Formal Hepatitis C Education Enhances HCV Care Coordination, Expedites HCV Treatment and Improves Antiviral Response
Samali Lubega, Uchenna Agbim, Miranda Surjadi, Megan Mahoney, Mandana Khalili
Liver International. 2013;33(7):999-1007.
Full Text Available Medscape
This is the first study to evaluate the impact of formal HCV patient education on receipt of HCV therapy, treatment outcomes and primary provider HCV management practices in a safety-net healthcare system. We have shown that formal HCV education expedites receipt of HCV antiviral therapy and is associated with higher rates of virologic response to HCV treatment. In addition, a majority of providers reported that the formal HCV education class improved their patient's knowledge, communication, interest in therapy, understanding of resources for HCV management and improved the overall management of the HCV-infected patients in their practice. Furthermore, a positive provider attitude towards the impact of formal HCV education was associated with higher rates of patient referral to the HCV education class.
The vulnerable patient population within the safety-net healthcare system is disproportionally affected by HCV and adverse disease outcomes. A prior study in this healthcare setting has shown that formal HCV education class results in improvement of patient's HCV knowledge across all ages, racial groups, education backgrounds and socioeconomic status. Prior studies have also shown that HCV patients consider HCV education an important healthcare need that results in a marked increase in willingness to accept treatment.[15, 19] In this study, the majority of primary providers also perceived that their patients' HCV knowledge had increased as a result of participation in the class. In addition, over half of providers reported that HCV education class increased their patient's interest in HCV treatment. Moreover, the HCV class appeared to improve patient's understanding of available resources for HCV care within the healthcare system, improved patient-provider communication, assisted providers in addressing patients' concerns regarding HCV disease, and improved overall HCV management within the primary care practice by provider report. These findings are important in that while primary care providers often feel confident in their ability to screen for HCV and provide initial HCV disease evaluation, and believe they should be involved in HCV co-management with specialists, they feel less confident about HCV monitoring and treatment [20–22]. Therefore, in addition to their patient's direct benefit in receipt of education, they too may benefit from additional resources and support in these areas.[20, 21] Indeed, approximately 40% of providers also reported that HCV education class facilitated HCV co-management within their practices and increased access to liver specialty care services.
Interestingly, in this study primary providers did not report a significant increase in patient adherence to HCV management plans or interest in substance abuse therapy within their practices. In the practices surveyed in this study approximately 25% of providers indicated that over 25% of patients within their practice were infected with HCV. In contrast, in a national survey of primary providers, 73% of respondents had reported caring for 5 or less HCV-infected patient within the past year.
Given the high prevalence of HCV infection within practices in the San Francisco safety-net healthcare setting, it is possible that our providers had previously implemented their own mechanisms within practices to effectively address substance abuse therapy and adherence to HCV monitoring.
Whether the observed improvement in patient's knowledge and the positive impact on provider practices following formal HCV education actually influences HCV treatment initiation and treatment outcomes has not been previously studied. We have found that the time to initiation of HCV therapy was reduced by half in those patients who underwent formal HCV education compared to those who did not receive disease-specific education. This patient-centred approach to HCV education may have resulted in faster uptake of treatment by helping motivated patients to self-identify, more actively participate in their medical decision-making,[24, 25] and overcome treatment-related fears that impede or delay antiviral therapy. This also suggests that the education class has resulted in efficiencies within this resource-limited healthcare system that allow better utilization of specialty care services in this population.
HCV education appears to improve adherence to HCV therapy.[27, 28] However, there are only limited studies evaluating the role of patient education on HCV treatment outcome. In a study by Cacoub et al., there was a 7% increase in the rate of SVR and 6% decrease in rates of virologic relapse among those received support documents and educational material during individual sessions compared to those who did not receive disease specific education, but these findings did not reach statistical significance. Larrey et al. assessed the impact of ongoing patient education during HCV therapy.
In that study, the odds of achieving SVR were 2.5 times higher among patients who received systematic consultation by a nurse regarding patient adherence and the efficacy of therapy compared to those who did not receive the education. Similarly, we have shown that a formal HCV education class prior to HCV treatment resulted in an 18% increase in rates of SVR, and patients who received education were three times more likely to achieve SVR, independent of medication adherence and patient or viral factors. It is known that adherence to anti-HCV medications impacts rates of response to therapy. We did not observe a significant difference in patient adherence to medications in those who did and did not receive patient education. The overall rates of adherence to medication by self-report was high at 88% in this study, similar to that reported in other HCV populations ranging from 76–89%. However, our study did show that patients who attended formal HCV education were less likely to discontinue treatment because of side effects (3% vs 12%), one of the most common reasons for early discontinuation of treatment in several prior studies [9, 31, 32]. Higher rates of early discontinuation of therapy and delay in initiation of treatment in those who did not undergo HCV education, can potentially contribute to lower rates of SVR observed in this population.
The recent single topic conference cosponsored by the AASLD and CDC has emphasized the value of 'systemic changes in our healthcare delivery system and enhanced coordination of prevention and care services through education of the public and healthcare providers, and linkage of infected persons with care and treatment services to successfully prevent viral hepatitis and increase treatment efficacy'. Primary care providers play a significant role in linkage of HCV-infected persons to available HCV care and treatment services. Limited data, predominantly in the HIV-HCV co-infection setting, suggest that provider attitudes affect rates of both provider HCV treatment recommendation and patient uptake of HCV treatment.[33, 34] A national survey of family physicians has also shown that having a positive attitude regarding HCV care in the primary care setting was associated with more provision of HCV care services. Moreover, patients interpret a lack of referral to HCV specialty care or discussion of treatment by primary care providers as an indicator that pursuit of HCV treatment should not be considered a priority. We have shown that a positive provider attitude towards the impact of HCV education is independently associated with higher rates of referral to formal HCV education class. Therefore, increasing provider understanding of the impact of patient education on HCV care and treatment outcomes will be essential to improving patient access to HCV care services and success of antiviral therapy.
The main limitation of this study is the retrospective patient data collection, while the primary strengths include long-term patient follow-up and prospective assessment of provider attitudes and practices. Because the formal HCV education class was instituted as a mandatory component of referral of HCV patients to the liver specialty clinic, the study was limited by a lack of randomization of patients to education vs no education class when evaluating treatment outcomes. However, we were able to utilize a historical control of HCV patients prior to the initiation of education class to compare HCV treatment outcomes. Both the formal HCV education patient cohort and the historical controls likely represent individuals who are motivated to receive HCV therapy and management. Therefore, selection bias is unlikely to play a role in our finding that HCV education significantly impacts time to initiation of HCV therapy and HCV antiviral response. In addition, as the anti-viral therapy regimen (pegylated interferon in combination with ribavirin), the treating providers, and the liver specialty clinic scheduling procedures did not change before and after institution of formal HCV education, it is unlikely that differences in antiviral therapy management practices or scheduling practices overtime would impact the findings. Generalization to other non-safety-net practice settings may also be limited; nevertheless, our results present a potentially effective intervention to improve linkages to HCV specialty care, HCV treatment uptake and treatment outcome.
In summary, formal HCV education by liver specialists creates efficiencies in resource-limited healthcare systems, which not only allows better access to specialty care and treatment services but also improves HCV antiviral effectiveness. Provider attitudes towards the impact of HCV patient education play a significant role in referral to these services. Along with improvements in the healthcare delivery system, interventions directed at increasing provider knowledge of HCV disease and the important role of patient education in improving HCV management will likely enhance HCV care coordination and ultimately amplify the success of antiviral therapy, particularly in vulnerable populations.