An award-winning project to improve access to hepatitis C testing and treatment in community pharmacy for patients addicted to opioid drugs is set to be extended over the next few months.
NHS Tayside’s public health team won a Quality in Care (QiC) Programme award for researching and developing a new pathway to test and treat these hard-to-reach patients, which makes use of their daily contact with community pharmacists to receive opioid replacement therapy (ORT).
The project, which initially involved six pharmacies in Dundee, found these patients were almost four times more likely to get tested for hepatitis C in community pharmacy than in other care settings.
The team is about to commence a cluster randomised controlled trial (RCT) across an additional eight pharmacies in Tayside to evaluate further whether this approach can increase the uptake of testing among these patients and improve progression to treatment.
Hepatitis C infection can cause serious liver damage if left untreated, but new drugs are available that can cure infection. Injecting drug users are at greatest risk of acquiring the virus, yet only a small proportion of patients receiving ORT, which is the largest infected group, come forward for treatment.
An estimated 4,100 people are infected with hepatitis C in Tayside among a total population of 413,000. Around one in four patients prescribed ORT are likely to have been infected with hepatitis C.
Andrew Radley, consultant in public health pharmacy at NHS Tayside, says the team plans to run a phase II trial involving around 100 pharmacies across Scotland in 2016 to test the generalisability of the results they have observed.
For the RCT, the primary clinical outcome is the number of patients who achieve a clinical cure. “With the new hepatitis C medicines you’d expect around 95% cure [rate], so there’s a benchmark,” he says. “We’d want to confirm that this also happened in pharmacies.”
Secondary measures within the RCT will include looking at the number of patients that enter the clinical pathway and receive treatment.
“With the previous modelling around hospital attendance, around 2.5% of people per year actually manage to access treatment [for hepatitis C]. We think that with the pharmacy model it will be closer to 40% of eligible people,” adds Radley.
In the initial phase of the project – awarded ‘Best Treatment Pathway Initiative’ in the hepatitis C category of the QiC Programme Awards in October 2015 – the NHS Tayside team interviewed 45 people receiving ORT about their experiences of using pharmacy services and their preferences for care.
“We got many descriptions and experiences of positive care provided from pharmacies,” says Radley.
To understand more about the implementation of pharmacy services, the team trained staff at six participating pharmacies in the use of dry blood spot testing for hepatitis C, which was conducted opportunistically. Samples were sent for laboratory analysis and returned within a week, and identified patients who could benefit from treatment. The team found rates of testing were better than that recorded by other testing services.
For the pilot RCT, called DOT-C, investigators recruited two of the original pharmacies plus a further six, including independents, those in small groups and those that are part of large chains.
The pharmacists have undertaken good clinical practice training and pharmacy staff have been taught how to perform the blood spot test, how the treatments work and how to monitor and manage patients on treatment.
The team has also trained a community pharmacist who is an independent prescriber to organise treatment for individuals identified through the test, avoiding the need for patients to visit hospital.
Radley says the project is a good example of how clinical work is developing in community pharmacy. “[The Scottish Government’s] Prescription for Excellence [programme] tells us that pharmacists will increase the range of services that they offer and provide more responsive and flexible services for patients. This project takes them down this route, where they offer services that are more valued and more meaningful to the patients they serve.”
“I’ve been very proud to work as a member of this team, which has involved community pharmacists, hospital pharmacists, specialist nurses and the consultant medical team, who have all supported this move to develop services in community pharmacy,” he adds.
The QiC awards recognise good practice in patient care and joint working in key therapy areas. Current programmes include anticoagulation, diabetes, hepatitis C and oncology. The award judges said of the project: “This is a fantastic model and is the way forward, with potential to replicate in GP practices. It meets national objectives and shows great community awareness.”