Doorbraakprojecten HCV in de verslavingszorg

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1 Doorbraakprojecten HCV in de verslavingszorg Doorbraak of niet? Esther Croes MD PhD

2 Disclosure De Doorbraakprojecten zijn gefinancierd met publiek-private bijdragen: Publiek: Ministerie van VWS & ZonMW Privaat: Roche, MSD, Janssen, Gilead, Abbvie 2

3 HCV in Nederland n = first generation migrants Drug users n = Low fruit 2% 5% 25% 27% % MSM Hiv-positieven (non-du, non- MSM) haemophilia patients low risk population 2% 18% 3% 2% 15% % Vriend et al, 2012 Koopsen et al, submitted 3

4 Drugsgerelateerde infectieziekten Prevalence* Low - medium (<0.1 10%) HIV HBV HCV Low (<5%) Diagnosed High Medium Low In treatment/ in follow up High Medium Low C/ HCV is de grootste uitdaging High (30-80%) En: incidentie is nihil, dus eliminatie zou mogelijk moeten zijn! *estimates! 4

5 1 e respons: Informeren! 5

6 Conclusies informatiecampagne Drugsgebruikers campagne Publieke campagne Identificatie nieuwe patiënten ICER (95% CI) 9,056 ( ,523) 18,421 ( 7,376 25,490). Probabilistic sensitivity analysis naar kosteneffectiviteit 100% 34% Gemodelleerd met behandeling met DAAs: kosteneffectiviteit nog beter. Helsper et al.,

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8 Lokale belemmeringen Op de locatie waar ik werk De grootste barrière is there is hardly attention for HCV sometimes HCV tests; sometimes not HCV is always tested, but treatment arrangements are made screening and treatment are embedded in our regular work

9 Doorbraakprojecten Samenwerking 8-15 teams Gedurende een jaar Doel: realisatie van concrete verbeteringen in de patiëntenzorg, gebaseerd op evidence en/of best practices. Ondersteuning door inhoudelijke en methodische deskundigen. Sinds 2004 doorbraakprojecten in de GGZ in NL; conclusies: Redelijk groot bereik onder instellingen én cliënten Standaard werkwijze wordt in het algemeen goed gevolgd Processen verbeteren over het algemeen Cliënten profiteren, tussen 10% - 50% gaat er op vooruit Verbetering is in de regel minder dan gepland Teams zijn vaak enthousiast over nieuwe aanpak Men probeert ingeslagen weg te vervolgen (borgen) en soms verspreidt nieuwe werkwijze zich in regio of instelling.

10 Plan Do Study Act (Deming) 1. Doel: wat willen we bereiken? 2. Meten: hoe weten we dat een verandering een verbetering is? 3. Veranderen: welke veranderingen leiden tot een verbetering? PDSA-cyclus: plan do study - act act plan study do BSC R. Huijsman, vrij naar Deming

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12 Verzamelde best practices 12

13 Resultaten project 2013/2014 Participated clients during breakthrough project n=790 Tested for HCV antibody status n= 332 Positive HCV antibody test n=100 Not tested for HCV antibody status: n=442 Wish no HCV test: n=16 42% Data from 8/11 participating locations on 790 patients; data collection in Conclusions: % of patients tested differs widely between locations (29-100%)* Tested for HCV RNA status n=69 HCV testing still needs scaling up Positive HCV RNA test n=52 Referred to the hospital n=48 Not referred to the hospital: n=1 Unknown: n=3 92% 61% Referral to hospital and start of treatment has limited drop-out (NOTE: data include pre-daa era) Started with HCV treatment n=32 Sustained Viral Respons (SVR) n=16 Deferred HCV treatment: n=5 No treatment indicated: n=7 Unknown: n=4 No Sustained Viral Respons: n=6 Unknown: n=10 * The location with 29% of patients tested only included tests taken during the project, i.e. in 2014; other locations supplied data including the FU-period, in which testing was consolidated in daily practice Eijkhoff,

14 DOEN WE HET GOED? 14

15 Doen we het goed? QoL heroin dependence 0.57 QoL heroin dependence + chronic HCV /20/ Smit et al, 2008;

16 VHPB meeting May 2002 Health Strategy on HCV in The Netherlands van Hattum UMC utrecht MDL

17 HCV in The Netherlands current situation HC treatment of (ex) i.v. drug users active awareness programs in risk groups starting up nation wide training courses to professionals pilot study: - feasible in cooperation with the various professional societies if using infrastructure of drug user control programs special aspects concerning each professional group if the present staff is trained aiming - good at compliance IFN 6 months, 56 patients, 2 dropouts hygienic measures providing information to clients / patients diagnosing new patients In NL most drug addicts providing are registered treatment in programs everybody has a (mandatory) health insurance special HC treatment (IFN+riba) programs is available of risk groups and refundable UMC utrecht MDL

18 Implementeren - Dissemination of information by itself does not lead to successful implementation (research literature, mailings, existence of practice - guidelines) - Training itself does not lead to successful implementation - Policies and funding alone do not lead to successful implementation 18

19 1 X 0 = 0 1 X 1 = 1 X =? Vrij naar Hedda en Ferry

20 President Obama about implementation: We have the best medical schools, the most sophisticated labs, the most advanced training of any nation on the globe. Yet we're not doing a very good job harnessing our collective knowledge and experience on behalf of better medicine. Less than 1 percent of our health care spending goes to examining what treatments are most effective. And even when that information finds its way into journals, it can take up to 17 years to find its way to an exam room or operating table Conference of the American Medical Association, 2009

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