Allowing self-referral to specialists has been shown to increase access to relevant expert care in HIV-infected individuals in the United States (7
). Our data demonstrate that self-referral also increases access to specialist hepatitis C care in Canada. During the five-year study period, 21.5% of our patients were self-referred. In the United States, the inability to self-refer may be a barrier to specialist care because it is linked to the patient’s insurance coverage, whereas in Canada self-referral is hindered by physician remuneration policies that commonly pay more for referred consultations. In our setting, self-referral is facilitated by an alternate remuneration plan that does not rely on a fee-for-service model. Eliminating the financial disincentive to physicians for accepting self-referral in other parts of Canada may improve access to hepatitis C care.
Although the reason for self-referral was not routinely documented, the primary reason recorded was the lack of access to a primary health care provider to initiate the referral. The shortage of family physicians in Canada is increasing for a variety of reasons such as requirements for longer physician training, restrictions on foreign-trained physicians and an increase in the average age and number of physicians retiring (8
). Approximately 56% of prevalent HCV cases and almost all new infections acquired in Canada are related to injection drug use, with an estimated 20% occurring among the immigrant community; both groups whose access to primary care may be even less optimal (9
) than that of the general population. Providing an option to access hepatitis C care through self-referral – as supported by our data – should increase the ability to provide hepatitis care to the rising number of Canadians without a primary care physician.
Potential drawbacks to allowing self-referral for HCV care may include more ‘inappropriate’ referrals, such as those who are HCV RNA-negative or have absolute contraindications to therapy. This scenario has not been observed in our experience. Patients who self-referred were similar to those who were physician-referred in all baseline characteristics, including the proportion who were HCV RNA-negative, and were equally as likely to be treated and achieve an SVR.
Our data emphasize the need for additional education for primary health care providers and the general public. This is underscored by the fact that 16% of HCP-referred patients were HCV RNA-negative and that a commonly cited reason for self-referral was being told by a primary care provider that their infection was ‘dormant’ or that there was no treatment available. Similar findings were described in a recent survey (10
) of members of the New Jersey Academy of Family Physicians, which highlights the insufficient knowledge of family physicians about screening and counselling for chronic hepatitis.
In both HCP- and self-referred groups, approximately one-third of patients were started on HCV therapy, comparable with other large clinical series (11
). Also comparable with other clinic experiences (12
) and between the two groups was the SVR in our population: 38% to 48% of HCV genotype 1 and 66% to 72% of genotype 2 or 3 fully evaluable patients achieved an SVR. Importantly, the ability to self-refer also provided access to risk reduction education, screening for HIV coinfection and appropriate vaccination against hepatitis A and B.
Given that the prevalence of hepatitis C in Canada is increasing, improving access to hepatitis C care and treatment is a vital component in the strategy to limit the impact of hepatitis C infection on the Canadian health care system. Our data suggest that given the opportunity, patients infected with hepatitis C will access care through a self-referral process, thereby resulting in an appropriate provision of care to a group who may otherwise not have had access.