Cluster randomised trial to evaluate a complex intervention to increase diagnosis and treatment of patients with Hepatitis C in primary care: HepCATT trial qualitative evaluation

Problem

Public Health England (PHE) estimates that there are upwards of 160,000 individuals in England and Wales with chronic Hepatitis C Virus (HCV) infection, but thus far, only around 100,000 laboratory diagnoses have been reported to PHE and, of these, 28,000 have been treated. Thus, there is a significant number of infected individuals in whom the diagnosis has not been made and a large number of people who have not been treated. Targeted case finding in primary care is estimated to be cost-effective, but there is no robust RCT evidence of specific interventions. The HepCATT trial consisted of a complex intervention to support NICE recommendations on HCV infection by aiming to increase testing of high risk individuals, and increase the treatment of newly-diagnosed individuals within primary care.

Approach

HepCATT trial intervention practices received training on HCV for practice staff; HCV poster and leaflets and a HCV risk prediction audit-tool algorithm based on information on possible risk markers in the electronic patient record, run using Audit+ software (Informatica Systems Ltd). The audit-tool was used to recall and offer patients a HCV test either opportunistically through pop-ups or by inviting patients by letter. Control practices followed usual care. This qualitative evaluation aimed to examine intervention practice staff’s experiences and acceptability the intervention. Semi-structured interviews were conducted with 15 practice staff (GPs, Nurses, practice managers and IT managers). Interviews were audio recorded, transcribed, imported into NVivo 10 and analysed thematically. Normalisation Process Theory (NPT) was used to understand the process of implementing the intervention.

Findings

One of the main reasons practices engaged with the HepCATT trial was led by an interest in finding out whether there were any patients at the practice at higher risk of HCV who had not been previously identified. Practices felt that having the study in the practice and receiving the training improved people’s knowledge of the risk factors and prompts for testing for HCV. While some practices experienced initial teething problems with setting up the audit-tool the majority found it helpful and useful. However, some practices felt that screening lists of patients identified were not always appropriate and benefits of the audit tool were offset by the time and resources needed to screen patients. This was more of a problem in some practices, depending on practice profile and type of registered patients. ‘Pop-up fatigue’ impacted on opportunistically offering patients a HCV test. Interviewees suggested that the intervention would benefit from greater integration with existing GP practice IT systems.

Consequences

Our results indicate that there is an appetite amongst practices to engage with a complex intervention to identify and test patients who are at higher risk of HCV. However, careful implementation of the intervention is needed to fully realise its potential.