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Hepatitis C Testing, Treatment, Care and Support. Dr Kirsty Roy Health Protection Scotland On behalf of Members of the Working Group on Testing, Treatment, Care and Support. Testing, Treatment, Care and Support Working Group Activities. Overall aim

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Hepatitis c testing treatment care and support

Hepatitis C Testing, Treatment, Care and Support

Dr Kirsty Roy

Health Protection Scotland

On behalf of Members of the Working Group

on Testing, Treatment, Care and Support


Testing treatment care and support working group activities
Testing, Treatment, Care and Support Working Group Activities

Overall aim

“to gather robust data to inform the development and expansion of testing, treatment and care services beyond 2008”

Specifically,

  • to describe the existing provision of HCV testing, treatment, care and support services across Scotland

  • to examine the way in which HCV services operate with regard to testing, treatment, care and support

  • to identify gaps in and issues related to existing HCV service provision


Hepatitis c needs assessment information sources
Hepatitis C Needs Assessment Information Sources Activities

  • Questionnaire surveys:

    • All Laboratories undertaking HCV testing

    • Services on HCV Directory (71% response)

    • GP training practices (69% response)

  • Focus groups & interviews (29 service providers)

  • Literature review

  • Surveillance data:

    • National HCV Diagnoses Database

    • Local HCV Clinical Databases

  • Modelling and cost-effectiveness studies


  • Testing, Diagnosis and Referral ActivitiesIssueInsufficient numbers of chronically infected persons, particularly IDUs, are diagnosed, and many diagnosed fail to reach and stay in specialist services



    HCV testing in general practice 2006

    • Laboratory data, 2006

      • 380 persons newly diagnosed with HCV by 200 GPs (representing only 4% of all GPs in Scotland)

    • GP survey (N=160)

      • Majority practices indicated that GPs should undertake pre- and post- test discussion, while practice nurses should undertake HCV testing

      • Only 18% practices actively seek out risk factors to offer an HCV test


    117 tested 2006 28% of those offered

    110 tested  60% of those offered

    15 tested pos  13% of those tested

    89 tested pos  81% of those tested

    Comparison of different HCV screening

    approaches in general practice

    (B) Patients aged 30-54 years

    with history of IDU*

    (A) All patients aged 30–54 years

    (N= 1165)

    Target Population

    (N= 467)

    Attended Practice

    (during 6 months)

    Offered HCV Test

    HCV Tested

    HCV Antibody

    Positive

    100

    0

    20

    40

    60

    80

    Proportion (% of N)

    * Provisional data


    Barriers to testing and diagnosis 2006

    Alternatives

    Need for venepuncture

    • “.. some people might not want tested if they have poor venous access because it can be embarrassing ..”Clinical nurse specialist

    • “.. a major problem when we are implementing our outreach programme was actually well, who’s going to take the blood …”Consultant physician

    • “.. I think we should be using oral fluid testing out in the community ….”Laboratory services rep.


    Referral to specialist care
    Referral to Specialist Care 2006

    “Referral to specialist care should be considered for all patients with active HCV infection (HCV RNA positive)”SIGN, 2006


    Testing diagnosis and referral
    Testing, Diagnosis and Referral 2006

    Phase II Actions

    Action 10: NHS Boards to develop and implement a plan, to improve HCV testing and referral activities by GPs and other community setting practitioners

    Action 11: An awareness raising campaign, to prompt Hepatitis C testing among those at risk of being infected, will be implemented and evaluated

    Action 12: A programme of work to evaluate different approaches to Hepatitis C testing/body fluid sampling

    Outcome

    A reduction in the proportion of Hepatitis C infected individuals who are undiagnosed


    Treatment, Care and Support (1) 2006IssueWidespread variations in the approach to clinical management and social care of Hepatitis C infected persons exists


    Among gps in their approach to diagnosing hcv infected individuals
    Among GPs in their approach to diagnosing HCV infected individuals

    • Themajorityof practices opportunistically offer HCV test when client presents with i) a history of appropriate risk or ii) medical indications of liver disease

    • Less than 20% would actively seek out risk factors to offer a test


    Among laboratories in the way they test and report results to clinicians
    Among laboratories in the way they test and report results to clinicians

    • Multiple tests performed:

      Minimum: 1 Ab test and 1 PCR test on 1st sample

      Maximum: 2 Ab tests and 1 PCR test on 1st sample, plus 2 Ab tests and 1 PCR test on 2nd sample

    • Median turn-around time for antibody and PCR test results at local and reference laboratories = 15-21 days


    Among clinics in the approaches they take to manage their patients
    Among clinics in the approaches they take to manage their patients

    20-70% of referred patients fail to attend first appointment

    HCV service survey (12 clinics)


    Treatment care and support 1
    Treatment, Care and Support (1) patients

    Phase II Actions

    Action 1: Establishment of MCNs for all NHS Boards

    • representation from relevant specialists in healthcare and other stakeholder groups (prison, local authority, social work, voluntary sector, mental health, addictions, patient representative)

    • Practice guided by “Care” guidelines and SIGN guidelines on the management of Hepatitis C

      Action 2: Standards for Hepatitis C testing and the treatment care and social support of person with HCV infection to be developed by NHS Quality Improvement Scotland

      Outcome

      Effective and where appropriate, consistent approaches to the diagnosis and management of Hepatitis C infected persons


    Treatment, Care and Support (2) patientsIssueInsufficient numbers of infected persons receiving antiviral treatment, and resources to support the persons journey through the patient pathway are inadequate


    Numbers initiated on hcv antiviral therapy in scotland to end 2006
    Numbers initiated on HCV antiviral therapy patientsin Scotland (to end 2006)

    • Approx55%of persons ever diagnosed with chronic HCV have ever been in specialist care

    • Approx 14% of persons ever diagnosed with chronic HCV have been initiated on antiviral therapy


    Treatment care and support 2
    Treatment, Care and Support (2) patients

    Phase II Actions

    Action 6: Testing, treatment, care and support services within each NHS Board will be developed to increase the number of persons undergoing therapy in Scotland

    • 450/year to 500 in 2008/09

    • 1,000 in 2009/10

    • 1,500 in 2010/2011

    • At least 2,000 per year thereafter

      Action 7: SLAs/Memoranda of Understanding between NHS Boards & Scottish Prison Service to promote the treatment of Hepatitis C infected inmates in prisons to be developed in the context of the SPS Blood Borne Virus strategy

      Outcome

      An increase in the number of persons who clear their infection and thus reduce the numbers of infected persons developing sever Hepatitis C-related liver disease


    Treatment, Care and Support (3) patientsIssueLack of integration among primary care, specialist, addiction, prison and social care services


    Focus groups social care and support
    Focus Groups: patientsSocial Care and Support

    • Many clients chaotic lifestyles

      • Major barrier to entering and remaining on pathway

    • Many clients require significant social support

      • Currently limited

      • Provide from early stage

      • Support for development of dedicated services

    • Partnership working

      • Need improved communication and clear referral routes between services


    Outward referral links at HCV patientstreatment centres

    • Proportion of HCV treatment centres reporting outward referral links to the following services:

      • Drug & alcohol – 5/12 clinics

      • Mental health – 5/12 clinics

      • Social care – 3/12 clinics

      • Voluntary sector support – 2/12 clinics


    Treatment care and support 3
    Treatment, Care and Support (3) patients

    Phase II Actions

    Action 8: NHS Boards to develop and implement a formal plan, for integrating specialist services with those for social care, mental health and addiction in local authority, voluntary sector, primary care and secondary care settings.

    Action 9: Local Authorities will identify a strategic and operational lead for Hepatitis C infection

    Outcome

    An integrated approach to the management of Hepatitis C infected persons involving Hepatitis C treatment, social care and mental health/addiction


    Testing treatment care and support phase ii actions summary
    Testing, Treatment, Care and Support Phase II Actions: summary

    Aim: To ensure that those infected receive optimal treatment, care and support

    Actions: Measures to improve clinical and support services

    • Managed Care Networks & Standards

    • National workforce development framework

    • Increase the number of patients on therapy

    • Integrated approach, involving HCV treatment, social care,

    • SLAs/MoU between NHS Boards and SPS

      mental health/addiction services

    • National HCV Clinical Database


    • Acknowledgements summary

    • Members of the Working Group on Testing, Treatment, Care & Support

    • Participants of the HCV Needs Assessment Surveys & Focus Groups

    • Laboratories and HCV Clinics providing data for the National HCV Diagnoses Database and Local HCV Clinical Databases

    • HCV Needs Assessment Team: Beth Cullen, David Goldberg, Gillian Hawkins, Sharon Hutchinson, Scott McDonald, Allan McLeod, Justin Schofield, Amanda Weir, and Toni Williams


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