Case-finding for Hepatitis C in Primary Care Dr Shivani Datta, Academic FY2 Supervisors: Professor Matthew Hickman, Dr Jeremy Horwood & Professor Debbie Sharp School of Social and Community Medicine, University of Bristol Aug-Dec 2012
Context Hepatitis C is: Common- National prevalence 0.5%, Chronic infection = 216000 Harmful- Hospital admissions and deaths have tripled 1998-2010 Curable- <10% in treatment pathway What do we know about testing for hepatitis C? Case-finding is cost-effective Targeting people at risk increases diagnosis of asymptomatic patients Various barriers to testing e.g. treatment side-effects Most interviews have been with patients- few studies of GPs views of testing
Aims & Objectives AIM: To evaluate testing for hepatitis C in primary care OBJECTIVES 1. Design a method for identifying people at risk from the database routinely used by GPs 2. Determine what proportion have been tested, and what proportion have not and are potentially undiagnosed 3. Determine how GPs approach case-finding for hepatitis C and explore any barriers to testing
Method - mixed methods service evaluation project Quantitative 1. 6 practices recruited (purposive sampling according to number of PWID) 2. EMIS search to find at risk people (RCGP risk factors) 3. Test results from the HPA Virology laboratory 4. Compare the 2 lists to determine which of the at risk people were positive/negative/unknown 5. At 2 practices pilot a method of in-depth searching of patient records Qualitative 1. Interview 17 GPs (2 or 3 from each practice) for 30 min each 2. Thematic analysis of anonymised transcripts 3. Key themes: current practice, testing, interaction with other services, training & guidelines
Results: Quantitative Total patients = 73,814 Total at risk patients = 3765 The distribution of risk factors
Results: Quantitative Hepatitis C test result of at risk patients 3500 3000 3051 (81%) 2500 2000 1500 1000 500 308 (8%) 406 (11%) 0 Positive Negative No result Variation in test uptake between practices and by risk factor PWID (29-63%), HIV (0-83%), Hepatitis B (30%) Statistically significant variation but explanatory variables cluster
Sample description Total GPs Gender Years since qualification Deprived area Special interest in drug addiction Male Female <15 15-24 25+ Yes No Yes No 17 9 8 5 6 6 11 6 7 10
Results- Qualitative: Who to test? When considering immigrants GPs think of HIV and hepatitis B more than hepatitis C more heightened in terms of our concern under those circumstances [testing immigrants] tends to be HIV risk, um er rather than hep C to be fair All GPs test drug users absolutely anybody who comes to me with a with a with a drug problem really. Well of course particularly those who are injecting, but um even those who say they re not injecting Dr F, male, interest in drug addiction Dr L, male, interest in paediatrics
Results- Qualitative: Barriers to testing drug addicts with lots of other issues, and OK they might have hepatitis C, um but that s not their major problem Dr H, female, interest in mental health & ENT Priority: Patient Priority: GP if you ve got a say enormous fat diabetic sitting in front of you, you re gonna want to spend the effort addressing his lifestyle and weight issues rather than bringing up hep C. Um unless he s known to have risk factors Data Dr M, female, interest in diabetes a nightmare to actually to get a good database, which I think is the prerequisite for actually better care, because we don t actually know the numbers Dr I, male, interest in statistics
Results- Qualitative: Barriers to testing Further barriers to testing: Venous access Patients lives too chaotic/unable to address the issue of hepatitis C Hepatitis C is seen as a slowly progressing infection and not an urgent issue Time pressure within consultation & competing healthcare priorities Difficult to develop rapport with patients as frequent DNAs Poor awareness of hepatitis C in groups other than drug users Unknown scale of the problem GPs forgetting to bring up hepatitis C at a later date
Conclusions 1. It is possible to identify people at risk of hepatitis C using EMIS 2. Data on risk factors poorly recorded e.g. Ethnicity, children 3. 81% of at risk patients had no test result (53% of PWID had no test result) 4. GPs clearly recognise the need to test PWID 5. Most GPs do not recognise the need to test immigrant people from countries with high prevalence of hepatitis C 6. Barriers to testing include hepatitis C not being high on the agenda for the patient nor the GP
Recommendations 1. Routine questioning of all patients to identify those with risk factors 2. A system to allow testing of all at-risk patients (e.g. computer prompts?) routinely 3. Public education campaigns to heighten awareness of hepatitis C 4. GP education to aid clarity on who to test
Questions? Dr Shivani Datta Academic FY2 shivani.datta@bristol.ac.uk