Hepatitis C: Screening, Identification, and Care

Digestive Disease Week (DDW) 2015

Nancy S. Reau, MD; Lauri R. Graham


July 21, 2015

In This Article

Linkage to Care

Medscape: For patients diagnosed with hepatitis C, what are some of the hurdles to their access to effective care? Are there strategies that could be implemented to improve their access to care, especially in rural or underserved areas?

Dr Reau: One of the biggest issues is just making sure that the patients are aware of their infection, the importance of the disease, and how to avoid transmission. For clinicians, this means being more effective at communicating with patients about their results. It also means linking them to a specialist or an experienced provider for care. While patients need to be aware that hepatitis C is curable, they also need to be aware of the potential health consequences of the disease until it can be cured, and how they can lower the risk for progression and transmission. Many times patients are told that they have hepatitis C and they will see a specialist in a few months. If that is all they hear, it implies that the disease isn't that important. Patient education and patient motivation are key.

We also need to recognize the hurdles involved in getting patients to the clinic—that is, the amount of time between the referral and the actual appointment and the distance patients may have to travel to that appointment. These affect the success of referral. This is especially true when screening is done in an acute care clinic or the emergency room. This patient will now "change hands" several times, potentially back to a primary care provider who could then be tasked with making a referral. Having a specialist on site who you or a primary care provider can refer to has been shown to be fast and effective.

That's part of the attractiveness with screening at the time of colonoscopy. Although the endoscopist may not have a long-term relationship with the patient, gastroenterologists often provide hepatitis C therapy, so the patient can be linked to an experienced provider who should be able to communicate test results and then facilitate treatment.

For patients in rural or underserved areas, and where it's not reasonable for them to travel, we have strategies to bring the provider to them so that they can obtain treatment for their hepatitis C. There are different, creative models with pretty good success rates. They include telemedicine or Project ECHO™ (Extension for Community Healthcare Outcomes), as well as mentoring projects in which an experienced provider is paired with a less experienced provider for training in the treatment of hepatitis C.

Medscape: Do you think the care of patients with hepatitis C will move more toward primary care providers?

Dr Reau: We uniformly thought that hepatitis C would be a disease that moved to primary care, but this transition is very difficult when getting access to the medicine is a challenge. The more difficult the rules, the less someone who's already busy is going to want to take on another project.

If you think about therapy for hepatitis C right now, even if it was one-size-fits-all, most of the therapy is prioritized by disease severity. A primary care provider certainly could be trained to interpret or evaluate a patient's disease severity, but there are still steps that they might not be as comfortable with, and the paperwork needed to get a clear-cut, patient-appropriate treatment approved is daunting. No primary care provider can spend hours doing precertification, even if they are comfortable knowing how to prescribe the drugs.

When we look at moving to a primary care model, the biggest concerns are those patients who are not recognized as having advanced disease when they do, or just the complexity of a treatment algorithm that requires an understanding of liver function, genotypes and subgenotypes, viral load, and degree of fibrosis. There is also the drug approval process, where the rules are all different and you may or may not get that drug for a patient. You may not understand when to appeal versus when you should be content to wait because it was truly justified that you didn't need that drug today. These are all challenges in an experienced hepatology office.


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