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
- 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
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
“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.”