MedicineInsight Novel use of electronic health record (EHR) data to improve the diagnosis and treatment of chronic hepatitis C in Australian general practice Kendal Chidwick 16 October 2019 Commercial in confidence
CHRONIC HEPATITIS C (CHC) IN AUSTRALIA Chronic hepatitis C is a major public health threat, leading to liver disease and mortality. New oral direct-acting antiviral (DAAs) have shown cure rates of 95%-99% and are largely well tolerated. DAA regimens PBS listed March 2016, available through GP prescribing (broadening access) Expanded the role of GPs in the management of CHC (new Australian guidelines) Despite this, by the end of 2018 only 30% of the estimated number of people living with CHC in Australia had been treated . People with chronic hepatitis C (CHC) in Australia: - 2015: 227,310 - 2017: 170,000 Commercial in confidence
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UPTAKE OF DAA MEDICINES IN AUSTRALIA 74,600 individuals initiated DAA treatment - 2014-18 (33% of 2015 total) 67% men, 33% women Age: - 51-60 yrs 33% - 41-50 yrs 26% - 48% >50 yrs Ref: Kirby report: Monitoring hepatitis C treatment uptake in Australia June 2019, based on 10% PBS Commercial in confidence
CHALLENGES Primary care workforce development is needed to promote and deliver hepatitis C testing and treatment GP prescribers of DAAs have increased but more are needed: - Mar 2016: 8% - Oct-Dec 2017: 41% - 2018: 39% There is a pressing need to develop and evaluate GP-centred interventions that increase testing, diagnosis and treatment of CHC. Commercial in confidence
WHAT IS MEDICINEINSIGHT? A large-scale national general practice dataset Flagship program for NPS MedicineWise Extracts longitudinal, de-identified, whole of practice data (including historical data) from clinical information systems (Best Practice and Medical Director) except for progress notes Provides local, state and national level data insights GPs opt in Patients opt out 6 Commercial in confidence
MEDICINEINSIGHT PRACTICES ACROSS AUSTRALIA 722 participating 12 general practices 131 79 22 3.5 M 258 regular patients 12 5,074 50 GPs 158 Data: July 2019 7 Commercial in confidence
MEDICINEINSIGHT DATA GOVERNANCE Robust data governance framework underpins all activities to ensure: Ownership of data remains with originating general practices Data are collected, stored and shared according to legal and ethical requirements, and in line with the principle of public good Data conform to a minimum standard of quality prior to use Rigorous information security protocols protect the data Independent and External Data Governance Committee Provides advice and approval on use and sharing or the MedicineInsight data Members include GPs, researchers, experts on data security, external academics, privacy, legal and consumer advisors Program ethics approval MedicineInsight program has been granted ethics approval from RACGP National Research and Evaluation Ethics Committee (NREEC) The program is in line with other international datasets (including CPRD) that have generic ethics approvals Commercial in confidence
USING MEDICINEINSIGHT TO INFORM EACH STAGE OF THE QUALITY IMPROVEMENT PROCESS 1. Formative Research to identify evidence- practice gaps (observational studies) 2. Design and Build Quality 4. Evaluate the impact Improvement Intervention of the intervention (Data driven audit & (RCT using EHR data ) feedback tool) 3. Deliver Quality Improvement Intervention (targeted or randomised) 9 Commercial in confidence
MedicineInsight: CHC in general practice Stage 1. Observational study to identify evidence practice gaps Commercial in confidence
PATIENT FINDING A novel algorithm for identifying patients with probable or possible CHC using the data from GP systems was developed - Searched for the patients most recent recorded diagnosis relating to CHC - Additional criteria were applied to confirm CHC in patients whose most recent status was indeterminate, including: prescriptions, tests, and complications related to CHC. 11 Commercial in confidence
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MANAGING CHC IN GENERAL PRACTICE - MAIN FINDINGS Results strongly indicated a substantial opportunity for GPs to recall more patients with CHC for confirmation of diagnosis and pre-treatment assessment. Majority of patients with CHC appear suitable for management of HCV in primary care (non-cirrhotic). Proactive reviews of patient records by GPs to identify patients living with HCV infection are critical to maintain treatment momentum. Commercial in confidence
MedicineInsight CHC in general practice Stage 2: Design & build education and quality improvement program Commercial in confidence
EDUCATIONAL VISITING: SMALL GROUP – MEDICINEINSIGHT DATA Commercial in confidence
MEDICINEINSIGHT PRACTICE AND AGGREGATE REPORTS Cohort of patients with possible or confirmed CHC. Comorbidities Commercial in confidence
MEDICINEINSIGHT PRACTICE AND AGGREGATE REPORTS Patients with possible or confirmed CHC who have a record of a HCV RNA test Commercial in confidence
MEDICINEINSIGHT PRACTICE AND AGGREGATE REPORTS Treatments prescribed for patients with confirmed CHC Commercial in confidence
PATIENT LISTS FOR RECALL (CASE FINDING) - Patient name GPs who are part of - Age MedicineInsight will - Usual GP - Date of last encounter receive a list of their - Diagnosis as possible or confirmed CHC patients with confirmed or - Record of a HCV RNA test (ever) - Reference to Hepatitis B infection (ever) possible CHC for case - Reference to HIV infection (ever) finding and further - Record of a HCV genotype test - Cirrhosis documented assessment - AST and platelet results in the last 2 years - Calculated APRI value - Last medicine prescribed - Date of last medicine prescribed Commercial in confidence
MedicineInsight CHC in general practice Stage 3: Delivery of the QI intervention Commercial in confidence
2017 - TARGETED DELIVERY OF THE INTERVENTION 104 general practices Targeted delivery to practices with the greatest potential need for education - Practices with high CHC caseloads but low treatment rates were approached first. Survey results: - GP confidence in screening, diagnosis and treatment of hepatitis C increased significantly 21 Commercial in confidence
2019 – RANDOMISED DELIVERY These practices 150 Intervention will be offered a practices visit 300 eligible practices These practices 150 Control will NOT be practices offered a visit 22 Commercial in confidence
MedicineInsight CHC in general practice Stage 4: Evaluation EQUIP- HEP C Cluster Randomised Controlled Trial Commercial in confidence
PRIMARY OBJECTIVE Evaluate the number of new prescriptions for direct acting antiviral (DAA) therapy over 6 months in practices who received the intervention as compared to control practices who did not receive the intervention. Hypothesis: compared to control practices, those practices randomised to receive the intervention will have a higher number of patients with CHC who initiate DAA Commercial in confidence
GOVERNANCE AND ETHICS Approved by RACGP National Research & Evaluation Ethics Committee on 29 April 2019 (Application number: NREEC 18-015) The independent Data Governance Committee for MedicineInsight approved the study on 3rd December 2018 (Application number: 2018-040) External Independent Advisory Group - Dr Anne Balcomb, General Practitioner - Prof Gregory Dore, Program Head, Viral Hepatitis Clinical, Research Program, Kirby Institute, UNSW Australia - Prof Anthony Rodgers, Professorial Fellow, Executive Director's Office, George Institute for Global Health, Professor of Global Health, Faculty of Medicine, UNSW Australia, NHMRC Principal Research Fellow - Dr Min Jun, Senior Research Fellow, Renal & Metabolic Division, Scientia Fellow and Senior Lecturer, Faculty of Medicine, UNSW Sydney, George Institute for Global Health Commercial in confidence
STRENGTHS & LIMITATIONS Large national sample Assist with understanding GPs’ management of hepatitis C, in high and low caseload practices Help with case finding Doesn’t capture clinical activity happening at non -MedicineInsight practice Prescribing information, not what has been dispensed or taken Could not use test result data to define hepatitis C Reliance on recorded diagnosis and indirect indications of CHC status Relies on information being available in fields collected Commercial in confidence
CONCLUSIONS Routinely collected longitudinal GP data can be used across key stages of the quality improvement process The first MedicineInsight randomised controlled trial has commenced We hope to show a benefit of the NPS MedicineWise educational program on the uptake of DAAs to help Australia reach WHO Hepatitis C elimination targets 27 Commercial in confidence
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