January 4, 2017
Hepatitis C virus (HCV) infects and injures the liver and in many cases becomes a chronic infection. Over time, HCV slowly degrades the liver. Eventually, serious bacterial infections, kidney dysfunction, internal bleeding and other complications can develop as the liver deteriorates. Also, the risk of liver cancer is greatly increased.
Most new cases of HCV infection in high-income countries happen among people who share equipment for injecting or inhaling street drugs.
Researchers with the New York Department of Health and Mental Hygiene have been trying to find ways to increase awareness of HCV and testing for it among people at high risk for this infection.
According to the researchers, "Chronic HCV infection is commonly associated with persons who are marginalized in the healthcare system, with injection drug use as the primary risk factor. [Also] patients with socio-behavioural and other conditions/issues such as homelessness, psychiatric illness and HIV co-infection have historically been classified as difficult-to-treat and have required increased support to access HCV care."
The term patient navigator refers to a person who works for a health system, usually based in a hospital or large clinic, who helps people with serious chronic or catastrophic illness engage with and move through the many steps in a continuum of care (from diagnosis through treatment).
Specifically, patient navigators are used to enhance the ability of patients to enter into care, understand complex medical information, keep appointments, cope with the stress of illness, access health insurance and/or subsidies for medications, take their medications exactly as prescribed and directed, and keep in touch with the clinic over the medium- and long-term. By doing all of these things, patient navigators can improve health outcomes and address what the researchers have described as "patient- and systems-level barriers to care and treatment." Studies have found that the services and support provided by patient navigators have played an important role in improving the health of some people with cancer and others with HIV infection.
In 2012, the Department, with funding from the private sector, implemented a one-year demonstration project with the patient navigator program Check Hep C. That program helped to screen 4,751 people for HCV and linked 85% of infected people to a clinic. However, researchers with the program noted that only six of the participants who made a visit to a clinic to be medically assessed, were "known to have successfully completed treatment."
The Department gained much experience from the program's first year and received additional private sector funding, which enabled it to modify the program. In the second year, the Department refined the program so that it focused on "supporting persons diagnosed with chronic HCV infection to complete a medical evaluation, access and initiate treatment, and achieve [a cure]."
In its second year of operation (in 2014), the modified program, through its patient navigators, helped to provide the following:
This time the program enrolled 388 participants. Of these, 129 people (33%) initiated HCV treatment, and 119 (91%) of them were cured. According to the researchers, "Check Hep C successfully supported high-need participants through HCV care and treatment," resulting in high cure rates.
The revised patient navigator program was implemented at four community-based organizations in New York City:
All four sites were located in neighbourhoods where HCV infection was relatively common.
Once participants were in the program, doctors and/or nurses assessed each one for "clinical and psychological factors" in order to make a decision about eligibility for treatment.
Treatment-eligible participants were contacted by patient navigators and received the following services:
According to the researchers, "Patient navigators supported participants through medical evaluation, preparation for antiviral treatment and treatment adherence." Furthermore, the patient navigators helped participants connect to the complex and sometimes cumbersome aspects of access to subsidized healthcare and medications in the U.S. Due to the high cost of modern HCV treatment, some health insurance systems have imposed restrictions on medication access -- in other words, they are rationing treatment.
For the purposes of their analysis, the researchers designated participants with no or only one "sociobehavioural or mental health condition as low need, and those with two or more sociobehavioural or mental health conditions as high need."
Data on participants in the program were assessed between April 2014 and January 2015.
The average profile of 388 participants upon entering the study was as follows:
Out of the 388 people who entered the Check Hep C program, 77% (299 people) visited clinics to undergo medical evaluation. Among the people who sought such an evaluation, 79% were judged to be treatment eligible.
According to researchers, the chief reasons that participants were not eligible for treatment were as follows:
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