Reasons for Telephone and Unscheduled Consultation in Patients Undergoing Hepatitis C Treatment
Marta Gallach1*, Maria López2,3, Meritxell Casas4, Mireia Miquel2,4, Angelina Dosal3, Laura Moreno3, Jordi
Sánchez Delgado2,4, Blai Dalmau4, Xavier Calvet2,4 and Mercedes Vergara2,4
1Emergency Department, Hospital de Sabadell, Spain
2Universitat Autònoma de Barcelona, Spain
3Nursing, Hospital de Sabadell, Spain
4Hepatology Unit, Hospital de Sabadell, Spain
Submission: July 26, 2016; Published: August 05, 2016
*Corresponding author: Marta Gallach, Emergency Department, Hospital de Sabadell, Parc Taulí, 1, 08208 Sabadell, Spain.
How to cite this article: Marta G, Maria L, Meritxell C, Mireia M, Angelina D,et al. Reasons for Telephone and Unscheduled Consultation in Patients Undergoing Hepatitis C Treatment. Adv Res Gastroentero Hepatol. 2016; 1(5): 555574. DOI: 10.19080/ARGH.2016.01.555574
Adherence to treatment is a key to improve cure rates in patients with chronic hepatitis C on interferon-based therapies. We aimed to determine the main reasons for telephone consultations and unscheduled visits in hepatitis C patients under antiviral treatment.
Methods: We included all patients with hepatitis C treated with pegylated interferon plus ribavirin who consulted our department by telephone or unscheduled visits.
Results: A total of 176 patients (mean age, 48 years; 67.6% male) were under treatment in the inclusion period. We registered 264 phone consultations and 193 unscheduled visits by 109 patients (53% women). The most common reason for telephone consultation was adverse effects (40.2%). The most common actions in response to telephone consultation were providing information (58.3%) and ARGHanging or advancing appointments (22%). Reasons for unscheduled visits included adverse effects (59.1%), errors or administrative queries (13.4%), questions or doubts related to treatment (10.4%), and problems with medication devices (7.7%). Actions in response to unscheduled visits included medical visits (33.7%), training by nurses (24.9%), referral to other specialties (10%), laboratory tests (8.8%), prescription of medication (7.8%), administrative procedures (6.8%), discontinuation of treatment (2.6%), and transfusion (2.1%).
Conclusion: Most telephone consultations or unscheduled visits of patients on chronic hepatitis C treatment are related to adverse events.
It is estimated that 1.6% to 2.6% of the population in Spain is infected with the hepatitis C virus (HCV) . About 80% of infected people will develop chronic hepatitis (CHC), and 20% of these will eventually develop cirrhosis, and 5% to 10% of patients with cirrhosis due to HCV will develop hepatocellular carcinoma . CHC is the most common cause of cirrhosis and liver transplantation, not only in Spain, but throughout developed countries [3-5].
Until 2011, the treatment of hepatitis C was based primarily on the use of pegylated interferon (peg interferon) alpha-2a or alpha-2b plus ribavirin for 24 to 72 weeks depending on viral genotype and viral kinetics during treatment . The infection is considered cured when the patient shows a sustained viral response (SVR), defined as undetectable viral load (HCV RNA) 12 weeks after the end of treatment. In patients with an SVR, laboratory test results return to normal, liver disease stops progressing, and histological examination can even show regression of liver damage . Newly developed direct antiviral agents will dramatically increase the rate of SVR in patients with chronic hepatitis C; however, direct antiviral agents are currently considered too expensive in many countries, including Spain.
Thus, it will probably continue to be necessary to use peg
interferon alpha-2a or alpha-2b in certain groups of patients
Interferon-based antiviral treatment is associated with
a high rate of severe adverse events, so it requires close
monitoring. Moreover, peg interferon must be administered
subcutaneously, so it requires frequent visits to the hospital
[5-11]. However, many adverse events are easily controlled
. The accurate and intensive management of adverse
events improves adherence, and consequently increases the
SVR rate . Some studies have shown that some specific
interventions in the setting of a multidisciplinary team
(psychiatrist, pharmacist or a dermatologist) to improve the
management of adverse effects can increase adherence and
effectiveness [4,14,15]. Communication with the rest of the
healthcare team and monitoring patients by telephone is
important . We hypothesized that most doubts related to
hepatitis C treatment could be resolved by telephone. The aim
of our study was to determine the reasons for telephone and
emergency consultations of patients treated with interferonbased
therapies for chronic C hepatitis in the setting of a
multidisciplinary team and the extent to which telephone
consultations resolved patients’ doubts without the need for
This was a prospective observational study of clinical
practice in the setting of our multidisciplinary team to manage
patients undergoing treatment for CHC. Our institution’s
clinical research ethics committee reviewed and approved
the study, and all patients provided written informed consent.
On starting antiviral treatment, all patients had an initial
educational visit with a nurse, who instructed them in the
subcutaneous administration of peg interferon and informed
them about self-care for adverse events. Moreover, patients
received educational materials including a telephone number
to contact during working days and the timetable for care in
outpatient clinics. We registered all telephone consultations
and unscheduled visits by patients under antiviral treatment
with peg interferon and ribavirin that took place from January
2009 to January 2011.
Quantitative variables are presented as means and
standard deviations and qualitative variables as frequencies
or percentages with their 95% confidence intervals. We used
SPSS v21 (IBM, Chicago Illinois, USA) for all analyses.
Between January 2009 and January 2011, a total of 160
patients (108 (67.6%) men; mean age, 48±11.7 y) received
antiviral treatment in our unit. HCV infection was classified as
genotype 1 in 112 (69.9%) patients, genotype 2 in 9 (5.7%),
genotype 3 in 22 (13.6%), and genotype 4 in 17 (10.8%). Peg
interferon was injected with a syringe in 60.3% of cases (peg
interferon alpha-2a) and using a pen system in 39.7% (peg
interferon alpha-2b). The rate of patients that abandoned
treatment was 3.5%.
We received 264 telephone consultations from 109
patients (median calls per patient, 2; range, 0-14). Callers
were women in 59% of cases. Patients themselves called in
53% of cases, and family members (partner, child, and sibling)
called for patients in 47% of cases.
Telephone consultations were most common during the
first 12 weeks of treatment (57.2%). The main reasons for
telephone consultation included: adverse effects (40.2%);
doubts about hygiene, diet, or self-care (28%); administrative
errors or doubts (21.2%); problems related to medication
(e.g., missing a treatment dose or concomitant treatments)
(8.8%); and reporting on the result of a previous consultation
(1.8%) (Figure 1). Telephone consultation alone resolved
patients’ problems in 58.3% of cases, whereas it was
necessary to schedule an urgent appointment or advance a
previously scheduled appointment in 22% of cases (Figure 2).
In 41 (15.5%) telephone consultations, patients were advised
to come to the emergency department.
A total of 193 unscheduled visits were recorded.
Unscheduled visits were recorded throughout treatment,
but mainly occurred in the first 12 weeks (44.6%). Women
accounted for 53% of unscheduled visits. The main reasons
for unscheduled visits were adverse effects (64.7%), mainly
dermatological problems (19.2%) and asthenia with or
without anemia (17.6%) (Figure 3). These unscheduled
visits resulted in medical visits (33.7%), education by nurses
(reviewing recommendations) (24.9%), referral to other
specialists (13.4%), laboratory tests (8.8%), prescription of
medication (7.8%), administrative changes (6.8%), treatment
discontinuation (2.6%), or transfusion (2.1%) (Figure 4).
Most of the telephone consultations and unscheduled
visits in patients undergoing antiviral treatment for hepatitis
C were due to adverse events secondary to treatment.
However, most of these problems could be solved by
providing advice on the telephone or during the unscheduled
visit without requiring a visit with a physician. These results
show the utility of nurses help patients improve their selfcare.
A previous study in Spain pointed out the usefulness of
telephone communication with patients with chronic disease
and their relatives . Our results confirm that a direct
telephone line improved follow-up in patients undergoing
interferon-based treatment. The main reason for telephone
and unscheduled consultations or emergency visits was
adverse effects. It is important to control adverse effects
because severe adverse effects can decrease adherence to
the treatment and/or require decreased dosage of antiviral,
both of which decrease the chances of obtaining an SVR .
Similarly, adherence improves when adverse effects are well
Interestingly, although over two-thirds of our patients
were men, 59% of the callers in telephone consultations were
women. Other studies have reported similar results, probably
because women more frequently act as caregivers .
Analyzing the reasons for unscheduled consultations
has helped us identify gaps in our educational program. Our
results show that we need to pay more attention to adverse
events in the educational program and to improve patients’
knowledge for self-care. Better patient education could
reduce the need for consultation and improve adherence and
quality of life during treatment. Hopwood et al.  used
structured interviews to analyze factors that could improve
treatment. These authors found that identifying the patient’s
strengths in an interview before the beginning of treatment
can help clinicians manage hepatitis C treatment regimens.
Wartelle Bladou et al.  found that preparing the treatment
with the patient and employing a multidisciplinary team
promote adhesion to treatment. Some authors emphasize the
importance of assessing patient expectations with regard to
adverse effects, as many patients are unrealistically optimistic
before starting treatment .
The rate of treatment discontinuation due to intolerance
range between 7,9%-18% [2,22]. Previous results published
by our group in clinical practice showed a drop-out of 11%
, lower than others published elsewhere. We hypothesize
that easy access to the multidisciplinary team by telephone
or outpatient clinics probably contributed to this low rate.
The limitations of our study include the potential loss of
information during telephone consultations. To minimize this
point, we assigned specific members of the multidisciplinary team to handle telephone consultations and developed a
standardized questionnaire to avoid loss of information.
Our day hospital was only open from 7 a.m. to 17 p.m.,
Monday through Friday. Patients attended at the emergency
department outside this timetable did not necessarily
contact the day hospital if their problem was solved; thus,
we cannot know the possible impact of telephone inquires or
unscheduled visits outside this timetable. We found that most
consultations of patients on interferon-based treatment for
CHC were due to adverse effects, and that providing patients
with the opportunity to consult with professionals by
telephone facilitated contact. The multidisciplinary team will
incorporate the lessons learned from this study to improve
the self-care educational program.