RAAT Rapid Access Model of Care in HCV

Marrianne Black CN Cheryl Sendall CNC

Dr Caroline Tallis/Dr Rebecca Ryan Elizabeth Peat/Courtney Balk/Mirjana Palezevic AO

Special thanks for the support and input of

Professor Gerald Holtmann and Dr Katherine Stuart.

What is RAAT?

Not this:

It is:

Rapid Access to Assessment and Treatment.

An Innovative Model of Care.

Epidemiology in Queensland

Second highest number of patients with HCV to NSW .

2696 new cases reported per year. Approximately 45,000 HCV infected

patients in Queensland. PAH has highest incidence of newly

reported cases in the state.

Background The burden of HCV related complications will

continue to rise over the next 3 decades. There will be a significant percentage of HCV related

cirrhosis, many with decompensated liver disease and HCC.

The current level of burden in Australia of untreated HCV in Australia is estimated at: 9474 estimated cases of cirrhosis. 4829 cases of liver failure. 2438 cases of hepatocellular carcinoma 873 liver transplants. (www.hepatitisaustralia.com)

Burden Projected Prevalence of Chronic HCV,

Cirrhosis, and Complications

Davis GL, et al. Gastroenterology. 2010;138(2):513-521 e516.

Projected Number of Patients With Decompensated Cirrhosis and Hepatocellular Carcinoma

Num

ber o

f Cas

es

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Year1950 1960 1970 1980 1990 2000 2010 2020 2030

Hepatocellular Carcinoma (HCC)Decompensated Cirrhosis

Why did we consider this new model of care? KEY POINT Demand for liver outpatient services far exceeded capacity ISSUES At the time the number of patients on the waiting list = 1309 Waiting times far exceeded the recommended and acceptable

timeframes. Local population – much undiagnosed chronic liver disease

Immigrant population Also a Primary health care issue

Future demand will only increase further with current calculations

Growth of cases of chronic liver disease Increased growth of hepatocellular carcinoma cases

Early and late stage presentation

Waiting times as at January 2012. Cat 1 –

Number 44 Waiting time 11 weeks

Cat 2 – Number 481 Waiting time 26 months

Cat 3 – Number 722 (most of which are referred with

HCV) Waiting time 6 years, 5 months

Potential Risks Adverse Events:

progression disease on waiting list “Image” of our waiting list:

nationally and internationally Potential cost saving longer term Impact on Hospital stays:

CLD management, HCC management longer term

Let alone impact on QALY for the patient.

Why did we establish this new model of care?

RAAT was conceived as a component of the FibroScan project.

Following consideration of all the factors already outlined and the potential adverse effects to our patients, this innovative model of care was established.

In the beginning:

The initial plan: To review and rationalise the Long Wait

Category 3 Hepatology Outpatient List. To review those patients with viral hepatitis

who would be suitable for treatment/trials. To screen Category 3 patients for CLD

(chronic liver disease).

In the Beginning:

Clinical Audit: 890 charts reviewed. Referrals placed on waiting list from

10/8/2005 to 30/6/2013.

Clinical Audit

Assessment of referrals: Suitable for treatment -> RAAT clinic Suitable for trials -> RAAT clinic -> refer to

trials. Stay on waiting list for now – (non- viral,

or not suitable for RAAT)

Findings from clinical audit

50 Patients with Hepatitis B. These patients were deemed a priority for RAAT assessment.

523 Patients with Hepatitis C 301 Patients to remain on waiting list as

not suitable for RAAT clinic. 2 patient deaths whilst waiting were

identified.

What we needed

Increase Staffing – all levels Administrative Nursing, include specialist nursing Medical

Infra - structure – Consulting rooms already available Laboratory resources available Radiology resources available

Proposed Structure

6 new cases per clinic session– initially HBV and HCV. This was quickly increased to 10 new cases per clinic.

Friday PM – Gastroenterology OPD, Level 4: 1230-1530. This clinic will also have access to the FibroScan

Patients with Hepatitis B

Assessment in RAAT clinic. FibroScan undertaken, Ultrasound and

Blood tests ordered. Follow up at Burke St and management

plan implemented. Details also provided to Trials co-

ordinators.

HCV patients seen in Friday PM RAAT clinic 209 patients (to 4/4/2014). 132 males FibroScan results: 18 patients with LSM >12kPa 57 patients with LSM >7kPa and <12kPa.

Not all patients were treated due to either

Being too sick to commence treatment. Significant co-morbidities. Personal preference to delay or not undergo treatment (Warehouse)

3 patients have been identified with HCC. 5 patients have been identified with de-compensated liver disease

Total number of patients seen in Friday PM RAAT clinic 29/6/2012 to 4/4/2014.

0

100200

300400

500600

700800

900

# booked #DNA # Seen #Resched

# Cx Prev DNA SecondDNA

Patie

nts

Patients with HCV treated:

62 patients commenced treatment

8 patients accessed clinical trials 54 RAAT HCV treatment

8 cirrhosis

Results Thus Far

~ 90% RVR SVR 10 TPV – 12 BOC – 5

Previous Culture regarding HCV treatment.

Warehouse. Trials Treatment.

There is a shift away from warehousing

patients.

Authors: Jennifer A Whitty, Caroline Tallis, Kim-Huong Nguyen, Paul A. Scuffham, Paul Crosland, Kaye Hewson, Rehka Pai Mangalore, Marrianne Black, Gerald Holtmann

Cost-effectiveness of RAAT.

Waiting times Where we started Cat 1

Number 44 Waiting time 11 weeks

Cat 2 Number 481 Waiting time 26 months

Cat 3 Number 722 Waiting time 6 years, 5

months

AS AT 4/4/2014

Cat:1 Number 0 Waiting time 0 weeks

Cat: 2 Number 233 Waiting time 7 months

Cat:3 Number 257 Waiting time 2 years 3

months

Disclaimer

To ensure equity all patients to 1/1/2012 have been seen in the RAAT clinic.

All Category 3 patients with HCV deemed suitable for RAAT clinic have been seen from the waiting list with referrals received prior to June 2013.

Thank-you Special thanks to Cheryl Sendall for establishing the Treatment clinic. Elizabeth Peat, Courtney Balk and Mirjana Palezevic

AO for the booking of the appointments. The Gastro OPD admin staff for their help with

checking in these patients. And special mention to the team at Burke Street for

their work in commencing some of the patients in this co-hort.

The next phase To date greater than 2100 patients have

undergone a FibroScan procedure since the introduction of this new technology to our department.

ARFI (acoustic radiation force impulse) has been trialled in the assessment of liver fibrosis in patients with liver disease.

The Future: Supersonic Aixplorer is now undergoing trials

within this department in the assessment of fibrosis for our patients.

And then.

Perhaps we can stop the RAAT clinic and go to the CAT clinic.

Completed Anti-viral Therapy.

Thank you.