Thursday, February 13, 2014

British Columbia: Prolonged wait time from HCV diagnosis to treatment

Presented at CDDW - February 8-11, 2014

For an estimated 300,000 Canadians living with hepatitis C the approval of Sovaldi  most certainly is a game changer, especially for persons who have failed treatment previously or worse, sadly, facing a liver transplant.

New, effective and better hepatitis C treatment options with and without interferon are now available, with more on the way.

However, its unfortunate that some Canadians may be missed, and never offered these life changing therapies. A few shocking reports have found not all Canadian general practitioners recognize current HCV cure rates, and when treatment is initiated, wait times to see a specialist and eventually begin therapy is often far too long.

This year Winnipeg writer Don Marks wrote about general practitioners in relation to the approval of Sovaldi in his article titled;The deadly toll of drug-approval drag.  An eye-opening piece to be sure. 

The author writes:
A recent survey of general practitioners by the Canadian Liver Foundation revealed 57 per cent of GPs don't know hepatitis C can be cured despite the fact more than 70 per cent of hep C patients who undergo treatment with available medicines are being cured right now.

Another report by the Fraser Institute, “ 2013 - Waiting Your Turn: Wait Times for Health Care in Canada,” apparently found Canadians are waiting longer to see a specialist, undergo testing, and begin treatment for medical problems ranging from cancer to cardiovascular surgery then they did last year. 
The results of this year’s survey indicate that despite provincial wait times reduction strategies and high levels of health expenditure, it is clear that patients in Canada continue to wait too long to receive medically necessary treatment.

So what about Canadians who have been diagnosed with hepatitis C and ready to embark on therapy? 

Some Canadian patients diagnosed with hepatitis C waited more then 71 months after diagnosis to begin HCV treatment. The average wait time from general practitioner (GP) referral to treatment is over 9 months, and a little over 7 months from a hepatologist consult to HCV treatment, according to an analysis presented this week at Canadian Digestive Diseases Week (CDDW) by A. Yau T. Lee, A. Ramji, H. Ko from the University of British Columbia.


Researchers set out to investigate why the current treatment rate is less than optimal despite the availability of efficacious antiviral therapy.  
In the analysis a chart review was performed on chronic HCV patients being evaluated for treatment at a hepatology clinic from 02/08 to 01/13. Several analyses were performed to identify predictors of antiviral therapy initiation.

One hundred and seventy seven patients were investigated, mean age was 54.6 and 67.8% were male.
Treatment was initiated in 54 patients out of 177, or 30.5% which included pegylated interferon and ribavirin alone, or with triple therapy;
boceprevir = 11 patients
telaprevir = 11 patients
investigational therapies - sunaprevir, daclatasvir 11 patients
*2 patients without ribavirin

Delaying Treatment
Reasons for delaying treatment included: no or minimal liver fibrosis in 39 patients/31.7%, and persistently normal ALT in 37 participants/30.1%, lastly patient unreadiness - 17 patients/13.8%

Non - initiation of treatment
Reasons for treatment non - initiation included: medical comorbidities in 27 subjects/22.0%, patient refusal, 26 patients/21.1%, psychiatric comorbidities in 6 persons/4.9%, and decompensated cirrhosis in 5 patients/4.1%.

Patients who deferred treatment had no cirrhosis, lower ALT, and less hepatic stiffness as assessed by Fibroscan. On the other hand, patients in whom treatment was not recommended were more likely to be actively smoking and have a higher Charlson comorbidity index.
Define Charlson comorbidity index - Assess whether a patient will live long enough to benefit from a specific screening measure or medical intervention

In multivariate analyses, ALT (greater than 75 IU/L) was a positive predictor of treatment, whereas Charlson comorbidity index (per point increase) was a negative predictor of treatment.

Lag from HCV diagnosis to general practitioner (GP) referral
There was a statistically significant difference in the median time lag from HCV diagnosis to general practitioner referral between the treated and untreated patients (68.0 vs 119.6 mo. respectively, p = 0.046).

Lag from referral to hepatologist consult
The median time lag from G P referral to hepatologist consult was similar between the treated and untreated patients (1.7 vs 1.5 mo. respectively, p = 0.952).

HCV diagnosis to treatment
Among the treated patients, the median time lag was 71.7 months from HCV diagnosis to treatment, 9.8 months from GP referral to HCV treatment, and 7.4 months from hepatologist consult to HCV treatment.

The study conclude: 
Medical comorbidities remain a major obstacle to HCV treatment in the era of direct - acting antiviral agents. The prolonged time lag from HCV diagnosis to GP referral highlights a strong need for enhancing knowledge of HCV management in primary care in British Columbia. Better nursing support is also desperately needed to shorten the wait time from hepatologist consult to HCV treatment


A. Yau , T. Lee, A. Ramji, H. Ko University of British Columbia, Department of Medicine, Division of Gastroenterology, Vancouver, BC, Canada.

Please follow the above url to ensure the summary abstract is accurate.

Enjoy the rest of evening.
Always Tina

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