Missed opportunities for hepatitis C treatment at a tertiary care hospital in South Australia

Abstract

BACKGROUND Hepatitis C is a global epidemic and an estimated 230 000 Australians were living with chronic hepatitis C in 2016. Through effective public health policy and state commitment, Australia has utilised the advent of direct acting antiviral (DAA) therapy to transform the therapeutic landscape for hepatitis C virus (HCV). However, treatment rates are falling and novel public health approaches are required to maintain momentum for HCV elimination. Contemporary discourse in cascades of care have focused on expanding testing capabilities but less attention has been given to linking previously diagnosed patients back to care. Our simple and focused study rests on the premise that hospital admissions are an excellent opportunity to identify and refer previously diagnosed patients for HCV treatment. AIM To assess whether inpatients with HCV are appropriately referred on for treatment. METHODS We conducted a retrospective single centre cohort study that examined all patients with HCV presenting to The Queen Elizabeth Hospital (QEH) inpatient service between January 1 and December 31, 2017. QEH is a tertiary care hospital in South Australia. The main inclusion criteria were patients with active HCV infection who were eligible for DAA therapy. Our study cohort was identified using a comprehensive list of diagnosis based on international classification of diseases-10 AM codes for chronic viral hepatitis. Patients were excluded from the analysis if they had previously received DAA therapy or spontaneously cleared HCV. Patients presenting with decompensated liver cirrhosis or other systemic medical conditions conferring poor short-term prognosis were also excluded from the analysis. The primary outcome of our study was referral of patients for HCV treatment. Secondary outcomes included assessment of factors predicting treatment referral. RESULTS There were 309 inpatients identified with hepatitis C as a principal or additional diagnosis between January 1 and December 31, 2017. Of these patients, 148 had active HCV infection without prior treatment or spontaneous clearance. Overall, 131 patients were deemed eligible for DAA treatment and included in the main analysis. Mean patient age was 47.75 ± 1.08 years, and 69% of the cohort were male and 13% identified as Aboriginal or Torres Strait Islander. Liver cirrhosis was a complication of hepatitis C in 7% of the study cohort. Only 10 patients were newly diagnosed with HCV infection during the study period with the remainder having been diagnosed prior to the study. CONCLUSION Under 25% of hepatitis C patients presenting to an Australian tertiary hospital were appropriately referred for treatment. Advanced age, cirrhosis and admission under medical specialties were predictors of treatment referral