Jan Tait

The impact of a managed care network on attendance, follow-up and treatment at a hepatitis C specialist centre.

Summary.  Infection with the hepatitis C virus commonly occurs in patient groups who have difficulty accessing conventional medical care, reducing their chance of successful antiviral therapy. Managed care networks (MCNs) have been suggested as a mechanism of improving access to care; however, there is little evidence to support their use in patients with hepatitis C. The aim of this study was to evaluate the impact of a MCN for patients with hepatitis C. This was a retrospective cohort study of all individuals in our area who had received a positive hepatitis C antibody test between August 1994 and June 2008. The MCN introduced a new referral pathway, which included nonmedical referrals and outreach nurse‐led clinics. These interventions were introduced in 2004 and evaluated in 2008. After the introduction of the MCN, the proportion of individuals who accessed care increased from 61% (280/430) to 82.4% (721/875). There was an increase in nonmedical referrals with 81 (18.3%) being directly referred from Drug Problem Services and 75 (17%) from the Prison Service. The changes to referral did not have a negative impact on treatment outcomes as the number who completed treatment increased from 66.1% (43/65) to 73.7% (98/133) and the sustained virological response increased from 50.7% (33/65) to 60.9% (81/133). This study provides evidence that the collaboration of health care professionals within a network can have a radical effect in improving access to care in a traditionally hard to reach population. This has been achieved with little additional resource, but rather working smarter with existing staff.

DOT-C: A cluster randomised feasibility trial evaluating directly observed anti-HCV therapy in a population receiving opioid substitute therapy from community pharmacy

BACKGROUND Direct-acting antiviral therapy (DAAs) for hepatitis C infection (HCV) have a much smaller burden of treatment than interferon-based regimes, require less monitoring and are very effective. New pathways are required to increase access to treatment amongst people prescribed opioid substitution therapy (OST). METHODS An exploratory cluster randomised controlled trial with mixed methods evaluation was undertaken to compare the uptake of dried blood spot testing (DBST) and treatment of people with genotype 1 HCV infection in a conventional service pathway versus a pharmacist-led pathway in a population receiving OST. RESULTS Pharmacies randomised to the conventional pathway obtained 58 DBST from 244 patients (24%):15 new reactive tests and 33 new negative tests were identified. Within the pharmacist-led pathway, 94 DBST were obtained from 262 patients (36%): 26 new reactive tests and 54 new negative tests were identified. Participants in the pharmacist-led pathway were more likely to take a DBST (p<0.003). Of participants referred for treatment through the conventional pathway, 4 patients from 15 with new reactive tests (27%) attended clinic for assessment. In the pharmacist-led treatment pathway, 20 patients from 26 with new reactive tests (77%) attended for assessment blood tests. Participants in the pharmacist-led pathway were more likely to proceed through the assessment for treatment (p<0.002). One participant completed treatment through the conventional pathway and three patients completed treatment through the pharmacist-led pathway. The process evaluation identified key themes important to service user completers and staff participants. CONCLUSION The study provides evidence that testing and treatment for HCV in a pharmacist led-pathway is a feasible treatment pathway for people who receive supervised OST consumption through community pharmacies. This feasibility trial therefore provides sufficient confirmation to justify proceeding to a full trial.

Dry blood spot testing for hepatitis C in people who injected drugs: reaching the populations other tests cannot reach

Objective The aim of the study was to evaluate the effectiveness of Dry Blood Spot testing (DBST) for hepatitis C within a geographical area. Design This is a prospective cohort study of all individuals living in Tayside who had received a hepatitis C virus (HCV) DBST between 2009 and 2011. Results During the study, 1123 DBSTs were carried out. 946 individuals had one test. 295 (31.2%) of these individuals were HCV antibody positive on their first test. Overall, 94.3% (902/956) individuals returned for the results of their test. During the course of the study 177 individuals were retested and 29 new cases of hepatitis C were detected. 249 individuals attended for further follow-up, and 164 (65.5%) were PCR positive. All 164 PCR-positive individuals were offered referral into specialist HCV services for further assessment. Data showed 62.5% were genotype 3, 65.1% had a low viral load (<600 000 iu/ml) and 77.5% had a Fibroscan score below 7 KPa. To date, 40 have commenced treatment and a further 16 are currently in the assessment period. Overall, we have retained in services or treated 63.6% (105/164) of patients who were initially referred and with effective support mechanisms in place we have achieved sustained viral response rates of 90%. Conclusions The study has shown that DBST is a complementary technique to conventional venepuncture for the diagnosis of HCV. The majority of patients have low viral loads and low fibrosis scores, so that while this group of patients may be difficult to reach and may be challenging to maintain in therapy, they are easier to cure.

A quasi-experimental evaluation of dried blood spot testing through community pharmacies in the Tayside region of Scotland

Objective Comparison of uptake of dried blood spot testing (DBST) for hepatitis C virus (HCV) infection between community pharmacies and established services. Design Quantitative evaluation of a service development with qualitative process evaluation undertaken in parallel. Setting Six pharmacies from 36 community pharmacies within Dundee City, a large urban settlement with high levels of socioeconomic deprivation. Participants Patients in receipt of opioid substitution therapy (OST) not tested for HCV within 12 months. The 6 pharmacies provided OST for approximately 363 patients from a cohort of 1385 patients within Dundee City. Intervention Provision of DBST by pharmacists. Main outcome measure Receipt of DBST between January and December 2014. Results 43 of 143 service users with no record of testing from the 6 community pharmacies accepted DBST. Of 561 from the remaining 1022 service users with no record of testing, 75 were tested for HCV (30% vs 13%). The OR for increased uptake of testing within the 6 pharmacies was 2.25 (95% CI 1.48 to 3.41, Z statistic=3.81, p=<0.0001) compared with other services. The DBST taken by the pharmacies provided 12 patients with a reactive test. The process evaluation identified key themes important to staff and recipients of the service. A logic model was constructed. Limitations Non-experimental service evaluation performed in community pharmacies records service activity in one location across a single time period. Interpretation Some evidence that DBST from community pharmacies may be feasible. Service users received the service positively. Staff reported that DBST was straightforward and achievable.

Multidisciplinary managed care networks-Life-saving interventions for hepatitis C patients.

Successful hepatitis C virus (HCV) therapy depends on effective pathways of care. Over two decades, we have developed four sequential models of care latterly using a multidisciplinary managed care network to improve HCV testing, care and treatment. This was a cohort study to evaluate the effectiveness of care pathways, carried out using all HCV antibody‐positive individuals tested in a geographical region between 1994 and 2014. The study involved 3122 HCV‐positive patients. They were divided into four subgroups representing different care pathways defined by their date of HCV antibody diagnosis. The number who accessed treatment services within 1 year of diagnosis increased from 77 of 292 (26.3%) to 521 of 821 (72.9%). The rate of treatment starts within 1 year of diagnosis increased from 6 of 292 (2.0%) to 133 of 821 (16.2%), and the sustained viral response rate improved from 61.6% to 77.4%. All‐cause mortality decreased from 232 of 688 (33.7%) in subgroup A to 55 of 1207 (4.5%) in subgroup D, and multivariate analysis showed that pathway type was an independent predictor of mortality irrespective of age, sex, SVR status or HIV co‐infection with pathway in D having an odds ratio of 0.53(0.40‐0.77; P<.001) compared to pathway in A. At study end, 78% (3122) of an estimated 4000 HCV positive had been diagnosed. In total, 97.5% of HCV caseload was referred to specialist services and 89% attended for assessment. The introduction of a managed care network increased access to care and reduced all‐cause mortality.

Scottish Home Parenteral Nutrition Managed Clinical Network: coordination and standards.

Home parenteral nutrition is required by patients with intestinal disease such that they are unable to maintain nutritional status or fluid volume without this treatment. A Managed Clinical Network has been established in Scotland. The aims of this multi-professional group are to ensure equity of access and that patients are managed according to nationally-agreed evidence-based procedures and protocols. The Clinical Standards Board for Scotland has provided support in preparing a quality-assurance framework to which the network must adhere.

PWE-188 Patient Selection for Peg Insertion: Are we Making the right Decisions?

Introduction Careful patient selection is key in the success of percutaneous endoscopic gastrostomy (PEG) procedures1. The 30 day mortality rate post insertion is an indicator of appropriate selection in those who are chosen for PEG, but reveals nothing about the patients judged unsuitable for PEG. We evaluated our decision making behind patient selection based on outcomes in those with a PEG inserted and those without. Methods The study identified all patients referred for specialist nurse-led PEG assessment between Jan 2007 – Dec 2011 within our centre. Data regarding age, sex, diagnosis, indication for PEG, date of referral, reason for non-insertion and RIG referrals were stored prospectively on a clinical database and analysed retrospectively. Patients were stratified into groups and mortality in each examined. Further information regarding cause of death and alternative feeding methods were obtained for selected patients from paper and electronic patient notes. Results A total of 555 PEG referrals were received with 38% of all referrals to the PEG team resulting in PEG non-insertion. The 30 day mortality rate following PEG insertion was on average 6.1%; this reduced from 8.6% in 2007 to 2.2% in 2011. 50% of all patients in the non-insertion group had a CVA as their diagnosis. 47% of all non-insertion patients and 83% of insertion patients were alive 120 days after referral. Reasons for non-insertion were grouped into unfit (n = 98, 46% of total), improved (n = 44, 21%), contraindicated (n = 34, 16%) and refused (n = 26, 12%). 74% of those deemed unfit died within 30 days of referral, and 93% of those judged to be improving were alive at 4 months post-referral. RIG referrals were arranged in 19 of 34 patients contraindicated against a PEG procedure. Patient or family refusal was the main reason for non-insertion in 12% of the non-insertion group. 12 notes were examined in patients who died in 60–180 days following PEG referral: 9 had evidence of NG feeding and 3 received RIGs. Extensive MDT input was evident. 4 patients were re-referred to the service for a second assessment if the best option was unclear. Conclusion Patient selection for PEG will continue to be complex. The nurse-led PEG assessment team, in conjunction with other MDT members, make well-informed and justifiable decisions, based on the low 30 day mortality rate post insertion, and that reasons against insertion correlate with how patient condition progresses. Alternative feeding methods are employed in the non-insertion group to combat ongoing nutritional needs. Lack of information on quality of life is the main limitation to the conclusion. Disclosure of Interest None Declared. Reference Kurien M, McAlindon ME, Westaby D, Sanders DS. Percutaneous endoscopic gastrostomy (PEG) feeding. Bmj. 2010 May 7; 340(may07 2):c2414–c2414.

P82 The use of dry blood spot testing for hepatitis C in injecting drug users attending substance misuse services

Introduction Diagnosing hepatitis C virus (HCV) in current injecting drug users has often proved challenging. This is due to the individuals reluctance to attend hospital clinics, lack of testing in substance misuse services and poor venous access. Dry blood spot testing (DBST) has proven to be a robust and easy method of determining HCV status which can be carried out by staff working in Drug Services. Aim The aim of this study was to evaluate the ease of use of DBST in clinical practice. Method The study was carried out between August 2009 and April 2010. Staff within local substance misuse services were given appropriate training in the use of DBST. Testing for HCV was offered to individuals who accessed services during this period. A follow-up appointment was given for 2 weeks after testing and a referral to specialist services was offered to those individuals who tested positive. Results A total of 361 individuals were tested during the study period. 65.1% (235/361) of the individuals tested were male, the age range was between 18 and 51 years. 73.1% (264/361) were negative for HCV antibodies and 26.8% (97/361) were positive. 93.3% (337/361) attended a follow-up appointment for their results. Of the 88 individuals who received their antibody positive results, all were offered referral to health services to provide further information and check HCV PCR. 6 are awaiting an appointment date and 17 have not attended any follow-up appointment. 79.2% (65/82) have attended a follow-up appointment at specialist services, the prison clinic or their GP to have blood checked for HCV PCR. Results available to date show that 60% (36/60) are PCR positive. Individuals who are PCR negative have been informed they do not require any further follow-up and all PCR positive people have been encouraged to attend drug treatment services and/or offered an appointment at specialist services for assessment of liver disease and treatment. Conclusion The study has shown DBST is easy to use and can be carried out without difficulty by staff within drug services. The offer of HCV testing was well received by this particular client group with over 90% of individuals returning for their results. Knowing HCV status also allowed staff to reiterate the appropriate harm reduction measures and encourage referral to services for drug treatment. 79% attended a follow-up appointment therefore suggesting that providing BBV testing is valuable in a group who are often envisaged as being too chaotic to engage with health services.

P83 Intravenous drug use: not a barrier to achieving a sustained virological

Introduction Chronic hepatitis C (CHC) is a leading cause of liver disease with a variable rate of progression to decompensated cirrhosis, hepatocellular carcinoma and death. It is a common infection among intravenous drug users (IDU). It can be cured by combination therapy of Pegylated interferon and Ribavarin. IDU patients are under represented in many treatment cohorts, this has been justified on grounds of safety and the fear that lowered treatment success would reduce the cost effectiveness of therapy. Aim To ascertain in routine clinical practice the outcomes of treating individuals with HCV who are active IDU or are on substitution therapy such as methadone. The primary outcome measure was the rate of sustained virological response (SVR) in those from an IDU background compared to those infected by other aetiologies. Method The HCV treatment database was retrospectively analysed for consecutively treated patients. The patients treated were divided in three groups based on the risk category for acquisition of Hepatitis C. Primary end point was SVR which was calculated on intention to treat basis in these groups. Similarly patients were not excluded because of co-infection with HBV and HIV or comorbidity such as haemophilia and chronic renal failure. Results We assessed treatment outcome in 291 consecutively treated, predominately treatment naive patients who received Peg interferon and Ribavarin for HCV. They were predominately male (70.3%) in the economically productive age group with 10% of the patients having cirrhosis. Major genotype was three accounting for 53.9% followed by G1 at 36.7%. The overall SVR rate was 55.3%. The SVR rates achieved were; Non IDU 61.4%, Ex IDU 54.8%, and Active IDU 47.1% (p=n/s). In each of the three groups G1 patients obtained an SVR of ; Non IDU 52.7%, Ex IDU 30.7% and active IDU 35.4% (p=n/s). In the non G1 patients non IDU 65.1%, Ex IDU 76.7% and active IDU 53.5%. Ex IDU had a significantly better SVR than active IDU (p=0.02), other differences not significant. Conclusion Our results demonstrate that with simple support SVR rates in the active drug user group can be achieved which are comparable with non IDU infected individuals. Intravenous drug use should not be seen as a barrier to treatment of individuals with HCV.