Summary

This project set out to identify patients in general practice with a diagnosis of hepatitis B or hepatitis C with a view to encouraging appropriate investigation, management and referral of these patients. Patients were reviewed and offered further testing, immunisation and referral as clinically indicated. 

The project also encouraged practices to screen high-risk patient groups for blood-borne viruses and to immunise at-risk patients against hepatitis B.

Data from the hospital service showed there was an increase in BBV screening and testing for HIV, hepatitis B and hepatitis C by 62%, 16% and 18% respectively compared to the same period 12 months previously. A total of 124 immunisations were given.

Challenge

One of Scotland’s most deprived cities, Dundee has a high incidence of sexually-acquired HIV in men who have sex with men (MSM), and certain ethnic groups. 

Access to records of hepatitis B and C positive patients showed that a significant number had never accessed the hepatitis service, or had done so but missed follow-up care. Practice registers of hepatitis patients were poor. 

Dundee CHP already knew that screening those at risk of BBV helped uncover unknown cases of hepatitis B and C. The best way to encourage BBV patients back into service was through contact with a general practice, and that the best approach to screening at-risk patients was for GPs to proactively screen those with BBV transmission-associated risk factors.

Objectives

The aim was to engage as many Dundee GP practices as possible, establish a credible BBV team to support clinical engagement and give GPs access to current clinical knowledge. 

The project hoped to reconcile the BBV Managed Clinical Network (MCN) hepatitis B database with GP practice registers, and to furnish the latter with read codes to allow call/recall of patients. GPs were to be encouraged to refer patients with suspected BBV back into secondary care. 

Objectives included boosting the number of at-risk patients screened by GPs, carrying out more screenings in general practices and increasing immunisation. The project also aimed to improve patient access to diagnosis, treatment and follow-on care. The model had be suitable for roll out across Tayside. 

Solution

Guidance was created for practices on identifying patients at risk, investigation, treatment and referral, and immunisation. New tools helped practices spot, at the new patient screening stage, patients who had migrated from BBV endemic areas.

Wallet-sized BBV ‘screening cards’ were designed, containing information on BBV risk factors and encouraging the at-risk population to self present for testing. Practices were advised to allow card holders to book blood testing without prior GP authorisation. 

The laboratory service created  a ‘BBV bundle’ of blood tests. Practices ordering this were then contacted, first by email and then in person, to encourage them to join the project.

Caldicott approval was obtained to allow the sharing of the MCN BBV database with practices.

Direct payment to practices allowed audits to make appropriate interventions such as patient contact and immunisation, and for the collation of the project’s results.

Results

Rates of hepatitis C varied across practices, low in student areas and high in deprived areas. Rates of hepatitis B were highest in areas with significant overseas populations, intravenous drug users or immigrant Asian communities.

Practices knew of 66 per cent of the hepatitis C patients on the MCN register, and 69 per cent of Hepatitis B patients. There were 117 hepatitis C hospital referrals, nine of them cured, and 50 in continuing treatment. Twenty-six of the 64 hepatitis C patients known lost to follow-up were referred back to the hospital service, and 124 immunisations were given. 

HIV, hepatitis B and hepatitis C testing increased by 62 per cent, 16 per cent and 18 per cent respectively, year on year.

Learnings

Reconciliation of data between the MCN and primary care created a more comprehensive disease register, now shared by the hospital service and general practices.

The use of a set of dedicated read codes has allowed practices to develop and maintain a clean register of patients with BBV diseases. The majority of patients have reacted positively to a discussion about BBVs and have agreed to testing, immunisation and referral where necessary.

This initiative has also taught Dundee CHP that a project with clear clinical outcomes and tangible, person-to-person, will result in better uptake and completion rates.

Evaluation

Effective practice registers will support a call/recall system for patients who have defaulted from treatment. Use of codes should prevent newly diagnosed patients being lost to follow up, while patients lost to the system are being referred back into it.

The project has highlighted variability in Hepatitis B and C prevalence across practices, and demonstrated the importance of engaging directly with general practices in reaching this population.

There is greater awareness of BBVs across practices, and an increase in testing and referral. There has been a 50 per cent reduction in those never referred, a 30 per cent fall in those referred without attending and a 25% reduction in those referred who attended but were lost to follow-up.