Primary Care Services for blood borne viral hepatitis prevention, treatment and care

Transcription

1 Primary Care Services for blood borne viral hepatitis prevention, treatment and care Author: Josie Smith, Marion Lyons Page 1 of 13 October 2006 Status : Final

2 Contents: Page: Executive Summary 3 Introduction 4 Methodology 4 Findings 5 Recommendations 8 Appendix 1 9 Questionnaire for secondary and tertiary Service providers Author: Josie Smith, Marion Lyons Page 2 of 13 October 2006 Status : Final

3 Executive Summary This report represents a summary of the findings from a survey of General Practitioners (GPs) on: provision of hepatitis B vaccination; testing for hepatitis C; and support and management to patients infected with blood borne viral hepatitis. It aims to provide a contemporary (2005) evidence base for those working within primary care Key Aims: To ascertain whether hepatitis B vaccination is provided to at-risk groups The extent to which hepatitis C is actively identified in patients and whether testing is offered to those in at-risk groups To outline what protocols are in place for the screening of patients for blood borne viruses with primary care To describe existing referral pathways for those patients identified as being infected with blood borne viral hepatitis. To assess current support for the management and treatment of hepatitis C within primary care To describe shared care arrangements with other relevant agencies Key Findings: Over half of GPs in Wales provide hepatitis B vaccination to babies born to mothers infected with chronic hepatitis B, injecting drug users and men who have sex with men. Two thirds of GPs offer screening for hepatitis C, however, variation exists across practices as to which patient groups are offered screening Less than 5% of GPs who offered screening identified a protocol for pre and post test discussion. A clear need was identified by GPs for a standardisation protocol for screening for blood borne viruses Less than one third of GPs across Wales were involved with shared care with relevant agencies including drug agencies, specialist tertiary services A lack of information for patients relating to treatment for hepatitis C was identified Author: Josie Smith, Marion Lyons Page 3 of 13 October 2006 Status : Final

4 Introduction and Methodology The National Public Health Service for Wales (NPHS Wales), in collaboration with Welsh Assembly Government, are responsible for development of the Blood Borne Viral Hepatitis Action Plan for Wales to address all aspects of hepatitis B and hepatitis C from prevention through to treatment and support for the population in Wales. A research programme was designed by NPHS Wales to provide a robust evidence base upon which to draw and implement recommendations. In Wales, there are an estimated 12,000 (0.4% of the population) individuals with chronic hepatitis C. If left untreated, hepatitis C can cause serious liver disease in some patients, including cirrhosis and liver cancer. Hepatitis C is transmitted through blood-to-blood contact. To date, the majority of hepatitis C infections in the UK have occurred through the sharing of blood-contaminated needles and injecting equipment among injecting drug users. Contaminated blood or blood products accounted for a further 2.5% of reported infections. Other people may have become infected with hepatitis C through non-sterile medical or dental procedures; non-sterile tattooing, body-piercing or other skin-incision procedures; other forms of blood-to-blood contact. Primary care services have an important role in the identification of and screening for blood borne viral hepatitis, and the support and treatment of patients infected with blood borne viruses. Many of those individuals infected with chronic hepatitis C remain unaware of their disease status and, as they may not have been involved in any risk behaviour for a number of years, would not consider themselves to be potentially at risk of or seek screening for blood borne viruses. GPs need to be aware of the potential for infection that risks taken years previously poses to their patients. GPs are ideally placed therefore to engage with this population who would not be targeted by any of Wales specialist services so health gain for this population group would be dependent on the sign up of GPs for action in this area. A questionnaire tool (see appendix 1) was developed by the Research Team, National Public Health Service for Wales (NPHS) designed to provide evidence on the provision of hepatitis B vaccination and hepatitis C testing, support and management within primary care. Each of the 512 main GP practices in Wales were issued with a questionnaire. A total of 206 completed forms were returned representing a return rate of 40.2%. Author: Josie Smith, Marion Lyons Page 4 of 13 October 2006 Status : Final

5 Findings Table 1 Provision of Hepatitis B vaccinations Provide Hep B vaccination for babies of hepatitis B positive mothers Provide Hep B vaccination for injecting drug users Provide Hep B vaccination for men who have sex with men Satisfactory service provided Service provided beyond GMS Awareness of guidelines All Wales Total 61.0% 66.4% 58.5% 35.9% 8.1% 38.4% Table 2 Active Provision of Hepatitis C (HCV) testing service % actively identifying HCV Who undertakes the screening? Offer HCV Test GP Nurse Other All Wales Total 30.1% 66.1% 26.4% 59.1% 23.3% Table 3 To whom is testing offered? Ever injecting drug use Current injecting drug users Blood Transfusions prior to 1991 Blood Products prior to 1991 Transplants Children of HCV positive parents Partner of hepatitis C positive person Abnormal Liver Function Tests All Wales Total 55.2% 56.2% 25.8% 24.0% 26.0% 41.3% 47.5% 53.7% 2.5% Other Author: Josie Smith, Marion Lyons Page 5 of 13 October 2006 Status : Final

6 Table 4 Protocols & Counselling/Discussion Pre-test counselling undertaken Is there a protocol in existence Would like a Protocol Post-test counselling undertaken Is there a protocol in existence Would like a protocol All Wales Total 50.0% 4.4% 67.9% 50.5% 6.4% 70.1% Table 5 Referral into treatment for those individuals diagnosed with Hepatitis C to whom are Hep C positive patients referred? All Wales total Gastroenterologist Hepatologist Infectious Diseases Specialist Provide Hep B vaccination 51.6% 21.3% 10.6% 54.0% Table 6 Which tests are undertaken by GPs? All Wales Total Confirmatory HCV PCR Liver Enzyme FBC Hepatitis screening Ultrasound Genotype 16.3% 7.3% 47.3% 43.9% 39.1% 20.9% 5.4% Author: Josie Smith, Marion Lyons Page 6 of 13 October 2006 Status : Final

7 Table 7 Shared care between GPs and other providers Agencies with whom GPs undertake shared care All Wales Total % GPs who get involved in shared care GUM Community Drug Team Hospital Specialist Voluntary Agencies Other 31.7% 9.2% 6.7% 25.1% 2.2% 1.5% Table 8 GPs who access information and provide support to patients awaiting treatment Percentage of GPs with access to information Percentage of GPs who support patients waiting to be treated All Wales Total 35.4% 31.8% Author: Josie Smith, Marion Lyons Page 7 of 13 October 2006 Status : Final

8 Recommendations Vaccination and Immunisation Co-ordinators to work with GPC Wales to consider how best to resource vaccination of high risk groups Through the National Framework, consider how best to support primary care in encouraging GPs to actively identify those patients who may have put themselves at risk of infection with blood borne viruses, and initiate the referral process Raise awareness of standard guidelines for provision of hepatitis B vaccination to high risk populations Develop and strengthen recording system between GPs and specialist clinics including those in prisons to ensure where possible that the full course of hepatitis B vaccination is administered to all relevant patients Develop a standardised protocol for pre and post test discussion for use in screening for blood borne viruses. Distribute with appropriate training. Develop and implement increased levels of shared care with Community Drug Teams and other relevant statutory and voluntary agencies including alcohol services. Ensure GPs are aware of referral pathways to specialist services Provide specific information and support packages to GP practices in order to provide improved service to those infected with hepatitis C Author: Josie Smith, Marion Lyons Page 8 of 13 October 2006 Status : Final

9 Appendix 1 - Questionnaire for GPs re Hepatitis B & C General 1. Do you provide hepatitis B vaccination for any of the following groups: YES NO a) Babies born to Hep B mums or families with Hep B positive members? b) Injecting drug users? c) Men who have sex with men? d) Occupational risk groups? Please specify which: e) Other please specify: 2. Do you think that there is satisfactory support for the management/treatment of Hepatitis C for your patients? 3. Do you provide a service beyond GMS for your patients affected by Hepatitis C? 4. Are you aware of any guidelines for dealing with Hepatitis C? 5. What are they? Testing 6. Do you actively identify patients at risk of Hepatitis C? 7. Do you offer Hepatitis C testing in your practice? Author: Josie Smith, Marion Lyons Page 9 of 13 October 2006 Status : Final

10 8. If offered, which groups do you offer testing to: a) People who have ever injected drugs in the past? b) People who are current injecting drug users? c) People who have received a blood transfusion in the UK prior to Sept 1991? d) People who have received blood products in the UK prior to 1986? e) Organ/tissue transplant recipients in the UK prior to 1992? f) Children/babies born to hepatitis C positive mothers? g) Regular sexual partners of hepatitis C positive individuals? h) Patients with unexplained abnormal liver function tests? i) Other please specify 9. If you offer testing who takes the blood for the test a) GP? b) Practice nurse? c) other please specify 10. (a) Is pre-test counselling undertaken? Author: Josie Smith, Marion Lyons Page 10 of 13 October 2006 Status : Final

11 (b) Do you have a protocol? (c) If no protocol, would you like a model one? 11. (a) Is post test counselling undertaken? (b) Do you have a protocol? (c) If no protocol, would you like a model one? 12. If you do not offer hepatitis C testing do you refer patients elsewhere? 13. If you do refer for testing where do you refer them: a) Community Drug Team? b) GUM? c) Other please specify Positive Patients 14. If you have a patient who is Hepatitis C positive to which Trust do you refer: 15. Who do you refer them to: a) Gastroenterologist? b) Hepatologist? c) ID Specialist? Author: Josie Smith, Marion Lyons Page 11 of 13 October 2006 Status : Final

12 16. Do you provide Hepatitis B vaccination to these patients? 17. If you diagnose a patient with hepatitis C do you arrange any of the following tests: a) Confirmatory HCV? b) PCR? c) Liver enzymes? d) FBC? e) Hepatitis serology? f) Ultrasound? g) genotype? 18. Do you get involved in supporting patients with Hep C through shared care? 19. If you undertake shared care, with whom? a) GUM? b) CDT? c) Hospital specialist please specify d) Voluntary agency please specify Author: Josie Smith, Marion Lyons Page 12 of 13 October 2006 Status : Final

13 e) Other please specify 20. Does your practice have access to information on Hepatitis C e.g leaflets?(please say which or please send copy with form) If not, would you like details of sources of information 21. While waiting to see a specialist does the practice offer any support? Please specify Personal Comments What services do you think should be in place to support your Hepatitis C patients. Author: Josie Smith, Marion Lyons Page 13 of 13 October 2006 Status : Final