Randi Sokol, Jessica Early, Amanda Barner, Sarah Gottfried, Richard Gumpert, Lorky Libaridian, Virginia Morrison, Alexandra Santamaria, and Linda Shipton
While the opioid overdose epidemic has become palpable across our country, another associated problem is rising to crisis levels: over the past five years, there has been a nearly 300% increase in the number of new cases of Hepatitis C. 1 Among new cases, 85 % will go on to become chronic, and if left untreated, 25% of these will progress to cirrhosis and risk consequences of liver cancer and liver failure.2
Fortunately, the medications to treat and cure Hepatitis C have come a long way. Before 2011, patients required a long course of treatment with interferon and ribavirin. Because these medications had the potential for serious side effects, patients often stopped the medications prior to completion and many even shied away from pursuing treatment. Even among those patients who completed the treatment, cure rates were suboptimal.
We now have new medications that are nearly 99% effective and with a minimal side effect profile. Patients can take a once daily medicine for 8-12 weeks, achieve high cure rates, and many report not even knowing they are on medications!3-5
Despite the potential to easily cure patients of chronic Hepatitis C, there are have been barriers to getting patients engaged in care. As one provider at our clinic explained, “I would refer patients to Infectious Disease, the appointment would often be booked several months out at a different site and the patients often no-showed.” In fact, one of our Infectious Disease doctors reported a no-show rate of about 50% for new Hepatitis C consultation appointments. At the same time though, the demand for Hepatitis C care was increasing in the speciality clinics. At one point, 65% of her clinical visits were dominated by treating patients with Hepatitis C, precluding evaluations of potentially more complex infectious disease-related issues and leading to long wait times for initial consultations.
Cambridge Health Alliance is an academic health care system that serves as a safety-net for a large urban population across the greater Boston area with 12 different primary care sites. We wanted to see if we could deliver Hepatitis C care in the primary care setting, thus helping patients more readily gain access to evaluation and treatment in sites that felt comfortable and familiar to them. We thus created a model for delivering Hepatitis C care in primary care in which the Infectious Disease physician trains one or two “Primary Care Hepatitis C Specialists” at each clinic. These Primary Care Hepatitis C Specialists, working in conjunction with an onsite pharmacist, take referrals from their clinic colleagues for the evaluation and treatment of patients with chronic Hepatitis C. They also serve as local experts, educating their clinic colleagues about the management of Hepatitis C so that the primary care providers feel more confident initiating the work up and counseling.
Our paper, “Implementation of a multidisciplinary, team-based model to treat chronic hepatitis C in the primary care setting: Lessons Learned” published in Healthcare: The Journal of Delivery Science and Innovation, outlines our experience during the first year of implementation related to the practical components of delivering this model through sequential “plan-do-study-act” (PDSA) cycles. We describe our initial plans, barriers we encountered, and how we responded to ensure successful and sustainable delivery of high quality care. Particularly, we point out the evolution of how Primary Care Hepatitis C Specialists were trained and received ongoing support, how our primary care colleagues were informed and updated about the model, how we provided team-based care within a patient-centered medical home infrastructure, how we addressed insurance hurdles, and how we developed an internal quality review to ensure the effectiveness of our treatment.
After one year of implementation, we demonstrated that all patients seen in primary care who completed treatment achieved sustained virological response (ie cure). We also demonstrated the potential for this model to provide cost-savings within an accountable care organization. Feedback from patients, primary care colleagues, and the team of providers involved in the model was overwhelmingly positive, and we now have plans to further expand our model to all twelve of our primary care sites.
We hope readers will get a glimpse of a rich quality improvement strategy that allowed us to continually grow and improve our delivery model to provide effective, patient-centered, multidisciplinary team-based care to address a health concern in the primary care setting that has traditionally been addressed at specialty sites. We also believe that this model offers potential for expanding access to other types of specialty-level care within the primary care setting, such as latent tuberculosis, management of chronic hepatitis B, and pre-exposure HIV prophylaxis.
1CDC, National Notifiable Diseases Surveillance System (NNDSS) “Rising number of reported acute hepatitis C cases — United States, 2000–2015.” Available at: https://www.cdc.gov/hepatitis/statistics/2015surveillance.
2Lawrence, Steven P. Advances in the treatment of hepatitis C. Adv Intern Med. 1999;45:65-105.
3Afdhal N, Zeuzem S, Kwo P, Chojkier M, Gitlin N, Puoti M, et al. Ledipasvir and sofosbuvir for untreated HCV genotype 1 infection. N Engl J Med. 2014;370(20):1889–1898.
4Afdhal N, Reddy KR, Nelson DR, Lawitz E, Gordon SC, Schiff E, et al. Ledipasvir and sofosbuvir for previously treated HCV genotype 1 infection. N Engl J Med. 2014;370(16):1483–1493.
5Feld J, Jacobson I, Hezode C, Asselah T, Ruane P, Gruener N, et al. Sofosbuvir and velpatasvir for HCV genotype 1, 2, 4, 5, and 6 infection. N Engl J Med. 2015;373(27):2599-2607.