J Gastroenterol Hepatol. 2015 Mar;30 Suppl 2:1-5. doi: 10.1111/jgh.12863.

Statewide hepatitis C model of care for rural and remote regions.
 

Wendy Cheng MBBS, FRACP, MD1,2; Saroj Nazareth NP, BHlth Sc, MSc, MN1;  James Patrick Flexman MBBS, PhD, FRCPA3

1Head, Liver Service, Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia;

2 School of Medicine and Health Sciences, Edith Cowan University;

3Department of Microbiology and Infectious Diseases Royal Perth Hospital, PathWest Laboratory Medicine WA and Department of Microbiology and Immunology, University of Western Australia

 

Please direct all correspondence to:

Dr Wendy Cheng

Phone (618) 92242179

Fax (618) 92241329

E-mail: Wendy.Cheng@health.wa.gov.au

 

Abstract

The evolution of management of hepatitis C virus (HCV) has seen a majority of patients treated being regarded as cured. Despite this development, uptake of treatment remains low in Australia and this is particularly true in rural and remote areas. The largest state in Australia, Western Australia (WA), covers an area of 2,500 square kilometres. As the rural and remote population of WA is scattered in small areas rather than major centres, poor accessibility to remote areas and lack of adequate of medical and nursing resources pose major problems in providing equity of care to patients with chronic HCV. A Statewide Hepatitis Model of Care, established in 2009, has led to an increase in identification and treatment of patients living with HCV. Strategies used to facilitate these changes include Telehealth, Nurse Practitioner Model, and GP Shared-Care and prescriber Model. The Statewide program will be modified to meeting the changing needs of patients as all-oral treatment regimens become available, with further emphasis being placed on the role of rural and remote health professionals in identifying patients with HCV and initiating and monitoring treatment.

Keywords: hepatitis C, rural, model of care, telehealth

PMID: 25641223

 

Supplements

Introduction

The management of hepatitis C virus (HCV) has evolved rapidly over the last 20 years. Interferon-based therapies have been superceded by IFN-free all oral direct-acting antiviral (DAA) regimens.  Apart from the unfavourable side effect profile, the duration of therapy with interferon-based therapy was between 24 weeks to 48 weeks, in contrast to DAA regimes of 12 weeks to 24 weeks. With the approval of several DAA regimes in March and May 2016 by Pharmaceutical benefit Scheme (government subsidised) in Australia, patients with chronic hepatitis C are eligible for treatments which are more efficacious, of shorter duration and have significantly less side effects. The model of care has to be modified in response to the new treatments now available.

Hepatitis C in Australia

To date only approximately 2% of infected Australians access treatment.To have any real impact on the problem, the number of people being treated will have to increase from 2,000 to 10,000 per year. Approximately 20% of the population of WA lives outside the metropolitan area. As the rural and remote population of WA is scattered in small areas rather than major centres, poor accessibility to remote areas and lack of adequate of medical and nursing resources pose major problems in providing equity of care to patients with chronic HCV.

Western Australia (WA), the largest state in Australia, covers an area of over 2.5 million square kilometres with a population of approximately 2 million. . In 2013, 27,000 people were living with HCV, while the total number of viremic cases was approximately 20,000. While over half of these were classified as having mild liver fibrosis (F0-F1), approximately 3,500 had severe fibrosis and/or cirrhosis

Two populations that generally have a higher incidence of HCV yet are more likely to lack access to care, are Aboriginal and Torres Strait Islanders and custodial inmates.

 

Strategies to increase treatment

In the anticipation of availability of DAA, an Australian consensus statement, a treatment algorithm and remote consultation form were developed to facilitate treatment of chronic hepatitis C, aiming particularly at GP who are keen to be involved in treatment of chronic hepatitis C. These DAA drugs, although relatively easy to use in one or two pills per day in most patients, can have serious drug-interaction with commonly prescribed drugs such as lipid-lowering agents and anticonvulsants. Reactivation of hepatitis B in patients co-infected with HCV following treatment with DAA can also lead to serious consequences.

 

Statewide HCV Model of Care

Over the decade leading up to 2009, the WA Department of Health employed several strategies to increase patient access to and uptake of HCV treatment in metropolitan, rural, and remote areas. The strategic intent of the Model is to enhance prevention and intervention and increase treatment numbers to a level that has an impact on the epidemic curve.. This model of care evolved to incorporate advances in therapy and increased accessibility and equity of care across all health care sectors for people with chronic HCV and in particular, those living in rural and remote areas, those in prisons and ethnic minority groups.

With the recent availability of DAA in Australia, the expanded role of general practitioners in prescribing in consultation with specialists, multiple treatment regimens for different genotypes and potentially serious drug-drug interactions, the focus of the model of care evolves around:

  • Education for GPs and health care workers (treatment regimens and drug-drug interactions)

o   Multi-modal education program incorporating web-based learning  and telehealth

o   Selection of patients suitable for treatment in the community

  • Coordination between specialists and GP prescribers
  • Accessibility to treatment, in particular patients in rural and remote areas and minority groups such as indigenous patients, custodial inmates and other ethnic groups

Strategies that have been implemented to improve access of patients to treatment in rural and remote areas include telehealth, a Nurse Practitioner model, and GP prescribers.

 

 

fig1

Figure 1: Remote telehealth centres in Western Australia participating in hepatitis C management

 

Telehealth

The necessity for HCV-positive patients living in rural and remote areas to commute long distances results in inadequate medical supervision and low treatment uptake. Telehealth (teleconferencing) has the potential to improve the capacity of rural health services and offers patients the opportunity to access treatment, breaking the barrier of geographical isolation (Figure 1).

A telehealth service for the management of the chronic hepatitis C was established in 2006 in Western Australia. Rural and remote patients were reviewed and treated for HCV by a hepatologist and/or nurse practitioner from the Royal Perth Hospital using telehealth. Telehealth is a feasible and effective option for treatment of patients with chronic HCV living in rural and remote areas, reducing the barriers to treatment (Figure 2). Sustained virological response and patient satisfaction are well established using this mode of service delivery

There is now an extensive network of videoconferencing units within health facilities across WA, enabling access to a significant proportion of the state.

The telehealth service is currently focused on the following areas of service delivery:

  • Live, synchronous interaction between two or more locations conducted by videoconference.
  • Store and forward technology enabling patient information, including images and results and to be documented, to be uploaded and reviewed by a clinician in a secure manner.
  • Training, education and meetings: providing opportunities for patients with HCV and healthcare professionals to participate in educational events via videoconference, regardless of the geographical location of participants.

One of the key focuses of the telehealth service is the training and support of GPs and nurses in underserved areas to develop knowledge and self-efficacy so they can deliver best practice care for chronic HCV. Working together, the community providers and specialists manage patients following evidence-based protocols.

 

 

fig2

Figure 2: Total number of treated by regions in telehealth clinics

 

Nurse Practitioner model

A Nurse Practitioner (NP) model of care increases the opportunities to improved overall prevention and management of HCV, targeting lifestyle factors associated with the disease and expanding the range of health settings where patients can be identified and treated.  The Nurse Practitioner runs independent clinics and facilitates remote consultation for GP prescriber program to improve access to treatment, particularly in rural and remote areas.  In addition, investigations, checking drug-drug interactions and ensuring compliance are pivotal to the success of the treatment program.

The shorter duration of therapy with DAA with less monitoring required will result in modified roles for the NP.  Drug-drug interaction with many of the common prescribed medications such as lipid lowering agents, anticonvulsants and cardiac drugs, in particular Amiodarone can result in severe consequences if not identified at the onset or during treatment. Compliance may also be an issue for treatment durations of 12 weeks to 24 weeks in selected populations.

Patients with chronic hepatitis C that have established cirrhosis still require hepatocellular carcinoma (HCC) surveillance with 6-monthly alpha-protein and ultrasound. A Nurse-led HCC surveillance clinic which has been established forms an important part of the multidisciplinary team. In addition to chronic hepatitis C, NP role has also been expanded to include chronic hepatitis B, non-alcoholic fatty liver disease, cirrhosis caused by other liver diseases.

The creation of a statewide hepatitis C shared care program coordinated by regional nurse-led care has facilitated access to HCV testing and treatments. Since their introduction, autonomously conducted hepatitis NP clinics have seen the number of new patients accessing treatment increase from 60 to 120 per year in interferon-based therapy era. A patient satisfaction survey conducted 13 months after the implementation of the program revealed that 98% of patients surveyed were the satisfied with the quality of the care provided by the NP.  It is anticipated that with the introduction of DAA in the treatment of chronic hepatitis C, the number of patients treated will escalate.

 

Increasing involvement of GPs

GP Shared Care Model

Rural and remote health services are more dependent on primary health care services, particularly those provided by GPs. The WA model involves collaboration between GP and specialists in tertiary centres in a coordinated fashion to facilitate patient management.   With the availability of all oral DAAs, this model has now expanded to encourage GP prescribers in consultation with specialists, which in the past had been rare,

GP prescribers

Education programs  in particular the web-based learning programs –  Edith Cowan University (ECU) in conjunction with Health Department of Western Australia ( http://hepatitis.ecu.edu.au ) and Australian Liver Association in conjunction with National Prescriber System (NPS) MedicineWise,  are intended to encourage GP to become prescribers for viral hepatitis drugs are being offered. The ECU Internet-based program includes three modules for HCV and two for hepatitis B virus (HBV).

The recent listing of several DAA by the heavily subsidised Pharmaceutical Benefit Scheme enables GP to prescribe these drugs provided it is done in consultation with a gastroenterologist, hepatologist, or infectious disease physician experienced in the treatment of chronic hepatitis C infection.  A remote consultation request form and treatment algorithm have been developed to facilitate GP prescribing.

With the ease of use and shorter treatment durations of the new generation of therapies, even more emphasis will be placed on equipping rural and remote health professionals to identify and treat HCV-positive patients.

 

Conclusion

Rural and remote health services can benefit from innovative approaches using new technologies such as telehealth and expanding scopes of practice for doctors, nurses and other health care workers. Such innovations have contributed towards improvements in access to health services and the quality of care for many rural and remote Western Australians living with HCV. With the recent approval of the subsidised DAA in WA, nurse-led models are more streamlined to cater for patients with more severe liver disease, in both treatment and hepatocellular carcinoma patients in those at risk and other liver diseases.

 

References

Nazareth S, Kontorinis N, Muwanwella N, Hamilton A, Leembruggen N, Cheng WSC. Successful treatment of patients with hepatitis C in rural and remote Western Australia via telehealth. J Telemed Telecare 2013;19:101-6.

Nazareth S, Piercey C, Tibbett P, Cheng WSC. Innovative practice in the management of chronic Hepatitis C: introducing the nurse practitioner model. Australian J Adv Nurs 2008;25:107-13.

Department of Health, Western Australia. Hepatitis C Virus Model of Care. Perth: Health Networks Branch, Department of Health, Western Australia; 2009. http://www.healthnetworks.health.wa.gov.au/network/infections.cfm

 

 

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