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HEPATITIS C MANAGEMENT ISSUES CONCERNING RURAL GENERAL PRACTITIONERS WORKING IN NORTHERN NEW SOUTH WALES
A REPORT BY
Christian Alexander, Ph.D
Dr. John Fraser, FAFPHM, FRACGP, FACRRM
New England Area Rural Training Unit
Tamworth
Karin Fisher, RN, Bcouns. MHSc (Hons)
New England Public Health Unit
Tamworth
Funded by the NSW Health Department, AIDS and Infectious Diseases Branch
April 2001
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TABLE OF CONTENTS
Executive Summary i
1. Introduction 1
2. Methodology 3
3. Results 5
A. Response Rate 5
B. Practice Issues 5
C. Hepatitis C Management Issues 8
D. Hepatitis C Education Issues 13
E. Responses from General Practitioners 22
Who Attended 1998 Workshops
F. Responses from General Practitioners 22
According to Number of Hepatitis C
Patients
4. Discussion 24
A. Response Rate 24
B. Hepatitis C Management Issues 24
a. Hepatitis C Management Protocols 24
b. Hepatitis C Care Models 25
C. Hepatitis C Education Issues 25
a. Seminars, Conferences and 25
Workshops
b. Internet Sites, CD-ROMs and 30
1800 Phone Number
5. Conclusions 31
Recommendations 32
References 33
Appendix 1: Survey Form
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Executive Summary
Rationale
Hepatitis C has become the most common notifiable communicable disease in NSW as well as Australia. GPs will increasingly become involved in the care and treatment of patients with hepatitis. Advances in treatment options as well as increasing patients’ expectations require GPs to be fully conversant with hepatitis C best management practice models and up-to-date on hepatitis C information. This project, funded by the NSW Health Department, aims to elicit data from the region’s GPs in respect of the most relevant hepatitis C management models as well the most appropriate educational information delivery modes concerning hepatitis C.
Method
During 2000 a questionnaire was sent to all 634 General Practitioners working in the Northern Rivers, Mid North Coast and New England Health Service areas of NSW.
Results
Response Rate
292 General Practitioners returned completed survey forms; a response rate of 46.1%.
Hepatitis C Management Issues
All but one of the 288 General Practitioners who answered the question ‘Have you tested any patients for Hep C since becoming a GP?’ indicated that they had tested patients for Hepatitis C. On average, the participating General Practitioners have seen 21 Hepatitis C patients (range: 0 to 500) during the past 12 months.
63% of respondents (184 GPs) stated that they were aware of Hepatitis C Management Protocols introduced since 1995. Hepatitis C Management Protocols were assessed as being very useful in the management of Hepatitis C.
The three most preferred Hepatitis C management models are:
· Hepatitis C to be managed by a shared multi-disciplinary model with the GP as the principal care giver (preferred by 88% of GPs);
· GPs to be the principal care giver (preferred by 80% of GPs); and
· GPs with special training to manage Hepatitis C (preferred by 67% of GPs).
The three least preferred Hepatitis C management types are:
· for medical specialists to be the principal care giver (preferred by 13% GPs);
· for Hepatitis C to be managed by drug and alcohol services (preferred by 13% of GPs); and
· for Hepatitis C to be managed by sexual health clinics (preferred by 12% of GPs).
Hepatitis C Education Issues
The following access strategies were favoured by at least 50% of respondents: seminars (63%); special 1800 phone number (56%); special CD-ROM (52%); workshops (52%); special Internet site (51%); and conferences (50%).
The respondents stressed the importance of the need for any information provided to be accurate, up-to-date and relevant. As far as seminars, workshops and conferences are concerned, the General Practitioners emphasized the need to consider the appropriateness of the venues (local venues are preferred) and times as well as for written material to be handed out to the participants. Preference was also expressed for a multi-disciplinary approach and the presentation of the latest data, statistics and protocols. As far as Internet sites are concerned, the respondents emphasized the importance of being able to access credible, user friendly Internet sites which contain the latest protocols, practice management tools and statistics, best practice models. Separate patient information access, providing relevant information for patients, their families and carers is also deemed essential. Such Internet sites should also be publicized effectively so that General Practitioners are aware of the specific Internet addresses. As far as CD-ROMs are concerned the same issues as for Internet sites were mentioned. When commenting on the establishment of a special 1800 phone number, the respondents were most anxious for such a phone line to be staffed by suitably qualified professionals, to be available ‘free of charge’ and to be accessed when required (i.e. not being put ‘on hold’).
Recommendations
Recommendation 1: Establishing Locally Appropriate Management Pilot Projects
Given that the participating General Practitioners request access to relevant Hepatitis C information, including best management practice models, and have vastly different medical practice profiles (ranging from part-time to full-time work, seeing very few Hepatitis C patients to managing up to 500 Hepatitis C patients per year, being comfortable with dealing with injecting drug users, their relatives and carers to being uncomfortable with dealing with such patients) a range of locally specific Hepatitis C management model pilot projects be considered for implementation in order to document best practice models which take into account the local (medical service) environment, the GPs’ and patients’ preferences in RRMA 4 to 7 classifications respectively. Such pilot projects would, in the first instance, need the full cooperation of all (local) key stakeholders, cover, if possible, to whole range of possible management models and be comprehensively evaluated (process and outcome evaluation).
Recommendation 2: Publicising Currently Available Information
It is recommended that consideration be given to effectively publicizing:
Ø the availability of Hepatitis C Management Protocols;
Ø the most appropriate Hepatitis C Internet addresses; and
Ø the availability of Hepatitis C patient and carer information pamphlets.
Recommendation 3: Establishing Additional Flexible Information Avenues
It is recommended that consideration be given to the:
Ø production and regular update of an appropriate CD-ROM; and
Ø setting up of a dedicated Hepatitis C 1800 Phone line, staffed by suitably qualified professionals and available, free of charge, to health professionals.
Recommendation 4: Organising Seminars, Workshops, Conferences
It is recommended that, prior to organising Hepatitis C seminars, workshops and/or conferences liaising with individual Divisions of General Practice, relevant GPs, medical specialists and health care providers be undertaken as to the contents, venues and dates of such activities.
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1. INTRODUCTION
Infection with hepatitis C virus is epidemic in Australia.1 Hepatitis C is Australia’s most common life threatening chronic infection, having already infected about 200,000 Australians and having infected an additional 20,000 Australians in 2000.2 Between 80% to over 90% of these new infections are associated with injecting drug use. 3,4 Dr. A Wodak wrote that “when comparing the risk of occupational needle stick injury, hepatitis C is about 10 times more infectious than HIV.” 3 Compared to HIV, hepatitis C is much more prevalent (200,000 Hepatitis C cases compared to16,000 HIV cases) and recording a much higher incidence (20,000 Hepatitis C cases per year compared to 600 HIV cases per year). In 2000, 8,181 cases of hepatitis C were notified to have occurred in New South Wales.2 It has been claimed that some 80,000 injecting drug users in New South Wales are hepatitis C virus positive.5 As General Practitioners are pivotal in the detection of early infections, their role in the diagnosis and management of hepatitis C will be critical in the effective treatment of hepatitis C. According to Professor M Kidd “…hepatitis C has become the new challenge of the 1990s for Australia’s General Practitioners”.6
In 1995 the North Coast Public Health Unit, NSW Health Department carried out a postal survey of 355 General Practitioners practising on the north coast of New South Wales.7 The aim of this project was to assess the General Practitioners’ knowledge and management of hepatitis C. The survey’s results showed, in part, that the respondents had a sound knowledge of the transmission risks and natural history of the hepatitis C virus and that “there was a reluctance to refer patients with HCV for specialist care”.7
In 1997 the NSW Health Department funded four Hepatitis C Demonstration Projects. One of these projects was a rural hepatitis C project, covering the Northern Rivers, Mid North Coast and New England Area Health Services. The aim of this rural project was to “…improve the co-ordination of care for people with hepatitis C”.8 Out of a total of over 600 General Practitioners servicing these three Health Service areas, 116 General Practitioners attended one of the 7 workshops/presentations organised as part of this rural hepatitis C demonstration project. Workshop evaluations have identified, in part, a need by over 95% of General Practitioners to be up-to-date with hepatitis C management as well as a need for General Practitioners to be kept up-to-date on all aspects of hepatitis C management as the “knowledge about hepatitis C and its management and treatment is constantly evolving”.8 In addition, the report states that, while there was “a high level of interest in hepatitis C education (in most areas) from GPs…there was less interest among GPs in parts of New England and further investigation of education needs is warranted”.8 Barriers for some of the region’s General Practitioners being able to attend hepatitis C continuing medical education sessions may relate to the following:
· In its 1997 Needs Assessment report the North West Slopes Division of General Practice noted, for example, that 49% of its General Practitioners found dealing with drug addicted patients a major or medium problem. 9
· In its 1997 Needs Assessment report the Barwon Region Division of General Practice stated, for example, that 50% of its GPs experienced difficulties in accessing continuing medical education courses, due to lack of time, the distances required to travel as well as the lack of locum provisions. 10
Further barriers for General Practitioners to attend hepatitis C education sessions have been reported. For example, in their 1999 report Lowe and Hardwick write “discriminatory attitudes towards caring for IDUs is also pervasive among GPs with the SWSAHS reporting that of the GPs enrolled in their Shared Care Project, only 4% were comfortable dealing with this client group”.5 In their 1999 report, Lowe and Cotton summarise the major problems concerning hepatitis C education for General Practitioners as follows: “prejudice about and fear of injecting drug users, constraints on GPs’ consultation times, and lack of knowledge if hepatitis C is not a GP’s particular interest”.4
The fact that General Practitioners will need to be heavily involved in the management of hepatitis C has been reinforced in a report entitled 'Consultation Draft of the NSW Hepatitis C Care and Treatment Services Plan 1999/2000 - 2001/03' which states, in part, that "there has been a clear recognition in recent years that there is scope to considerably expand the involvement of GPs in hepatitis C care and treatment. This approach is strongly supported. For the majority of people with hepatitis C, needs will focus around diagnosis, counselling, clear and concise information, and monitoring. All of these needs are capable of being met in the general practice setting".5 In their report Lowe and Hardwick also write that, "it is desirable that all GPs meet the following minimum standards:
· have accurate knowledge on the modes of transmission of hepatitis C and effective prevention measures;
· be able to provide education and prevention messages to patients at risk and those already infected;
· be able to undertake diagnosis of hepatitis C through risk assessment and testing, accompanied with pre and post-test counselling;
· provide accurate information on prognosis and available treatments;
· monitor patients with chronic hepatitis C infection according to established protocols, including ordering of tests which may indicate a need for further treatment assessment at the specialist level;
· make appropriate referrals to specialists for further treatment assessment or the management of advanced disease". 5
As part of their recommendations, Lowe and Hardwick state, in part, that "maximum efforts to be directed at ensuring that, wherever possible and clinically appropriate, suitably skilled general practitioners are fully involved in the diagnosis and management of hepatitis C as an integral component of primary care……there is a need for further continuing medical education programs to improve the knowledge and skills of general practitioners in relation to hepatitis C". 5
These themes referred to by Lowe and Hardwick and Lowe and Cotton above have been taken up in the most recent hepatitis C strategic directions published by the Commonwealth and New South Wales Governments. 11,12 The ‘National Hepatitis C Strategy 1999/2000 to 2003/2004’ report, published by the Commonwealth Department of Health and Aged Care, when referring, for example, to access issues, states, “it is necessary to explore options that will support broader access to treatments and specialist advice…” and, when referring to treatment of hepatitis C infection, states that one of the challenges is ”to review, consider and trial models of providing treatment and care…that would improve access to treatments and specialist advice.11 The report ‘2000-2003 Hepatitis C Strategy’, published by the NSW Health Department, states, in part, that “the review of care and treatment services has as a key recommendation the shifting of care and treatment to primary care providers, in particular GPs…In order for this to succeed, adequate training, education and support mechanisms need to be established and sustained”.12
The rural Hepatitis C Project Report, published in March 1999, recommended, in part, “that a survey be undertaken of GPs in New England, Northern Rivers and Mid North Coast who didn’t attend workshop/seminars regarding their hepatitis C education needs”.8 Funds to carry out this project ($30,000) were allocated and, in mid 1999, the New England Area Rural Training Unit was approached to conduct this survey.
As all General Practitioners need to be appropriately involved in hepatitis C care and treatment our survey included all General Practitioners practising in these three Health Service areas. Including all the region’s currently practising General Practitioners was also necessary because the management of hepatitis C is evolving and continuing educational information is required by all General Practitioners to be kept up-to-date on hepatitis C management issues and because we wanted to obtain information concerning the General Practitioners’ preferred hepatitis C management models. Our project aims to obtain data from the region's General Practitioners relating to the most appropriate educational information delivery modes in respect of hepatitis C management as well as to the most relevant hepatitis C management models.