Introduction Hepatitis C causes life threatening disease which may affect 270 million people worldwide and up to 2% of the UK population. HCV is an RNA virus which usually causes asymptomatic infection but leads to chronic liver disease, and if left untreated, liver failure in the majority of cases. It may be treated successfully with ribavirin and pegylated interferon used in combination. Sustained response to therapy ranges from 50 to 75%, dependant on viral genotype. Treatment is physically and psychologically demanding. As a result, patients are usually treated in dedicated clinics with specialist nurse support. Such clinics may be expensive to staff and are most commonly found in tertiary referral centres.
Methods Our hospital, a district general in SW London started to treat patients with HCV as part of its general gastroenterology and hepatology work in 2001. Now, an outpatient nurse with a special interest in HCV devotes 4 h a week to run the service with the support of three gastroenterologists. The service undertakes all aspects of hepatitis C diagnosis, treatment and monitoring. About 30 patients are now treated pa. Through auditing the service in 2005 and 2008 against NICE guidelines,1 we aimed to determine whether such a low cost, local model of service provision was effective and safe.
Results From 2004 to 2007 89 patients were treated. By 2008 all had had their genotype tested and documented before treatment (2005, 92%). 82% had had their viral load recorded (2005, 92%). All patients with genotypes 1 and 4 had their initial response to treatment checked at 12 weeks (2005, 74%). Treatment duration, 24 or 48 weeks, was appropriate in all (2005, 86%). The results of “end of treatment” PCR were recorded for 80% of patients (2005, 74%). 96% of those returned for a HCV PCR 6 months later to ensure a sustained virological response (2005, 85%). None of our patients suffered any serious adverse event during treatment. The 2008 findings demonstrated a clear improvement since the 2005 audit in the six standards assessed, reflecting the introduction of a clearer “pathway” for patients as a result of findings in 2005, and greater staff experience. Of the 89 cases audited, documented sustained virological response rates improved from 25% for genotypes 1 and 4 and 44% for genotypes 2 and 3 in 2005 to 46% and 75%, respectively. The actual response rates are likely to be higher if allowance is made for those lost to follow-up.
Conclusion It is possible to run a local, safe HCV service with few dedicated resources in a DGH. Audit is useful in focusing attention on areas for improvement; documentation that encourages appropriate, timely testing before, during and after treatment helps.