Specialty care and education associated with greater disease-specific knowledge but not satisfaction with care for chronic hepatitis C

Hepatitis C Virus Knowledge Among Pregnant Women with Opioid Use Disorder

Objectives To evaluate Hepatitis C virus (HCV) knowledge and awareness among pregnant women with opioid use disorder (OUD). Methods From May through November 2015, a one-time survey was distributed to a convenience sample of pregnant women with OUD to assess their knowledge and awareness of (a) risk factors for HCV infection, (b) HCV transmission prevention strategies, (c) hepatotoxic risk reduction and (d) perinatal transmission and neonatal implications of HCV infection. Chi square and Fisher's exact tests were used to compare demographic characteristics and HCV knowledge between participants who were HCV positive and negative. Results Of 179 pregnant women with OUD approached, 169 (94%) completed the survey. Of these, 153 (90.5%) reported at least one risk factor for HCV infection, 85 (50.3%) were HCV positive and 38 (44.7%) of HCV positive women were diagnosed with HCV for the first time during pregnancy. When HCV knowledge was evaluated, 114 (66.7%) responded that sharing eating utensils could transmit HCV, 69 (55.0%) responded that there is a vaccine to prevent HCV and 56 (32.7%) did not identify intranasal drug use as a risk factor for HCV transmission. Among HCV positive women, 61 (71.8%) associated breastfeeding with an increased risk for HCV transmission, 33 (38.1%) failed to identify the importance of pediatric follow-up for HCV-exposed children and 16 (18.8%) perceived the risk of HCV vertical transmission as "likely" or "very likely." Conclusions for Practice Gaps in HCV knowledge exist among a rapidly growing population of pregnant women with OUD. Healthcare providers have a unique opportunity to provide HCV education and counseling during pregnancy.

Pilot Study: Combining Formal and Peer Education with FibroScan to Increase HCV Screening and Treatment in Persons who use Drugs

BACKGROUND

Treatment uptake for hepatitis C virus (HCV) infection remains low in persons who inject drugs (PWID), due to lack of knowledge and low perceived need for treatment. Therefore, we conducted a pilot study to assess the influence on knowledge and willingness for HCV screening and treatment among persons who use drugs (PWUD) by combining formal and peer education with FibroScan measurement.

METHODS

Clients of the Center for Alcohol and other Drug problems (CAD) in Limburg (Belgium) were randomized into a control group, which received the standard of care, and an intervention group, which received an innovative combination of formal and peer education followed by FibroScan. Knowledge of HCV infection and willingness for screening and treatment were evaluated at baseline, after intervention and 1 and 3months after intervention by means of questionnaires.

RESULTS

Baseline knowledge was similar for the control (n=27) and the intervention group (n=25) (58 vs. 59%; p=0.67). Immediately after the information session, knowledge increased to 86% (p<0.001) in the intervention group. After 3months, knowledge decreased significantly (69%; p=0.01). No significant changes in knowledge were found in the control group. Baseline willingness for treatment was 81% in both the control and intervention groups, but after 1 month decreased in the control group (44%) and remained stable in the intervention group (75%). Differences in actual screening uptake between the control and intervention group were not significant (7% vs. 20%). Four percent of the intervention group and no one in the control group started treatment.

CONCLUSION

The small number of subjects should be considered when interpreting the results of this study. In brief, the single information session significantly improved HCV knowledge among PWUD, but did not result in a higher uptake for screening and treatment. This could signify that there are other important reasons, besides lack of knowledge, not to undergo screening or start treatment. The fact that knowledge decreased after 3months indicates that it would be beneficial to repeat the information session regularly.

The Patient-Provider Relationship Is Associated with Hepatitis C Treatment Eligibility: A Prospective Mixed-Methods Cohort Study

Hepatitis C virus (HCV) treatment has the potential to cure the leading cause of cirrhosis and hepatocellular carcinoma. However, only those deemed eligible for treatment have the possibility of this cure. Therefore, understanding the determinants of HCV treatment eligibility is critical. Given that effective communication with and trust in healthcare providers significantly influences treatment eligibility decisions in other diseases, we aimed to understand patient-provider interactions in the HCV treatment eligibility process. This prospective cohort study was conducted in the VA Pittsburgh Healthcare System. Patients were recruited after referral for gastroenterology consultation for HCV treatment with interferon and ribavirin. Consented patients completed semi-structured interviews and validated measures of depression, substance and alcohol use, and HCV knowledge. Two coders analyzed the semi-structured interviews. Factors associated with patient eligibility for interferon-based therapy were assessed using multivariate logistic regression. Of 339 subjects included in this analysis, only 56 (16.5%) were deemed eligible for HCV therapy by gastroenterology (GI) providers. In the multivariate logistic regression, patients who were older (OR = 0.96, 95%CI = 0.92-0.99, p = .049), reported concerns about the GI provider (OR = 0.40, 95%CI = 0.10-0.87, p = 0.02) and had depression symptoms (OR = 0.32, 95%CI = 0.17-0.63, p = 0.001) were less likely to be eligible. Patients described barriers that included feeling stigmatized and poor provider interpersonal or communication skills. In conclusion, we found that patients' perceptions of the relationship with their GI providers were associated with treatment eligibility. Establishing trust and effective communication channels between patients and providers may lower barriers to potential HCV cure.

Increasing hepatitis C knowledge among homeless adults: results of a community-based, interdisciplinary intervention

Homeless adults have high rates of hepatitis C virus infection (HCV) and low levels of HCV knowledge. This study reports results of an interdisciplinary, community-based intervention using stakeholder cooperation, case management, risk factor identification, and modification of dysfunctional psychosocial factors to increase HCV knowledge among homeless adults (N = 747). Data are from a randomized quasi-experimental study, with the major goal of evaluating the effectiveness of a Nurse Case Managed Intervention compared to a Standard Intervention, encouraging completion of a three-series hepatitis A/hepatitis B vaccination program. Increased HCV knowledge was measured with an 18-item questionnaire discerning risk factors for HCV and common misconceptions about individuals with HCV. A significant increase in HCV knowledge resulted regardless of intervention format. Receiving the Nurse Case Managed Intervention predicted greatest gain in HCV knowledge (p < 0.000). Successfully engaging key stakeholders, outreach workers, community organizations, and homeless people themselves proved most efficacious in increasing HCV knowledge.

A comparative study of patients' knowledge about hepatitis C in the United States and in urban and rural China

BACKGROUND

Hepatitis C (HCV) is the predominant cause of chronic liver disease in the USA and is increasingly recognized as a common cause of liver disease in China. Studies of HCV patients in the US found major gaps in knowledge but little is known about HCV knowledge among patients in China.

METHODS

We conducted a survey in three cohorts of HCV patients in Ann Arbor, MI, US, and in Beijing and Hebei, China, between April and November 2012 to compare patient knowledge about HCV in the US and in urban and rural China.

RESULTS

A total of 525 patients (US 186; Beijing 186; Hebei 153) were enrolled. Mean ages of the three cohorts ranged from 52-56 years; 63% of US and 47% of Chinese patients were males; 63% of US and 39% of Beijing patients had college or postgraduate education compared to 0.7% in Hebei. More than half of the US and Beijing patients but only 13% of Hebei patients had received HCV treatment. The average HCV knowledge score out of a total of 16 in the US, Beijing, and Hebei was 12.7, 11.7, and 6.4, respectively (p < 0.001). Study site, education, gender, and prior HCV treatment were independent predictors of HCV knowledge.

CONCLUSIONS

Knowledge about HCV in the US and Beijing patients was similar and significantly better than in Hebei patients. Our data show that efforts to improve HCV knowledge are necessary for all three cohorts and should be tailored to the education level and health literacy of the patients.

Formal hepatitis C education enhances HCV care coordination, expedites HCV treatment and improves antiviral response

BACKGROUND & AIMS

Formal Hepatitis C virus (HCV) education improves HCV knowledge but the impact on treatment uptake and outcome is not well described. We aimed to evaluate the impact of formal HCV patient education on primary provider-specialist HCV comanagement and treatment.

METHODS

Primary care providers within the San Francisco safety-net health care system were surveyed and the records of HCV-infected patients before and after institution of a formal HCV education class by liver specialty (2006-2011) were reviewed retrospectively.

RESULTS

Characteristics of 118 patients who received anti-HCV therapy were: mean age 51, 73% males and ~50% White and uninsured. The time to initiation of HCV treatment was shorter among those who received formal education (median 136 vs 284 days, P < 0.0001). When controlling for age, gender, race and HCV viral load, non-1 genotype (OR 6.17, 95% CI 2.3-12.7, P = 0.0003) and receipt of HCV education (OR 3.0, 95% CI 1.1-7.9, P = 0.03) were associated with sustained virologic treatment response. Among 94 provider respondents (response rate = 38%), mean age was 42, 62% were White, and 63% female. Most providers agreed that the HCV education class increased patients' HCV knowledge (70%), interest in HCV treatment (52%), and provider-patient communication (56%). A positive provider attitude (Coef 1.5, 95% CI 0.1-2.9 percent, P = 0.039) was independently associated with referral rate to education class.

CONCLUSIONS

Formal HCV education expedites HCV therapy and improves virologic response rates. As primary care provider attitude plays a significant role in referral to HCV education class, improving provider knowledge will likely enhance access to HCV specialty services in the vulnerable population.

Frequency and predictors of no treatment in anti-hepatitis C virus-positive patients at tertiary liver centers in Greece

BACKGROUND/AIMS

Despite the improving efficacy of antiviral therapy, a significant proportion of chronic hepatitis C patients never start treatment. We determined the magnitude and reasons for no treatment in anti-hepatitis C virus (HCV)-positive patients visiting tertiary liver centers in Greece.

MATERIALS AND METHODS

We retrospectively enrolled 1146 consecutive anti-HCV-positive patients who visited four physicians at two tertiary liver centers between 2002 and 2010.

RESULTS

Treatment was initiated in 628 (55%) of the 1146 patients. In particular, 309 (27%) patients were lost to follow-up before HCV RNA testing. Independent predictors of no HCV RNA testing were first visit before 2007, parenteral drug use, and the treating physician. Of the 837 patients tested for HCV RNA, 768 (92%) were eligible for antiviral therapy, had detectable serum HCV RNA, and no contraindication to treatment. Among them, 140 (18%) patients were lost to follow-up before the initiation of treatment or refused antiviral therapy. Independent predictors of no treatment were the treating physician, absence of liver biopsy or transient elastography (odds ratio: 3.5, 95% confidence interval: 2.3-5.4, P<0.001), and normal compared with elevated alanine transaminase levels (odds ratio: 1.7, 95% confidence interval: 1.1-2.8, P=0.027).

CONCLUSION

A significant proportion (>40%) of anti-HCV-positive patients visiting Greek tertiary liver centers do not receive antiviral therapy. Most of them are lost during the initial evaluation process, whereas the majority (>80%) of eligible patients who complete the initial evaluation eventually start antiviral therapy. The probability of treatment seems to be significantly associated with the treating physician, the alanine transaminase levels, and whether liver biopsy or transient elastography was performed.

Development and validation of the chronic hepatitis C virus treatment satisfaction (HCVTSat) instrument

BACKGROUND

While current medications used to treat patients with chronic hepatitis C virus (HCV) effectively produce sustained viral response (SVR), postponement of therapy is often times attributed to patient perceptions of unfavourable outcomes. However, an instrument to assess patient perceptions of therapy (i.e. treatment satisfaction) has not been developed.

AIM

To describe the development and validation the chronic Hepatitis C Virus Treatment Satisfaction (HCVTSat) instrument.

METHODS

Focus groups, expert review and cognitive debriefing were used to develop a draft 37-item instrument (scale: 1 = not important at all; 5 = extremely important). The preliminary instrument was administered to a pre-test sample of 145 patients through Mayo Clinic, Rochester, MN. A refined HCVTSat was administered to a main sample of 333 participants with a chronic HCV diagnosis through Harris Interactive.

RESULTS

The HCVTSat was completed by 333 participants with an average age of 51 (s.d. = 12.1) years, 55% male, current or previous HCV treatment experience, and a diagnosis of HCV for approximately 12 (s.d. = 8.9) years. Twelve items for the 3 dimensions, Treatment Experience (TE), Side Effects (SE) and Social Aspects (SA), were internally consistent (Cronbach's α range: 0.70-0.90), responsive and valid. Confirmatory factor analysis (goodness-of-fit indexes: χ(2) = 20.9, df = 23, P = 0.59; CFI = 1.00, GFI = 0.99, TFI = 1.00, RMSEA = 0.001) revealed a better fit with 9 items. All path coefficients were significant (P < 0.05). SE and SA were strong predictors of TE, while TE was positively associated with the 1-item global measure of TS (path coefficient = 0.12).

CONCLUSIONS

The 10-item HCVTSat demonstrated valid psychometric properties and assessed patient satisfaction with HCV therapies. However, additional studies are needed to validate the HCVTSat in conjunction with SVR and in patients in underrepresented populations.

Importance of patient, provider, and facility predictors of hepatitis C virus treatment in veterans: a national study

OBJECTIVES

Several patient characteristics are known to impact hepatitis C virus (HCV) antiviral treatment rates. However, it is unclear whether, and to what extent, health-care providers or facility characteristics impact HCV treatment rates.

METHODS

Using national data obtained from the Department of Veterans Affairs (VA) HCV Clinical Case Registry, we conducted a retrospective cohort study of patients with active HCV viremia, who were diagnosed between 2003 and 2004. We evaluated patient-, provider-, and facility-level predictors of receipt of HCV treatment with hierarchical logistic regression.

RESULTS

The overall HCV treatment rate in 29,695 patients was 14.2%. The strongest independent predictor for receipt of treatment was consultation with an HCV specialist (odds ratio=9.34; 8.03-10.87). Patients were less likely to receive HCV treatment if they were Black, older, male, current users of alcohol or drugs, had HCV genotype 1 or 4, had higher creatinine levels, or had severe anxiety/post-traumatic stress disorder or depression. Patients with high hemoglobin levels, cirrhosis, and persistently high liver enzyme levels were more likely to receive treatment. Patient, provider, and facility factors explained 15, 4, and 4%, respectively, of the variation in treatment rates.

CONCLUSIONS

Treatment rates for HCV are low in the VA. In addition to several important patient-level characteristics, a specialist consultant has a vital role in determining whether a patient should receive HCV treatment. These findings support the development of patient-level interventions targeted at identifying and managing comorbidities and contraindications and fostering greater involvement of specialists in the care of HCV.

Formal patient education improves patient knowledge of hepatitis C in vulnerable populations

BACKGROUND

Hepatitis C (HCV) knowledge is limited in injection drug users (IDU). Vulnerable populations including IDUs are disproportionally affected by HCV. Effective HCV education can potentially reduce disparity in HCV prevalence and its outcome in this population.

AIM

This study aimed to assess the impact of formal HCV education and factors associated with improved HCV knowledge in the vulnerable population.

METHODS

Over 18 months, 201 HCV-infected patients underwent a 2-h standardized education and completed demographic and pre- and post-education questionnaires.

RESULTS

Patient characteristics were: 69% male, mean age 49±10, 49% White (26% AA, 10% Latino), 75% unemployed, 83% high school education and above, 64% were IDU, and 7% were HIV co-infected. On multivariate analysis, baseline knowledge scores were higher in patients with at least a high school education (coef 7.1, p=0.045). Baseline knowledge scores were lower in African Americans (coef -12.3, p=0.004) and older patients (coef -0.7, p=0.03). Following HCV education, the overall test scores improved significantly by 14% (p=0.0001) specifically in the areas of HCV transmission (p=0.003), general knowledge (p=0.02), and health care maintenance (p=0.004). There was a high compliance with liver specialty clinic attendance following education.

CONCLUSIONS

Formal HCV education is effective in improving HCV knowledge. Although White race, younger age, and higher education were predictors of having more HCV knowledge prior to education, all patients independent of racial background had a significant improvement in their knowledge after education. Therefore, promoting effective HCV education among vulnerable populations may be an important factor in reducing the disparities in HCV disease.