Reasons for Nonattendance across the Hepatitis C Disease Course

Abstract

This descriptive qualitative study examined the patient, provider, and institutional factors contributing to nonattendance for hepatitis C (HCV) care throughout the disease course. Eighty-four patients and health and social care providers were interviewed. Thematic analysis of the data yielded 6 interrelated nonattendance themes: self-protection, determining the benefits, competing priorities, knowledge gaps, access to services, and restrictive policies. Factors within the themes varied with the disease course, type of provider/service, and patient context. Nonattendance could span months to years and most frequently began at diagnosis where providers either advised that followup was not necessary or did not recommend any followup. The way services were organized (low barrier access) and delivered (nonjudgmental approach) and higher HCV knowledge levels of patients and providers encouraged attendance. This is the first study to explore the reasons for nonattendance for HCV care throughout the disease course and validate them from multiple perspectives. There are missed opportunities for providers to encourage attendance throughout the disease course beginning at diagnosis. Interventions required include development of integrated health and social service delivery models; mechanisms to improve knowledge dissemination of the disease, its management, and treatment; and implementation of standardized followup protocols for liver disease monitoring in primary care.

Reasons for missed appointments with a hepatitis C outreach clinic: A qualitative study

“…Despite a different health system and culture the findings from the research into nonattendance in hepatitis C in Canada (Butt et al, 2013) appear to largely concur with those in this study. However, there appear to be a small number of factors which were not identified in the latter.…”

“…However, in contrast to other literature for hepatitis C and related groups where the distance and location are cited as contributing to missed appointments (Hayter, 2005;Morrison et al, 2011;Butt et al, 2013) this research based on the perspectives of clients revealed the complexity of what is meant by a term such as a 'difficult journey'. The factors that made for a difficult journey include: having to get two buses; the timing of the appointment, such as whether it was morning or afternoon; whether the appointment was on a different day to the clients' substitution treatment script; the cost of travel and difficulties with reimbursement; and physical and psychological co-morbidity such as problems with walking and suffering from agoraphobia which for some meant relying on a lift.…”

“…In Scotland, the mean travel time of 20 minutes to a specialist centre was not found to be a factor for non-attendance but A c c e p t e d M a n u s c r i p t 6 other factors were identified: living in more deprived areas; younger age; male gender; current or past injecting drug use; excess alcohol consumption (more than 21 units per week); and higher body mass index (Astell-Burt et al, 2012). A qualitative study in Canada (Butt et al, 2013) identified six themes to explain non-attendance (including patients who delayed or deferred care) throughout the disease course i.e. from primary to specialist care (see Box 1).…”

“…The study appeared to include a range of hepatitis C treatment services including community and walk-in clinics that would be considered 'outreach settings'. Thus, a further reflection of the findings from the Butt et al (2013) study is provided at the beginning of the discussion.…”

The Population Level Cascade of Care for Hepatitis C in British Columbia, Canada: The BC Hepatitis Testers Cohort (BC-HTC)

“…A major factor for lack of genotyping among those RNA tested was history of drug use. Data from Canada and other countries suggest that lack of knowledge among primary care physicians, especially those not involved in providing care to those with known risk activities, regarding next steps in the cascade and poor knowledge among patients are associated with the gap from HCV diagnosis to RNA testing (Butt et al, 2013, Grebely et al, 2013, Guirgis et al, 2012). Although guidelines and education for primary care physicians are important instruments to bridge this gap, a single blood sample test strategy in which those testing positive for antibody are also tested for RNA (reflex testing) and possibly for genotype could be an effective structural intervention to bridge this gap.…”