Needs Assessment of Hepatitis C Testing, Treatment and Support Services: Survey of General Practitioners in Primary Care

Survey objectives To identify and describe: i)existing Hepatitis C testing services in general practice setting ii)Hepatitis C test practice among these services (e.g. number tested, number of antibody positives, number of PCR positives) iii)enablers and blocks to patient undergoing Hepatitis C test where considered appropriate or where risks identified iv)resources needed by general practitioners to address any barriers

GP survey population All GP training practices throughout Scotland included in survey (n=235); represents 23% of all GP practices in Scotland (235/1031) Survey response rate 233* of 235 training practices sent questionnaire survey (309 GPs in total) Response rate by GP = 52% (162/309) Response rate by practice = 69% (160/233) * 1 GP on long-term sick leave and 1 addressee unknown excluded

Practice characteristics i)by NHS Board All 14 NHS Board areas represented ii) by geographical location Of 160 practices responding to survey: 5%10%26%31%28% Remote rural areas Accessible rural areas Accessible small towns Other urban areas Large urban areas

HCV caseload (as at April 2007)

HCV testing and diagnosing 91% (145/160) of practices responding to survey currently undertake HCV testing HCV testing reported in at least one responding practice in each NHS Board area (except Shetland NHS Board) In an average month, 98% (142/145) of testing practices test <10 patients (60% urban-based/40% rural-based) In last 12 months, 96% of testing practices (139/145) diagnosed <6 patients with hepatitis C

Factors influencing HCV testing

Key populations to test for HCV

Barriers to testing (associated with client)

Barriers to testing associated with practice

From a GP perspective, who should perform i) pre-test discussion? * ii) testing? iii) post-test discussion? * Responses are not mutually exclusive

From a GP perspective, who should perform i) pre-test discussion? ii) testing? * iii) post-test discussion? * Responses are not mutually exclusive

From a GP perspective, who should perform i) pre-test discussion? ii) testing? iii) post-test discussion? * * Responses are not mutually exclusive

Referral practices Proportion (%) of practices which offer Hepatitis C patients referral to a specialist for further evaluation (n=160)

Acceptance of referral (No. of patients estimated to accept referral based on arbitrary number of 10 newly diagnosed patients) Mean = 8 Median = 9

From a GP perspective, what are the main reasons for: a) patient non-acceptance of referral? HCV is not a priority or relevant to the client at the time (46%, 58/127) Patient does not want to see a specialist (30%, 38/127) Other reasons (e.g. fear, ) (12%, 16/127) Distance to specialist service (8%, 10/127) Long wait for specialist appointment (4%, 5/127)

From a GP perspective, what is the single most important reason for: a) patient non-acceptance of referral? HCV is not a priority or relevant to the client at the time (46%, 58/127) Patient does not want to see a specialist (30%, 38/127) Other reasons (e.g. fear, stigma, lack of motivation ) (12%, 16/127) Distance to specialist service (8%, 10/127) Long wait for specialist appointment (4%, 5/127) b) non-offer of referral? Current injectors with chaotic lifestyles (58%, 47/81) Alcohol related current mental illness (15%, 12/81) Another physical illness (13%, 11/81) Non-alcohol related current mental illness (9%, 7/81) Current injectors with stable lifestyles (5%, 4/81)

Summary: 1.Majority of GPs from testing practices would opportunistically offer HCV test when client presents with: a) history of appropriate risk b) medical indications of liver disease 2.Approximately, 1 in 5 GPs would actively seek out risk factors 3.GPs would offer an HCV test to current/former IDUs, known HIV positive patients, and sexual partners/household contacts more than half the time 4.Poor awareness of HCV, HCV not a priority for client, and fear of diagnosis perceived by GPs to be barriers to testing for clients 5.Poor awareness of HCV among practice staff, limited knowledge of testing protocols, lack of time and skills for pre/post-test discussion considered barriers to testing associated with practices

Summary: 6.Majority of GPs indicate practice nurses should perform HCV testing while GPs should undertake pre/post-test discussion 7.Majority of GPs refer both PCR positive and PCR negative patients for specialist evaluation 8.One third of GPs consider the main reason for non-acceptance of referral by patients is the fact that HCV is not a priority for the client at the time 9.Current injectors with chaotic lifestyles would not be offered a referral by one third of testing practices