Formal Hepatitis C Education Enhances HCV Care Coordination, Expedites HCV Treatment and Improves Antiviral Response

Samali Lubega; Uchenna Agbim; Miranda Surjadi; Megan Mahoney; Mandana Khalili

Disclosures

Liver International. 2013;33(7):999-1007. 

In This Article

Abstract and Introduction

Abstract

Background & Aims Formal Hepatitis C virus (HCV) education improves HCV knowledge but the impact on treatment uptake and outcome is not well described. We aimed to evaluate the impact of formal HCV patient education on primary provider-specialist HCV comanagement and treatment.

Methods Primary care providers within the San Francisco safety-net health care system were surveyed and the records of HCV-infected patients before and after institution of a formal HCV education class by liver specialty (2006–2011) were reviewed retrospectively.

Results Characteristics of 118 patients who received anti-HCV therapy were: mean age 51, 73% males and ~50% White and uninsured. The time to initiation of HCV treatment was shorter among those who received formal education (median 136 vs 284 days, P < 0.0001). When controlling for age, gender, race and HCV viral load, non-1 genotype (OR 6.17, 95% CI 2.3–12.7, P = 0.0003) and receipt of HCV education (OR 3.0, 95% CI 1.1–7.9, P = 0.03) were associated with sustained virologic treatment response. Among 94 provider respondents (response rate = 38%), mean age was 42, 62% were White, and 63% female. Most providers agreed that the HCV education class increased patients' HCV knowledge (70%), interest in HCV treatment (52%), and provider-patient communication (56%). A positive provider attitude (Coef 1.5, 95% CI 0.1–2.9 percent, P = 0.039) was independently associated with referral rate to education class.

Conclusions Formal HCV education expedites HCV therapy and improves virologic response rates. As primary care provider attitude plays a significant role in referral to HCV education class, improving provider knowledge will likely enhance access to HCV specialty services in the vulnerable population.

Introduction

Hepatitis C virus (HCV) is the most common chronic blood-borne disease and the leading cause of liver transplantation in the US, affecting an estimated 3.2 million Americans.[1,2] Recent advancement in antiviral treatment options has significantly increased the response rates to anti-HCV therapy even among the difficult to treat populations.[3,4] Despite this, it is estimated that only 34–48% of chronic carriers are referred for liver specialist assessment,[5–7] and less than 37% of patients receive treatment for hepatitis C.[6–8] Therefore, instituting models of care that have the potential to overcome barriers and improve access to care represents a critical goal in addressing the HCV epidemic.[9] The Institute of Medicine recently released a report identifying 'missed opportunities' in the prevention and control of HCV, and specifically recommended the development, coordination and evaluation of education programs targeting at-risk populations, as well as improved coordination of hepatitis care delivery services in its national strategy to improve hepatitis care services.[10] In addition, the American Association for the Study of Liver Diseases (AASLD) and Centers for Disease Control and Prevention (CDC) joint conference proceedings on viral hepatitis emphasized the importance of a multidisciplinary approach to HCV care and HCV care coordination, including linkage of infected persons with care and treatment services to improve prevention of viral hepatitis and the effectiveness of treatment.[8]

Patients within the safety-net healthcare systems that predominantly serve the uninsured and underinsured populations are especially at risk for experiencing health disparities, have limited access to care, and represent a growing vulnerable patient population.[11] HCV patient education is associated with positive outcomes in various models of HCV care, including increased disease-specific knowledge,[12,13] interest in treatment,[14] willingness to accept treatment,[5,15] and increase liver specialty care clinic attendance.[12,13] In a prior study within the San Francisco safety-net healthcare system, formal HCV education by liver specialists not only resulted in a significant improvement in HCV knowledge among patients but also appeared to create efficiencies in this healthcare system to allow better access to specialty care for these individuals.[13] Therefore, this patient-centred approach has the potential to impact HCV management, interest in receipt of HCV treatment and treatment outcome. However, the impact of formal HCV education by specialists on facilitating HCV treatment initiation, adherence to treatment and treatment outcome is not clearly understood. Furthermore, although primary care providers have a pivotal role in identifying patients with HCV, referring patients to specialty consultants for treatment, and collaborating with specialty care providers;[16] whether formal patient education by a specialist has a positive impact on HCV co-management between primary and specialty care providers has not been previously studied.

Considering the increasing emphasis on systemic improvements to our healthcare delivery system and enhanced coordination of health services, this study was conducted to evaluate the impact of the institution of a mandatory formal HCV education class by liver specialty providers on HCV treatment initiation and outcomes and to evaluate provider attitudes towards the impact of formal patient education on HCV management.

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