Interdisciplinary Primary Care Model Achieves Sustained Virologic Response in Hepatitis C

As the worldwide disease burden increases and the need for expanded access to care rises concomitantly, primary care clinics utilizing an interdisciplinary staffing model offer a promising alternative to treating patients with hepatitis C (HCV), according to a poster presented by Samuel Ho, MD, of the VA San Diego Healthcare System and the University of California-San Diego.

At the annual meeting of the American Association for the Study of Liver Disease, held November 1-5, 2013, in Washington, DC, Ho and his co-authors offered a retrospective analysis of the outcomes and productivity at a once-weekly primary care HCV clinic.

In that clinic, which was held one half-day per week in a primary care outpatient facility, 4 primary care physicians (PCPs), 2 nurse practitioners, 1 nurse case manager, and 1 to 2 hepatologists were able to provide 215 patient slots per month. A pharmacist and a psychiatrist also participated in the clinic, as well as in team meetings that were held 2 times per month. Over the 18-month study period, the clinic completed 1,690 patient visits — for a total pool of 1,890 HCV patients — and initiated direct-acting antiviral (DAA) treatment in 75 patients. The clinic, which was initiated in 2000, was structured in a way that made same-day appointments available, as well.

PCPs treated 48 of the 75 patients who received DAA therapy, while hepatologists provided care for the rest. Patient characteristics varied by provider, as 32% of primary care patients were cirrhotic, compared to 44% of the hepatologists’ patients. In terms of treatment, 27.6% of all patients were able to complete more tthan 36 weeks of antiviral therapy, 10.3% completed 29 to 36 weeks of treatment, 36.2% achieved 20 to 28 weeks of treatment, and 25.9% completed just 0 to 19 weeks of treatment. Adverse events necessitated early termination of treatment in 6.6% of patients, while virologic non-response was the reason for treatment termination in 21.6% of patients.

The researchers reported that final sustained virologic response (SVR) was 46% overall, with an SVR rate of 60% for PCPs and 25% for hepatologists. The authors said the lower SVR rate for the hepatologists’ patients was probably attributable to the greater number of cirrhotic patients treated by the hepatologists. As expected, the SVR was lower for the pool of cirrhotic patients (33.3%) when compared to individuals without cirrhosis (55.2%).

In a discussion regarding the real-world implications of the study, Ho and a nurse case manager noted that PCPs were able to help patients achieve SVR rates comparable to those seen in published clinical trials. The patient population seen in the clinic had a high incidence of comorbidities, and treatment regimens were challenging, as they included triple therapy consisting of boceprevir or telaprevir plus pegylated interferon alfa and ribavirin.

The authors noted that as many as 170 million people worldwide may have HCV infection, though most of those patients have never been treated. As the need for HCV treatment increases and newer therapies raise the potential for initiation and compliance with treatment, new care delivery models may be necessary. Thus, the poster authors proposed that the collaborative clinic model described in their study offers potential for expanding access to care for HCV patients.

The authors reported funding support by the Research Service of the Department of Veterans Affairs and the VA HIV/HCV QERI program.