In Australia, at the end of 2017, an estimated 200,000 people were living with chronic hepatitis C virus (HCV) infection and almost 10,000 had HCV related cirrhosis . The introduction of direct-acting antiviral drugs (DAAs) with their greater efficacy, shorter treatment duration and fewer side effects compared with interferon-based treatment regimens, provides an opportunity to eliminate HCV as a public health threat [2, 3]. The World Health Organisation (WHO) has set a target to eliminate HCV as a public health threat by 2030. Specific targets set by the WHO include increasing HCV treatment coverage from about 1% of affected individuals in 2015 to 80% in 2030 [2, 3].
To help further this aspirational goal, DAAs were listed in the Australian Pharmaceutical Benefits Scheme (PBS) in March 2016, allowing subsidised access to treatment for all patients with HCV. Specialists, “experienced” general practitioners (GPs) and nurse practitioners (NPs) can prescribe DAAs. “Experienced” is defined as participating in a formal education session and managing at least ten patients in consultation with an experienced hepatology, gastroenterology, or infectious diseases specialist . GPs and NPs who are not experienced in HCV management need to consult with a specialist to prescribe DAAs. To receive specialists’ advice and approval for HCV treatment initiation, primary care providers need to submit a ‘remote consultation form’ to specialists .
Although this policy aimed to engage Australian primary care providers in provision of HCV treatment, there are still few GPs and NPs providing HCV treatment, and most continue to refer patients to hospitals [5, 6]. The number of patients prescribed DAAs by GPs did not change between 2017 and 2018, and the number who received HCV treatment is falling below the number required to achieve the goal of HCV elimination in Australia by 2030 .
New models of care for HCV treatment are needed, which engage more primary care providers and thus increase accessibility by transferring HCV treatment into community settings [3, 4, 8]. To facilitate this, hospitals may need to play a role in training and providing ongoing support for primary care providers.
The Prince Charles Hospital (TPCH), Brisbane, Australia, is a tertiary referral hospital which in 2016 implemented an innovative model called Cure-It aimed at engaging primary care providers in community-based HCV treatment. This paper aims to describe the model of care and to evaluate its initial experience and short term patient outcomes.
Model of care description
The Cure-It program sought to engage community health centres and general practices in the Metro North area of Brisbane in the provision of HCV treatment. The prevalence of chronic HCV in this region is estimated to be 0.89% of whom 38.3% are diagnosed and 16.2% have received treatment .
The program provides training and ongoing support for primary care providers, to empower them to undertake HCV management in community settings. The program was implemented in March 2016 following the availability of DAA therapies on the PBS and associated changes to prescribing requirements which allowed GPs and NPs to prescribe DAAs in consultation with a specialist experienced in HCV treatment. The service is a partnership between TPCH, Brisbane North Primary Health Network and a government-funded drug and alcohol organisation. A hepatology Clinical Nurse Consultant (CNC) facilitated communication between hospital and primary care providers throughout the progam.
The Cure-It program team applied different methods to make GPs in community settings aware of the program. In this regard, information about the program was sent by email and post to practising GPs in the Brisbane Metro North area. The program was advertised in GP targeted newsletters, and the team conducted some educational meetings with GPs at their practices (at 9 general practices) and at other venues. The Education content delivered to GPs was in the form of presentations at 14 meetings delivered by a Clinician experienced in the treatment of HCV. The average of the duration of the meetings was 1 h and on average, 6 GPs attended each meeting. Education covered basic pathophysiology, assessment of HCV infectivity, risk factors for acquisition, fibrosis assessment, treatment options and assessment of successful treatment. Education was further reinforced with the provision of written information, posters, newsletters and email notifications.
Current Australian national guidelines, note that ‘DAA treatment naïve’ patients without decompensated liver disease, renal failure, HIV coinfection, or hepatitis B coinfection are eligible to be treated in community settings [4, 10]. The program assessed the patient’s eligibility for community-based treatment based on the patient’s situation and the primary care provider’s ability and experience in HCV treatment. Potential drug interactions were checked using the University of Liverpool HEP drug interaction website. Disease extent was assessed based on Aspartate Aminotransferase to Platelet Ratio Index (APRI) or FibroScan® results. Patients with APRI < 1 or liver stiffness < 12.5 kPa were considered as patients with low probabibilty of advanced fibrosis or cirrhosis. Other factors such as platelet count, synthetic liver function and +/− ultrasound results and duration of infection were also factored into decision making by the Hepatologist.
The GPs were engaged in the program, either through review of the treatment waiting list by the program team or by direct approach from the GP. The list of patients waiting for treatment at TPCH was reviewed and eligible patients for community-based treatment were identified. A specialist reviewed the documents and provided advice on eligibility. The GP who referred the patient was contacted to discuss the possibility of HCV treatment in their practice with training and support from the hospital. If GPs agreed to initiate the treatment, the CNC would provide initial information and send the pre-filled remote consultation form and asked GPs to fill it out and order tests as required and send it back to the CNC.
Additionally, primary care providers who were aware of the program sent the remote consultation form to the hospital or contacted the hospital directly via email or phone to receive approval.
In all cases, the Hepatologist assessed the patient’s eligibility for community-based treatment based on clinical information provided in the remote consultation form. If the patient was eligible, the specialist provided advice on the medication regimen, treatment duration and side effects monitoring along with further investigations required. The CNC then discussed the treatment plan with the primary care providers and provided the specialist’s advice along with a direct contact number for advice.
Current Australian recommendations do not require treatment monitoring by way of pathology testing . Case managers within the drug and alcohol settings and practice nurses or other staff within general practices contacted some patients who required more active monitoring. These patients were identified based on the individual primary care provider’s assessments and the program team were not involved in this process. Data on this was not collected.
To monitor the effectiveness of the program, primary care providers reported patients who had achieved sustained virological response (SVR), failed treatment, or re-acquired HCV. Additionally, the Hepatology CNC monitored treatment response periodically through follow up of patients’ pathology results.