GP intervention increases detection of hepatitis C

Author: Ingrid Torjesen

An intervention to identify and test patients with risk factors for hepatitis C virus (HCV) through GP practices has been found to be effective in picking up infections, acceptable to staff and low cost.

The National Institute for Health Research (NIHR) funded trial assessed whether a multi-part intervention in GP practices could increase the identification and treatment of HCV-infected patients compared to usual care.

The intervention involved the use of an electronic algorithm devised to flag patients with HCV risk markers and invite them for an HCV test by letter, or opportunistically through pop-up messages during consultations. Practice staff received HCV educational training, and HCV posters and leaflets were placed in waiting rooms to increase patient awareness.

The trial took place in South West England, with 22 practices randomised to provide the intervention and 23 to provide usual care.

The results*, published in the BMJ, show that of patients the algorithm flagged around 5% of patients at the practices had HCV risk markers, and 16% of these were tested for HCV in the intervention practices compared to 10% in control practices - a 59% increase after adjusting for the characteristics of different practices. Five times as many patients were assessed for treatment in the intervention practices, compared to the control practices.

The cost of the intervention was comparatively low, at an average of £624 per general practice and £3,165 per additional patient assessed at hepatology. The overall benefit, taking into account future reduction in chronic illness, was estimated to be £6,212 per Quality Adjusted Life Year (QALY) gained which is well below the average cost of an intervention in the NHS and the National Institute for Health and Care Excellence (NICE) threshold for recommending interventions of £20,000 per QALY.

Matt Hickman, professor in public health and epidemiology and co-director of NIHR Health Protection Research Unit in Evaluation of Interventions at the University of Bristol, who led the study, said: “We know that scaling up hepatitis C case-finding and treatment alongside interventions that minimise transmission among people who inject drugs is critical for long-term prevention of chronic hepatitis C and hepatitis C-related disease and mortality. The HepCATT intervention had a modest impact but was highly cost-effective. We therefore recommend that it is considered for roll-out across the NHS, with further refinement and improvement before widescale implementation."

Dr Sema Mandal, medical consultant epidemiologist lead for Hepatitis at Public Health England, said: "With nearly 100,000 people living with hepatitis C without a diagnosis it's vital that we optimise and implement new ways to enhance case finding in primary care. This new approach not only increases testing but ensures more people access life-saving treatments. Public Health England is working with NHS England and partners across academia to eliminate hepatitis C as a major public health threat and this new approach will help accelerate these efforts."

A qualitative evaluation of the study** published in the British Journal of General Practice found that GPs valued the electronic algorithm, which provided them with a list of patients with HCV infection risk factors that GPs may not already know about to target for testing. GPs also appreciated the opportunity to discuss testing with patients, especially those who may not have been aware of their HCV risk. The training enhanced GPs' HCV awareness and knowledge of risk factors, which itself acted as a prompt for opportunistic testing.

GPs suggested refining the algorithm to weight risk factors, fully integrating the pop-up software with electronic patient record systems, and additional resources to screen lists and conduct tests.

Dr Jeremy Horwood, associate professor of social sciences and health at the Centre for Academic Primary Care at the University of Bristol and ARC West, who led the qualitative evaluation, said the intervention “could help the UK reach the World Health Organisation's target of 90% of infected people knowing their status by 2030, and help stem the HCV epidemic”.

Around 143,000 people in the UK have chronic HCV infection, and 85% have a history of injecting drugs. As symptoms do not appear for several years, less than half of people infected are aware of they have HCV and many more are not receiving treatment, increasing the risk of liver damage and passing the virus to others.

NICE in England recommends that GPs should increase testing and treatment, especially among people who inject drugs.

*Roberts K, Macleod J, Metcalfe C, et al. Cost effectiveness of an intervention to increase uptake of hepatitis C virus testing and treatment (HepCATT): cluster randomised controlled trial in primary care. BMJ 2020; 368:m322

**Horwood J, Clement C, Roberts K, et al. Increasing uptake of hepatitis C virus infection case-finding, testing, and treatment in primary care: evaluation of the HepCATT (Hepatitis C Assessment Through to Treatment) trial. British Journal of General Practice, 24 February 2020. DOI: 10.3399/bjgp20X708785