175,000 Australians live with chronic HCV infection (December 2017) - - PowerPoint PPT Presentation

An eHealth model of care for the community and prison treatment of chronic hepatitis C

Dr James Haridy

BPhysio MBBS MPH (Nutrition) CHIA FRACP

Gastroenterologist & Hepatologist, PhD Candidate University of Melbourne, Royal Melbourne Hospital @jamesharidy

175,000 Australians live with chronic HCV

infection (December 2017)

Stigma Symptoms

Screened HCV Ab + 83% Confirmed Cured 33%

Uptake of new hepatitis medications in Australia over the first 18-months

Source: The Kirby Institute, Sydney(2)

Hepatitis C is easily curable with new

• treatments. Elimination is possible.

Treatment needs to take place in the community in

• rder to reach everybody who needs it

Declining treatment rate and most community clinicians have not prescribed these new treatments Followup in community settings to check for cure and other liver problems is an issue Current methods to support GPs/nurses are slow, rely on fax, do not offer ongoing support

The problem

GP

NURSE PRACTITIONER

An eHealth model of care for the community and prison treatment

• f hepatitis C

Prospective Studies

What is the ‘eHealth model’?

GP

PRACTICE NURSE

SPECIALIST

HEPATITIS NURSE

PATIENT

This study aims to compare the use of an online shared care system for treating hepatitis C compared to the current standard of care using the remote consultation form

What is the ‘eHealth model’?

Four main components

• 1. Clinical Decision Support System

Potential Benefits: Increase ease of prescribing Overcome unfamiliarity with drugs Increase adherence to guidelines

• 2. Electronic Messaging

Potential Benefits: Allow direct link with specialist Referral of treatment plans

• 3. Electronic Patient Portal

Potential Benefits: Involves patient in treatment Direct line of communication for followup

• 4. Shared Disease Record

Potential Benefits: Database to allow follow-up Remote monitoring from specialist teams

Methods

Quasi experimental, prospective pre-post study

Arm 1: Community

All patients intended for HCV treatment by enrolled GPs and nurses without physical specialist review

Arm 2: Prison

All patients intended for HCV treatment by prison medical officers without physical specialist review

Compared to community and prison cohort managed via remote consultation (paper, fax, phone) March 1st 2016 – February 28th 2017

Efficacy (SVR12) - Primary Outcome

Acceptability

Questionnaire, interviews

Usability

System Usability Scale, Interview, Usability Testing

Uptake, Utilisation and Demand

Usage of doctor, nurse and patient portal

Integration & Implementation

Questionnaire, feedback and semi-structured interviews

Quality & Safety

Adherence to guideline, optimal treatment selection

Efficiency

Time per referral, Turnaround time for approval

Outcomes

Recruitment

8 Tertiary Hospitals 13 SPECIALISTS 9 HEPATITIS NURSES

61 GPs

8 PRACTICE NURSES 2 PRISONS

3 medical officers, 7 prison nurses

273 PATIENTS

Pre-intervention group 588 community treatments 84 prison treatments

273 PATIENTS Treatment plan initiated (n=173)

Excluded (n=28): Referral Rejected (n=1) Draft plan only (n=27)

Completed (n=33) Treatment plan initiated (n=62)

Excluded (n=10): Draft plan only (n=10)

Completed (n=16) COMMUNITY ARM (n=201) PRISON ARM (n=72)

Treatment in progress (n=46) Treatment in progress (n=140)

Study Population

Patient Characteristics Control (n=588) HealthElink (n=273) Age, years, median (IQR#) 48 (40-56) 46 (38-54) Sex, male, n (%) 400 (68.0%) 204 (74.7%) ATSI*, n (%) 17 (4.3%) 30 (11.0%) Patient Residence (ARIA## Score) Major City, n (%) 329 (57.6%) 169 (61.9%) Inner Regional n (%) 156 (27.3%) 13 (4.8%) Outer Regional n (%) 42 (8.2%) 84 (30.8%) Remote n (%) 34 (7.4%) 5 (1.8%) Very Remote n (%) 10 (0.3%) 2 (0.7%) Medical History HIV, n (%) 4 (0.7%) 1 (0.4%) HBV, n (%) 1 (0.2%) 3 (1.1%) Diabetes, n (%) 19 (3.5%) 14 (5.2%) Obesity, n (%) 30 (14.2%) 23 (8.7%) ETOH, >50g daily, n (%) 25 (12.0%) 56 (20.6%) Cirrhosis, n (%) 30 (5.4%) 41 (18.0%) Opioid Substitution Therapy, n (%) 80 (31.6%) 33 (12.1%) PWID, current, n (%) N/A 22 (8.1%) PWID, ex, n (%) N/A 125 (45.8%) Primary treating clinician Nurse-led treatment, n (%) 141 (24.0%) 159 (79.1%) General practitioner-led treatment, n (%) 447 (76.0%) 42 (20.9%) Hepatitis C Assessment Treatment experienced, n (%) 40 (8.1%) 18 (7.9%) Genotype 1a, n (%) 262 (44.6%) 97 (37.3%) Genotype 1b, n (%) 40 (6.8%) 21 (8.1%) Genotype 1 not specified, n (%) 5 (0.9%) 0 (0%) Genotype 2, n (%) 22 (3.7%) 12 (4.6%) Genotype 3, n (%) 257 (43.8%) 118 (45.4%) Genotype 4, n (%) 1 (0.2%) 3 (1.2%) Genotype 6, n (%) 0 (0%) 9 (3.5%)

Interim Outcomes

49/236 (21%) of outcomes collected in interim analysis

GP Nurse Prison 20 40 60 80 100

SVR12 %

Intention to Treat SVR12%

HealthElink Control Community

25 28 4 5 14 16 279 447 104 141 62 87

80% 62% 88% 74% 71% 89%

Interim Outcomes

HealthEl Control

20 40 60 80 100

Completion %

Liver Biochemistry

44 46

96%

372 665

56%

HealthEl Control

20 40 60 80 100

Completion %

Treatment to National Guideline

251 251

100%

656 665

98.6%

Interim Outcomes

23/61 GPs have entered at least one patient on the system All specialists and hepatitis nurses have utilised the system

Total Eligible Registered

50 100 150 200 250

number (n)

Patient Portal Usage 201 23 5

Enablers, barriers and experience

Highest uptake and early positive feedback from ‘closed’ systems such as prison/hepatitis nurses. Early issues with integration across web browsers and internet access in some areas Double data entry a barrier (even if it takes the same time as the paper- based form) Data management - assessments not available in the control group Notifications utilising email have been problematic Uptake appears highest in areas where value is perceived (prisons, rural)

Supervisors

Dr Edmund Tse - Royal Adelaide/Darwin Hospitals Dr Guru Iyngkaran – Royal Melbourne/Darwin Hospitals A/Prof Amanda Nicoll - Eastern Health A/Prof Geoff Hebbard - Royal Melbourne Hospital

Collaborators & Investigators

Dr Rod Omond – Top End Primary Care Dr Catherine Marshall – Royal Darwin Hospital Dr Jane Davies - Royal Darwin Hospital Dr Suresh Sivanesan - Royal Melbourne Hospital Prof Meredith Temple-Smith – University of Melbourne Dr Mark Wilson - Royal Hobart Hospital Dr Stephen Bloom - Eastern Health A/Prof John Lubel - Eastern Health Dr Niranjan Ararachi - Western Health Ms Rachel Liddle - Western Health Dr Kate Muller - Flinders Medical Centre Ms Rosalie Altus - Flinders Medical Centre Mr Anton Colman - Royal Adelaide Hospital Dr Dep Huynh - Queen Elizabeth Hospital Dr Zina Valaydon – Western Health Dr Jeyamani Ramachandran – Flinders Medical Centre RMH Foundation MSD (Grant, Speaker Fees) BMS (Grant, Speaker Fees)

Disclosures and Grants

www.healthelinkstudy.com.au

Thankyou

@jamesharidy

Dr Renjy Nelson - Queen Elizabeth Hospital Dr Dep Huynh – Queen Elizabeth Hospital Mr Jeffrey Stewart - Queen Elizabeth Hospital Ms Jaclyn Tate-Baker - Royal Darwin Hospital Dr Tim Fazio - Royal Melbourne Hospital Ms Sally Watkinson - Royal Melbourne Hospital Prof Alan Wigg – Flinders Medical Centre Professor Danny Liew – Monash University

References & Acknowledgements

• 1. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2017 [Internet]. Sydney; 2017. Available from:

https://kirby.unsw.edu.au/sites/default/files/kirby/report/SERP_Annual-Surveillance-Report-2017_compressed.pdf

• 2. The Kirby Institute. Monitoring hepatitis C treatment uptake in Australia: Issue #8 December 2017 [Internet]. Sydney; 2017 Dec. Available from: https://kirby.unsw.edu.au/sites/default/files/kirby/report/Monitoring-hep-C-

treatment-uptake-in-Australia_Iss8-DEC17.pdf

• 3. Hajarizadeh B, Grebely J, Matthews GV, Martinello M, Dore GJ. Uptake of direct acting antiviral treatment for chronic hepatitis C in Australia. J Viral Hepat. 2017 Dec 23.
• 4. Wade AJ, Macdonald DM, Doyle JS, Gordon A, Roberts SK, Thompson AJ, et al. The Cascade of Care for an Australian Community-Based Hepatitis C Treatment Service. Shoukry NH, editor. PLoS ONE. Public Library of Science;

2015 Dec 11;10(11):e0142770.

• 5. Bloom S, Lubel J, Nicoll A, Gow P, Dev A, Roberts S, et al. Comparison of direct-acting antiviral therapy for hepatitis C between specialist centers and primary care: Efficacy and adherence to response assessment . Journal of

Gastroenterology and Hepatology. 2017:32(Suppl 2): pp. 65–86.

• 6. Scott N, Iser DM, Thompson AJ, Doyle JS, Hellard ME. Cost-effectiveness of treating chronic hepatitis C virus with direct-acting antivirals in people who inject drugs in Australia. J Gastroenterol Hepatol [Internet]. 2016

Apr;31(4):872–82. Available from: http://doi.wiley.com/10.1111/jgh.13223

• 7. Read P, Lothian R, Chronister K, Gilliver R, Kearley J, Dore GJ, et al. Delivering direct acting antiviral therapy for hepatitis C to highly marginalised and current drug injecting populations in a targeted primary health care
• setting. Int J Drug Policy. 2017 Sep;47:209–15.
• 8. Sud R, Zekry A, Freiman J. General practitioners face significant barriers to prescribing direct-acting antiviral therapy for hepatitis C. Journal of Gastroenterology and Hepatology. Journal of Gastroenterology and …; 2016 Oct

1;31.

• 9. Wade A, Draper B, Doyle J, Allard N, Grinzi P, Thompson A, et al. A survey of hepatitis C management by Victorian GPs after PBS-listing of direct-acting antiviral therapy. Aust Fam Physician. 2017;46(4):235–40.
• 10. Doyle A, Kontorinis N, Kong J, Nazareth S, Sebastian M, Cheng W. General practitioners’ perspectives on and use of remote consultation referral system for hepatitis C treatment in primary care: Interim results. 2017.
• 11 Levy M, Glass A, Welan M, Mohsen W. Primary care: do current learning opportunities allow them to be confident prescribers for viral hepatitis? Journal of Gastroenterology and Hepatology: 2016 Oct 1;31:75–6.
• 12. Nazareth S, Leembruggen N, Tuma R, Jones R, Budge T, Leung J, et al. Expanding Access to Treatment for Patients with Hepatitis C through the use of the Remote Consult Request Form. Cairns; 2017. pp. 1–1.
• 13. Andric N, Cheng W, Chaney A, Davies A, Wolfe J. Remote consultation referral system: An effective way to treat homeless and marginalized patients with chronic hepatitis C in primary care. Journal of Gastroenterology and
• Hepatology. 2017:32(Suppl 2): pp. 65–86.
• 14. Read P, Lothian R, Chronister K, Gilliver R, Kearley J, Dore GJ, et al. Delivering direct acting antiviral therapy for hepatitis C to highly marginalised and current drug injecting populations in a targeted primary health care
• setting. Int J Drug Policy. 2017 Sep;47:209–15.
• 15. Balcomb A. Primary Care based viral hepatitis clinic in rural NSW - Outcomes from the first 15 months of Direct Acting Antivirals. 2017. pp. 1–1.
• 16. Haridy J, Wigg A, Muller K, Ramachandran J, Tilley E, Shaw D et al. Outcomes of direct-acting antiviral therapy for chronic hepatitis C following unrestricted access in Australia: Real-world outcomes from the state of South

Australia (Unpublished – to be presented at European Association for the Study of Liver Disease 2018)

• 17. Papaluca T, McDonald L, Craigie A, Jarman M, Stoove M, Hellard M, et al. Outcomes of a nurse-led model of care for HCV treatment in Victorian Prisons. Australasian Viral Hepatitis Elimination Conference, Cairns 2017.
• 18. Wenke J, Evans R, Harkness B, Levy M. 12 Months of DAA Treatment in Canberra's Prison System. 2017. pp. 1–1. Australasian Viral Hepatitis Elimination Conference, Cairns 2017.

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