Hepatitis C: Screening, Identification, and Care
Hepatitis C: Screening, Identification, and Care
Medscape: What are some of the barriers that still exist in the treatment of hepatitis C?
Dr Reau: I think the biggest barrier is access, regardless of how you define it—whether it's cost or whether it's restrictive practices. Restrictive practices might include ensuring that a patient drug-tested negative prior to treatment, or allowing only experienced providers to provide treatment; some systems may not allow nurse practitioners or physician assistants to prescribe, for example. Where you practice greatly affects the restrictive practices. Some places really have no restrictions, whereas in other places, payers can be quite creative in how to deny treatment.
The hurdles from a patient standpoint are a lot of misconceptions. A lot of my patients still think you need a biopsy in order to be evaluated for treatment, or that treatment is still interferon based (with the side effects). A lot of my patients don't realize that hepatitis C is curable. If the patient doesn't know that, it's usually a sign that whoever counseled them about their disease either didn't know what information to pass on to them or may have misinformed them. Or maybe patients are looking online and finding information that is out of date. It all depends. So, again, patient education is important.
Medscape: What are the implications of delayed treatment?
Dr Reau: We absolutely recognize that not all patients with hepatitis C will die of hepatitis C. But we also recognize an unmeasurable grey zone, because there is an increase in all-cause mortality in patients who have hepatitis C and there is a decrease in all-cause mortality in patients who have their disease eradicated. So you can't just look at the liver involvement.
Despite that, there are patients who have great quality of life and yet they have hepatitis C with minimal fibrosis. You probably can't make a great case that they need urgent therapy right now, or that they'll ever even need therapy.
As a physician, I think it's hard, when you have a disease that is curable and increases all-cause mortality, to try to gamble and identify those patients who don't need treatment. They may not need treatment now, but to say that they are never going to need treatment is a hard sell.
A recent study looked at patient outcomes in those treated before and after the development of advanced liver disease. They determined the progression of liver disease using FIB-4. Interestingly, the results showed that the effectiveness of therapy is diminished if therapy is delayed. It's a retrospective analysis, so it has to be taken with a grain of salt, but it was one of the first studies that showed that there probably is a reason to treat patients without advanced disease. We always assumed it, but this actually put it in black and white that we lose something if we defer therapy.
Medscape: Are there instances in which you would wait to treat a patient with hepatitis C?
Dr Reau: There certainly are patients in whom treatment can be delayed, but it's still important to regularly monitor them. Some patients are not ready emotionally for therapy. Adherence to the medications is vital, so I delay therapy for all patients who are not committed to treatment.
One of the issues we run into, though, is that patients who are being told repeatedly that they do not need treatment now may be lost to follow-up, or they may go back to their primary care provider who may not remember that they have hepatitis C, or they may not monitor them in the way they need to be monitored.
Barriers to Treatment
Medscape: What are some of the barriers that still exist in the treatment of hepatitis C?
Dr Reau: I think the biggest barrier is access, regardless of how you define it—whether it's cost or whether it's restrictive practices. Restrictive practices might include ensuring that a patient drug-tested negative prior to treatment, or allowing only experienced providers to provide treatment; some systems may not allow nurse practitioners or physician assistants to prescribe, for example. Where you practice greatly affects the restrictive practices. Some places really have no restrictions, whereas in other places, payers can be quite creative in how to deny treatment.
The hurdles from a patient standpoint are a lot of misconceptions. A lot of my patients still think you need a biopsy in order to be evaluated for treatment, or that treatment is still interferon based (with the side effects). A lot of my patients don't realize that hepatitis C is curable. If the patient doesn't know that, it's usually a sign that whoever counseled them about their disease either didn't know what information to pass on to them or may have misinformed them. Or maybe patients are looking online and finding information that is out of date. It all depends. So, again, patient education is important.
Medscape: What are the implications of delayed treatment?
Dr Reau: We absolutely recognize that not all patients with hepatitis C will die of hepatitis C. But we also recognize an unmeasurable grey zone, because there is an increase in all-cause mortality in patients who have hepatitis C and there is a decrease in all-cause mortality in patients who have their disease eradicated. So you can't just look at the liver involvement.
Despite that, there are patients who have great quality of life and yet they have hepatitis C with minimal fibrosis. You probably can't make a great case that they need urgent therapy right now, or that they'll ever even need therapy.
As a physician, I think it's hard, when you have a disease that is curable and increases all-cause mortality, to try to gamble and identify those patients who don't need treatment. They may not need treatment now, but to say that they are never going to need treatment is a hard sell.
A recent study looked at patient outcomes in those treated before and after the development of advanced liver disease. They determined the progression of liver disease using FIB-4. Interestingly, the results showed that the effectiveness of therapy is diminished if therapy is delayed. It's a retrospective analysis, so it has to be taken with a grain of salt, but it was one of the first studies that showed that there probably is a reason to treat patients without advanced disease. We always assumed it, but this actually put it in black and white that we lose something if we defer therapy.
Medscape: Are there instances in which you would wait to treat a patient with hepatitis C?
Dr Reau: There certainly are patients in whom treatment can be delayed, but it's still important to regularly monitor them. Some patients are not ready emotionally for therapy. Adherence to the medications is vital, so I delay therapy for all patients who are not committed to treatment.
One of the issues we run into, though, is that patients who are being told repeatedly that they do not need treatment now may be lost to follow-up, or they may go back to their primary care provider who may not remember that they have hepatitis C, or they may not monitor them in the way they need to be monitored.
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