Promoting hospital and primary care collaboration for timely and effective care for chronic hepatitis B in western Melbourne
Katherine Sievert
A B , Rachel Liddle C , Annie Tan D , Niranjan Arachchi C , Zina Valaydon C and Nicole Allard E F
A Hepatitis Victoria, 5/200 Sydney Road, Brunswick, Vic. 3068, Australia.
B Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Vic. 3004, Australia.
C Department of Hepatology and Gastroenterology, Western Health, Gordon Street, Footscray, Vic. 3011, Australia. Email: rliddle101@gmail.com; niranjan.arachchi@wh.org.au; zina.valaydon@wh.org.au
D Department of Intensive Care Medicine, Austin Health, Melbourne, Vic. 3084, Australia. Email: annie.tan@austin.org.au
E WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Vic. 3000, Australia.
F Corresponding author. Email: nicole.allard@vidrl.org.au
Australian Health Review 44(4) 521-526 https://doi.org/10.1071/AH19135
Submitted: 8 June 2019 Accepted: 21 February 2020 Published: 28 July 2020
Abstract
Objective The aims of this study were to: (1) identify the characteristics of patients with chronic hepatitis B (CHB) who do not attend their hospital liver clinic appointments; and (2) raise awareness among general practitioners (GP) of alternative pathways to care for CHB in order to prevent long-term complications of CHB (liver cancer and cirrhosis).
Methods This prospective study was conducted between May 2018 and January 2019 at one site of a tertiary referral hospital in western Melbourne. Patients with minimal liver complications who did not attend their first two initial appointments were included in the study, in addition to referring GPs of new CHB patients to the liver clinic who had minimal liver complications (characterised by minimal fibrosis (<7 kPa)) and no liver comorbidities (including cirrhosis and/or hepatocellular carcinoma). GPs of patients who failed to attend the liver clinic as a new patient were sent an alternative discharge letter that included information on alternative pathways to care in the community for their patients. A follow-up survey to referring GPs was conducted afterwards for feedback. Demographic data was also collected for included patients.
Results Thirty patients with non-complicated CHB were included in the study (median age 32.5 years). Patients were from 11 different countries and six regions. The mean wait time from referral to clinic date was 424 days (SD 218.9). Only four GPs responded to the letter, with non-responding GPs surveyed primarily not participating due to having over 1 year of no contact from the patient or hospital.
Conclusion This study showed that there were long waiting lists for CHB referrals and alerting GPs to alternative pathways after patients failed to attend appointments was ineffective. There needs to be improved coordination between tertiary and primary services to provide timely and effective care for patients with CHB.
What is known about this topic? There are 239 000 Australians living with CHB: most recent estimates indicate that only 62% have been diagnosed, 15% are being monitored and 6% of those requiring treatment are receiving antiviral therapy. The complications of CHB (liver cancer and cirrhosis) can be averted by routine monitoring and timely commencement of highly effective oral antiviral therapy. In Australia, both GPs and specialists in gastroenterology and infectious diseases are involved in the management of CHB patients, but most prescribing occurs in specialist services. The current specialist-centred model of CHB care has been described as neither practical nor sustainable given the limited resources and capacity of specialist services, and the challenges for people with CHB to access public hospitals for routine care.
What does this paper add? Non-attending patients were a primarily young population. The median wait time for a clinic appointment in this hospital setting was 424 days, with some patients waiting ≥800 days for an appointment. This extensive wait time for a largely asymptomatic condition may have affected attendance rates. Although this particular intervention to engage GPs in collaborative care had limited results, it is clear that management of CHB by GPs, transparency in wait lists and adequate resourcing of specialist services would help alleviate the referral burden on hospitals.
What are the implications for practitioners? GPs should be aware that waiting lists for liver clinic appointments can be extensive in public hospital settings due to the high referral burden and limited resources of these services. Alternative pathways to care, such as GPs trained to prescribe Schedule 100 drugs, are an effective means of alleviating this burden while also ensuring CHB patients are seen in a timely manner and receive routine monitoring.
References
[1] World Health Organization. Global hepatitis report, 2017. 2017. Available at: https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/ [verified 11 May 2020].[2] MacLachlan J, Allard N, Carville K, Haynes K, Cowie B. Mapping progress in chronic hepatitis B: geographic variation in prevalence, diagnosis, monitoring and treatment, 2013–15. Aust N Z J Public Health 2018; 42 62–8.
| Mapping progress in chronic hepatitis B: geographic variation in prevalence, diagnosis, monitoring and treatment, 2013–15.Crossref | GoogleScholarGoogle Scholar | 28712127PubMed |
[3] Allard NL, MacLachlan JH, Cowie BC. The cascade of care for Australians living with chronic hepatitis B: measuring access to diagnosis, management and treatment. Aust N Z J Public Health 2015; 39 255–9.
| The cascade of care for Australians living with chronic hepatitis B: measuring access to diagnosis, management and treatment.Crossref | GoogleScholarGoogle Scholar | 25716519PubMed |
[4] Lavanchy D. Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures. J Viral Hepat 2004; 11 97–107.
| Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures.Crossref | GoogleScholarGoogle Scholar | 14996343PubMed |
[5] Wallace J, Hajarizadeh B, Richmond J, McNally S, Pitts M. Managing chronic hepatitis B – the role of the GP. Aust Fam Physician 2012; 41 893–8.
| 23145424PubMed |
[6] Department of Health and Human Services. Victorian hepatitis B strategy 2016–2020. 2016. Available at: https://www2.health.vic.gov.au/about/publications/policiesandguidelines/victorian-hepatitis-b-strategy-2016-2020 [verified 11 May 2020].
[7] Department of Health and Human Services. Third national hepatitis B strategy 2018–2022. 2018. Available at: https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp-bbvs-1/$File/Hep-B-Third-Nat-Strategy-2018-22.pdf [verified 11 May 2020].
[8] MacLachlan J, Thomas L, Cowie B, Allard N. National report 2016. Hepatitis B mapping project. Estimates of geographic diversity in chronic hepatitis B prevalence, diagnosis, monitoring and treatment. Sydney: Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM); 2017. Available at: https://www.ashm.org.au/products/product/HepB-Mapping-Report-2016 [verified 11 May 2020].
[9] Western Health. About us. 2019. Available at: http://www.westernhealth.org.au/AboutUs/Pages/default.aspx [verified 30 December 2019].
[10] Wallace J, Hajarizadeh B, Richmond J, McNally S. Challenges in managing patients in Australia with chronic hepatitis B: the general practitioners’ perspective. Aust N Z J Public Health 2013; 37 405–10.
| Challenges in managing patients in Australia with chronic hepatitis B: the general practitioners’ perspective.Crossref | GoogleScholarGoogle Scholar | 24090321PubMed |
[11] Dahl TF, Cowie BC, Biggs BA, Leder K, MacLachlan JH, Marshall C. Health literacy in patients with chronic hepatitis B attending a tertiary hospital in Melbourne: a questionnaire-based survey. BMC Infect Dis 2014; 14 537
| Health literacy in patients with chronic hepatitis B attending a tertiary hospital in Melbourne: a questionnaire-based survey.Crossref | GoogleScholarGoogle Scholar | 25338513PubMed |
[12] Hajarizadeh B, Wallace J, Richmond J, Ngo N, Enright C. Hepatitis B knowledge and associated factors among people with chronic hepatitis B. Aust N Z J Public Health 2015; 39 563–8.
| Hepatitis B knowledge and associated factors among people with chronic hepatitis B.Crossref | GoogleScholarGoogle Scholar | 26095536PubMed |
[13] Allard N, Emery J, Cowie B, Furler J. Knowing and telling: how African–Australians living with chronic hepatitis B understand hepatocellular carcinoma risk and surveillance. Aust J Prim Health 2018; 24 141–8.
| Knowing and telling: how African–Australians living with chronic hepatitis B understand hepatocellular carcinoma risk and surveillance.Crossref | GoogleScholarGoogle Scholar | 29481766PubMed |
[14] Sievert K, O’Neill P, Koh Y, Lee J-H, Dev A, Le S. Barriers to accessing testing and treatment for chronic hepatitis B in Afghan, Rohingyan, and South Sudanese populations in Australia. J Immigr Minor Health 2018; 20 140–6.
| Barriers to accessing testing and treatment for chronic hepatitis B in Afghan, Rohingyan, and South Sudanese populations in Australia.Crossref | GoogleScholarGoogle Scholar | 28120131PubMed |
[15] Mude W, Fisher C, Richmond J, Wallace J, Le Gautier R. A qualitative investigation of barriers, support-seeking and coping among South Sudanese people with chronic hepatitis B in Australia. Aust J Prim Health 2019; 25 264–74.
| A qualitative investigation of barriers, support-seeking and coping among South Sudanese people with chronic hepatitis B in Australia.Crossref | GoogleScholarGoogle Scholar |
[16] Tran S, Bennett G, Richmond J, Nguyen T, Ryan M, Hong T, Howell J, Demediuk B, Desmond P, Bell S, Thompson A. ‘Teach-back’ is a simple communication tool that improves disease knowledge in people with chronic hepatitis B – a pilot randomized controlled study. BMC Public Health 2019; 19 1355
| ‘Teach-back’ is a simple communication tool that improves disease knowledge in people with chronic hepatitis B – a pilot randomized controlled study.Crossref | GoogleScholarGoogle Scholar | 31647001PubMed |
[17] Gore FM, Bloem PJN, Patton GC, Ferguson J, Joseph V, Coffey C, Sawyer SM, Mathers CD. Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet 2011; 377 2093–102.
| Global burden of disease in young people aged 10–24 years: a systematic analysis.Crossref | GoogleScholarGoogle Scholar | 21652063PubMed |
[18] Zhu RX, Seto W-K, Lai C-L, Yuen M-F. Epidemiology of hepatocellular carcinoma in the Asia–Pacific region. Gut Liver 2016; 10 332–9.
| Epidemiology of hepatocellular carcinoma in the Asia–Pacific region.Crossref | GoogleScholarGoogle Scholar | 27114433PubMed |
[19] MacLachlan J, Cowie B. Chronic hepatitis B: what’s new? Aust Fam Physician 2013; 42 448–51.
| 23826594PubMed |
