Examining Hepatitis C patient care pathways and services in Canada: results from a national specialists' survey

Background and Aims: This study was designed to examine management practices of Canadian physicians trained in the specialties of infectious diseases, gastroenterology and hepatology in order to increase understanding of how people living with the Hepatitis C Virus (HCV) receive treatment across Canada. Approximately 170-175 million people worldwide are infected with HCV and the current prevalence of HCV in Canada is approximately 0.8%. It is known that treatment outcome and hence management strategies differ based on factors such as genotype and viral load, liver histology, body weight, co-infection with HIV and adherence. Canadian hepatologists have varied perspectives towards treating HCV patients [1]. The purpose of the study was to examine health care services provided to HCV patients by HCV health care providers (infectious disease specialists, hepatologists, gastroenterologists) and to see if there is variation in treating HCV in Canada. It is hypothesized that regional variation in treatment exists because of unequal access to care across Canada and that staffing capacity will be a major barrier to care. -- Methods: A nationwide anonymous postal survey was conducted to determine if treatment varies by geographical location. HCV health care providers were identified through the Canadian Medical Directory [2]. A cover letter outlining study objectives and a questionnaire were sent to all eligible HCV health care providers. The survey requested information regarding health care provider demographics, referral pathways, treatment eligibility, pattern of drug prescribing, barriers to providing high quality service, and the role of physicians in providing treatment. -- Results: A structured questionnaire was sent to 562 physicians and 222 returned completed questionnaires with an adjusted response rate of 42%. Forty-three percent of respondents provided a comprehensive service (included treatment and follow-up), 33 % provided a diagnostic and investigative service (followed by referral to dedicated HCV service), and 24 % had no role in the management and diagnosis of people with HCV. The estimated number of patients managed by the total number of comprehensive service providers was over 27,000 with an increasing trend over the previous years. Regional variation was observed between comprehensive care providers across Canada, including the size of practice community, number of patients, and type of service provided. The majority of comprehensive service providers indicated that they would not provide treatment to a current injection drug user; the provinces most likely to provide treatment were Alberta and Nova Scotia. Key barriers to quality of care identified by the majority of comprehensive service providers were funding for treatment and patient non-attendance. -- Conclusions: Survey respondents revealed that there are regional variations across Canada at many levels of the patient pathway, which could contribute to inequalities in health care services provided to patients with HCV. The results provide a baseline assessment of the overall HCV services across Canada. Services involving a multidisciplinary clinic setting need to be expanded and regional networks should be formed in order to allow for a more comprehensive approach to the identification of HCV patients and health care delivery of HCV antiviral therapy.