於腸胃科醫療資源缺乏社區C肝根除基層醫療模式

背景 2016 年WHO訂下2030年清除C型肝炎目標—肝炎新感染病人減少80%、致死人數減少65%。有鑑於慢性肝病、肝硬化及肝癌佔臺灣主要死因及主要癌症死因，衛生福利部在「國家消除C肝政策綱領」進一將清除C型肝炎目標設定在2025年之前完成80% C型肝炎RNA陽性者接受治療的目標，自2017年起將口服C型肝炎抗病毒藥物(DAA)納入健保給付範圍，有鑑於台灣各地區C型肝炎照護需求常存有鄉鎮間的地理差異，為消弭此差異，彰化縣衛生局則於2019年啟動彰化縣C肝根除整合計畫(Changhua-Integrated Program to Stop Hepatitis C Infection, CHIPS-C)，以期利用系統性組織化的公共衛生手段提升肝炎連續。目的本研究旨在以彰化縣實證資料分析鄉鎮別於C肝根除整合計畫前後C型肝炎連續照護(Cascade of Care)之系列指標—篩檢率、診斷率與治療率，並以C肝根除整合計畫前為基礎，首先分析比較各鄉鎮在C肝根除整合計畫後之進步率，再以成效最佳鄉鎮為例，探討影響因素及成效。方法本研究以2019年7月設籍彰化縣30歲以上民眾共計902,054人為對象，分析CHIPS-C之前(1999年4月至2019年3月)與之後(2019年4月至2021年12月)各鄉鎮C肝篩檢、發現與治療情形。彰化縣CHIPS-C計畫針對高危險群進行組織性篩檢與追蹤，利用門診與整合性篩檢服務搭配中央成人預防保健45至79 歲終身1次BC肝免費篩檢政策，找出大規模個案；再者，連結社區相關癌症防治及篩檢，最後還有專科團隊進駐合作，轉介抗體陽性個案，建立社區C肝治療網，推動社區C肝行動醫療站、C肝給藥點，提高抗病毒藥物治療的可近性。敍述性統計包括各鄉鎮人口學變項，包括性別、年齡、婚姻狀況、教育程度、就醫型態等，本研究進一步分析鄉鎮別Cascade of Care之監測指標—抗體篩檢率、RNA診斷率與抗病毒藥物治療率。利用Cox比例風險模式計算CHIPS-C計畫對篩檢、發現與治療利用之風險比，並加入交互作用項檢視各鄉鎮指標達成率的相對差異。研究亦針對根治效果成效最佳的二水鄉，進一步分析影響Cascade of Care監測指標之相關因子。結果截至2021年12月31日彰化縣30歲以上抗體篩檢率47.6%，抗體陽性率6.2%，RNA檢驗率70.7%，RNA陽性率75.8%，治療率92.8%，根治達成率110.67%。其中抗體篩檢與RNA檢測速率以二水鄉上升最快，但治療上升情形各鄉鎮市差異性不大。執行前後根除目標達成率進步最多依序為北斗鎮、伸港鄉、二水鄉，其中北斗鎮內有一家腸胃科醫療院所，而伸港鄉內雖沒有腸胃科醫療資源，但執行前目標篩檢率已達100%以上，另二水鄉沒有腸胃科醫療資源，執行前目標篩檢率只有71.04%且根除達成率是全縣鄉鎮市之中最低38.80%，因此能在3年內達到根治目標成效卓越。二水鄉抗體篩檢率56.1%(6,476人)，抗體陽性率4.1%(265人)，RNA檢驗率86%(228人)，RNA陽性率64%(146人)，治療率90.4%(132人)，將計畫執行前已完成抗體篩檢或RNA病毒量檢查或治療個案排除後分析，性別對抗體篩檢沒有顯著影響，不同年齡層對抗體篩檢影響有統計上顯著不同，年齡層越高篩檢機率越高，但到了80歲以上則往下趨緩，婚姻狀況以喪偶者抗體篩檢機率高，可能因喪偶的年齡層較高緣故，教育程度則以國小程度抗體篩檢機率高，且有無至衛生所就醫習慣對抗體篩檢有很大影響，以持續來過衛生所族群最高。就治療模式而言，二水鄉資料顯示2017年之前只有干擾素、2017-2018年雖有DAA給付但對象仍受到限制，而2019年之後普及使用DAA治療，以RNA病毒量陽性146人為分母，這三個時期的治療率由17.8%上升至25.3%及90.4%。結論彰化縣CHIPS-C計畫以系統性的資源整合針對高危險群進行組織性篩檢與追蹤，即使在各鄉鎮醫療照護存在異質性的情況下，於2019年開始計畫執行至2021年仍然達到根除標準。以腸胃科醫療資源缺乏的二水鄉為例，利用基層醫療模式以衛生所為中心，公共衛生介入方式，3年時間即可達成根治目標，成效卓越，期許能將彰化縣特別是二水鄉成功模式提供給全國其他鄉鎮C肝根除計畫做為參考。

關鍵字

C型肝炎；根治； Cascade of Care ；直接作用抗病毒藥物；鄉鎮差異

並列摘要

Background In 2016, WHO proposed the goal of eliminating hepatitis C to reduce new chronic infection by 80% and mortality by 65% by 2030. Owing to the high disease burden of chronic liver diseases and hepatocellular carcinoma in Taiwan, the Taiwanese government has advanced the goal of treating 80% of patients with HCV seropositive by 2025. Changhua Public Health Bureau has launched the Changhua-Integrated Program to Stop Hepatitis C Infection (CHIPS-C) project in order to achieve the goal of HCV elimination with a collaborative care team in Changhua. Aims This study aims 1.to evaluate the cascade care for hepatitis C after the implementation of CHIPS-C across townships in Changhua county with empirical data, 2.to compare the change of HCV screening rate, HCV RNA confirmation rate, and treatment rate before and after CHIPS-C across townships, 3.to analyze factors related to the three key performance indices (KPIs) in (2) demonstrated by the township, Ershui, with the best performance after CHIPS-C. Method A total of 902,054 Changhua County residents aged 30 years and older in 2019 were enrolled in this study. We compared the HCV screening rate, the RNA confirmation rate, and the treatment rate before (April 1999-March 2019) and after (April 2019-December 2021) CHIPS-C across 26 townships in Changhua. In the CHIPS-C project, the Changhua County Health Bureau formed a collaborative care team to identify subjects with HCV, find those of RNA positive, and refer to those for treatment. This project started from the high-risk approach and gradually extended to general population. Data on outpatient service and integrated screening services were combined with the free health check-up program for adults aged 45 to 79, which included one shot screening for hepatitis B and C during the lifetime to ascertain nationwide-scale cases. In addition, the proposed screening for hepatitis was collaborated with community-based cancer prevention and screening program. The CHIPS-C also integrated medical resources of gastroenterology in Changhua County to facilitate the referral of antibody-positive cases and to provide antiviral therapy. The descriptive statistics for demographic characteristics, including age, sex, marriage status, education, and medical utility by county was given first. Town-specific KPIs—HCV screening rate, HCV RNA confirmation rate, and treatment rate—was calculated. We used the Cox proportional hazards regression model to estimate the rate ratio of uptake of screening, RNA confirmation, and treatment among eligible subjects after CHIPS-C. An interaction term between townships and CHIPS-C was considered in the model to evaluate the heterogeneity of the improvement of the three KPIs between towns. Finally, factors associated with the update of screening, RNA confirmation, and treatment were elucidated in Ershui township, which was the one with best performance. Result As of December 31, 2021 in Changhua County, the antibody screening rate was 47.6%, the antibody positive rate was 6.2%, the RNA test rate was 70.7%, the RNA positive rate was 75.8%, the treatment rate was 92.8%, and the elimination rate was 110.67%. The improvement of increasing the screening rate and RNA diagnosis was the highest in Ershui. More importantly, there was little difference between towns and cities in the rate of increase in treatment. There is one gastroenterology medical institution in Beidou, and although there are no gastroenterology medical resources in Shenkang, the target screening rate before implementation reached more than 100%. In spite of scanty medical resources in gastroenterology leading to 71.04% screening rate and the lowest 38.80% elimination rate before the implementation of CHIPS-C, Ershui still achieved the goal of elimination within 3 years with the best performance. The antibody screening rate in Ershui was 56.1% (6,476 persons), the antibody positive rate was 4.1% (265 persons), the RNA testing rate was 86% (228 persons), the RNA positive rate was 64% (146 persons), and the treatment rate was 90.4% (132 persons), and analyzed after excluding antibody screening or RNA viral load testing or treatment cases that had been completed before the implementation of the plan, gender had no significant effect on antibody screening, and different age groups had statistically significant differences in the impact of antibody screening. The higher the probability of screening, the higher the probability of screening, but it shows the plateau after the age of 80. Regarding the martial status, the high probability of antibody screening was noted for widowed persons, which may be due to the higher age of the widow. High, and the habit of visiting health centers has a great impact on antibody screening, with the highest group of people who have been to health centers continuously. Based on the data analysis of Ershui, the cumulative treatment rate of hepatitis C infected patients was divided into three periods: before 2017, there was only interferon; from 2017 to 2018, the recipients of DAA were still limited; after 2019, the use of DAA treatment was popularized, and the amount of RNA virus was positive. With 146 people as the denominator, the cumulative treatment rate increased in all three periods, from 17.8% to 25.3% and 90.4%. Conclusion This study shows the implementation of the Changhua-Integrated Program to Stop Hepatitis C Infection (CHIPS-C) program successfully achieve the goal of HCV elimination by using an integrated and organized approach to combat the geographic difference in demand and supply of care cascade. Even in the township with scarce resource of gastroenterology, a collaborative care team formed by public health authority together with a primary medical model in the local health center successfully demonstrated the achievement of HCV elimination within a three-year period. It is anticipated that such a model for elimination can be applied to other townships in island-wide Taiwan.