the role of the hepatology nurse in the difficult-to-treat...

Can J Gastroenterol Vol 21 No 6 June 2007 353

The role of the hepatology nurse in the difficult-to-treat hepatitis C population

Jo-Ann Ford RN MSN1, Cindy Cheong-Lee RN2

1Canadian Association of Hepatology Nurses; 2BC Hepatitis Program, Vancouver, British ColumbiaCorrespondence: Ms Jo-Ann Ford, Canadian Association of Hepatology Nurses, 5153 – 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9.

Telephone 604-875-5705, fax 604-875-5221, e-mail [email protected] for publication November 14, 2006. Accepted November 22, 2006

Currently, the primary risk factor for hepatitis C virus(HCV) is injection drug use; it is estimated that 80% to

95% of intravenous drug users (IDUs) are infected or willbecome infected with HCV in the near future (1). This mar-ginalized group in our society is well recognized to be at riskfor alcoholism, psychiatric illness and psychosocial instability(2,3), and historically, they have not been considered viablecandidates for HCV treatment. In this issue of The CanadianJournal of Gastroenterology, Moirand et al (pages 355-361), intheir paper titled “Determinants of antiviral treatment initi-ation in a hepatitis C-infected population benefiting fromuniversal health care coverage”, retrospectively reviewedHCV treatment and the determinants of antiviral treatmentinitiation in a vulnerable, urban, inner-city population. Theauthors evaluated the chart documentation of 3300 patientsand identified 378 patients eligible for HCV antiviraltherapy. Of the 378 eligible patients, 143 were offered andinitiated treatment, while 95 were offered but rejected treat-ment. Variables that influenced treatment included a resoluterequest for treatment, participation in methadone mainte-nance therapy, younger age and past alcohol use. Factors thatnegatively influenced treatment included current intra-venous drug use, alcoholic liver damage on biopsy, precariousor unspecified housing, current depression and personalitydisorders. An important observation to note from the paperby Moirand et al is that of the patients considered medicallyeligible for treatment, only 63% were offered therapy, and ofthese, only 60% accepted (ie, less than 40% of the medicallyeligible cohort). This suggests that potentially viable patientpopulations may not be receiving treatment. The work ofMoirand et al is consistent with other studies that reportedsuccessful treatment of IDUs provided that they were closelysupervised. Backmund et al (4) reported on the treatment of50 IDUs with interferon or interferon and ribavirin combina-tion therapy. The rate of sustained virological response(SVR) was 36% and was not significantly different betweenthose patients who relapsed to drug use and those who didnot. Van Thiel et al (1) also demonstrated that the SVR inIDUs was similar to that in non-IDUs. They also reportedthat the recent use of intravenous drugs or continuedmethadone use during treatment did not impair the SVR incomparison with non-IDUs.

Unfortunately, in today’s world, the number of treatedHCV patients needs to increase dramatically or we will notbe able to prevent new infections or reduce the burden ofend-stage liver disease. Clearly, we can no longer ignorevulnerable populations, and effective interventions must be

in place to meet this challenge. Moirand et al acknowledgethe need for a multidisciplinary approach to the managementof patients infected with HCV, including the potential role ofcommunity organizations, IDU peer groups and social sup-port. Although it was not elaborated on, a team approachmust incorporate the knowledge, skills and expertise of thehepatology nurse.

The Canadian Association of Hepatology Nurses(CAHN) was established in November 1999. The genesis ofcreating a professional national nursing association in hepa-tology occured in January 1999, when over 30 hepatologynurses from across Canada had the unique opportunity ofcoming together for a meeting and realized the need for cre-ating a nursing hepatology organization. In February 2000,the first executive was elected, with Colina Yim as President.The CAHN is currently an associate member organization ofthe Canadian Nurses Association. The membership consistsof over 150 registered nurses from across Canada whose clin-ical practice, research, administration, education or interestresides in the domain of hepatology. The mission of theCAHN is to advance the quality of nursing practice, and topromote advanced clinical and research nursing practice inhepatology across Canada. The CAHN’s mandate includesthe maintenance and improvement of the qualifications andstandards of hepatology nurses. The CAHN promotes educa-tional opportunities for its members both on a national and alocal level. Annually, the CAHN holds an education confer-ence in conjunction with its annual general meeting. Thismeeting has, over the past few years, been held in conjuctionwith the Canadian Association for the Study of the Liver.Local workshops are supported across the country with topicsthat include critical appraisal of literature, management of psy-chological side effects, and the natural history of hepatitis Band its treatment. The organization provides a network inwhich its members can exchange information as well as givesthe opportunity to share the best practices and guidelines onprevention, care, treatment and support. Our newslettersinclude journal review articles, information on upcomingmeetings, highlights from conferences and latest study results.The Web site, which is in the process of being redeveloped(www.cahn.ca), provides membership with access to docu-ments such as the Canadian Consensus Guidelines, as well asthe administration and monitoring of erythropoietin guide-lines. In the near future, it will provide a slide kit that can beused to educate novice nurses on viral hepatitis. In addition,standards of practice for hepatology nurses have benapproved and will be posted on the CAHN Web site (5). The

EDITORIAL

©2007 Pulsus Group Inc. All rights reserved

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purpose of the standards document is to provide a basis forthe evaluation and guidance of professional, ethical and nurs-ing practice in hepatology. The standards encompass thehepatology nursing role of leadership, education, researchand clinical practice with the client as its central focus.

Hepatology nursing is a recognized specialized area ofnursing that focuses on the promotion of health, the preven-tion of illness, the care and support of clients experiencingliver-related diseases, and research. Key components include:

• Promotion of health – hepatology nurses performactivities that include providing educational sessionsfor the general public, marginalized populations andother health care professionals, as well as promotingharm-reduction initiatives such as safe needle disposal.

• Prevention of illness – activities includeimmunization, education regarding the prevention ofthe spread of disease and the needle exchangeprogram.

• Care, support and treatment – nurses educate patientsand their families; provide emotional support andadvocacy; counsel both before, during and aftertreatment on benefits, risks, side effects, copingstrategies and adherence to treatment; interpretresults; and liaison with the family, support groups andother health professionals (ie, psychiatrist,ophthalmologist, social worker, etc).

• Research – nurses are active in clinical trials (industryand/or pharmaceutical), monitoring adherence totreatment, their own nurse-initiated studies, quality oflife and continually incorporate new research- andevidence-based findings into their practice.

The hepatology nursing roles incorporate the activities ofclinical practice, education, advocacy, counselling, collabora-tion, community support, leadership, administration andresearch.

From a recent survey completed by our membership, thehepatology nurse works with patients in a variety of settingsincluding community or public health, street outreach clin-ics, methadone programs, correction facilities, private physi-cians’ offices, hospitals and academic centres. Because of newdevelopments in antiviral therapy for hepatitis, the hepatol-ogy nurses have become a vital part of the multidisciplinaryteam. The marginalized populations are complex, time con-suming and resource intensive. The hepatology nurse is criti-cal to their care and management. These dedicated nurses gothe extra mile in providing support, education, counsellingand referrals that provide the greatest opportunity for stayingon treatment and receiving care.

In conclusion, Moirand et al have reported that onlyapproximately 40% of the identified eligible patients in ourinner-city HCV population actually receive treatment.Clearly, the proportions need to increase, and there are manychallenges in the prevention, care and treatment for vulner-able populations. The multidisciplinary team approach, withthe hepatology nurse playing an integral role, is a key strategythat can provide the opportunity for this population toreceive care and management.

Editorial

Can J Gastroenterol Vol 21 No 6 June 2007354

REFERENCES

1. Van Thiel DH, Anantharaju A, Creech S. Response to treatmentof hepatitis C in individuals with a recent history of intravenousdrug abuse. Am J Gastroenterol 2003;98:2281-8.

2. Sylvestre D. Hepatitis C treatment in drug users: Perception versusevidence. Eur J Gastroenterol Hepatol 2006;18:129-30.

3. Sylvestre DL, Loftis JM, Hauser P, et al. Co-occurring hepatitis C,substance use, and psychiatric illness: Treatment issues anddeveloping integrated models of care. J Urban Health 2004;81:719-34.

4. Backmund M, Meyer K, Von Zielonka M, Eichenlaub D. Treatmentof hepatitis C infection in injection drug users. Hepatology2001;34:188-93.

5. Canadian Association of Hepatology Nurses (CAHN). Hepatologynursing standards <www.cahn.ca> (Version current at January 23,2007).

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