Asynchronous electronic consultation between primary care and specialized care proved effective for continuum of care for viraemic hepatitis C patients / La consulta electrónica asíncrona entre atención primaria y atención especializada resultó eficaz para la continuidad de la atención a los pacientes con hepatitis C virémica

Introduction: It has been proposed that primary care diagnose and treat hepatitis C virus (HCV) infection. However, a care circuit between primary and specialized care based on electronic consultation (EC) can be just as efficient in the micro-elimination of HCV. It is proposed to study characteristics and predictive factors of continuity of care in a circuit between primary and specialized care. Methods: From February/2018 to December/2019, all EC between primary and specialized care were evaluated and those due to HCV were identified. Variables for regression analysis and to identify predictors of completing the care cascade were recorded. Results: From 8098 EC, 138 were performed by 89 (29%) general practitioners over 118 patients (median 50.8 years; 74.6% men) and were related to HCV (1.9%). Ninety-two patients (78%) were diagnosed>6 months ago, and 26.3% met criteria for late presentation. Overall, 105 patients required assessment by the hepatologist, 82% (n=86) presented for the appointment, of which 67.6% (n=71) were viraemic, 98.6% of known. Finally, 61.9% (n=65) started treatment. Late-presenting status was identified as an independent predictor to complete the care cascade (OR 1.93, CI 1.71–1.99, p<0.001). Conclusion: Communication pathway between Primary and Specialized Care based on EC is effective in avoiding significant losses of viraemic patients. However, the referral rate is very low, high in late-stage diagnoses, heterogeneous, and low in new diagnoses. Therefore, early detection strategies for HCV infection in primary care are urgently needed.(AU)

Introducción: Se ha propuesto que atención primaria diagnostique y trate la infección por virus de la hepatitis C (VHC). Sin embargo, un circuito asistencial entre atención primaria y especializada basado en la consulta electrónica (CE) puede ser igual de eficiente en la microeliminación del VHC. Se propone estudiar características y factores predictivos de la continuidad asistencial en un circuito entre atención primaria y especializada. Métodos: Desde febrero/2018 y diciembre/2019 se evaluaron todas las CE entre atención primaria y especializada, y se identificaron aquellas por VHC. Se registraron variables para análisis de regresión e identificar factores predictores de completar cascada de atención. Resultados: De un total de 8.098 CE, 138 realizadas por 89 (29%) médicos generales de 118 pacientes (mediana de 50,8 años; 74,6% varones) fueron por VHC (1,9%). Noventa y dos pacientes (78%) fueron diagnosticados hace más de 6 meses), y el 26,3% cumplía criterios de presentación tardía. En total, 105 pacientes requirieron valoración por el hepatólogo. El 82% (n=86) se presentaron a la cita, de los cuales el 67,6% (n=71) eran virémicos, el 98,6% de los conocidos. Finalmente, el 61,9% (n=65) inició tratamiento. El estado de presentación tardía se identificó como un factor predictivo independiente para completar la cascada de atención (OR: 1,93; IC 95%: 1,71-1,99; p<0,001). Conclusión: La comunicación entre atención primaria y especializada basada en la CE es eficaz para evitar pérdidas significativas de pacientes virémicos. Sin embargo, la tasa de derivación es muy baja, elevada en diagnósticos en fase tardía, heterogénea y escasa en nuevos diagnósticos. Por tanto, se necesitan con urgencia, estrategias de detección precoz de infección por VHC en atención primaria.(AU)

Asynchronous electronic consultation between primary care and specialized care proved effective for continuum of care for viraemic hepatitis C patients.

INTRODUCTION: It has been proposed that primary care diagnose and treat hepatitis C virus (HCV) infection. However, a care circuit between primary and specialized care based on electronic consultation (EC) can be just as efficient in the micro-elimination of HCV. It is proposed to study characteristics and predictive factors of continuity of care in a circuit between primary and specialized care. METHODS: From February/2018 to December/2019, all EC between primary and specialized care were evaluated and those due to HCV were identified. Variables for regression analysis and to identify predictors of completing the care cascade were recorded. RESULTS: From 8098 EC, 138 were performed by 89 (29%) general practitioners over 118 patients (median 50.8 years; 74.6% men) and were related to HCV (1.9%). Ninety-two patients (78%) were diagnosed>6 months ago, and 26.3% met criteria for late presentation. Overall, 105 patients required assessment by the hepatologist, 82% (n=86) presented for the appointment, of which 67.6% (n=71) were viraemic, 98.6% of known. Finally, 61.9% (n=65) started treatment. Late-presenting status was identified as an independent predictor to complete the care cascade (OR 1.93, CI 1.71-1.99, p<0.001). CONCLUSION: Communication pathway between Primary and Specialized Care based on EC is effective in avoiding significant losses of viraemic patients. However, the referral rate is very low, high in late-stage diagnoses, heterogeneous, and low in new diagnoses. Therefore, early detection strategies for HCV infection in primary care are urgently needed.

Hepatitis C virus infection screening reduces mortality and is cost-effective independently of the intervention test.

INTRODUCTION: Chronic infection due to hepatitis C virus (HCV) is frequently asymptomatic even in advanced stages of liver disease. Implementation of a screening program based on different HCV tests may enable an earlier diagnosis of HCV liver disease and subsequent application of highly effective treatment. PATIENTS AND METHODS: A Markov model which compares three different screening strategies for hepatitis C versus no screening in low-risk prevalence (general population) and high-risk prevalence population (people who inject drugs or prison population) was designed, taking into account age at the start of screening and participation. The three strategies were: 1) serological detection of antibodies against the HCV, 2) dried blood spot test (DBS) to detect antibodies against HCV and 3) detection of RNA from HCV. Quality-adjusted life-years (QALY) were taken as a measurement of effectiveness. The incremental cost-effectiveness ratio (ICER) was calculated and a deterministic and probabilistic sensitivity analysis was performed. RESULTS: All three screening strategies were found to be cost-effective with an ICER of €13,633, €12,015 and €12,328/QALY for AntiHCV, DBS-AntiHCV and DBS-RNA HCV, respectively. There was a decrease in mortality due to liver disease in comparison to no screening for AntiHCV (40.7% and 52%), DBS-AntiHCV (45% and 80%) and DBS-RNA HCV (45.2% and 80%) for low-prevalence and high-prevalence populations, respectively. CONCLUSION: All test interventions for HCV screening are cost-effective for the early detection of HCV infection, also achieving a reduction in mortality. Thus, implementation of screening programs for HCV should not be halted by decisions on monetary policy.

Comparison of flipped learning and traditional lecture method for teaching digestive system diseases in undergraduate medicine: A prospective non-randomized controlled trial.

INTRODUCTION: This study examined the effects of a large-scale flipped learning (FL) approach in an undergraduate course of Digestive System Diseases. METHODS: This prospective non-randomized trial recruited 404 students over three academic years. In 2016, the course was taught entirely in a Traditional Lecture (TL) style, in 2017 half of the course (Medical topics) was replaced by FL while the remaining half (Surgical topics) was taught by TL and in 2018, the whole course was taught entirely by FL. Academic performance, class attendance and student's satisfaction surveys were compared between cohorts. RESULTS: Test scores were higher in the FL module (Medical) than in the TL module (Surgical) in the 2017 cohort but were not different when both components were taught entirely by TL (2016) or by FL (2018). Also, FL increased the probability of reaching superior grades (scores >7.0) and improved class attendance and students' satisfaction. CONCLUSION: The holistic FL model is more effective for teaching undergraduate clinical gastroenterology compared to traditional teaching methods and has a positive impact on classroom attendances.

Evaluación de la precisión diagnóstica del sistema Cobas 6800 para la detección de los niveles de viremia del virus de la hepatitis C a partir de muestras de gotas de sangre seca en papel de filtro / Diagnostic test accuracy of the cobas 6800 system for detection of hepatitis c virus viraemia levels from dried blood spots

INTRODUCCIÓN: La infección por el virus de la hepatitis C (VHC) es curable en la mayoría de los casos tratados, siendo actualmente una prioridad diagnosticar a todos los infectados. Para ello se necesitan, especialmente en poblaciones de difícil diagnóstico, métodos diagnósticos simples, como es el uso de muestras de gotas de sangre seca (GSS), como alternativa a la extracción de sangre mediante venopunción. Como paso previo para poder implantarlo como método diagnóstico de detección de pacientes con VHC dentro del Sistema Nacional de Salud se precisa evaluar la precisión diagnóstica en equipos de uso hospitalario habitual. METODOLOGÍA: Se evaluaron in vitro y en ensayo de campo muestras de GSS tras ser procesadas en el equipo Cobas 6800, estableciendo una correlación con el resultado obtenido con sangre completa. Se realizaron pruebas de correlación y de variabilidad intraensayo de la determinación con sangre completa y GSS para cuantificar la carga viral del VHC. RESULTADOS: En muestras de sangre completa, con una carga viral ≥ 3 log10UI/ml, se detectó viremia en todos los casos cuando se utilizaron eluciones de 2 gotas (94 detecciones de 95 eluciones de círculos). El rendimiento con 2 gotas fue menor en muestras con < 3 log 10UI/ml (7/20). La correlación entre la viremia determinada con sangre completa y con GSS fue excelente (máximo con 2 gotas, r2 = 0,906; p < 0,001), con un coeficiente de variación del 0,05%. En práctica clínica habitual con muestras de pacientes analizados (n = 61) se obtuvo igualmente una excelente precisión diagnóstica. CONCLUSIÓN: La determinación de la carga viral mediante GSS, procesando al menos 2 gotas, es un método fiable para el diagnóstico de infección por el VHC. La estandarización del método es factible en nuestro equipo Cobas 6800 local, y nuestros resultados respaldan la incorporación de esta herramienta diagnóstica al Sistema Nacional de Salud para facilitar planes de microeliminación

INTRODUCTION: Because hepatitis C virus (HCV) infection is curable in the majority of cases, the diagnosis of all infected patients has become a priority. In difficult-to-diagnose populations, simpler diagnostic methods are required such as the use of dried blood spots (DBS) as an alternative to blood drawn by venipuncture (VP). Before being able to include it as a HCV diagnostic detection method within the Spanish National Health System, the diagnostic accuracy of standard hospital equipment must be evaluated. METHODOLOGY: DBS samples were evaluated in vitro and in a field test after being processed in the Cobas 6800 system, establishing a correlation with the result by VP. Performance with different viral loads and intra-assay variability was compared. RESULTS: In samples with a viral load of>3 log10IU/ml, viraemia was detected in all cases when at least two blood spot elutions were used (94 detections out of 95 spot elutions). The performance with 2 spots was lower in samples with<3 log10IU/ml (7/20). Correlation between VP and DBS viraemia was excellent (maximum with 2 spots, r2=0.906, P<.001) with a coefficient of variation of 0.05%. In routine clinical practice with specimens from screened subjects (n=61), excellent diagnostic accuracy was also observed. CONCLUSION: Viral load detection using DBS of at least two spots is a reliable method for HCV diagnosis. The standardisation of the method is feasible and our results support the incorporation of this diagnostic tool in Spain's Public Health System

Diagnostic test accuracy of the cobas 6800 system for detection of hepatitis c virus viraemia levels from dried blood spots. / Evaluación de la precisión diagnóstica del sistema Cobas 6800 para la detección de los niveles de viremia del virus de la hepatitis C a partir de muestras de gotas de sangre seca en papel de filtro.

INTRODUCTION: Because hepatitis C virus (HCV) infection is curable in the majority of cases, the diagnosis of all infected patients has become a priority. In difficult-to-diagnose populations, simpler diagnostic methods are required such as the use of dried blood spots (DBS) as an alternative to blood drawn by venipuncture (VP). Before being able to include it as a HCV diagnostic detection method within the Spanish National Health System, the diagnostic accuracy of standard hospital equipment must be evaluated. METHODOLOGY: DBS samples were evaluated in vitro and in a field test after being processed in the Cobas 6800 system, establishing a correlation with the result by VP. Performance with different viral loads and intra-assay variability was compared. RESULTS: In samples with a viral load of>3 log10IU/ml, viraemia was detected in all cases when at least two blood spot elutions were used (94 detections out of 95 spot elutions). The performance with 2 spots was lower in samples with<3 log10IU/ml (7/20). Correlation between VP and DBS viraemia was excellent (maximum with 2 spots, r2=0.906, P<.001) with a coefficient of variation of 0.05%. In routine clinical practice with specimens from screened subjects (n=61), excellent diagnostic accuracy was also observed. CONCLUSION: Viral load detection using DBS of at least two spots is a reliable method for HCV diagnosis. The standardisation of the method is feasible and our results support the incorporation of this diagnostic tool in Spain's Public Health System.