A “one stop liver shop” approach improves the cascade-of-care for Aboriginal and Torres Strait Islander Australians living with chronic hepatitis B in the Northern Territory of Australia: results of a novel care delivery model

Abstract

Background Aboriginal and Torres Strait Islander Australians are disproportionately affected by Chronic Hepatitis B (CHB) with a prevalence of 6.08% in the Northern Territory (NT) and liver cancer rates 6 times higher than non-Indigenous Australians. Without appropriate care, overall 25% of those living with CHB will die from either liver failure or liver cancer, outcomes that can be minimised with regular follow up, antiviral treatment and hepatocellular carcinoma (HCC) screening. This care including antiviral treatment is publicly funded in the Australian setting however the care cascade still shows inequities in access to treatment for Aboriginal Australians. We describe the impact of a mobile care delivery model, “One Stop Liver Shop”, on the cascade of care for people living with CHB in a remote Australian setting. Methods A retrospective analysis was performed for CHB care received between 2013 and 2018 in one very remote Northern Territory community, where the “One Stop Liver Shop” was iteratively developed with the community. Patients with positive Hepatitis B virus surface antigen (HBsAg) were identified through electronic medical records. Proportions of patients who are up-to-date with monitoring investigations and HCC screening were evaluated and compared to national guidelines and targets. Results Eighty-three HBsAg positive patients were evaluated. Eighty-eight percent were engaged in care, 16% of whom were receiving antiviral treatment. Liver function tests (LFT) were up to date in 71% of patients in 2013 and 88% in 2018. Viral load (VL) monitoring was up to date for 61 (73%) of patients. There were 44 patients in whom HCC screening was indicated. Of these, 38 (86.4%) were up to date with 6 monthly alpha-fetoprotein (AFP), 35 (79.5%) were up to date with 6 monthly liver ultrasound scan (USS), and 34 (77.3%) were up-to-date for both. Conclusions A “One Stop Liver Shop” developed with and including Aboriginal Health Practitioners bridges gaps in the availability of services to those living with CHB in a very remote community and improves the cascade of care.

Measuring quality of hepatitis B care in a remote Australian Aboriginal community: opportunities for improvement

“…26 An obvious barrier contributing to HCC surveillance nonadherence is lack of access to radiology facilities; however, successful models of mobile liver clinics including mobile ultrasound have been implemented in remote indigenous clinics and may provide solutions to this difficult problem. 27 The explanation for the suboptimal results in HBV quality measures are complex and are likely to reflect the many competing health priorities in indigenous communities. Other barriers to implementing high quality CHB care are likely to include remoteness, language, cross-cultural barriers, low health literacy in both patients and healthcare providers and frequent turnover of healthcare staff.…”

“…Multiple HCC cofactors in CHB patients have not been previously well‐described and are a potential contributor to the higher incidence and mortality of remotely living Indigenous Australians 26 . An obvious barrier contributing to HCC surveillance non‐adherence is lack of access to radiology facilities; however, successful models of mobile liver clinics including mobile ultrasound have been implemented in remote indigenous clinics and may provide solutions to this difficult problem 27 …”

Preventing early childhood transmission of hepatitis B in remote Aboriginal communities in northern Australia

“…The ongoing transmission shown in this study despite vaccination strategies highlights the importance of the provision of this care and antivirals during pregnancy and further research should continue to examine rates To achieve hepatitis B elimination equitably across very remote Aboriginal communities a targeted and holistic approach is needed, as although the tools are available, they have been demonstrated not to be universally implemented. The "one stop liver shop" has been shown to improve the cascade of care in these communities, but there remains a significant number of individuals who are not yet diagnosed [29]. Data linkage and coding has attempted to improve identification of cases; however, many individuals do not have hepatitis B testing results [30].…”

Hepatocellular carcinoma amongst Aboriginal and Torres Strait Islander peoples of Australia

“…Solving the “tyranny of distance” to deliver high quality liver ultrasound surveillance to at-risk individuals in remote communities represents another significant health challenge. However, the advent of simple serum based fibrosis tests, together with high quality mobile ultrasound devices, has already led to the development of mobile liver clinics to remote Indigenous communities in a number of Australian jurisdictions, with improved rates of HCC surveillance reported [21] . High quality studies evaluating the effectiveness and cost effectiveness of this model of care are an important research priority.…”