Use of Pharmacists and Collaborative Practice Agreements to Treat Hepatitis C: A Survey of Primary Care Clinicians in Washington State

Abstract

Background:

Collaborative care models that utilize pharmacists can expand hepatitis C (HCV) treatment access, but little is known about primary care provider (PCP) views on such models of care. We characterized PCP experiences of HCV treatment and assessed acceptability of leveraging pharmacists to treat HCV.

Methods:

We surveyed a convenience sample of Washington (WA) State PCPs regarding HCV treatment, experience of collaborating with pharmacists, and comfort with pharmacists managing HCV care. We report summarized descriptive statistics of survey responses.

Results:

Seventy-three PCPs completed the survey, 55% of whom prescribe buprenorphine for opioid use disorder. Nineteen percent directly treat HCV. Forty-five percent were aware of collaborative practice agreements (CPAs) and 22% reported interest in establishing a CPA to treat HCV. Most respondents were comfortable or extremely comfortable with pharmacists managing key elements of HCV care.

Conclusions:

In a sample of WA State PCPs, of whom greater than half prescribe buprenorphine for OUD, fewer than 1 in 5 directly treat HCV. Comfort with pharmacists managing most components of HCV treatment was high, but a minority of PCPs were familiar with or interested in establishing CPAs. Additional efforts are needed to leverage pharmacists to treat HCV, including among people who use drugs.

Keywords

hepatitis C opioid related disorders collaborative practice agreement pharmacists acceptability

Introduction

Hepatitis C, which affects approximately 2.4 million Americans¹ and in recent years has contributed to at least 12 000 deaths annually,² now has cure rates of >95% thanks to direct-acting antiviral medications. Hepatitis C elimination by 2030, defined as a 90% reduction in incidence and a 65% reduction in mortality,³ is a goal the U.S. is not on track to meet. Washington State announced a hepatitis C elimination campaign in 2018, and soon after, the state’s Healthcare Authority implemented a pharmacy policy to address common barriers to treatment, including by removing prescriber restrictions and entering into a modified subscription -based payment model for glecapresvir/pibrentasvir,⁴ 1 of 2 pan-genotypic medications recommended by guidelines for treatment of hepatitis C infection.⁵ Despite these policies, hepatitis C treatment rates in Washington State remain low; data suggest that three-fourths of people who inject drugs in Seattle who have known hepatitis C have not initiated treatment.⁶ Available estimates suggest that there are >59 000 people in Washington living with hepatitis C.⁷

Evidence supports non-specialist treatment of uncomplicated hepatitis C,^8
-12 and policy and practice guidelines call for task sharing and integration of hepatitis C treatment in primary care and addiction settings.¹³ People who use drugs are disproportionately impacted by hepatitis C and other syndemic conditions and often experience stigma that negatively affects access to healthcare.¹⁴ Providing low-barrier hepatitis C treatment in settings in which people who use drugs are seen is critical, and more providers are needed to address treatment gaps. For decades, pharmacists in clinic and hospital settings have assisted with management of acute and chronic diseases, including hepatitis C, through a range of collaborative care models. Collaborative care models that utilize pharmacists to deliver hepatitis C care have demonstrated capacity to provide services to a population of people who use drugs who are racially diverse and often unhoused.¹⁵ Collaborative practice agreements (CPAs), a model of collaborative care in which an agreement between clinical pharmacists and physicians allows pharmacists to provide comprehensive care for specific conditions, have demonstrated promise in expanding hepatitis C treatment access.^16
-20 Yet, there has not been widespread implementation of such strategies, and primary care clinician views toward collaborative care models that utilize pharmacists for hepatitis C treatment, including through CPAs, are unknown. This study, supported by the Washington State Department of Health, was designed to survey Washington State primary care clinicians to, (1) Characterize their perspectives and practices regarding hepatitis C treatment, including for people who use drugs, and (2) Assess the acceptability and feasibility of implementing collaborative care models utilizing pharmacists, including CPAs, for treating hepatitis C in primary care settings.

Methods

Overview, Setting, and Sample

This was a cross-sectional, survey-based observational study of Washington State primary care clinicians regarding attitudes and practices related to hepatitis C screening, hepatitis C treatment, and collaborative care models that utilize pharmacists for hepatitis C treatment. We included advanced practice nurse practitioners (ARNPs), physician assistants (PAs), and physicians, including medical trainees. We utilized convenience sampling by recruiting through professional networks in Family, Internal, and Addiction Medicine: the Washington Academy of Family Physicians, the University of Washington Medicine primary care network, the Washington Society of Addiction Medicine (2023 conference attendees), the Annual Primary Care Update Conference held in Spokane, Washington (2023 conference attendees), and the WWAMI Region Practice and Research Network (WPRN). We intentionally included networks beyond metropolitan King County, Washington. Surveys were electronically distributed to provider groups, conference attendees, and professional societies via email lists and newsletters in the spring of 2023 (Supplemental Appendix 1 provides an example email/newsletter solicitation). In some cases, a second reminder invitation was sent by email, but not all networks permitted this due to pre-existing communication protocols. Participants from a targeted network of rural serving clinics were offered a $20 gift card for completing the survey. This study received a determination of exempt status from the University of Washington IRB on November 30, 2022 (STUDY00016781).

Survey Instrument

The survey instrument (Supplemental Appendix 2) included 37 questions and was administered electronically via REDCap. Forced choice was not utilized, so participants could complete the survey without answering every question. No identifying information was collected. The survey instrument was informed by examples provided by the WPRN, researchers studying provider and health system barriers to hepatitis C treatment,²¹ and a study of pharmacist and physician views on collaborative practice.²² Survey items related to CPAs were designed de novo. The survey began with the question, “Do you provide primary care as part or all of your practice?” and included demographic information; specialty; provider type; practice characteristics (eg, type of facility, county, most common insurance coverage, and estimated percentage of patients with histories of injecting drugs); whether or not they prescribed buprenorphine for opioid use disorder; practice relating to hepatitis C screening, treatment, and referral; experience of collaborating with pharmacists; experience and interest in collaborative practice agreements; and comfort with pharmacists managing key aspects of hepatitis C care. One question, “Assuming that protocols were in place, how comfortable would you be with pharmacists in your practice assisting with hepatitis C treatment in the following ways?” used a 5-point Likert scale ranging from 1 (extremely uncomfortable) to 5 (extremely comfortable). This question assessed participant comfort with pharmacists performing numerous specific roles to support HCV treatment.

Statistical Analysis

We utilized simple descriptive statistics to characterize the sample and summarize survey results, calculating percentages of responses for questions of interest. Due to our small sample size—in particular, the small number of participants who reported directly treating hepatitis C and the small number who reported interest in establishing a CPA for hepatitis C treatment—we did not perform statistical analyses to evaluate for associations between variables.

Results

Demographics and Practice Characteristics

Ninety-five individual providers initiated the survey; 16 indicated they did not provide primary care as part or all of their practice and were excluded, and 6 surveys were incomplete beyond basic demographic information and were also excluded. Among the remaining 73 Washington State primary care clinicians, mean age was 45 years, 78% were physicians, 66% self-identified as female, and 74% identified as white. Forty of 73 (55%) reported prescribing buprenorphine for opioid use disorder. Respondents represented 10 Washington counties but most indicated that they worked in a primarily urban serving county/site and the majority worked in a hospital-based or academic clinic. Additional demographics and practice characteristics are shown in Table 1.

Table 1.

Participant Demographics, Practice Characteristics, and Typical Nature of Collaboration With Pharmacists (N = 73).

Provider demographics and practice characteristics	Total, n (%)
Age (years), mean (SD)	44.8 (12.9)
Gender
Female	48 (66)
Male	23 (32)
Prefer not to identify	1 (1)
Race
Black or African American	1 (1)
Asian	9 (12)
White	54 (74)
More than 1	3 (4)
Other^a	2 (3)
Prefer not to identify	3 (4)
Ethnicity
Hispanic/Latino	6 (8)
Non-Hispanic/Latino	61 (84)
Prefer not to identify	5 (7)
Provider type
Physician	57 (78)
Nurse practitioner	9 (12)
Physician assistant	6 (8)
Other^b	1 (1)
If you indicated being a physician, are you a trainee (resident or fellow)?^c
No	42 (58)
Yes	10 (14)
Missing	5 (7)
Practice clinic/facility type
Community health clinic	5 (7)
Private office practice or freestanding clinic	9 (12)
Hospital-associated clinic	30 (41)
Health maintenance organization or other prepaid practice	1 (1)
Community health center (eg, Federally Qualified Health Center)	4 (5)
Academic/university-affiliated clinic	20 (27)
Federal government-operated clinic (eg, VA)	3 (4)
Other^b	1 (1)
Most common insurance type among patients
Medicaid	34 (47)
Medicare	14 (19)
Private insurance	12 (16)
None of the above/unable to estimate	13 (18)
County of primary care practice^d
Rural	10 (14)
Urban	52 (71)
Don’t know	5 (7)
Missing	6 (8)
Which of the following describe the nature of your communication/collaboration with pharmacists in the routine practice of patient care?
Collaborative/co-management of medical conditions	26 (36)
Consultation about specific patient care questions	41 (56)
Limited /brief communication	29 (40)
None	2 (3)

No participants who selected “Other” for race or practice clinic/facility type provided write-in responses.

One participant who selected “Other” indicated that they are a pharmacist.

This item was only shown to participants who indicated that they are physicians; percentages are calculated out of column totals.

Urban Influence Codes were used to determine rurality based on county of primary care practice.

Hepatitis C Treatment and Referral

Among participants, 14/73 (19%) reported directly treating hepatitis C among their patients. Thirty-eight of 73 (52%) reported that providers in their clinic treat hepatitis C and 19/73 (26%) reported that their clinic’s providers refer outside their clinic/health system for hepatitis C treatment. Twenty-five of 73 (34%) participants estimated that >75% of their patients with hepatitis C had been cured. Among a subset of 18 respondents who do not prescribe hepatitis C treatment and who responded to the question, “If you do not prescribe hepatitis C treatment, why is this,” the most common responses were “not trained to provide hepatitis C treatment” (67%), “others in my practice offer hepatitis C treatment” (44%), “not enough time to learn to treat hepatitis C” (39%), and “few patients with hepatitis C” (33%).

Experience Collaborating With Pharmacists and Experience With CPAs

Among respondents, 37/73 (51%) reported having at least 1 clinical pharmacist embedded in their clinic, and 29/73 (40%) reported that pharmacists help deliver hepatitis C care in their practice. Thirty-one of 73 (42%) respondents reported having frequently, always, or nearly always collaborated with pharmacists; the reported nature of such collaboration is incorporated into Table 1. Overall, majorities of respondents reported that they were comfortable or extremely comfortable with pharmacists managing most specific components of hepatitis C care, including taking clinical histories, ordering and interpreting diagnostic and pre-treatment testing, making treatment recommendations, monitoring on treatment, and identifying need for referral (Figure 1). Thirty-three of 73 (45%) respondents reported having heard of CPAs, while 23/73 (32%) reported their practice has a CPA. Twenty-three of 73 (32%) participants reported interest in referring patients to a pharmacist who has a CPA with another physician, whereas 16/73 (22%) reported interest in establishing a CPA for hepatitis C treatment. Among respondents who reported interest in establishing a CPA for hepatitis C treatment, 44% (7/16) had a pharmacist embedded in their clinic, 44% (7/16) had previously heard of CPAs, and 25% (4/16) had existing CPAs in their practice for other conditions. When asked to describe what concerns they would have, if any, about delivery of hepatitis C care by pharmacists practicing under a CPA, the majority of respondents (38/73, 52%) selected “none,” and endorsed concerns were related to compensation, time, risk management, and care coordination (Figure 2).

Figure 1.

Comfort with pharmacists managing key aspects of hepatitis C care (N = 73).

Figure 2.

Primary care clinician concerns about hepatitis C care delivery by pharmacists practicing under a CPA (N = 73)^a.

Discussion

In this study of 73 physicians, ARNPs, and PAs practicing primary care in 10 counties in Washington State, more than half of whom prescribe buprenorphine for opioid use disorder, only 19% directly offer hepatitis C treatment and more than 1 in 4 refer patients with hepatitis C outside their clinic or health system, indicating missed opportunities to integrate care and reduce barriers to hepatitis C treatment. Providers report lack of training in hepatitis C treatment, lack of time to learn to treat hepatitis C, and that others in their system treat hepatitis C as reasons that they do not directly treat their own patients. Majorities of respondents report that they are comfortable or extremely comfortable with pharmacists managing most specific components of hepatitis C treatment; yet, a minority report interest in establishing a CPA with a pharmacist for hepatitis C treatment.

It is striking that in a state with >5 years of progressive policies regarding direct-acting antiviral prescribing that include ability for non-specialists to prescribe treatment, only a small minority of primary care clinicians who responded to our survey reported directly treating hepatitis C. The percentage of primary care clinicians directly treating hepatitis C is slightly under that among participants of a larger study of primary and specialty care providers in Washington State, including pharmacists, which found that 29% treated hepatitis C themselves. The low treatment rate seen in our study is particularly notable given that more than half of respondents prescribe buprenorphine for opioid use disorder, which at the time of our survey still required an “X-waiver,” such that waivered providers were a select population offering opioid use disorder treatment in primary care. Opioid use disorder and hepatitis C are syndemic and highly comorbid conditions that constitute public health crises that can effectively be treated in primary care. While primary care clinicians cited training and time to train as barriers to offering hepatitis C treatment, learning to treat uncomplicated cases of hepatitis C is in fact straightforward.

In our study, pharmacists were accessible (ie, embedded within clinics) for most primary care clinicians and were already assisting with hepatitis C care in the clinics of 40% of primary care clinicians surveyed. Most primary care clinicians expressed feeling comfortable with pharmacists managing a wide range of hepatitis C care, extending from diagnosis to treatment. Yet, we found a gap between primary care clinician comfort with pharmacists managing key components of hepatitis C treatment and reported interest in collaborating with pharmacists through CPAs, which may be related to lack of familiarity with CPAs as well as other logistical concerns. While studies of CPAs for other conditions have explored acceptability among patients and pharmacists,^23,24 we are unaware of any studies that examine the perspective of PCPs, who could play key roles in expanding access through CPAs. Better understanding the gap we observed between PCP comfort with pharmacist involvement in hepatitis C care and interest in collaborating with pharmacists through CPAs will be important to develop and implement pharmacist-involved hepatitis C treatment programs more broadly, including in rural areas. Qualitative studies would be useful to explore these and/or other concerns about CPAs. Our results also identify an opportunity to educate primary care clinicians in Washington State about both CPAs and the professional scope of pharmacists in this state.

Our study has several limitations. While the survey was sent to several PCPs with expertise in hepatitis C treatment to test it for usability and to estimate time required for completion, we did not undertake any formal content validation. The sample size was modest and used convenience sampling. Estimates of response rates were not available because of uncertainty in the number of providers mailed and receiving the electronic communications since we relied on multiple third parties for distribution. Data are self-reported and may be subject to social desirability bias. Some respondents did not answer every question, likely because of the length of the survey and because we did not use forced choice. Washington State has an expanded Medicaid program and was one of the earliest to remove hepatitis C prescribing barriers²⁵; primary care clinician experiences and attitudes reported here may not be generalizable to other states and regions of the United States.

Conclusions

In a sample of Washington State primary care clinicians, more than half of whom prescribe buprenorphine for opioid use disorder, fewer than 1 in 5 directly treat hepatitis C, a common comorbidity. Comfort with pharmacists managing hepatitis C treatment was high, but a minority of primary care clinicians were familiar with or interested in establishing CPAs. To leverage pharmacists to treat hepatitis C through CPAs, additional efforts are needed to educate primary care clinicians.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319251359547 – Supplemental material for Use of Pharmacists and Collaborative Practice Agreements to Treat Hepatitis C: A Survey of Primary Care Clinicians in Washington State

Supplemental material, sj-docx-1-jpc-10.1177_21501319251359547 for Use of Pharmacists and Collaborative Practice Agreements to Treat Hepatitis C: A Survey of Primary Care Clinicians in Washington State by Jocelyn R. James, Emalie Huriaux, Jon Stockton, Allison Cole and Judith I. Tsui in Journal of Primary Care & Community Health

Supplemental Material

sj-docx-2-jpc-10.1177_21501319251359547 – Supplemental material for Use of Pharmacists and Collaborative Practice Agreements to Treat Hepatitis C: A Survey of Primary Care Clinicians in Washington State

Supplemental material, sj-docx-2-jpc-10.1177_21501319251359547 for Use of Pharmacists and Collaborative Practice Agreements to Treat Hepatitis C: A Survey of Primary Care Clinicians in Washington State by Jocelyn R. James, Emalie Huriaux, Jon Stockton, Allison Cole and Judith I. Tsui in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

Not applicable.

ORCID iDs

Jocelyn R. James

Allison Cole

Judith I. Tsui

Ethical Considerations

This study received a determination of exempt status from the University of Washington IRB on November 30, 2022 (STUDY00016781).

Consent to Participate

Potential survey respondents were provided with key information about the study, approved by the IRB. Consent to participate was implied when individuals chose to complete the survey; the IRB did not require additional consent.

Consent for Publication

Not applicable.

Author Contributions

JRJ, JIT, EH, and JS conceptualized, designed, and originated this project. All authors contributed to survey design. JRJ and JIT were primarily responsible for data collection and analysis. JRJ and JIT drafted the initial manuscript. All authors participated in interpreting the results, contributed to the writing of the manuscript, provided critical feedback to the manuscript, and approved the final manuscript for submission.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: work was supported by the WA State Department of Health, Office of Infectious Disease and by the Institute of Translational Health Sciences, which is funded by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under award number UL1TR002319. The views expressed herein do not necessarily reflect the official policies of the WA State Department of Health or NIH.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Not applicable.

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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