Initial treatment for chronic hepatitis C: current therapies and their optimal dosing and duration

The main treatment goal in patients with chronic hepatitis C virus (HCV) infection is the prevention of progressive hepatic fibrosis by eradicating serum and intrahepatic virus. The current standard of care in previously untreated patients with chronic hepatitis C is combination therapy with pegylated interferon alfa and ribavirin. The duration of therapy and the dose of ribavirin should be determined according to the patient's HCV genotype. Adherence to the full dose of therapy for the prescribed treatment duration enhances the likelihood of sustained virologic response. Early virologic response is a good predictor of eventual sustained response for patients with HCV genotype 1 infection. Despite important gains in treating chronic hepatitis C, many treatment challenges remain.     

The role of physician extenders in managing patients with chronic hepatitis C

The number of "physician extenders" (nurse practitioners and physician assistants) caring for patients with chronic hepatitis C is rising rapidly. Their growing role in the management of these patients promises greater efficiency in the delivery of care and more provider interaction with patients. This may yield benefits in terms of patient education and support, management of medication side effects, and patient adherence to treatment regimens. This article reviews the role of physician extenders in the management of patients with hepatitis C and outlines strategies for maximizing their contribution to the care of these patients.     

Using cost-analysis techniques to measure the value of nurse practitioner care

Nurse practitioners are in a unique position to deliver high-quality care to a variety of populations and are being utilized in many countries worldwide. Although certain aspects of the nurse practitioner role may differ from country to country, limited financial support and competition for access to patients make it incumbent on nurse practitioners to document the cost-effectiveness of their care. Cost analysis, a business tool that can be used by any practitioner in any health care system, was used to examine business practices of an academic-based nurse-managed centre. In order for this tool to be effective, nurse practitioners must become comfortable with using cost-analysis techniques in their practices. Linking outcome data with cost data was found to be one method for explicating the value of nurse practitioner practice. Nurse practitioners must also recognize that they are competing with primary-care physician practices and other primary health-care practices. It is vital for nurse practitioners to document both the quality and the costs of their care in order to compete with physicians and other health care providers, in order to influence policy and other health-care decision makers.     

Physician - nurse practitioner teams in chronic disease management: the impact on costs,clinical effectiveness,and patients' perception of care

Increasing demand to deliver and document therapeutic and preventive care sharpens the need for disease management strategies that accomplish these goals efficiently while preserving quality of care. The purpose of this study was to compare selected outcomes for a new chronic disease management program involving a nurse practitioner - physician team with those of an existing model of care. One hundred fifty-seven patients with hypertension and diabetes mellitus were randomly assigned to their primary care physician and a nurse practitioner or their primary care physician alone. Costs for personnel directly involved in patient management, calculated from hourly rates and encounter time with patients, and pre- and post-study glycosylated hemoglobin (HbA(1c)), high-density lipoprotein cholesterol (HDL-c), satisfaction with care and health-related quality of life (HRQoL) were assessed. Although 1-year costs for personnel were higher in the team-treated group, participants experienced significant improvements in mean HbA(1c) ( - 0.7%, p = 0.02) and HDL-c ( + 2.6 mg dL( - 1), p = 0.02). Additionally, satisfaction with care improved significantly for team-treated subjects in several sub-scales whereas the mean change over time in HRQoL did not differ significantly between groups. This study demonstrates the value of a complementary team approach to chronic disease management in improving patient-derived and clinical outcomes at modest incremental costs.     

Role of the nurse practitioner in the management of patients with chronic hepatitis C

Purpose: To inform nurse practitioners (NPs) of the vital role they play in recognizing patients who may have hepatitis C. Data sources: Selected review of scientific literature. Conclusions: NPs involved in the management of patients with chronic hepatitis C are well positioned to provide supportive care and contribute to the development of effective treatment strategies that maximize the opportunity for successful treatment outcomes. Although peginterferon alfa plus ribavirin therapy is associated with a well-described series of side effects, effective measures are available for the management of these events that permit the continuation of treatment and enhance the likelihood of attaining sustained virologic response. NPs can play a pivotal role in ensuring that these measures are in place in a preemptive manner. For example, growth factor supplementation represents an alternative to dose reduction or treatment discontinuation in selected patients with neutropenia or anemia and may help to improve treatment adherence. Implications for practice: Hepatitis C is a widespread problem; approximately 3% of the global population is chronically infected with the virus. Awareness of risk factors for hepatitis C will help the NP to recognize at-risk patients, who should then be screened for the virus and referred for treatment based on specific criteria.     

Interdisciplinary Care Coordination in Chronic Viral Hepatitis C

Chronic viral hepatitis C (CHC) is the most common bloodborne infection in the United States and may lead to progressive liver disease including cirrhosis and hepatocellular carcinoma. Directly acting antiviral treatment can produce sustained virological response and eradication of disease in >95% of patients. CHC disproportionately affects racial minorities, especially those with limited access to care. To bridge these gaps for unfunded patients, a collaborative care model was established at an urban free clinic. Primary care nurse practitioners, an infectious disease physician, a pharmacist, and an RN developed and implemented a standardized onsite referral process to reduce long-term morbidity and mortality among these patients.     

Treatment options for nonresponders and relapsers to initial therapy for hepatitis C

As treatment for chronic hepatitis C virus (HCV) infection has advanced over the past decade, efforts have evolved to retreat patients who did not achieve a sustained virologic response to previous antiviral regimens. Retreating nonresponders to interferon alfa monotherapy with a combination of interferon and ribavirin yields a sustained virologic response in 9% to 32% of patients, whereas retreatment with peginterferon alfa plus ribavirin yields a sustained virologic response in up to 30% to 40% of patients. Sustained virologic response is more likely in retreated patients with HCV genotype 2 or 3, low serum HCV RNA levels, and lack of response to prior interferon monotherapy. Retreatment of nonresponders to interferon-ribavirin combination therapy is associated with lower response rates (< or = 20%). Despite treatment advances, the efficacy of current antiviral regimens for nonresponders remains inadequate. The next few years will see more-targeted antiviral regimens for these patients and therapies focused on slowing the progression of liver disease rather than viral eradication.     

Gender and the attribution of the nurse practitioner and physician status

The purpose of this study was to discover whether sex-role sterotypes were used to identify members of two professions, nurse practitioners and physicians. Participants reported whether they believed a videotaped health care provider was a physician or a nurse practitioner. Results showed that male providers tended to be identified as physicians, whereas female providers tended to be identified as nurse practitioners. Findings indicate that understanding and enactment of the nurse practitioner and physician roles are still affected by gender issues and that both physicians and nurse practitioners remain subject to the force of sex-role stereotypes.     

Nurse practitioner alcohol intervention for people with viral hepatitis: Randomised controlled trial

BackgroundIn Australia, alcohol use is accountable for 5.1% of the total burden of disease and injury along with being responsible for 24% of the burden as a result of chronic liver disease. There is a paucity of quality evidence-based programmes for alcohol use management and the chronic viral hepatitis population.AimsTo evaluate the effectiveness of an alcohol brief intervention for ambulatory patients with chronic viral hepatitis C attending a hepatology clinic.MethodsA randomised controlled trial determined the effectiveness of: a brief intervention and routine care (Group 1) compared to routine care only (no formalised intervention) (Group 2). Alcohol reduction is the primary outcome measure. Reduction in risky drinking and quality of life were also measured. Data was collected at three-time points, baseline prior to randomisation, four weeks and eight weeks.FindingsAlcohol intake reduced in both groups at 4 weeks, with 57% (intervention) and 41% (control) having a 50% reduction in alcohol (p = 0.295). This reduction was maintained by both groups at 8 weeks with 53% (intervention) and 43% (control) (p = 0.536). The intervention group showed a greater reduction over time, but this was not statistically significant.DiscussionIncreasing nurse led models of care, such as nurse practitioners specialising in hepatology, could provide an effective response for managing people with chronic viral hepatitis C and alcohol misuse.ConclusionAssessing for alcohol use using the AUDIT C and TLFB_A and providing a brief intervention with routine care by the Nurse Practitioner, Hepatology is an acceptable and useful intervention to reduce alcohol consumption in this population.     

Nominations for Excellence: Collegial Advocacy for Nurse Practitioners

This study examined physician nomination data submitted for Syntex Nurse Practitioner of the Year Awards for 1988, 1989, and 1990. The physicians identified nurse practitioner contributions to patient care, community service/outreach, and education and research. A content analysis of the text data yielded themes within four major domains that described outstanding nurse practitioners in mutual practice relationships with physicians. The domains were clinical expertise, holistic caring, patient-centered activism, and leadership. The findings in this study indicated that physicians value the contributions of nurse practitioners that enhance the quality and scope of health care for patients within a mutual practice.     

Who is a nurse practitioner? Processes of care and patients' and physicians' perceptions.

During a repeat of a previous study of nurse practitioners conducted at the University of Kansas, an opportunity occurred to examine the impact of two different styles of care provided by nurse practitioners on patients and physicians with whom they worked. The two nurse practitioners involved had similar backgrounds in terms of work experience. The participated in the same training program for nurse practitioners, practice in the same environment, and cared for patients randomly allocated to one or the other practitioner. One practitioner saw her patients more often and for longer periods of time, ordered more medications, and less often sought physician consultation. She also was most optimistic regarding the impact of her services on patients' conditions. The other was more dependent upon physicians for validation of her actions. Physicians did not distinguish between the two practitioners in terms of their performance. However, patients cared for by the practitioner whose behavior suggested an integration of medical and nursing care processes saw nurses as a more common source of information about illness and demonstrated more significant shifts in preferences for services provided by nurses rather than physicians. No significant changes were noted from pretest values among patients cared for by the other nurse practitioner.     

My Treatment Approach to Chronic Hepatitis C Virus

The treatment of chronic hepatitis C virus (HCV) is evolving rapidly. In 2014, the standard of care and new backbone of HCV treatment is the polymerase inhibitor sofosbuvir (SOF). Our treatment approach in patients with HCV genotype 1 is 12 weeks of SOF, peginterferon (PEGINF), and ribavirin (RBV). In patients with cirrhosis or extrahepatic manifestations of HCV who cannot tolerate PEGINF, we use 12 weeks of SOF and simeprevir. The latter is less costly and more effective than SOF and RBV for 24 weeks. Our treatment approach in all patients with genotype 2 is SOF and RBV for 12 weeks. Hepatitis C virus genotype 3 is now the most costly and difficult to cure. Our approach to treatment-naive patients with genotype 3 is SOF and RBV for 24 weeks. In patients who have previously undergone PEGINF and RBV treatment, we use PEGINF, SOF, and RBV for 12 weeks, which is equally if not more effective and less costly than SOF and RBV for 24 weeks. Patients with cirrhosis who cannot tolerate PEGINF should be treated for 24 weeks with SOF and RBV, although the sustained virologic response is suboptimal.     

Objective and subjective measures of the quality of managed care in nursing homes

BACKGROUND: The number of nursing home (NH) residents enrolled in managed care plans (HMO) will increase, and there is concern that the quality of their medical care may be compromised by cost-containment pressures. In this study, we evaluated the medical care of residents enrolled in 3 health maintenance organizations (HMO) that developed specific long-term care programs. OBJECTIVES: To compare the medical care received by NH residents enrolled in HMO and Fee-for-Service (FFS) plans with both objective process of care and consumer perception (subjective) measures. To describe the relationship between the objective and subjective measures. MEASURES: Number of primary care visits per month; process of medical care for 2 geriatric tracer conditions (falls, fevers); family and residents' perceptions of the adequacy of sickness episode management; and the frequency of primary provider visits. DESIGN: Quasi-experimental. RESULTS: HMO residents received more timely and appropriate responses to falls and fevers than did FFS residents. HMO residents also received more frequent routine visits by a primary care provider team consisting of a physician and nurse practitioner. Consumer perceptions of quality did not differ between the HMO and FFS groups. Families within both groups were significantly more positive than were residents about the frequency of visits by both physicians and nurse practitioners. Within the HMO group, both families and residents were more positive about the frequency of nurse practitioner visits than were physician visits even when the frequency of visits by the 2 providers were similar. CONCLUSIONS: Although the medical care received by HMO residents was better on most objective process measures than that received by FFS residents, consumer perceptions of care did not detect those differences. NH residents and families have different perceptions about the adequacy of visits by physicians and nurse practitioners, and both families and residents appear to have different expectations concerning how often they want physicians to visit as compared with nurse practitioners.     

Effects of a nurse practitioner on a multidisciplinary consultation team

Title.  Effects of a nurse practitioner on a multidisciplinary consultation team.
Aim.  This paper is a report of a study to evaluate the impact on office hours capacity, patient satisfaction, quality of life and costs of including a nurse practitioner in a multidisciplinary consultation team for patients with hand problems caused by rheumatoid arthritis.
Background.  Over 90% of patients with rheumatoid arthritis suffer symptoms in their hand joints and may be seriously disabled in performing daily, work or leisure activities. A recent promising development in the treatment of patients with a chronic disease is the co-ordinating and accompanying role of a nurse, such as a nurse practitioner, in a multidisciplinary treatment team.
Methods.  A two successive group time-series design was adopted. The intervention group ( n  = 78) visited a clinic with a nurse practitioner assigned to the team during 2003–2004. The control group ( n  = 69) was seen before inclusion of the nurse practitioner. Office hours capacity, patient satisfaction, quality of life and costs were assessed using questionnaires directly after consulting the team, and 3 and 6 months later.
Results.  Between-group comparisons of patient satisfaction and quality of life revealed no statistically significant differences. Changes within groups over time were not demonstrable. Mean office hour capacity increased by 17% ( t  = −1·906, d.f. = 32·879, P  = 0·065). The costs for professional home care or informal care were equal in the two groups.
Conclusion.  Evaluation of clinical practice using pre- and post-test design was impeded by changes in clinical practice, which made concrete conclusions difficult to draw. In future studies the satisfaction of participating clinicians should be evaluated, in addition to that of patients.     

Managing the hematologic side effects of antiviral therapy for chronic hepatitis C: anemia, neutropenia, and thrombocytopenia

Hematologic abnormalities such as anemia, neutropenia, and thrombocytopenia are common during combination therapy with pegylated (or standard) interferon and ribavirin for chronic hepatitis C. Ribavirin-induced hemolytic anemia is a common cause of dose reduction or discontinuation. Bone marrow suppression also contributes to the anemia and is the predominant mechanism for interferon-induced neutropenia and thrombocytopenia. Although dose reduction or discontinuation of combination therapy can reverse these abnormalities, they may reduce virologic response. Hematopoietic growth factors may provide a useful alternative for managing these hematologic side effects without reducing the optimal dose of the combination antiviral regimen. Treatment of anemia also may improve patients' health-related quality of life and their adherence to combination antiviral therapy. The impact of growth factors on sustained virologic response and their cost-effectiveness in patients with chronic hepatitis C need further assessment.     

Nurse practitioners substituting for general practitioners: randomized controlled trial

Title.  Nurse practitioners substituting for general practitioners: randomized controlled trial.
Aim.  This paper is a report of a study conducted to evaluate process and outcomes of care provided to patients with common complaints by general practitioners or specially trained nurse practitioners as first point of contact.
Background.  Studies in the United States of America and Great Britain show that substituting nurse practitioners for general practitioners results in higher patient satisfaction and higher quality of care. As the American and British healthcare system and settings differ from that in the Netherlands, a Dutch trial was conducted.
Methods.  A total of 1501 patients in 15 general practices were randomized to consultation by a general practitioner or a nurse practitioner. Data were collected over a 6-month period in 2006 by means of questionnaires, extracting medical records from practice computer systems and recording the length of consultations.
Findings.  In both groups, the patients highly appreciated the quality of care. No statistically significant differences were found in health status, medical resource consumption and compliance of practical guidelines in primary care in the Netherlands. Patients in the NP intervention group were more often invited to re-attend, had more follow-up consultations and their consultations took statistically significantly longer.
Conclusion.  Nurse practitioners and general practitioners provide comparable care. Our findings support an increased involvement of specially trained nurse practitioners in the Dutch primary care and contribute to knowledge of the effectiveness of care provision by nurse practitioners from a national and international perspective.     

A multimorbidity nurse practitioner-led clinic: Evaluation of health outcomes

BackgroundHealthcare services for people living with multiple chronic diseases have traditionally been organised around each condition, an approach which is neither resource-efficient nor convenient or effective for patients. The integrated nurse practitioner service reported here was developed to optimise patient experience and outcomes within a chronic disease self-management framework.AimTo evaluate patient outcomes following attendance at an integrated chronic disease nurse practitioner clinic for multimorbidity.MethodsA prospective service evaluation of adults with any combination of chronic kidney disease, diabetes and/or heart failure between June 2014 and December 2017. Demographic and clinical outcomes at entry and after 12 months of clinic attendance were collected from health records of all patients (n = 162); a subgroup also completed health-related quality of life and self-efficacy measures at entry and 12 months follow-up (n = 106).FindingsPatients attending the clinic had complex needs and poor health-related quality of life. Despite the complexity of their health problems, as a cohort blood pressure was well-controlled and self-efficacy for chronic disease management was relatively high. Over the first 12 months of integrated nurse practitioner care, there were large improvements in physical aspects of health-related quality of life and many patients achieved reductions in body mass index. Use of hospital inpatient and emergency services also decreased.DiscussionNurse practitioner-led services have the potential to reduce treatment burden and deliver integrated chronic disease management.ConclusionsThe multimorbidity clinic has improved health outcomes in this patient cohort and offers a model for enhanced primary care.     

Management of patients in the intensive care unit: comparison via work sampling analysis of an acute care nurse practitioner and physicians in training.

BACKGROUND: Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients' outcomes. OBJECTIVE: To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients' care in a step-down medical intensive care unit. METHODS: Work sampling techniques were used to collect data when the nurse practitioner had 6 months' or less experience in the role (T1), after the nurse practitioner had 12 months' experience in the role (T2), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T3). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities. RESULTS: Results for T1 and T2 were similar. When T2 and T3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P < .001) and less time in nonunit activities (15% vs 37%; P < .001). CONCLUSION: The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients' families and collaborating with health team members.     

The clinical trial as a means for organizational change: report of a case study.

An attempt was made to introduce an innovation (nurse practitioners) into an organization (an outpatient clinic) using the format of a clinical trial. Staff physicians evaluated patients as to their acceptability for care by nurse practitioners before and after a 12-month trial. "Acceptable" patients were randomly assigned to control (regular clinic) and experimental groups (nurse practitioner care). There was a statistically significant increase (p less than 0.001) in physicians' willingness to delegate patients to nurse practitioners for care after the trial. Initial assessments of "acceptable" were highly associated with demographic variables such as age, race, and level of education. Patients' medical status, rather than personal characteristics, were found to be associated with decision making on re-evaluation. Positions were created for nurse practitioners on the staff of the clinic at the end of the experiment.