The role of the general practitioner in the screening and clinical management of chronic viral hepatitis in six EU countries
PDF

Keywords

chronic viral hepatitis
clinical management
general practitioner
primary care
screening

Abstract

Introduction Chronic viral hepatitis is still a major public health concern in the EU. In order to halt the progression of the disease and to prevent onward transmission, timely recognition and accurate clinical management are crucial. The aim of the present study was to investigate the role of the general practitioner (GP) in the screening of persons at risk and in the clinical management of chronic viral hepatitis patients in six EU countries.

Methods An online survey among GPs and secondary care specialists was conducted in the UK, Germany, the Netherlands, Hungary, Italy, and Spain. In the GP survey we aimed to find out how commonly risk groups are screened, using a four-point Likert scale. In both surveys, we measured whether GPs are involved in monitoring clinical indicators in patients undergoing antiviral treatment and explored whether patients in four clinical scenarios are referred back to primary care.

Results Between five and 10 experts per professional group were reached except for Spain (GPs: n=2; Specialists: n=4) and, in the case of the GP survey, Hungary (GPs: n=4) and Germany (GPs: n=4). Migrants are variably or not routinely screened for Hepatitis B/C in the majority of cases. The majority of GPs reported that hepatitis B/C screening is routinely offered to people who inject drugs. In Hungary, Italy and in the Netherlands screening sex workers is not regularly practiced. As to whether GPs offer screening to men having sex with men, responses varied between variably and commonly practiced in Germany, the Netherlands and Italy, while in Hungary the practice seems to be sporadic; in the UK, while screening for hepatitis B seems to be common practice among GPs, hepatitis C testing is only occasionally offered to this risk group. Most GPs (>44%) in all countries except in Hungary reported that it is very common practice to offer hepatitis B/C screening to HIV patients.

The role of the GPs in monitoring hepatitis cases and the referral of cases back to the GPs varied within and between countries. GPs are unlikely to monitor clinical outcomes other than side effects in patients undergoing treatment. Patients who have had a sustained virological response are usually referred back to GPs, whereas patients who do not respond to treatment are rarely referred back to primary care.

Discussion The GPs decision to offer screening to risk groups often seems to be an individually motivated choice of the health care professional. Raising awareness among GPs about the disease, for example through the adoption of effective strategies for the dissemination and implementation of the existing guidelines for general practice, is highly needed. The role of GPs and specialists involved in the management of chronically infected patients should also be clarified, as the professionals opinion sometimes differed markedly even within the two professional groups.

https://doi.org/10.15167/2421-4248/jpmh2016.57.2.551
PDF

References

] Hahné SJM, Veldhuijzen IK, Wiessing L, Lim T-A, Salminen M, Laar M van de. Infection with hepatitis B and C virus in Europe: a systematic review of prevalence and cost-effectiveness of screening. BMC Infect Dis. 2013;13:181. doi: 10.1186/1471-2334-13-181.

] European Centre for Disease Prevention and Control. Hepatitis B and C in the EU neighbourhood: prevalence, burden of disease and screening policies. Stockholm: ECDC; 2010. Available at: http://www.ecdc.europa.eu/en/publications/Publications/TER_100914_Hep_B_C%20_EU_neighbourhood.pdf [Accessed 10/10/2015]

] European Centre for Disease Prevention and Control. Assessing the burden of key infectious diseases affecting migrant populations in the EU/EEA. Stockholm: ECDC; 2014. Available at: http://ecdc.europa.eu/en/publications/Publications/assessing-burden-disease-migrant populations.pdf [Accessed 10/10/2015]

] Sarkar M, Shvachko VA, Ready JB, Pauly MP, Terrault NA, Peters MG, Manos MM. Characteristics and Management of Patients with Chronic Hepatitis B in an Integrated Care Setting. Dig Dis Sci. 2014;59(9):2100-8. doi: 10.1007/s10620-014-3142-2.

] Burman BE, Mukhtar NA, Toy BC, Nguyen TT, Chen AH, Yu A, Berman P, Hammer H, Chan D, McCulloch CE, Khalili M.Hepatitis B management in vulnerable populations: Gaps in disease monitoring and opportunities for improved care. Dig Dis Sci. 2014 Jan;59(1):46-56. doi: 10.1007/s10620-013-2870-z.

] Clark EC, Yawn BP, Galliher JM, Temte JL, Hickner J. Hepatitis C identification and management by family physicians. Fam Med. 2005;37(9):644–9.

] Wallace J, McNally S, Richmond J, Hajarizadeh B, Pitts M. Challenges to the effective delivery of health care to people with chronic hepatitis B in Australia. Sex Health. 2012;9(2):131–7.

] Dev A, Nguyen JNH, Munafo L, Hardie E, Iacono L. Chronic hepatitis B: A clinical audit of GP management. Aust Fam Physician. 2011;40(7):533–8.

] Wallace J, Hajarizadeh B, Richmond J, McNally S. Challenges in managing patients in Australia with chronic hepatitis B: the General Practitioners’ perspective. Aust N Z J Public Health. 2013;37(5):405–10. http://doi.wiley.com/10.1111/1753-6405.12127.

] Peksen Y, Canbaz S, Leblebicioglu H, Sunbul M, Esen S, Sunter AT. Primary care physicians’ approach to diagnosis and treatment of hepatitis B and hepatitis C patients. BMC Gastroenterol. 2004;4:3.

] Ren J-J, Liu Y, Ren W, Qiu Y, Wang B, Chen P, Xu KJ, Yang SG, Yao J, Li LJ. Role of general practitioners in prevention and treatment of hepatitis B in China. Hepatobiliary Pancreat Dis Int. 2014;13(5):495–500.

] Ferrante JM, Winston DG, Chen PH, de la Torre AN. Family physicians' knowledge and screening of chronic hepatitis and liver cancer. Fam Med. 2008;40(5):345-51.

] Cohen C, Holmberg SD, McMahon BJ, Block JM, Brosgart CL, Gish RG, London WT, Block TM. Is chronic hepatitis B being undertreated in the United States? J Viral Hepat. 2011;18(6):377–83.

] Peksen Y, Canbaz S, Leblebicioglu H, Sunbul M, Esen S, Sunter AT. Primary care physicians' approach to diagnosis and treatment of hepatitis B and hepatitis C patients. BMC Gastroenterology 2004, 4:3.

] Fretz R, Negro F, Bruggmann P, Lavanchy D, De Gottardi A, Pache I, Masserey Spicher V, Cerny A. Hepatitis B and C in Switzerland - healthcare provider initiated testing for chronic hepatitis B and C infection. Swiss Med Wkly. 2013;143:w13793.

] Nicklin DE, Schultz C, Brensinger CM, Wilson JP. Current care of hepatitis C-positive patients by primary care physicians in an integrated delivery system. J Am Board Fam Pract 1999;12(6):427-35.

] Shehab TM, Sonnad SS, Lok AS. Management of hepatitis C patients by primary care physicians in the USA: results of a national survey. J Viral Hepat 2001;8(5):377-83. http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2893.2001.00310.x/abstract

] Shehab TM, Sonnad S, Gebremariam A, Schoenfeld P. Knowledge of hepatitis C screening and management by internal medicine residents: trends over 2 years. Am J Gastroenterol 2002;97(5):1216-22.

] Navarro VJ, St Louis TE, Bell BP. Identification of patients with hepatitis C virus infection in New Haven County primary care practices. J Clin Gastroenterol 2003;36(5):431-5.

] Shehab TM, Orrego M, Chunduri R, Lok AS. Identification and management of hepatitis C patients in primary care clinics. Am J Gastroenterol 2003;98(3):639-44.

] Coppola AG, Karakousis PC, Metz DC, Go MF, Mhokashi M, Howden CW, Raufman JP, Sharma VK. Hepatitis C knowledge among primary care residents: is our teaching adequate for the times? Am J Gastroenterol 2004;99(9):1720-5.

] Rocca LG, Yawn BP, Wollan P, Kim WR. Management of patients with hepatitis C in a community population: diagnosis, discussions, and decisions to treat. Ann Fam Med 2004;2(2):116-24.

] Clark EC, Yawn BP, Galliher JM, Temte JL, Hickner J. Hepatitis C identification and management by family physicians. Fam Med 2005;37(9):644-9.Gastroenterol. 2004;4:3.

] Smith BD, Morgan RL, Beckett GA, Falck-Ytter Y, Holtzman D, Ward JW. Hepatitis C virus testing of persons born during 1945–1965: recommendations from the Centers for Disease Control and Prevention. Ann Intern Med 2012;157:817–822.

] Sweeney L, Owiti JA, Beharry A, Bhui K, Gomes J, Foster GR, Greenhalgh T. Informing the design of a national screening and treatment programme for chronic viral hepatitis in primary care: qualitative study of at-risk immigrant communities and healthcare professionals. BMC Health Serv Res. 2015;15:97.

] European Centre for Disease Prevention and Control. Hepatitis B and C surveillance in Europe. 2012. Stockholm: ECDC; 2014. Available at: http://ecdc.europa.eu/en/publications/Publications/hepatitis-b-c-surveillance-europe-2012-july-2014.pdf [Accessed 10/10/2015]

] Wolffram I, Petroff D, Bätz O, Jedrysiak K, Kramer J, Tenckhoff H, Berg T, Wiegand J; German Check-Up 35+ Study Group. Prevalence of elevated ALT values, HBsAg, and anti-HCV in the primary care setting and evaluation of guideline defined hepatitis risk scenarios. J Hepatol. 2015;62(6):1256-64.

] Bechini A, Falla A, Ahmad A, Veldhuijzen I, Boccalini S, Porchia B, Levi M. Identification of hepatitis B and C screening and patient management guidelines and availability of for chronic viral hepatitis among health professionals in six European countries: results of a semi-quantitative survey. BMC Infect Dis. 2015;15:353.