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SUPPORT and training programs are needed to boost GP confidence in managing the complex and dynamic burden of chronic hepatitis B (CHB), according to Sydney-based GP Dr Linda Mann.
Dr Mann told MJA InSight that the current situation with CHB management in Australia was reminiscent of the rise of HIV/AIDS in the 1990s.
“It took a revolution for GPs to come together and say to specialists that they shouldn’t be the only ones testing for and managing HIV,” Dr Mann said.
“Yes, it’s true that hepatitis B is complex and the medicines are complicated. So we just need to better train GPs in how to give these medicines.”
Dr Mann was commenting on research published today in the MJA in which 123 GPs in the Sydney and South Western Sydney Local Health District were surveyed about their management and assessment of CHB.
Related: MJA — A survey of Sydney general practitioners’ management of patients with chronic hepatitis B
Related: MJA — Public health management of hepatitis B virus contacts
Each GP had seen at least one patient aged 18 years or more who had been notified to the Public Health Unit as having CHB during 2012 or 2013. Of the 123 GPs who completed the survey, most felt they were at least reasonably confident about managing CHB. However, almost 20% said they were “not very” or “not at all” confident, the authors wrote.
GPs were generally most comfortable with a model of care that involved initial referral to a specialist. Managing CHB without specialist input or with only review by a specialised nurse were less popular.
The authors concluded that their results indicated that barriers, including dependence on specialist input, still hindered the appropriate assessment and management of CHB by GPs.
“As the CHB burden in Australia rises and the capacity of specialist liver services is tested, a new model of care focusing on primary health care needs to be developed, but must be considered carefully, noting the clear preference of GPs for specialist support.”
Lead author of the study, Dr Zeina Najjar from the Public Health Unit of Sydney Local Health District, told MJA InSight that the survey backed up existing evidence.
“There is a lack of knowledge in general practice about CHB. It’s complicated to manage and the tests are hard to interpret.”
Dr Linda Mann was also not surprised by the results of the survey, saying it highlighted ingrained attitudes about GPs managing complex diseases like CHB, which in turn affected their confidence.
“It reflects that attitude of ‘look at how stupid GPs are and how great specialists are’. Our position as GPs gets downgraded.”
Dr Najjar said key to improving the confidence of GPs in managing this disease was not just providing GPs with more support, but also education.
“It’s about encouraging GPs to learn about CHB and take courses in prescribing S100 [medications for CHB].”
However, Dr Mann said that learning initiatives should steer clear of being presented as formal educational events, which could work against GP–specialist collaboration.
Instead, conversations that allow both GPs and specialists to share their stories on a level playing field should be encouraged.
“For example, GPs might want to discuss their experiences where patients with CHB have come to them asking about vaccination and travel advice,” she said
“When you get people together in a sit-down, status-neutral environment, the most amazing things can happen.”
Dr Mann was disappointed that the research made no mention of the HealthPathways initiative, an online resource for GPs.
“This project is very useful to GPs. It connects primary care with specialists, and outlines the process and steps to take.”
Dr Najjar agreed that online resources would play an essential part in better supporting GPs, especially for those working in rural and regional communities.
“But we need to be asking the GPs exactly how they want to receive the information and support. This might involve working out localised models of care,” she said.
Associate Professor Jane Smith, discipline lead for general practice at Bond University and fellow of the Royal Australian College of General Practitioners, said that while
CHB management was an important issue, it was essential to consider it in the wider context.
“The hepatitis B immunisation program, in particular the birth dose, is working, and rates of infection are in decline in Australia,” she told MJA InSight.
“Chronic hepatitis B affects less than 1% of the population, and these are mostly migrants.”
Professor Smith said the survey results reflected the “mixed messages” GPs received about CHB.
On one hand, GPs are told it is an uncommon condition, and on the other, they were being warned that lots of people were going undiagnosed, she said.
Professor Smith said that of the patients who were diagnosed, only a fraction would require antiretroviral therapy.
“The guidelines [for CHB management] are out there, but this is a niche market and only of high priority to select GPs working in high-risk areas.”
Professor Smith said that the main message to promote was that GPs should be aware and monitor patients who were at risk for CHB.
“I do not think it would be good to promote population-wide testing of CHB serology. This would lead to all sorts of harms.”
Although hepatitis B serology can sometimes be confusing, there are online resources available to assist GPs in this.
Hepatitis B immunisation is working, and birth dose inclusive infant vaccination has prevented tens millions of chronic hepatitis B (CHB) infections already. However the prevalence of CHB in Australia is actually increasing. This is one reason why liver cancer is the fastest increasing cause of cancer deaths in Australians.
It has been estimated that 15-25% of people living with CHB need treatment to prevent cirrhosis and/or liver cancer – our Second National Hepatitis B Strategy sets a target of 15% by 2017, meaning current treatment levels need to double in the next year. This will never happen unless GPs serving priority populations are properly supported and resourced to increase community-based testing, monitoring, and antiviral treatment.
A US study estimated screening for CHB is cost effective down to a population prevalence of 0.3% – compared to a prevalence in Australia of 1%. However with only just over half of the 220,000 Australians living with CHB believed to have been diagnosed, even for priority populations we have a long way to go.
Conflict of interest – co-author of the paper under discussion.
The study published this week in the MJA highlights the attitudes and confidence of GPs, but does not provide evidence about whether or not care can be successfully delivered in general practice. Chronic hepatitis B affects 1% of the population and identification of risk and appropriate screening is part of standard care and assessment of liver cancer risk in general practice. Advanced management and prescribing of antiviral treatment may be more appropriate for GPs with higher caseloads and an interest in this area. A relevant example is the care for people with HIV in Australia, where specialised GPs shoulder the majority of care in a complex chronic viral infection in partnership with specialist colleagues. In project ECHO in the USA, complex hepatitis C management was successfully devolved to primary care with supportive education and links to referral services. The evidence shows that care in general practice in complex chronic viral infections can be achieved. This is a realistic and necessary goal as we aim to increase delivery of care to the estimated 190,000 people living with chronic hepatitis B who are not receiving care. The paper by Najjar and colleagues demonstrates that first we need to enable interested GPs to gain confidence in management and antiviral treatment.
Its indeed a neat well performed job to assess the capacity of the GPs regarding HBV management, and provides important inputs regarding the attitude of GPs. The findings could pave the way for development of programs to educate the GPs and such interactions could also indirectly lead to greater participation of the GPs in various Hepatitis B Eradication and Control Programs.