Multidisciplinary collaboration to micro-eliminate hepatitis C in China: hospital-based experience | BMC Gastroenterology

Changes before and after the implementation of the multidisciplinary cooperation model

This retrospective analysis of hepatitis C serology showed that among 1,306 anti-HCV-positive cases, more men than women tested positive, which may be attributed to a higher trend of unsafe exposure behaviors in men (21). Other studies have reported similar results (10, 19). Furthermore, 84.533% of patients were ≥ 40 years old, which highlights the need for increased anti-HCV screening in male patients ≥ 40 years old (22, 23). Our results also showed that the anti-HCV antibody positivity rate increased year by year, which is consistent with the observations of previous studies (24, 25). However, hepatitis C elimination has been delayed due to the impact of COVID-19 and the national HCV surveillance system is still being established. Only 18% of Chinese hepatitis C patients are correctly diagnosed. Although 25% of patients require urgent treatment, only 1.3% have access to it (26).

Before the multidisciplinary collaboration, doctors in the hospital had limited knowledge of hepatitis C. Only 51.899% of clinicians recognized DAA as the first choice treatment method, and about 32.911% of doctors believed that asymptomatic patients did not need treatment. Physicians’ professional experience and knowledge about hepatitis C can significantly influence patients’ medical behaviors and willingness to receive treatment (27, 28). This study found that before implementation, 36.426% of anti-HCV-positive patients received confirmatory HCV RNA testing, 67.456% of RNA-positive patients were correctly diagnosed as hepatitis C, and only 12.426% of RNA-positive patients were correctly diagnosed as hepatitis C. hepatitis. – Positive patients received antiviral treatment. Overall, as in other countries, referral rates for diagnosis and treatment are low (29).

Under multidisciplinary cooperation, public health doctors supervised the entire process, used the infectious disease reporting management platform to track the RNA testing status of anti-HCV positive patients, and communicated with the attending doctors to ensure timely HCV RNA testing. Active follow-up via text messages or phone calls is recommended to spread treatment and prevention awareness and ensure that new hepatitis C patients in the hospital complete the treatment course. This study showed that 88.737% of anti-HCV-positive patients underwent HCV RNA testing, 98.113% of RNA-positive patients were diagnosed with hepatitis C, and 58.491% of patients were referred for treatment.

However, treatment rates remain below the target of 80% of people with hepatitis C receiving treatment. In this regard, multivariable logistic regression analysis revealed unfavorable factors for HCV antiviral treatment, including age ≥40 years and non-local residence; insurance for urban residents; lack of intervention from medical institutions; absence of liver fibrosis or tumors or other serious diseases (including esophageal cancer, gastric cancer, hemophilia, and syringomyelia). Among them, the OR of multidisciplinary cooperation in medical institutions showed the strongest correlation and was the most important factor for patients to receive HCV treatment. Implementing multidisciplinary collaboration in all health care settings can promote hepatitis C elimination.

China’s efforts to eliminate hepatitis C

To eliminate hepatitis C by 2030, China must treat at least 550,000 cases of hepatitis C each year (30). Since 2017, an increasing number of DAAs have been approved (31). Currently, 8 DAAs have been included in the national medical insurance directory, which has greatly reduced the financial burden of hepatitis C patients. For example, before the drug was included in the national medical insurance drug negotiations for the pan-genotypic drug sofosbuvir/velpatasvir (SOF/VEL), the cost of a complete course of treatment was approximately US$12,000. Currently, the drug costs about $1,500. After SOF/VEL is included in the medical insurance negotiations, the maximum cost of full treatment for urban residents’ basic medical insurance will not exceed 900 yuan, while for employee medical insurance it will be 600 yuan, which improves the accessibility of medication. Our study shows that employee health insurance is an advantage for antiviral treatment in HCV patients because it requires lower out-of-pocket costs.

In September 2021, nine departments including the National Health Commission and the Ministry of Science and Technology formulated and issued the “Action Plan to Eliminate the Public Health Hazards of Hepatitis C (2021-2030)” (32). To this end, the government proposes to take effective measures to vigorously prevent and control hepatitis C, curb new infections, effectively detect and cure patients, and reduce hepatitis C cirrhosis and cancer mortality. The “Work Plan” also proposes specific action goals for 2021, 2025 and 2030.

Current problems in eliminating hepatitis C in medical institutions

Although we have improved the diagnosis rate of hepatitis C, treatment rates remain suboptimal. First, DAA is not always available at many medical institutions. A study by the Chinese Center for Disease Control and Prevention found that only 10.84% ​​of medical institutions followed hepatitis C standard treatment guidelines in 2020 (33). Our study showed that patients from other cities had lower treatment rates, possibly because of limited access to treatment in their cities. Lack of DAA drugs in hospital facilities is an important factor. Under the reform of payment for diagnosis and treatment groups/diagnosis and treatment intervention packages, the medical insurance fund will be settled according to the established payment standards. Medical expenses exceeding the basic payment will be borne by the medical institution. If there is a surplus, it can be used as revenue for the hospital (34). Therefore, negotiating the high cost of drugs poses cost control challenges, further reducing the incentive to introduce DAA. On April 22, 2021, the National Health Commission and the National Health Commission jointly issued the “Guiding Opinions on Establishing and Improving the Dual-Channel Management Mechanism for National Medical Insurance Agreed Drugs” (35). In this way, after a hospital clinician issues a prescription, the patient can purchase and pay for the relevant drugs at a medical insurance designated pharmacy, and the proportion of drug costs in the total medical expenses will not increase accordingly. But so far, this policy has not been well implemented, and most hospitals still do not operate the dual-channel mechanism.

Secondly, only 46.1% of medical institutions in China are able to perform RNA testing (33). In addition, hospitals with the capability to perform RNA testing accumulate samples for cost-effectiveness, affecting the accuracy of RNA results. At the same time, if the RNA test results are released after the patient is discharged, treatment will not be initiated, especially for non-local patients, which will affect the treatment rate.

Third, my country only began to include DAA in the Class B medical insurance catalog in 2019, and the treatment has not yet become popular. At present, clinicians may not fully understand the clinical indications for hepatitis C antiviral drugs, especially the impact of DAAs on patients with hepatitis C and tumors or other serious diseases. Follow-up results for patients who tested positive for HCV RNA showed that treatment rates were lower for patients aged ≥60 years or with tumors or other serious diseases. However, some patients and doctors may refuse hepatitis C treatment due to a lack of awareness about the types of medications and importance of treating hepatitis C.

limitation

This study has several limitations. First, this is a retrospective study, conducted in a single center, including experience sharing, although our institution is a large, regional, comprehensive tertiary hospital treating patients with a variety of diseases. However, the findings may reflect the real situation of hepatitis C in the region. Future research could use multiple decentralized diagnostic care pathways to improve detection of potential infections (36). This may help us better understand the local prevalence of hepatitis C. Second, treatment information was obtained primarily through medical records and telephone follow-up. At present, our hospital has started the transformation of the treatment and follow-up data platform. In the future, clinicians will be able to directly input relevant information, improving the accuracy of treatment-related data. Finally, there is still a proportion of anti-HCV (+) patients who do not undergo HCV RNA testing. The gap in accurate diagnosis of HCV RNA needs to be narrowed; however, due to the layout of the hospital area, we were unable to perform a reflex test model such as the one established by Huang et al. (37). Future studies should be conducted at centers capable of rapid transfer of blood samples from collection to testing for such analyses.