In the JournalsPerspective

Multidisciplinary hepatitis C treatment program yields results

A hepatitis C treatment program at an urban safety-net hospital that utilized a public health social worker, general internists trained in hepatitis C treatment, pharmacists, and pharmacy technicians led to nearly one out of every four referrals receiving treatment, according to research recently published in Annals of Family Medicine.

“Prior studies have demonstrated that general internists can successfully deliver [hepatitis C virus (HCV)] care for urban underserved patients in primary care settings,” Karen E. Lasser, MD, MPH, general internal medicine section, Boston Medical Center, and colleagues wrote. “We are unaware, however, of primary care treatment programs in the era of newer oral medications. The simplicity of oral regimens that have few side effects and are effective across genotypes enables primary care physicians to provide treatment.”

In the study’s treatment model, a case manager coordinates care for patients with HCV. Patients are referred to physicians who advise on HCV treatment options and discuss substance use history, risks of nonadherence and reinfection, and reducing the risk for HCV transmission. Physicians also administer vaccines for hepatitis A and B when needed. Case managers then make referrals, if necessary, for mental health and/or substance use treatment, and assist with other needs such as housing and transportation. Pharmacy technicians prepare prior authorization paperwork for HCV treatment candidates, and if patients are approved, pharmacists educate patients about medication administration, adherence and adverse effects. Three months after completing treatment, patients see the physician to determine if the patient has achieved a sustained virologic response.

Lasser and colleagues also noted that financial support for their model came from revenue obtained by the 340b drug discount program. In addition, the model does not require videoconferencing to provide specialist backup, as is the case with the Extension for Community Healthcare Outcomes program.

Researchers found that over a 1-year period, the program received 302 referrals and 23% of the patients in the program received treatment.

“This program is unique in two ways; it is situated in a [patient-centered medical home] based in a safety-net hospital and uses a multidisciplinary approach with primary care staff working at the top of their license — that is, each team member practices to the full extent of their education and training instead of performing tasks that could be completed by another team member. Although our model employed general internists, we believe family physicians could play a similar role,” Lasser and colleagues wrote. “Additionally, physicians’ assistants and nurse practitioners could evaluate patients for HCV infection under physician supervision. Finally, we believe this model has transferability beyond large urban academic medical centers.” – by Janel Miller

Disclosure: The researchers report no relevant disclosures.

A hepatitis C treatment program at an urban safety-net hospital that utilized a public health social worker, general internists trained in hepatitis C treatment, pharmacists, and pharmacy technicians led to nearly one out of every four referrals receiving treatment, according to research recently published in Annals of Family Medicine.

“Prior studies have demonstrated that general internists can successfully deliver [hepatitis C virus (HCV)] care for urban underserved patients in primary care settings,” Karen E. Lasser, MD, MPH, general internal medicine section, Boston Medical Center, and colleagues wrote. “We are unaware, however, of primary care treatment programs in the era of newer oral medications. The simplicity of oral regimens that have few side effects and are effective across genotypes enables primary care physicians to provide treatment.”

In the study’s treatment model, a case manager coordinates care for patients with HCV. Patients are referred to physicians who advise on HCV treatment options and discuss substance use history, risks of nonadherence and reinfection, and reducing the risk for HCV transmission. Physicians also administer vaccines for hepatitis A and B when needed. Case managers then make referrals, if necessary, for mental health and/or substance use treatment, and assist with other needs such as housing and transportation. Pharmacy technicians prepare prior authorization paperwork for HCV treatment candidates, and if patients are approved, pharmacists educate patients about medication administration, adherence and adverse effects. Three months after completing treatment, patients see the physician to determine if the patient has achieved a sustained virologic response.

Lasser and colleagues also noted that financial support for their model came from revenue obtained by the 340b drug discount program. In addition, the model does not require videoconferencing to provide specialist backup, as is the case with the Extension for Community Healthcare Outcomes program.

Researchers found that over a 1-year period, the program received 302 referrals and 23% of the patients in the program received treatment.

“This program is unique in two ways; it is situated in a [patient-centered medical home] based in a safety-net hospital and uses a multidisciplinary approach with primary care staff working at the top of their license — that is, each team member practices to the full extent of their education and training instead of performing tasks that could be completed by another team member. Although our model employed general internists, we believe family physicians could play a similar role,” Lasser and colleagues wrote. “Additionally, physicians’ assistants and nurse practitioners could evaluate patients for HCV infection under physician supervision. Finally, we believe this model has transferability beyond large urban academic medical centers.” – by Janel Miller

Disclosure: The researchers report no relevant disclosures.

    Perspective
    Michael Saag

    Michael Saag

    This study highlights what a lot of us have been proposing for several years now; that is, that hepatitis C should be viewed as a public health challenge as much as a personal health challenge. Certainly, for the individuals who are infected with hepatitis C, getting them into care and curing them is a primary objective. But the epidemic demands that we think beyond the individual to the general public as well.

    In the case of this health center, they had taken a proactive approach to testing all individuals who are seen in their catchment area. Once identified, those who test-positive enter into an algorithmic approach of screening and evaluation, and ultimately, treatment and subsequent cure. This is accomplished with a multi-disciplinary team that includes physicians, pharmacists, case managers and coordinators. In addition, patients with more challenging and difficult to treat HCV infection are referred to gastroenterologists and infectious disease providers.  Yet the majority of the patients were taken care of by primary care providers.

    Their experience underscores the feasibility of having primary care providers effectively and efficiently treat and cure the majority of individuals who have hepatitis C. This should be motivating for all health systems to implement a program similar to this. Once we get enough clinics and health systems to adopt this type of approach, we can begin to think about eradicating hepatitis C from the United States.    

    • Michael Saag, MD
    • co-editor in chief, Healio publication HCV Next director, Center for AIDS Research, and associate dean for global health, School of Medicine, University of Alabama at Birmingham Editor's Note: This perspective has been updated from a previous version.

    Disclosures: Healio Family Medicine was unable to determine Saag's relevant financial disclosures prior to publication.