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Benjamin Cowie WHO Regional Reference Laboratory for Hepatitis B, VIDRL

Integrating services, enhancing care Mapping needs and targeting responses for people living with chronic hepatitis B. Benjamin Cowie WHO Regional Reference Laboratory for Hepatitis B, VIDRL Victorian Infectious Diseases Service, Royal Melbourne Hospital

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Benjamin Cowie WHO Regional Reference Laboratory for Hepatitis B, VIDRL

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  1. Integrating services, enhancing careMapping needs and targeting responses for people living with chronic hepatitis B Benjamin Cowie WHO Regional Reference Laboratory for Hepatitis B, VIDRL Victorian Infectious Diseases Service, Royal Melbourne Hospital Department of Medicine, University of Melbourne Board Member, ASHM

  2. Chronic hepatitis B - context • An estimated 170,000 Australians have CHB • >75% of people living with CHB in Australia were infected at birth or in early childhood • People born overseas in high prevalence countries, and Aboriginal and Torres Strait Islander people • >1/3 of Australians living with CHB remain undiagnosed • Without intervention, 15-25% of people living with CHB will die from complications - cirrhosis and liver cancer • 3% of Australians with CHB are receiving antiviral therapy, ~ 1/5 of the proportion who require it • The burden of hepatitis B is greatest in groups subject to broader health care disparities

  3. Migration and CHB, Australia, 1991 - 2006 ANZJPH 2011; 35 (1): 12-15

  4. Disproportionate impact of CHBLiver cancer by country of birth, NSW Robotin MJA 2008

  5. Can we harness health reform to improve our response to chronic hepatitis B? • Some examples of David’s Meta-data – hepatitis B and liver cancer

  6. Notifications of chronic hepatitis B by LGA per 100,000 persons per year, 1998 - 2011

  7. % of people born overseas Victorian Hepatitis B Serosurvey 1995 - 2005 HBsAg seroprevalence by SSD, Melbourne 1.5 0 0.6 2.8 1.0 3.0 1.0 0.9 0.9 0 7.2 3.6 0 Numbers = % of samples from SSD that are HBsAg + 1.7 0 0 Australian and New Zealand Journal of Public Health 2010; 34 (1): 72 - 78.

  8. Liver cancer incidence by LGA per 100,000 peopleMelbourne, 1998-2007

  9. Medicare Locals, CHB, and liver cancer - Melbourne

  10. Viral hepatitis and liver cancer • In Australia, liver cancer has the fastest increasing incidence, and equal fastest rising mortality of all cancers • The majority of liver cancer in Australia attributable to chronic viral hepatitis • Prognosis for patients diagnosed with liver cancer in Australia is very poor: median survival 15mo. • Late diagnosis a big problem – in NSW 1990-2002, ¼ of all deaths following HBV notification occurred within 6 months Cancer NSW IMR2010, AIHW 2005, Nguyen 2008, Amin 2006

  11. Cancer in New South WalesIncidence and Mortality Report 2008

  12. Anti-cancer programs in AustraliaCost effectiveness Incremental cost effectiveness ratios per QALY: • Breast cancer screening $10,000 • Colorectal cancer screening $20,000 • Cervical cancer screening $45,000 • HCC prevention in CHB • Incorporating cancer surveillance, routine 6 monthly monitoring, referral for specialist management and treatment if indicated $13,000

  13. Health care gaps in CHB Health literacy, access inequity, stigma, low awareness and engagement • 170,000 with chronic HBV • 106,000 (62%) diagnosed • ? Given accurate information / choices • ? Appropriate primary care • ? Appropriate referral / specialist care (delay?) • ~ 6,000 (~3%) receiving treatment, Nov 2011 Low primary care knowledge, lack of systematic response Tertiary care focus, no integration, not chronic disease Mx paradigm, failure to translate evidence Missed opportunities to prevent rapidly rising cancer mortality

  14. Gap: primary care awareness, education and support • National Hepatitis B Needs Assessment 2008 • Survey of ~90 GPs in northern suburbs of Melbourne • 70% of GPs highlighted need for more knowledge • Nearly 1/3 could not interpret HBV serology accurately • Guirgis et al, Int Med J 2012 • Survey of ~120 GPs in St George DGP, Sydney • 20% lacked confidence in interpreting HBV serology • 22% did not recognise HCC as a complication of HBV • 20% were unaware of any treatment for HBV

  15. Uptake of antiviral therapy for CHB in 10 priority Medicare Locals, 2011 • Dr Nicole Allard, WRHC and • University of Melbourne, 2012

  16. Summary • Conservative estimate: only 1/5 Australians needing treatment for CHB to prevent cirrhosis, cancer and death are receiving it • Liver cancer is the equal fastest increasing cause of cancer death in Australia • Antiviral treatment for CHB is clinically effective and cost effective as cancer prevention intervention • Existing tertiary services lack capacity to meaningfully increase treatment and monitoring – waiting lists • Substantial work needed to increase access to treatment and care • How?

  17. National responses: 1st National Hepatitis B Strategy 2010 - 2013 • Establish partnerships • Culturally competent community engagement • Increase health literacy • Increase opportunistic testing; screening • Workforce development • Shift focus of care to primary care • Improve diagnosis, access to treatment • Reduce waiting lists, free up specialist resources • Reduce costs • Address rising cancer mortality • GP and nurse-led models of integrated care • Cost-effective (community-based) chronic disease management – s100 community prescriber pilots

  18. Victorian priorities:Joining up the System • Metropolitan Health Priorities Framework: • Equitable access across the full continuum of health • Maximum returns on health system investments • Increasing the health system’s financial sustainability and productivity (community vs. acute) • Expanding service, workforce and system capacity • Care is clinically appropriate and cost-effective and delivered in the most appropriate settings.

  19. Shifting focus to primary care:National HBV Curricula for GPs and Nurses Staged approach to GP training From entry level through to community prescribing Linkage with specialist services, mentors, program support, CPD Supporting key role for specialist nurses in innovative roles Progress: Advanced GP course NSW April, Victoria in August Advanced nursing course NSW May In Victoria - partnership between ASHM and SH3ED program, General Practice Victoria

  20. Developing integrated and coordinated services: Melbourne Health Integrated Hepatitis B Service • 1 year pilot: commenced April 2012 • 0.6 EFT senior nursing position supported by funding from Department of Health in partnership with GPV • IHBS nurses – central element of service, bridging primary and tertiary care sites, facilitating integrated service delivery • Physician outreach – WRHC, ISIS, Shepparton, Mildura • Local primary care engagement – diverse partner services with high proportion of patients from CALD backgrounds • Supporting enhanced testing and shifting focus of monitoring and treatment away from tertiary services • Workforce development and support, facilitating systems development

  21. Conclusion • HBV is a major health problem globally, regionally and locally • In Australia, the burden of hepatitis B is greatest in groups subject to broader health care disparities • Failure to diagnose, manage and treat facilitate poor individual outcomes, and ongoing transmission • Treatment access must increase to avert rising mortality • Workforce development, and exploring new models of care are crucial, & mandated in the National Hepatitis B Strategy  General Practitioners, Nurses  Advanced management / community prescribing from 2012 • In addition to education, need to enhance primary/tertiary integration, capacity development, system approaches, mentorship and support

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