hepc“break through” project - · – break through 2 is financed and recruitment of new teams...
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Improving Mental Health by Sharing Knowledge
HepC “Break Through” project
A long story with a happy ending
Esther Croes MD PhD
• ~ 14,000 problematic opiate users (current); 70% in contact with addiction care
• ?? Ever opiate injectors; ?? current crack cocaïne users
• ~ 1000 current injectors
*estimates! 2
DRID situation in the NL
HIV HepB HepC
Prevalence* Low - medium
(<0.1 – 10%)
Low
(<5%)
High
(30-80%)
Diagnosed High Medium Low
In treatment/
in follow up
High Medium Low
• ~ 14,000 problematic opiate users (current); 70% in contact with addiction care
• ?? Ever opiate injectors; ?? current crack cocaïne users
• ~ 1000 current injectors
*estimates! 3
DRID situation in the NL
HIV HepB HepC
Prevalence* Low - medium
(<0.1 – 10%)
Low
(<5%)
High
(30-80%)
Diagnosed High Medium Low
In treatment/
in follow up
High Medium Low
C/ HepC is the biggest challenge
• 2009/2010: national HCV information campaign, with a sub-campaign targeting drug users
• IF drug users were reached, the campaign was effective:– Knowledge about HCV increased
– Uptake of screening and treatment improved
• BUT: far majority of drug users were not reached, due to a low level of implementation
• Many many many barriers for implementation:– “hepC has no priority in addiction care”
– “hepC is not a task for addiction care”
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Initial answer to the hepC challenge
Years of monitoring:
High number of
undiagnosed and
untreated HCV patients in
addiction care
Promising developments
in medication
Several local (small)
examples of good practice
Screening is cost-effective
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The pragmatic answer: Break Through
• Often used implementation method, based on PDCA cycle
• Aim: to realise concrete changes in care within a short period of time, recognising local differences
• Here: resulting in local HepC “care pathways” (who is whenresponsible for what), embedded in daily practice (protocols)
• SMART goals and use of indicators to monitor results
• Local multi-disciplinary teams exchange experience and knowledge in (four) conference days
• Experts guide and visit local teams
• Central coordinators facilitate with toolkits, training, teamsite(internet), etc
• From 4 of 11 organisations for addiction care
• Team members (minimum):
– addiction care (MMP or HAT): specialised nurse + MD + manager
– general hospital (gastroenterology or infectiology): hepatitis nurse + specialist MD
• Needed: – 1 local project leader
– Commitment from management (hours, mental support)
– Willingness to embed the “care path” permanently
– 1.5 years time (“quiet period”)
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Recruitment of 10 local teams
Think big, but start small! Start with few AC locations and hospitals and scale up when it works
• Identification of problems (some examples):– No contact between hospital and addiction care
– How to seduce patients
– How to diminish the threshold for patients to hospital
• Design project plan and test the plan in PDCA-cycles
• Working conferences for exchange with other teams
• A separate conference for managers of participating teams
• Solutions (some examples):– ‘Seducing’ patients with small incentives
– Testing with swabs or one venapuncture and test in phases (store blood)
– Counselling and information hours by nurses of AC and hospital together
– Use photos in information leaflet for patients
– Always psychiatric advice and always attention for birth control
– Share results with management regularly
– Monitor progress and visualise it (coloured excel)
– Ask for informed consent (to communicate to all relevant MDs) at the start
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Practice-based project
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https://www.youtube.com/watch?v=q6NthEQh5u4 9
The project in a glance
• An implementation method suitable for the problem (changing work processes requires expertise)
• Enthusiastic and multidisciplinary teams
• Teams were supported with tools and advice, but not financially (sustainability after ending of the project)
• Special attention to management
• Simple and convincing message about relevance hepC
• Excellent expert panel
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Success factors
• Simple and convincing message about relevance hepC
Remember the arguments:
• “hepC has no priority in addiction care”
• “hepC is not a task for addiction care”
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Success factor “message”
Central Bureau for Statistics, http://statline.cbs.nl/statweb/ ..
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“No priority”
0
100
200
300
400
500
600
1996 1998 2000 2002 2004 2006 2008 2010
dae
ths
/ yea
r
HIV
Made by
Mortality HIV in NL 1996-2010
13
“No priority”
0
100
200
300
400
500
600
1996 1999 2002 2005 2008
dea
ths
/ yea
r
HBV-HCV
Mortality hepB & C in NL 1996-2010
Central Bureau for Statistics, http://statline.cbs.nl/statweb/ ..
Made by
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Priority: our challenge
0
100
200
300
400
500
600
1996 1999 2002 2005 2008
dea
ths
/ yea
r
year
HBV-HCV
HIV
HepB&C deaths
Central Bureau for Statistics, http://statline.cbs.nl/statweb/ ..
Made by
Based on Urbanus et al, 2012; and Vriend et al, 2012
“HepC no task for addiction care”
First generation
migrants
41%
DU
and IDU
27%
Low risk groups
25%
MSM
5%hemofilie pt
2%
Total N = 30,000
Low fruit
Pickable fruit
High fruit
Medical specialist is responsible for treatment, but
support from AC is essential in all phases:
• Case finding: – Workers in AC know of the patient’s risk behavior
– Active testing enhances case finding (Helsper 2011, Singels 2010)
• Preparation for HCV treatment:– Working towards HCV treatment: stability in drug use, stable
living conditions and co-morbidity
• Guidance/support during treatment:– Expertise in venapuncture, motivational interviewing,
medication management, hospitalisation when needed, knowledge of specific addiction problems
• Aftercare: – Consolidation of positive results in various areas: a “new start”
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The importance of addiction care
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Success factor “expert team”
• Participating teams:– 1 organisation of AC was completely covered in this project
– 1 organisation has officially adopted hepatitis screening in their infectious disease protocol: other locations will adopt the care path
– 1 organisation is organising with all hospitals in the region the care path
– Cooperation is on more that hepatitis: “Now I know how to find addiction care for e.g., my alcoholic liver patients”
• Dissemination of the best practices– Break Through 2 is financed and recruitment of new teams is ongoing
– Website with best practices and other information
• Political awareness– The project is mentioned as good example in several letters of the MoH
– Expertise used in National Hepatitis Steering Group and Dutch Health Council advising on hepatitis screening
– Working visits for policy makers and politicians
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Impact
• Improving HCV care takes a long breath
• Sitting at our desk, we do not realise what the daily problems are; they are far more simple / far more complicated that we could ever imagine
• Don’t impose a fixed blue print, but support local solutions
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Lessons learned
EU Call : improving access to hepatitis care, based on knowlegde and experience from Break Through project.
• 3-4 countries, each with central coordinator and 8-10 teams
• Fitting with local needs and possibilities
• Possibility to extend to hepB or other risk groups/ settings
• Making use of modern conference techniques (e.g., video conferencing)
• Include modelling/ cost-effectiveness study?
Interested?
Contact: Esther Croes
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More …?