Hepatology Providers Research Articles

Pharmacist engagement within a hepatitis C ambulatory care clinic in the era of a treatment revolution

ObjectivesTo describe an innovative hepatitis C virus (HCV) care program and treatment outcomes resulting from pharmacist services. SettingAdult ambulatory care HCV clinic within the Miami Veteran Affairs Healthcare System. Practice descriptionPharmacists with limited prescriptive authority are integrated into a medical hepatology care team. Practice innovationPharmacists screen patients with HCV infection for treatment eligibility, counsel patients upon treatment initiation, assess ongoing treatment success and toxicity through patient appointments, telephone calls, and the ordering of pertinent laboratory data, and provide oversight of all patients on HCV therapies. Treatment outcomes are reported to the institutional Antimicrobial Stewardship Program. EvaluationData produced from a continuous quality assurance initiative were utilized. Descriptive statistics were used to present data. ResultsFrom January 2014 through September 2015 there were 1619 pharmacist encounters for 532 unique patients and 597 screenings (including 578 approvals) were completed by a pharmacist. During this time 555 patients were initiated on at least 1 HCV treatment course, with 565 total treatment courses initiated. As new agents became available for use, fluctuation in regimen selection was seen. The most commonly prescribed medications were sofosbuvir (46%), ledipasvir/sofosbuvir (37%), and simeprevir (33%). Of the 565 HCV treatment courses initiated, 360 were completed, 29 were stopped early during treatment, and 176 were ongoing. Of the 360 completed courses, 249 had sustained virologic response at week 12 results available, of which 225 (90%) achieved treatment success and 24 (10%) relapsed. Of the 29 courses stopped early, 11 were due to poor medication adherence and 8 were due to adverse drug reaction. ConclusionThrough a structured process employing a scope of practice, pharmacists can extend the capacity of medical hepatology providers and provide pharmacotherapy services to enhance care. Information provided here may serve beneficial to others looking to initiate or expand existing HCV pharmacist services.

Hepatic Encephalopathy and Driving: A Survey of Current Practice Patterns

Introduction: Hepatic encephalopathy (HE), a complication of cirrhosis, spans a spectrum of neuropsychiatric dysfunction. Driving requires careful visuomotor coordination which can be hindered by HE. Prior studies of cirrhotic patients with HE revealed increased traffic violations and motor vehicle accidents in this cohort. Practice variation in mandatory reporting for medical impairment from HE has not been evaluated. We surveyed providers in a U.S. state (Oregon) with mandatory reporting of HE to determine awareness of state laws and counseling practices for driver restrictions. We compared these findings to responses from a neighboring state (Washington) without mandatory reporting to determine the impact of the law on practice patterns. Methods: A 13-question electronic survey was sent to gastroenterology and hepatology providers in Oregon and Washington addressing demographics and management of medical impairment due to HE. Results: 34 providers replied: 85.3% were MDs/DOs, 55.9% identified their specialty as gastroenterology, 35.3% hepatology; 35.3% were academic-based, 64.7% community-based. The majority (70.6%) practice in Oregon; 62.5% OR providers correctly understood state law as mandating report of medically impaired drivers. 66.7% WA providers correctly understood state law as encouraging, but not requiring, reporting of medically impaired drivers. Most providers never reported a patient to the DMV for HE (82.4%); most providers did not counsel patients with mild HE to stop driving (85.3%). A higher percentage of hepatologists (10/12, 83.3%) than gastroenterologists (11/19, 57.9%) counsel patients treated with lactulose and/or rifaximin for HE to stop driving; 100% of hepatologists (12/12) documented this as part of the medical encounter compared to 68.4% of gastroenterologists (13/19). Time, risk of upsetting the patient, and risk of placing unseen burdens on the patient were the most commonly cited perceived barriers to reporting a patient to the DMV. Conclusion: Limited awareness of state laws is present among OR and WA gastroenterology and hepatology providers for reporting drivers with medical impairment due to HE. While patients receiving medications for HE are more likely to be counseled, different practice patterns exist between gastroenterology and hepatology providers in the management of counseling these patients to stop driving. Further research is needed to evaluate barriers to knowledge of state law and varied practice patterns in counseling patients with HE.

Hepatocellular Carcinoma Surveillance: A National Survey of Current Practices in the USA

The incidence rate of hepatocellular carcinoma (HCC) in the USA is rapidly rising. Surveillance using biannual ultrasound (US) is recommended, but actual practices are unknown. To determine current HCC surveillance practices among gastroenterology and hepatology providers in the USA. A 21-question electronic survey was emailed to 12,485 gastroenterology and hepatology providers in the USA. The survey contained questions concerning provider background, surveillance practices, and opinions. Pearson chi-square and multivariate logistic regression tests were used to analyze the data. We received 777 responses (6.2% response rate); 656 were eligible for analysis. 92% place cirrhotic patients under surveillance independent of etiology, 79% exclusively use a 6-month interval, and 77% use alpha-fetoprotein. While 93% use US, only 36% use US exclusively and 60% use two or more imaging modalities. Providers from transplant centers favor using additional imaging modalities, instead of only US. Multivariate analysis showed transplant center providers who allocate more time to patient care (OR 1.96, p = 0.004) and see more cirrhotic patients (OR 2.07, p = 0.033) have increased odds of using additional imaging modalities. Participating providers reported very high rates of surveillance utilization and use of a biannual interval. It is likely that the sample is composed of providers who are very engaged and informed about HCC surveillance. However, their surveillance imaging practices largely deviated from practice guidelines, which all recommend only using US. Providers affiliated with transplant centers tend to use additional imaging modalities such as computed tomography and MRI, instead of US only.