A Hepatitis C Educational Needs Assessment of Canadian Healthcare Providers

Background and Aim. Despite advances in the treatment of chronic hepatitis C infection (CHC), it remains a major public health problem in Canada and globally. The knowledge of healthcare providers (HCPs) is critical to improve the care of CHC in Canada. To assess the current knowledge and educational needs of healthcare providers (HCPs) in the area of CHC management a national online survey was conducted. Method. An interprofessional steering committee designed a 29-question survey distributed through various direct and electronic routes. The survey assessed several domains (e.g., participant and practice demographics, access to resources, knowledge of new treatments, and educational preferences). Results. A total of 163 HCPs responded to the survey. All hepatologists and 8% of primary care providers (PCPs) reported involvement in treatment of CHC. Physicians most frequently screened patients who had abnormal liver enzymes, while nurses tended to screen based on lifestyle factors. More than 70% of PCPs were not aware of new medications and their mechanisms. Conclusion. Overall, the needs assessment demonstrated that there was a need for further education, particularly for primary care physicians, to maximize the role that they can play in screening, testing, and treatment of hepatitis C in Canada.


Introduction
Chronic hepatitis C (CHC) is one of the leading causes of liver disease, including cirrhosis and hepatocellular carcinoma. Between 60 and 85% of individuals exposed to the hepatitis C virus (HCV) develop a chronic infection [1].
In the past, treatment for CHC was recommended for patients with increased risk of cirrhosis [1] and others might undergo periodic monitoring rather than treatment. Because of the limited treatment options, complexity of treatment, and reimbursement challenges, many physicians have not administered treatment of CHC in their practices.
Recent advances in CHC treatment have made it the first chronic viral infection to be reliably curable through pharmacotherapy, with newer antiviral medications demonstrating cure rates approaching 100% [2]. These new antiviral agents are now available to Canadian patients and their healthcare providers (HCPs). However, with rapid advances in HCV science including new treatment modalities, ensuring that the treatments are reaching individuals who would most benefit presents a challenging educational problem [2]. To bridge this gap, further education for a wide variety of HCPs is required. This education should include how to screen for patients with chronic infection, the selection of patients, and the treatment itself. In order to develop optimal education programs, a national needs assessment was conducted.
2 Canadian Journal of Gastroenterology and Hepatology

Study Population.
Invitations to participate were distributed through various means, including direct peer-topeer interactions by steering committee members, and by distribution to members of the CLF, members of CASL, and members of CAHN. Invitations were also delivered by facsimile and email to a targeted list of approximately 3500 individuals in the fields of hepatology, gastroenterology, pediatric gastroenterology, tropical travel medicine, infectious disease, sexually transmitted disease, communicable disease, hospitalist, native medicine, prison/detention medicine, internal medicine, general care, and family medicine physicians.

Data Collection and Analysis.
Partially completed surveys (i.e., those that did not have all questions completed) were accepted, with analysis based on the number of respondents for each question. Data analysis was simple summary statistics and included analysis of all participants (aggregated), as well as participants categorized by their declared medical role/specialization. For a series of questions specific to participant comfort for various activities, the average level of comfort was calculated. Each level of comfort ranging from very uncomfortable to very comfortable was assigned a value from 1 to 5, respectively. The average of the comfort level value was then calculated to yield a value from 1 to 5, with 1 representing very uncomfortable and 5 representing very comfortable.

Ethics.
The final survey was IRB approved (Veritas IRB) with distribution and results collected online through https://www.surveymonkey.com/.

Patient Subpopulations.
The most common subpopulation identified as being seen in clinical practice were patients with cirrhosis (noted by 80% of participants). 70% of nurses reported seeing injection drug users and an additional 60% of nurses reported seeing individuals from the aboriginal population.

Provision of Care.
All hepatologists reported involvement in the treatment of CHC, while it was reported to be 55% for gastroenterologists and 64% for other specialists. Only 8% of PCPs noted prescribing treatment for CHC as one of their aspects of care, while 92% reported a role in screening and diagnosis. In contrast, only 61% of hepatologists reported involvement in screening and diagnosis (Table 1).
Canadian Journal of Gastroenterology and Hepatology I am not involved in screening Individuals who currently/recently inject(ed) drugs Individuals with a history of ever having previously injected drugs Individuals with persistently abnormal liver enzymes Recipients of blood transfusions or organ transplants Healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposures to HCV-positive blood Individuals who currently or previously used noninjecting illegal drugs (e.g., intranasal cocaine) Individuals with a history of multiple sex partners or sexually transmitted diseases All (n = 159) Nursing (n = 74)

Gastroenterologist (n = 20)
Hepatologist (n = 31) Most participants reported inadequate access to both telehealth and government funding for allied health (only 29% and 31% of participants had access, resp.). There were only four resources that were available to more than half the participants in any specialty: FibroScan5 (transient elastography), social workers, psychiatry consultation, and industry funding for allied health (Figure 1).

Screening.
When selecting patients to screen for CHC, physicians most frequently tested patients with abnormal liver enzymes, while nurses tended to select patients based on lifestyle risk factors (injection drug use, body piercing, etc.). However, nurses reported less involvement with screening in general. Notably, PCPs tended to screen based on a wide variety of factors (i.e., from abnormal liver enzymes to medical and lifestyle history) (Figure 2).
The majority of the participants were either unsure or did not think that current screening guidelines would be able to identify all persons infected with hepatitis C. Hepatologists (84% certain, 6% unsure) had the highest level of certainty that current screening guidelines would not identify all infected persons. Nurses were the most likely to think that screening could identify all infected persons (24%).

Recommending and Initiating Treatment.
There was a general decrease in the comfort level of recommending treatment as patients were described as being more advanced, from mild fibrosis to decompensated patients. Overall, 74% of participants were comfortable or very comfortable recommending therapy for asymptomatic patients, 75% for symptomatic patients, and 58% for decompensated patients. PCPs were generally very uncomfortable with the role of identifying and recommending treatment (58% to 75% reported discomfort for the different patient types). Among PCPs, 78% expressed discomfort with initiating CHC therapy, while 71% of other participants felt comfortable with initiating treatment. Highest comfort levels were found in hepatologists (with average comfort level of 4.5 out of 5). Similar results were obtained on participant comfort for switching patients from one therapy to another because of poor efficacy; 70% of PCPs felt discomfort compared with 55% of participants expressing comfort for switching. Participants expressed greater comfort in monitoring patients' current therapy with an average comfort level of 4.10 out of 5 for all participants, but again lower for PCPs with an average comfort of 2.83.

Communication.
A large majority of participants (78% to 96%) were either comfortable or very comfortable in explaining the necessity of hepatitis C testing (Figure 3). A lower proportion of nursing participants were either comfortable or very comfortable explaining hepatitis C testing, though the average comfort level in this group was higher than PCPs.
Specialty and primary care providers both had lower levels of comfort educating patients about overcoming stigma than about emerging treatments.

Knowledge of New Treatments.
Overall, a large majority of participants agreed that hepatitis C would be a curable disease for almost all patients within five years; 21% of nurses were unsure of the statement, while 11% of physicians were unsure or disagreed with the statement (Figure 4). Seven of 10 PCPs were unsure or were not aware of new direct-acting antiviral medications (DAAs), while 74% were not sure of the mechanisms of action. This contrasts with 81% of the other participants who agreed they were aware of new DAAs and 73% who agreed that they understood their mechanisms of action. While 74% of participants agreed that they were aware of the medications, only 66% agreed that they were able to keep themselves up to date on recent clinical trial results. PCPs reported the lowest ability to keep up to date in this regard (78% unsure or disagreeing).
Overall, 63% of participants agreed that they were aware of current coverage (either formulary or private) for hepatitis C drugs. While PCPs had the lowest awareness at 22%, hepatologists reported the strongest awareness with 74% agreeing that they were aware.
3.8. Education. PCPs, gastroenterologists and nurses most frequently cited local conferences as a preferred format for learning; however only 1 in 5 hepatologists preferred that method. Hepatologists preferred national and international conferences ( Figure 5). Participants were generally less favorable towards preceptorships (20%), online webinars (32%), Canadian Journal of Gastroenterology and Hepatology Other specialists (n = 10)
or primary research papers (34%). Reading review articles was a generally accepted learning activity, with traditional lecture-style programs acceptable to the majority of participants in all groups except hepatologists. Participants (except hepatologists) were generally comfortable with the concept of conferring with HCV experts through regularly scheduled telemedicine calls. The majority of participants reported consulting more than one set of guidelines; the most common guidelines cited were the consensus guidelines from the Canadian Association for the Study of Liver (CASL) [3] (51% of participants) and the American Association for the Study of Liver Disease (AASLD)/Infectious Disease Society of America (IDSA) guidelines [4] (47% of participants). PCPs most frequently reported other guidelines (59%) or not using any guidelines at all (45%).

Discussion
While recent advances have made CHC reliably curable, incomplete knowledge of HCPs on hepatitis C is a barrier limiting access for qualified patients who could benefit [2]. The results of this survey demonstrate various educational needs with respect to CHC among HCPs.
Before a patient with CHC can access therapy, they must be diagnosed. In Canada, underdiagnosis of CHC is a significant problem [2,5]. The results of our study showed differences in screening criteria use between professional groups. Moreover, all 5 professional groups reported different levels of confidence in the ability of screening recommendations to find all infected patients. This demonstrates a need for improved CHC national screening guidelines and the need for increased education about them.
A significant finding of this survey was the disparate access to technologies, financial support, and interprofessional team members needed to provide CHC care especially to vulnerable populations. Government initiatives to increase treatment uptake must be accompanied by programs to scale-up access to the resources needed to achieve the best outcomes.
PCPs reported low awareness of DAAs and their mechanisms and also the lowest ability to keep up to date with new DAAs. In practice, this could translate to a lack of awareness about the highly effective nature of DAAs while having minimal side effects. This highlights the need for specific educational initiatives and designing new guidelines for the primary care audience. There were some marked differences in comfort levels in both treatment and monitoring patients. Specialists were the most comfortable with recommending and initiating treatment for CHC, while PCPs were particularly uncomfortable with those roles. This finding is consistent with other studies on PCP knowledge of new DAAs and comfort level with treatment [6]. The finding highlights the need to educate PCPs with novel and longitudinal educational models if PCPs are to become a source of increased capacity for care in the future.
There are several limitations to this study. First, the relatively small sample size limits the ability to be confident about the generalizability of results and any correlations seen in the descriptive analysis. Second, given that our participants were self-selected, selection bias is a concern. Participants with more knowledge or interest were more likely to participate in the study. Therefore, the results may overestimate the knowledge level of HCPs. Third, due to the nature of the recruitment efforts in which a unique individual may have been approached more than once, an exact survey response rate is difficult to report. Finally, this study was conducted in 2014-2015 and the therapeutic options for patients with CHC are rapidly evolving, so results relating to treatment educational needs may not apply for very long. Despite the limitations, our study did provide some important learning.

Conclusion
This study highlights several areas where HCPs perceive a high need for education including screening, patient education, and treatment. Further studies of PCPs who are the principle point of contact between the public and the healthcare system are recommended to determine the specific educational needs of this group of HCPs. Creating and continually updating the Canadian guidelines and encouraging HCPs to study and follow them with multimodal educational programs could be an appropriate solution to address the lack of knowledge about CHC and its promising new treatment.

Survey for Online Programming
Needs Assessment in Hepatitis C for Canadian Healthcare Professionals. Thank you for agreeing to share your expert insights to help the Canadian Association for the Study of the Liver (CASL) and Canadian Liver Foundation (CLF), in partnership with the Canadian Association of Hepatology Nurses (CAHN), shape future education on hepatitis C screening and treatment.
You are among a select group of hepatitis C treaters that has been asked to answer an online survey assessing your perceptions of (1) knowledge of hepatitis C in Canada; (2) needs for further learning on screening for hepatitis C; and (3) needs for further learning on management of patients with hepatitis C infection.
This survey should take no more than 10 minutes of your time to complete.
Your candor is appreciated and will help us tremendously in the development of clinically applicable educational programming to serve your learning needs.