BSG CSSC Service Development Prize 2022 highly commended submission by Sapna Gohil.

Antiviral treatment for hepatitis disease has significantly evolved in recent years, as multiple therapies have demonstrated higher cure rates and shorter treatment durations. Despite the widespread availability of these effective treatments, barriers continue to exist in establishing treatment access for these patients, particularly the most vulnerable due to various socio-demographic factors.

The Covid-19 pandemic has been a key driver in the transformation of hospital outpatient treatment access for hepatitis B and C patients across Coventry and Warwickshire. The UHCW Pharmacy High Cost Drug (HCD) Team have adopted a multi-agency approach with the Midlands Operational Delivery Network (ODN), clinical specialist teams and the commissioner to actively improve medication safety and adherence for these patients whilst fulfilling the NHS England and NHS Improvement (NHSEI) Commissioning for Quality and Innovation Scheme (CQUIN) Towards Hepatitis C Elimination.

Aims

This service evaluation explores the impact of multiple Plan-Do-Study-Act (PDSA) quality improvement initiatives, facilitated by the HCD Pharmacists in partnership with the multidisciplinary teams from September 2020 to July 2021 to achieve the following aims:

i) Hepatitis B (HB): FP10 HCD prescriptions to be switched to the new innovative hospital outpatient pharmacy hub and spoke model (HOP), enabling HCD collection from a patient’s local community pharmacy,

ii) Hepatitis C (HCV): conversely HCV patients struggled to reach the HOP and were offered HCV HCD homecare (HC) delivery, enabling direct delivery to the patient’s preferred address.

Methodology

Hepatitis B

95 patients were reviewed by the clinical team to determine eligibility for prescription processing via the HOP. Tenofovir and entecavir prescription supplies were increased from monthly to three monthly. Postage of FP10 prescriptions to patient homes ceased, and outpatient antiviral prescriptions were then clinically screened by a trained HOP pharmacist before being dispensed and collected from the patient’s local community pharmacy. Medication collection rates could be monitored as part of the new HOP key performance monitoring requirements.

Hepatitis C

The Pharmacy HCD team established robust service level agreements with two HC service providers to enable direct HC delivery to a patient’s preferred address. 18 patients were reviewed by the clinical team to determine eligibility for prescription processing via the new HC delivery model. All HC prescriptions were screened by trained HC screening pharmacists to check for timely blood results, clinical follow up reviews and completion of blueteq commissioning requirements to ensure prescribing compliance with the NICE Technology Appraisal criteria. Monthly HC service review meetings were scheduled between the Pharmacy HCD team and HC service providers to ensure monitoring of key performance indicators and reporting of clinical adverse events for the following antiviral therapies: i) elbasvir and grazoprevir ii) sofosbuvir, velpatasvir and voxilaprevir iii) sofosbuvir and velpatasvir iv) ledipasvir and sofosbuvir v) sofosbuvir vi) ribavirin.

The clinical teams offered virtual consultations to patients to support them and help reduce the potential risk of patient exposure to covid-19 during a hospital visit.

Results

100% of all HB and HCV patients were counselled, risk assessed and subsequently consented to the new prescription processing model offered to them by the clinical team. During the 11 month period, patients became well engaged with the new models as the hepatitis service observed a patient pool growth of 27% for HB and 89% for HCV with good patient feedback. There was a 64% reduction in the number of HB antiviral prescription dispensing episodes following the establishment of three monthly supplies. The new HOP key performance indicators showed more than 90% of HB patients were now well engaged in collecting their HB medications. The HCV HC clinical adverse event reports implied good tolerance to HCV antiviral therapies - only one clinical adverse event of drowsiness was reported during this time with the combination therapy, sofosbuvir and velpatasvir.

Conclusion

The hepatitis service across Coventry and Warwickshire is now able to treat more hepatitis patients locally in line with national standards, who had previously failed to engage with the clinical service. Regular pharmacist screening of prescriptions and monitoring of key performance indicators now provides greater assurance of medication safety. The outpatient HOP and HC delivery models both have robust governance arrangements and supply chains in place now for these specialist HCDs, to ensure service continuity during challenging times. Lean working practices and enhanced waste reduction via optimisation of dispensing cycles for HB prescriptions, have successfully achieved cost efficiencies in excess of £130,000. HC delivery to a patient’s preferred address has been particularly helpful for HCV patients who have no fixed abode – an effective service improvement at no extra cost to the commissioner or the hospital. This seminal work has been recognised nationally at the 2021 Health Service Journal Patient Safety Awards, where UHCW was shortlisted as a finalist in the Medicines Management category. The results were also acknowledged and praised by the NHSEI Midlands HCD Network.

In summary, these sustainable quality improvement initiatives tailored to patient’s socio-demographic needs across a vast geography, have safely improved antiviral hepatitis treatment access for those in need.