Integrating Hepatitis C Treatment in Primary Care

1. Integrating Hepatitis C Treatment in Primary Care D Swan, G McCombe, E O’Connor, C Murphy, G Avramovic, J Macias, J Surey, C Oprea, P Vickerman, Z Ward, JS Lambert, W Cullen School of Medicine, University College Dublin, Ireland

2. Acknowledgements • Co-funded by European Commission through its EU Third Health Programme and Ireland’s Health Services Executive • Participating GPs and patients • Our partners: UCL, U Bristol, SAS Seville Website:http://www.ucd.ie/medicine/hepcare/

3. Aims • To describe integrated model of HCV care and its implementation in practice • To examine current HCV care practice Website:http://www.ucd.ie/medicine/hepcare/

4. Aims • To describe integrated model of HCV care and its implementation in practice • To examine current HCV care practice Website:http://www.ucd.ie/medicine/hepcare/

7. “Between April 1980 and April 1985, a 2-3 doctor practice in Dolphin’s Barn with 3000 patients identified 67 patients who had injected heroin. Mostly male, poor, living in local authority housing and had spent time in prison…42 from families with alcohol / drug abuse…56 children…” A Family Doctor in Dublin… O'Kelly, O'Doherty et al., Ir Med J, 1986

8. O'Kelly, O'Doherty et al., Ir Med J, 1986

9. Does primary care have a role? “we see it in the faces and stories of our patients”

10. Introduction Arora et al, NEJM, 2011; Swan et al, AIDS Patient Care and STDs, 2010; Cullen et al, BJGP, 2006. Though HCV common among PWIDs attending primary care, complex barriers mean few have been treated HCV infection treatment in primary care now feasible, acceptable…. In Ireland and the EU, primary care is increasingly providing long-term care for people who inject drugs

11. Assess HCV status Advise on safe drug use, transmission Assess other bloodborne viruses too Refer to clinic for evaluation / treatment Address lifestyle / psychosocial issues Immunise (HBV, HAV) Provide ongoing psychosocial support Review / monitor for liver disease Provide continuing, holistic care Barry et al, IJMS, 2004 & HSE Hepatitis C Strategy, 2014 Cullen et al, Ir J Med Sci, 2004

12. Heplink Objectives To improve HCV care outcomes among patients receiving OST in general practice, by: - developing integrated model of HCV care - evaluating feasibility, acceptability and likely efficacy

13. Hepatitis C Integrated care model Education of community practitioners Outreach of HCV trained nurse into GP practices Enhanced access to community-based HCV evaluation (including fibroscan)

14. Recruitment & Data collection • GP practices eligible if: • OST prescribing • Catchment area of MMUH • Patients eligible if: • ≥ 18 years of age • on OST • attend the practice for any reason during the recruitment period

15. GP Practices recruited n=14 Patients recruited n=135 Baseline data on HCV care processes / outcomes extracted from the clinical records of participating patients

17. Academic detailing, education Intervention Nurse consultation Explain role, assessment, referral procedures Checks participant’s HCV Ab and risk status HCV Ab status: Unknown Nurse arranges HCV testing HCV Ab status: Known

18. HCV Ab negative HCV Ab positive Intervention • Addiction assessment • Info/Education • Arrange re-testing • Handover to GP Check PCR status PCR pos/UK PCR neg • Addiction assessment • Fibroscan • Information/Education • Facilitate RNA testing • GP handover

19. REFERRAL CRITERIA: HCV Ab+ and Ag/RNA positive / unknown Intervention • Referral to Hepatology/ID • Liaison between GP/patient and hospital clinic

20. Process of care • The integrated model of HCV care has been piloted in 14 practices

21. Practice & policy • Ireland East Hospital Group • HSE Clinical Programmes • Consultation

22. …and beyond

23. …and beyond

24. Discussion Recruitment and baseline data collection complete / targets achieved Most screened, access to specialist assessment / treatment a challenge (47% and 15% respectively) Intervention ongoing especially in other sites, evaluation pending 29% of HCV Ab+ participants fibro-scanned had cirrhosis Research into practice and policy…

25. Integrated Care • ‘…a worldwide trend in health care reforms focusing on more coordinated forms of care provision…may be seen as a response to the fragmented delivery of health and social services … in many health systems • WHO gives the following definition: "a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve services in relation to access, quality, user satisfaction and efficiency”’

26. Thank you • Email: Walter.cullen@ucd.ie Website:http://www.ucd.ie/medicine/hepcare/