • Primary care well placed • Multi-morbidity and health inequality agendas • Problems • Possible solutions • Potential barriers

  3. Primary Care • GPs already undertake chronic disease management • GPs have experience of alcohol, obesity, opioid substitution, migrant populations • Easy access, minimal travelling, supportive environment • GPs often see patients who do not attend hospital

  4. The problems: • liver disease risks being side-lined • crucial opportunities often missed • Poor detection • Late detection About 75% of people with cirrhosis are not detected until they present with end-stage liver disease.

  5. Liver Mortality

  6. The problems: liver disease risks being side-lined crucial opportunities often missed Poor detection Late detection About 75% of people with cirrhosis are not detected until they present with end-stage liver disease. Poor levels of treatment

  7. Hep C…the bad news • over half remain undiagnosed • ONLY 3% have been receiving treatment each year • Around half of those living with hep C are from the bottom socio-economic quintile and three-quarters from the bottom two • 2008-12 : 11% of men and almost 25% of women tested in prison were found to be hepatitis C positive

  8. The Hepatitis C Trust online survey of patients 2013 Before diagnosis: • Over 2/3 not offered a test despite visiting GP • 2/3 believe they were infected for 10+years before diagnosis After diagnosis: • 23% not told about alcohol re hepatitis C • 38% not advised how to avoid transmitting hepatitis C • 46% not told that hepatitis C is curable

  9. Hepatitis C in the UK 2009. London: Health Protection Agency Centre for Infections, December 2009.

  10. Implications of fibrosis/cirrhosis • Reduced cure rates in cirrhosis • Risk of liver cancer (reduced with cure) • Risk of liver related events (dramatically reduced by cure so long as alcohol not a co-factor)

  11. The problems: • liver disease risks being side-lined • crucial opportunities often missed • Poor detection • Poor levels of treatment • unclear investigation and management pathways • disparate availability of secondary care services • Social exclusion

  12. Hep C : migration risk Prevalence Pakistan 6% Russia 4% Poland 2.5% Romania 5%

  13. Social exclusion • Bad previous experience – stigma • Chaotic and complex lifestyles – competing problems/co-morbidities • Poverty – access to clinics • Poor social support networks – perhaps removed from family

  14. Nottingham alcohol profile: admissions Source: Alcohol profiles for England October 2015

  15. Obesity • 60% Adults overweight • 25% UK population obese • 45% don’t exercise • Obesity related to 10% non cancer deaths (in non smokers)

  16. New Hep C treatments • 95% cure rates for G1 & 4 • Shorter (12 week) courses • Hardly any side effects (if interferon free) • Payer anxiety £35K / course • Primary care?

  17. Richard Lehman BMJ 2014 “A deadly virus has been conquered. Hepatitis C genotype 1 can be cleared with a simple oral combination treatment, and compared to that, the rest of this week’s medical news seems minor.”

  18. Hep c in primary care • Windmill Practice: • A primary care based model for the treatment of injecting drug users infected with hep C

  19. Locally Enhanced Service for alcohol alcohol IBA biggest bang per buck Need to make it happen in more settings Alcohol Identification & Brief Advice (IBA)

  20. 1 in 8 This compares to 1 in 20 individuals offered smoking advice (1 in 10 when nicotine replacements are offered). Does brief intervention work? Alcohol: No Ordinary Commodity - Research and Public Policy (Babor et al 2003)

  21. How does Brief Intervention compare with other interventions? 1 CES = Cumulative Evidence Score; Mesa Grande: a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction 2002 Mar;97(3):265-77

  22. High Risk Groups Mental Health issues CVD Hypertension Diabetes Pancreatitis Liver disease Gastritis Epilepsy Psoriasis Accidents New patient Social problems Substance misuse Cancers Ment h Depression, anxiety, schizophrenia and suicide are all associated with alcohol misuse. Obv can be a bit chicken & egg

  23. Notts Area Prescribing Committee http://www.nottsapc.nhs.uk/

  24. NICE estimates for Nottingham City

  25. What may stop us …? Lack of time Poor attitude Lack of money Lack of education

  26. How…with so many competing needs…

  27. ‘My GP doesn’t understand about my disease’

  28. e- module (free to all) alcohollearningcentre.org.uk 2. Face to Face Training Day Certificate in the Management of Alcohol Problems in Primary Care

  29. Liver disease management in primary care • We need to tailor our approach to tackle this triad • Not just more testing… • Think LIVER RISK

  30. Contact Details Joint Drug & Alcohol Service:Nottingham Recovery Network Drop into: NEMS Platform One Practice, 79a Upper Parliament Street, NG1 6LD. Mon, Tues, Thurs, Fri 9.30-5.30pm   Wednedsay 9.30-6.30pm 12 Broad Street, Hockley, Nottingham NG1 3AL. Saturday 9.30am-1pm Phone 0115 970 9590 or 079205 86524 or 0800 066 5362 www.recoveryinnottingham.co.uk  or www.last-orders.org

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