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Knowledge of chronic hepatitis C among East London primary care physicians following the Department of Health's educational campaign

R.F.C. d'Souza, M.J. Glynn, E. Alstead, C. Osonayo, G.R. Foster
DOI: http://dx.doi.org/10.1093/qjmed/hch060 331-336 First published online: 19 May 2004

Abstract

Background: In August 2002, the Department of Health (DH) wrote to all general practitioners (GPs) in England about hepatitis C, enclosing an educational booklet.

Aim: To assess hepatitis C knowledge among East London GPs in June 2003.

Design: Postal questionnaire and face-to-face interviews.

Methods: A questionnaire was mailed to 250 (South-East) and 600 (North-East) London GPs, with reminders where needed. We randomly selected 10 GPs for face-to-face standardized interviews.

Results: Overall questionnaire response was 56% (South-East) and 57% (North-East), with little difference between the groups. Some 86% knew that hepatitis C was common in people who inject drugs, and that its prevalence was higher than HIV. However, 14% believed that antibodies to the virus indicated that the patient no longer had active disease. Some 49% thought that materno-fetal transmission was common, and 50% believed that blood transfusion in the 1990s carried a high risk of infection. Only 23% knew that 20% of patients develop cirrhosis after 20 years, and only 58% were aware that therapy was effective in > 50% of cases. Responses among the interviewed GPs were similar.

Discussion: Knowledge of hepatitis C among GPs remains poor. Every GP surveyed wished to be better informed. We hope the DH will produce and audit further educational campaigns.

Introduction

Chronic hepatitis C is an important public health problem world-wide.1 In England, the Department of Health estimates that > 200 000 individuals are infected and the majority are unaware of their infection.2 General practitioners (GPs) are often the first health care professionals to see infected individuals, and they need to be aware of the risk factors, diagnosis, management and complications of this common, treatable infection, to facilitate diagnosis and appropriate referral. In France and America, studies have found that primary-care physicians had little knowledge about hepatitis C.3,4,,5 In these studies, GPs most frequently asked for guidance regarding interpretation of positive tests, prevention of transmission, and guidelines on diagnosis and management of hepatitis C infection.6

The Department of Health has issued a booklet on hepatitis C that was developed with the assistance of an expert panel and key stakeholders in hepatitis C. The aims of this detailed 46-page booklet are to prevent new cases of hepatitis C infection, to identify those who are chronically infected by increasing testing for hepatitis C, and to offer specialist advice and appropriate treatment via co-ordinated pathways of patient care. The Department of Health wrote to all GPs in August 2002 to inform them about hepatitis C, and provided them with this educational booklet to improve their knowledge of the virus. We assessed the level of knowledge of East London GPs, 10 months after the Department of Health hepatitis C information campaign.

Methods

We devised a self-administered questionnaire of eight closed and two open-ended questions. Answers to our questions were contained within the August 2002 Hepatitis C booklet, sent to all GPs in the UK in August 2002. Ten senior practitioners were chosen from primary care trusts in the East End, and they assessed the questionnaire for content and relevance to them. Six suggested two further open-ended questions, which we included.

Permission was obtained from four primary care trusts in the South-East sector of London and six primary care trusts in North-East London to contact GPs in their area, and the revised questionnaire was then mailed to 250 GPs in the South-East and 600 GPs in North-East London, in June 2003. GPs were asked to fax their replies to a central office.

The 250 South-East London GPs were selected randomly from 750 GPs; the 600 North-East London GPs were chosen randomly from 650 GPs in North-East London. The majority of GP practices consisted of multiple partners, < 5% being single partners. The South-East region serves an underprivileged area with high levels of unemployment, where 30% of the population are 2nd and 3rd generation Afro-Caribbeans, while the North-East region serves a generally deprived area, with over 50% of the population being derived from the Asian continent. Both regions are reported to include people who inject drugs.

GPs who did not reply within the first 6 weeks were sent a postal reminder with a repeat questionnaire. After a further 6 weeks, if they still had not replied, they were telephoned and were offered an appointment for an interviewer to come to the surgery or to telephone them at a convenient time to aid filling in the questionnaire.

After 24 weeks the study was closed.

At the same time, we randomly selected 10 GPs for face-to-face open-ended interviews derived from the cohort of GPs from the East End of London who had been invited to complete the questionnaire. We conducted these interviews to try and assess the reasons for any lack of knowledge by GPs, and ways in which this knowledge could be improved. The interview was carried out in a standardized manner in the form of a list of structured open-ended questions with responses recorded. Selected GPs were telephoned and asked if they were willing to take part. Only six agreed, and a further four were selected. These latter four consented to be interviewed. All ten physicians were sent a letter thanking them for participating and confirming the time and date of the interview. The four practitioners who decided not to take part declined because of time constraints or understaffing in the practice.

Results

Face-to-face interviews

We discussed opinions and beliefs about hepatitis C, including transmission, screening, treatment, and ways of improving services. The general practitioners were encouraged to speak freely, to raise issues important to them, and to support their responses with examples from clinical practice.

Each general practitioner saw an average of 4.2 hepatitis-C-infected patients (range 0–15 patients). All were aware that infection was common in people who inject drugs and could be prevented by meticulous hygiene. Needle exchange facilities were available in three practices, who actively referred patients to these programmes; four were unaware of these facilities, and three did not refer patients as they believed it encouraged them to inject drugs. However, all of the ten general practitioners were aware of local drug services, and nine believed that they were effective.

Although our entire panel recognized that people who inject drugs were a major route of transmission, knowledge of other modes of transmission was limited. The majority believed that materno-fetal transmission was common (in fact transmission occurs in 5%7), and pregnant women were wrongly advised that there was a 50:50 chance of transmission to their child. All of our GPs urged mothers not to breast feed due to the risk of transmission. This is erroneous, as is the view of six practitioners who believed that blood transfusion throughout the 1990s carried a high risk of transmitting the virus.

We reviewed diagnosis and screening of hepatitis C in the practitioners surgery. Of concern, two general practitioners believed that the presence of antibodies against hepatitis C indicated that patients had eradicated the virus and had immunity from further infection. Most of our sample of primary care physicians did not screen people who inject drugs until they believed that they were ‘clean’. In their opinion if the first test was negative, unreformed people who inject drugs remained at risk of infection and therefore screening was futile. In their opinion these patients should take responsibility for their own health and show a commitment to being ‘clean’ prior to seeking testing or treatment. Two general practitioners did not screen patients at high risk for hepatitis C due to poor resources. They claimed that, in their experience ‘these patients’ (i.e. patients currently injecting drugs) consistently do not turn up for their appointments and are not compliant with treatment. Two doctors indicated that all homosexuals should be screened. All of our panel of GPs wanted routine screening of all pregnant women for HCV introduced.

All of our panel of primary care physicians would welcome open-access clinics manned by hospital staff, and all had insufficient time to counsel patients prior to hepatitis C testing. In their opinion, antibody-positive patients should be followed-up by hospitals automatically. Two of the panel routinely vaccinate hepatitis-C-infected patients for hepatitis A and B, and all advise their infected patients to cease all alcohol intake as this worsens progression of liver disease.

Knowledge about treatments for hepatitis C was limited, perhaps reflecting the rapidity of progress in this area. No practitioner was aware of the availability of pegylated interferon (which is now the treatment of choice for infected patients8,,9) and only three were aware of the value of combination therapy (ribavarin and interferon). Five general practitioners believed that chronic hepatitis C should be treated with interferon monotherapy, and two suggested combination treatment with lamivudine and interferon (lamivudine is recommended for therapy for HIV and hepatitis B). Three primary care physicians agreed that treatment is effective in more than 50% of patients and four, who recommended therapy with interferon and ribavirin, were aware of the main side-effects of treatment. Three GPs selected patients for referral based on their assessment of their fitness for therapy.

Knowledge of the complications of hepatitis C were discussed—six practitioners believed that 50% of patients develop end-stage complications of their HCV in 20 years (current opinion suggests that 20% will develop cirrhosis after 20 years10) and two only referred patients with cirrhosis who had decompensated liver disease for treatment (i.e. patients who have developed ascites, encephalopathy, variceal bleeding or electrolyte imbalance). The primary care physician followed-up patients with compensated cirrhosis, but no doctor screened these patients for hepatocellular carcinoma by ultrasound or alpha-fetoprotein evaluation. Our practitioners believed that the Department of Health booklet was useful to refer to, but was too detailed and long. A short summary with bullet points would have sufficed. More investment was promised in the document and is still awaited.

Primary care physicians were of the view that more should be done to facilitate education in hepatology. They suggested hepatitis C workshops and liver clinics in the primary care setting by hepatologists, together with training of primary care physicians with a specialist interest in hepatology. General practitioners complained that they are often not involved in liver meetings and want more involvement. They also saw a need for more public education, and were concerned that ethnic minorities were particularly poorly informed.

Postal questionnaire

A total of 250 GPs were mailed in South-East London, of whom 105 returned replies in the eight-week period from mailing; reminders resulted in a further 24 replies in the following eight weeks, and a further 12 replies from telephone calls or visits to the surgery. This resulted in a total of 141 (56%) general practitioners replying from South-East London. Similarly, 341/600 (57%) practitioners from North-East London completed the questionnaire: 284 replies in the first eight weeks, followed by 41 and subsequently 16 respondents at eight-week intervals, respectively. There were no clear differences between the two groups and Table 1 summarizes the responses. All respondents completed the whole questionnaire.

View this table:
Table 1

Percentage of correct responses

PropositionSE London studyNE London studyMean
1. Patients who are hepatitis C antibody-positive no longer have active disease84%88%86%
2. Hepatitis C is common (>40%) in those who have ever used intravenous drugs85%90%88%
3. The prevalence of HIV is higher than hepatitis C in the East End86%88%87%
4. More than 50% of pregnant women infect their children43%55%49%
5. Blood transfusion in the 1990s carries a high risk of transmitting hepatitis C44%55%50%
6. In patients using intravenous drugs, transmission of hepatitis C can be prevented by meticulous hygiene and non-sharing of all paraphernalia85%95%90%
7. Therapy for hepatitis C is effective in eradicating the virus in more than 50% of patients treated64%52%58%
8. Out of 100 patients with chronic hepatitis C, which proportion of patients will develop cirrhosis in 30 years (5, 10, 20, 50, 70)25%20%23%

The great majority of GPs (>86%) were aware that hepatitis C was common in people who inject drugs, and that the prevalence is higher than HIV. However, 14% believed that the presence of antibodies to the virus indicated that the patient no longer had active disease. Another common misconception related to transmission: 49% thought that materno-fetal transmission occurred in >50% of infected women (transmission occurs in around 5%) and 50% of practitioners believed that blood transfusion in the 1990s carried a high risk of infection.

Knowledge of the natural history of HCV was limited: only 23% of general practitioners knew that 20% of patients develop cirrhosis after 20 years, and only 58% were aware that therapy was effective in >50% of cases.

In response to our open questions, most doctors screened some patients for hepatitis C (23% did not) and of those who screened, 14% tested homosexuals or patients with learning difficulties. Every general practitioner requested more information, and 71% believed that there should be more public education, together with linguistically and culturally appropriate patient information for ethnic minorities in the East End. Links between primary care physicians and hepatologists should be improved, with representatives from the primary care trusts consulted in how this can best be set up. The only difference between the two groups was that the North-East London GPs requested that information about hepatitis C should be produced in Bengali or other Indian languages for the subset of their population who did not speak English.

Discussion

Chronic infection with the hepatitis C virus leads to advanced liver disease in a significant proportion of those who are infected.10,,11 Early diagnosis and treatment will significantly reduce the costs and mortality associated with this infection.12 The Department of Health acknowledges the problems associated with chronic hepatitis C infection, and has begun to address the issue by writing to general practitioners to inform them about this virus. Our study is the first to assess general practitioners knowledge of hepatitis C in England, 10 months after this campaign, and shows that knowledge about this virus remains limited.

We assessed knowledge by an open interview in a small cohort of general practitioners, and a postal questionnaire of over 800 primary care physicians. Both approaches led to very similar conclusions, and although the response rate to our questionnaire was only a little over 50%, the consistent patterns of response suggest that the results are truly representative. There was also no significant differences in the questionnaire responses between these two diverse areas of London, which suggests that the responses may be representative of those throughout the UK. Our overall response rate was comparable to that observed in other surveys of GPs,5,,6 and reason for non-response to a survey is often due to lack of interest in the subject.17 It is possible that the practitioners who completed the survey were more interested in hepatitis C than practitioners who did not participate in this study, and their responses may represent the ‘best-case’ scenario with regards to knowledge regarding hepatitis C.

It is not surprising to find that in a rapidly developing disease area, such as hepatitis C, general practitioners are unaware of the latest therapy but we were concerned to find that a significant minority of primary care physicians are unable to interpret hepatitis antibody test results. As a result patients with hepatitis C are likely to be under-diagnosed and under-referred. We were dismayed to receive feedback suggesting that some primary care physicians appear to restrict access to health care for patients who inject drugs. Previous research has revealed discrimination against people who inject drugs,18 and health care workers who manage these patients need to be cognizant of the impact that their attitude has on treatment outcome.

The GPs wished to be better informed about the management of hepatitis C. They felt that the Department of Health booklet was too long and detailed, and that the main points should have been sent to them on a single sheet. Some GPs felt that providing information in this form was insufficient, and that they should have been consulted about changes that need to be implemented in primary care. They preferred to have seminars on hepatitis C offered by hospitals at times that were convenient for them. They felt that these seminars should not just be lectures, but that their views and questions should be answered and changes in the practice of HCV at the primary care level made accordingly. Some GPs wrote that there needed to be more resources at the primary care level so that they could have an afternoon off to attend these meetings. They felt that a 30 min CD-ROM presentation would be of benefit. They also felt that due to time constraints and work commitments, they were unable to take on patients with liver disease, and that one GP from a number of practices should be educated at the hospital by a hepatologist, and then have a liver clinic once a fortnight at one of the practices to encompass these patients. Due to resource issues, they felt that training one GP at present was not feasible and one of the hepatologists from the hospital should come to the practice once a month. This hepatologist should also be able to be contacted by GPs with any queries with hepatitis C patients.

Our primary care colleagues recognize their shortcomings, and all wish to be better informed about management of hepatitis C so that they can improve their clinical practice. Specific educational initiatives and practice guidelines for GPs are required to optimize the recognition of patients at risk for hepatitis C and to ensure appropriate testing and referral. These findings are similar to other studies in other countries, which have also demonstrated the poor knowledge base and practice patterns of their primary care physicians.4–,6 In Canada, rural primary care physicians' knowledge and confidence in managing patients with hepatitis C has improved dramatically since being given CD-ROM-based medical programmes,13 and detection rates have improved since the French Health Insurance Fund set up open-access clinics for HCV screening.14 Other health care services have thus been able to improve knowledge about HCV in the community,15,,16 and we hope that in England the Department of Health will recognize that knowledge amongst general practitioners is still poor, and will go on to produce and audit further educational campaigns.

Acknowledgments

Professor Foster acts as a consultant to companies who sell drugs for the treatment of viral hepatitis, and he has received research funding from such companies. He has received lecture fees from companies who market antiviral therapeutics.

References

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