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

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/ 2

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/ 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

“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”

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

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

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

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

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

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

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

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

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

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

…and beyond

(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

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

Thank you Email: Walter.cullen@ucd.ie Website: http://www.ucd.ie/medicine/hepcare/ 22