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Improving referral from primary care boosts hepatitis C treatment uptake in UK study

Keith Alcorn
27 January 2016

Improving referral to hepatitis specialists and assessment by specialists resulted in almost four times as many people beginning hepatitis C treatment in one year at hospitals in Nottingham, the findings of a study published in Open Forum Infectious Diseases show.

Provision of specialist hepatitis care through drug treatment services and primary health clinics for people who inject drugs greatly improved treatment uptake, the study found.

Ensuring that people with hepatitis C benefit from recent improvements in treatment requires more than access to drugs. Diagnosing people, retaining them in care and ensuring that people undergo monitoring tests for liver disease, in order to identify people in most urgent need of treatment, are all part of the care pathway or `treatment cascade` that ultimately determines who gets cured of hepatitis C.

Many people with hepatitis C remain undiagnosed, but even after a positive hepatitis C antibody test result there are several stages at which people can get lost from care, or fail to undergo procedures which might speed them towards starting treatment. These include:

  • Testing for HCV RNA to confirm chronic infection
  • Referral to a hepatitis clinic after diagnosis by a general practitioner
  • Referral to a hepatitis clinic after diagnosis in a substance misuse service or drug treatment clinic
  • Referral to a hepatitis clinic on release after diagnosis in prison.

To address some of these problems doctors at Nottingham University Hospitals put in place some new protocols to improve care pathways in 2007-2008:

  • All blood samples testing positive for HCV antibody were immediately tested for HCV RNA, eliminating the need for patients to attend for repeat blood tests.
  • The laboratory results supplied to GPs and other sites requested that any patient testing positive should be referred to a hepatitis clinic, eliminating the need for GPs to interpret the result or decide on a course of action.
  • GPs and practice nurses received a training programme to raise awareness of hepatitis C.
  • Local treatment criteria were amended to permit HCV treatment for active drug users and nurse-led clinics were opened at the city’s drug treatment clinic and a primary health centre providing a specialised service for people who inject drugs.

A retrospective analysis, comparing patient retention through the care pathway in the period 2010-2011 with a previous study of retention in 2000-2002, was carried out. The study used the Nottingham University Hospitals database of blood samples tested for HCV to identify all newly diagnosed patients and track their engagement with specialist services. The study was conducted prior to the introduction of direct-acting antivirals, so the results could not have been affected by the uptake of a new form of treatment.

The study identified 377 newly-diagnosed patients, of which 348 had been tested for HCV RNA and 237 had tested positive for HCV RNA. Of these, 90 were diagnosed in general practice, 50 in substance misuse services, 54 through local hospitals (either as outpatients across many different specialties or as inpatients) and 43 through local prisons.

Patients diagnosed in primary care were most likely to see a specialist. Of the patients diagnosed in general practice 92% were referred to a specialist clinic and 89% of these attended the clinic. Among those diagnosed in substance misuse services 84% were referred to a specialist clinic and 83% of these had been assessed by a hepatitis specialist, mainly at community clinic sessions. Seventy-six per cent of patients diagnosed in hospital settings were referred, of which 93% attended the clinic.

The rate of referral was lower among prisoners, with only 56% referred for assessment. Of these 75% attended a clinic. Referral rates and clinic attendance were affected by transfer to other prisons or release from prison.

“Overall, 80% of the patients were referred to a hepatitis specialist, 70% attended assessment and 38% started treatment,” compared to 49% referred to a specialist, 27% assessed and 10% started on treatment in the 2000-2002 cohort, the authors concluded.

Referral rates had “improved dramatically” in substance misuse services, from 42% in 2000-2002 to 84% in 2010-2011.

“These improvements […] are likely to be a direct result of an intervention set designed to integrate and enhance the continuum of care,” the authors commented. “Our solution included the creation of facilities designed to meet the needs of our vulnerable populations, such as the delivery of antiviral therapy as part of drug treatment programmes.”

The main reasons for not starting treatment among those who attended an assessment with a hepatitis specialist were a decision to defer treatment (30) and disengagement with care before starting treatment (23).

The study “confirms that patient engagement is a prerequisite for realising the benefits of new directly acting antiviral therapies, and emphasises the importance of our central message that targeted public health measures can increase engagement of the HCV infected population with care pathways.”


Howes N et al. Clinical care pathways for patients with hepatitis C: reducing critical barriers to effective treatment. Open Forum Infectious Diseases, advance online access, 6 January 2016.