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Virtual Surveillance Pathway for Hepatitis B (HBV) Patients

Dr Cheh Kuan Tai & Dr Iain Ewing on behalf of the Academic department of medical and surgical gastroenterology at Homerton University Hospital NHS Foundation Trust

 

Authors and Institution

Dr Cheh Kuan Tai, Quality Improvement Fellow

Dr Iain Ewing, Consultant Physician and Gastroenterologist

Hayden Toner, Liver service administrator

 

Challenges

Hepatitis B (HBV) can lead to serious complications including hepatocellular carcinoma (HCC) and liver cirrhosis, but the disease is generally asymptomatic. We have a large cohort of treatment naïve chronic HBV patients requiring long term surveillance for HCC and periodic assessment of disease activity and liver fibrosis stage. These asymptomatic patients were being seen for follow up on a six-monthly basis in hepatology clinic primarily to organise surveillance investigations. This was causing a significant impact on follow-up waiting time, risked delaying surveillance investigations if clinics were cancelled or appointments missed, and patient experience of coming for a brief consultation for an asymptomatic condition was poor. We needed to design a robust virtual pathway to deliver evidence-based surveillance and disease assessment for these patients outside of a conventional outpatient setting.

 

How we managed the challenges

We created an electronic ‘virtual surveillance pathway’ commencing March 2018 based upon European Association for Study of the Liver (EASL) 2017 guidelines. Patients triaged to this pathway no longer have face-to-face clinic follow-up but are recalled by text message and postal invitation for surveillance ultrasound, with blood tests and elastography performed on the same visit when required. Results are reviewed in an electronic virtual clinic by a Consultant or Clinical Nurse Specialist with early recall to outpatient clinic if treatment indication is met or lesion found, or organisation of the next cycle of surveillance if there are no adverse findings. The virtual clinic outcome and future arrangements are electronically shared with the GP the same day with patients receiving a hard copy. The pathway is coordinated on the electronic patient record (EPR; Cerner Millennium) with patients booked into a timetabled ‘paper clinic’ after each cycle of surveillance tests.

 

Evaluation and Outcomes

  • 168 patients were recruited to the virtual pathway in the first year
  • Cancellation or non-attendance for surveillance investigations was less than 5% compared to just over 10% for face-to-face outpatient consultation
  • Liver clinic new to follow up ratio improved from 14:22 to 16:16
  • Routine follow-up waiting time fell from 24 weeks at inception of the pathway to 13 weeks at one year; weekly flexible appointments were added to the clinic template to allow rapid recall of patients meeting treatment criteria
  • 100% of respondents of patient satisfaction survey reported they were ‘very satisfied or fairly satisfied’ with the service (n=20)

 

Learning Points

  1. A virtual HBV pathway can deliver safe, evidence-based, and timely surveillance with a high degree of patient engagement and satisfaction
  2. Over a year, the virtual pathway saved more than 300 face-to-face outpatient appointments, improved new to follow-up ratio, and shortened waiting times for routine outpatient follow-up for other patients

 

Supporting information

Some examples are given below:

 

The protocol for testing HBV DNA, liver function tests and elastography alongside 6 monthly HCC surveillance ultrasound was derived from EASL 2017 guidelines as follows:

Virtual pathway (below):

 

Associated documents

HBV virtual clinic proposal October 2017 — attached below

 

References

EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection, Journal of Hepatology, 67; 370-398; 2017

 

Contact details for members interested in getting more information

Academic department of medical and surgical gastroenterology

Homerton University Hospital NHS Foundation Trust

Homerton Row, London, E96SR

[email protected]; [email protected]