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

7. A Family Doctor in Dublin…
“Between April 1980 and April 1985, a 2-3 doctor practice in Dolphin’s Barn with 3000 patients identified 67 patients who had injected heroin. Mostly male, poor, living in local authority housing and had spent time in prison…42 from families with alcohol / drug abuse…56 children…”
O'Kelly, O'Doherty et al., Ir Med J, 1986
And it was a family physician, Fergus O’Kelly, who published the first reports of this problem and documented its high prevalence among young men and association with social disadvantage…interestingly, they also highlighted the transgenerational nature of the issue… 7

8. O'Kelly, O'Doherty et al., Ir Med J, 1986

9. “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”

10. Introduction
Though HCV common among PWIDs attending primary care, complex barriers mean few have been treated
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
Arora et al, NEJM, 2011; Swan et al, AIDS Patient Care and STDs, 2010; Cullen et al, BJGP, 2006. 10

11. 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

12. 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 13

13. Hepatitis C Integrated care model
Education of community practitioners Outreach of HCV trained nurse into GP practices Enhanced access to community-based HCV evaluation (including fibroscan) 14

14. 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 15

15. GP Practices recruited n=14
Patients recruited n=135
Baseline data on HCV care processes / outcomes extracted from the clinical records of participating patients 16

16. 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

17. Intervention Academic detailing, education HCV Ab status: Known
Nurse consultation
Explain role, assessment, referral procedures
Checks participant’s HCV Ab and risk status
HCV Ab status: Unknown
Nurse arranges HCV testing
HCV Ab status: Known

18. Intervention HCV Ab negative HCV Ab positive Addiction assessment
Info/Education
Arrange re-testing
Handover to GP
Check PCR status
PCR neg
PCR pos/UK
Addiction assessment
Fibroscan
Facilitate RNA testing
Information/Education
GP handover

19. HCV Ab+ and Ag/RNA positive / unknown
REFERRAL CRITERIA:
HCV Ab+ and Ag/RNA positive / unknown
Intervention
Referral to Hepatology/ID
Liaison between GP/patient and hospital clinic

20. Process of care 100 Nurse assessments
The integrated model of HCV care has been piloted in 14 practices
100 Nurse assessments
45 HCV Ab+ patients had fibroscan
21/45 (46.7%) scored ≥8.5 kPa
13/45 (28.9%) were cirrhotic, i.e. scored > 12.5 kPa 21

21. Practice & policy Ireland East Hospital Group HSE Clinical Programmes
Consultation

22. …and beyond

23. (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

24. Discussion
Recruitment and baseline data collection complete / targets achieved
Most screened, access to specialist assessment / treatment a challenge (47% and 15% respectively)
Intervention ongoing especially in other sites, evaluation pending
29% of HCV Ab+ participants fibro-scanned had cirrhosis
Research into practice and policy… 25

25. 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”’ 26

26. Thank you Email: Walter.cullen@ucd.ie
Website: 27