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 1

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: 2

3. Aims
To describe integrated model of HCV care and its implementation in practice
To examine current HCV care practice
Website: 3

4. Aims
To describe integrated model of HCV care and its implementation in practice
To examine current HCV care practice
Website: 4

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

6. Introduction Injecting drug use main route of transmission globally
Complex barriers mean few have received HCV treatment
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 (62-81% are infected with HCV)
So…?
Arora et al, NEJM, 2011; Swan et al, AIDS Patient Care and STDs, 2010; Cullen et al, BJGP, 2006. 6

7. Advise on safe drug use, transmission
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

8. Clinical guidelines + education + referral resources + nurse support
Implementation
Clinical guidelines + education + referral resources + nurse support
Cullen et al, BJGP, 2006

9. 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 9

10. 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”’ 10

11. Integrated Care – Hepatitis C
Education of community practitioners Outreach of HCV trained nurse into GP practices Enhanced access to community-based HCV evaluation (including fibroscan) 11

12. Methods: 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
Baseline data on HCV care processes / outcomes extracted from the clinical records of participating patients 12

13. Baseline Data Collected n=134
GP Practices recruited n=14
Patients recruited n=135
Baseline Data Collected n=134 13

14. 10.5% initiated HCV treatment 10.5% initiated HCV treatment
92.5% screened for HCV
71.4% HCV antibody positive
55.6% referred to secondary care
47.4% attended secondary care
10.5% initiated HCV treatment
92.5% screened for HCV
71.4% HCV antibody positive
55.6% referred to secondary care
47.4% attended secondary care
10.5% initiated HCV treatment

18. Results: Fibroscan 45 HCV Ab+ patients have had fibroscan
21/45 (46.7%) scored ≥8.5 kPa
13/45 (28.9%) had cirrhosis, i.e. scored > 12.5 kPa 18

19. …and beyond

20. (SVB and Rahova prison)
…and beyond
DUBLIN
LONDON
BUCHAREST
SEVILLE
TOTAL
TARGET
No. of GP practices/clinical sites recruited 14 1 9 3 27 24
No. of patients recruited
135 39
169
109
452
240
No. of patients on whom baseline data has been collected
134 96
438
No. of GP practices/clinical sites received HCV education/academic detailing 35 53
No. of GP practices/clinical sites received nurse specialist liaison 18
No. of GP practices/clinical sites received enhanced specialist assessment (incl. fibroscan) 2
(SVB and Rahova prison) 20

21. Discussion
Most screened, access to specialist assessment / treatment a challenge (47% and 15% respectively)
Prevalence of cirrhosis high
Alcohol screening low!
Feasible, acceptable, but effectiveness?
Need for definitive intervention 21

22. Thank you Email: Walter.cullen@ucd.ie
Website: 22