Table 3:

Content analysis of physician interviews investigating barriers and facilitators to patient, physician and system-level access to HCV care

Group	Common themes	Interview samples
Barriers
Patient	Readiness to start treatment Medication adherence Adverse effects of the medication Reinfection concerns	A big challenge is … gauging whether or not a patient is ready to start treatment … and can they commit to taking the medications consistently … For my patients who are dealing with some of these issues, homelessness, ongoing substance abuse disorder, can they consistently take their hep C medications … over the next 8 to 12 weeks? (Participant 8) [An]other major issue is actually re-infection … I know that he’s likely going to get … the treatment covered, but they probably won’t approve more than once for this one individual. So, I have to have a conversation with him saying … “Are you ready? Are you really ready? And if you relapse and you start using again and you get infected again, that can mean that’s it, you don’t have another shot at this.” (Participant 8)
Physician	Lack of up-to-date knowledge about the standard of treatment Uncertainty about to how to monitor patients Easy access to specialists and other supports (no urgency to expand HCV knowledge) Lack of exposure to HCV complications (therefore lack of perceived urgency to treat) Lack of awareness of eligibility criteria Lack of confidence in treating Drug interactions	It would be hard to … keep up with … standards of treatment when it comes to hep C. The more the science and standards of treatments change around something, the less confident you feel around dealing with it yourself. (Participant 3) We see less of … the longer-term complications of hep C. The urgency of dealing with it is not as prominent because you’re not seeing the consequences of not dealing with it in the same way (Participant 3) The only issue is … drug interactions with the medications, but what I tend to do is verify with our really experienced pharmacist. (Participant 8)
System	Lack of resources (solo-practice practitioners) Limitations to access to medications (coverage or eligibility) Trillium copayment^* ODB dispensing rules (patients need to visit the pharmacy frequently) Cost of medications Many tools focusing only on HCV and not taking social context into account	ODB, sort of, dispensing rules…I think the maximum that you can dispense at one time through ODB, in terms of … overall cost of medications, is, I think it’s $10 000 … In some cases, what it’s meant is that patients of mine need to go to the pharmacy every week to pick up the next 7 pills of their regimen …You can’t take any holidays. You can’t go out of town … because they’re having to come back to the pharmacy regularly. (Participant 2) There are people who, perhaps, may want to go on treatment but they’re not eligible according to the … treatment criteria for coverage. (Participant 6)
Facilitators
	Consultative support (i.e., e-consult) Greater involvement of pharmacists Awareness around medication availability and family physicians’ management potential Clear and structured process to follow Improved provider confidence Education sessions for physicians Advocacy for patients Frequent follow-up visits (if the patient is on multiple medications) Follow-up phone calls (to assess adverse effects and adherence) Involvement of case workers, addiction counsellors Patient support groups Daily dispensing from the pharmacy Primary care guidelines Stamp in the EMR (i.e., eligibility criteria for treatment) Algorithmic tool Care flow sheet Reminder tools via email Apps Product monographs for common medications	You need to bring up provider’s confidence, so you’d need to have education sessions to get people ready for that type of move. And, then ideally, some sort of consultative support, in the background …. It doesn’t have to be specialists, but people who have specialized knowledge, they can help with any issues that come up, quickly. (Participant 3) Support within the team for follow up. If patients are started on medications and they’re having problems with compliance …. Nurses, or addictions workers, or whoever, could help to chase these patients down to, support them in being compliant. (Participant 7) I think through engaging patients and other organizations to help support them … the goal would be to eliminate hep C. (Participant 8) Sometimes get the pharmacist to take a look, do a consult, or, just monitor them a little more closely, a little more frequently. (Participant 5) I think a really powerful thing has been actually just talking with colleagues who are also treating people with hep C, and just what has been their experience. (Participant 8) We actually don’t have a lot of guidelines on treatment … and, particularly … primary care guidelines. (Participant 2) I find there’s stuff out there but … it’s not primary-care-focused …. I don’t have the time to go and read 30 papers on it. (Participant 7)

Note: EMR = electronic medical record, HCV = hepatitis C virus, ODB = Ontario Drug Benefit program.
↵* The Trillium Drug Program provides drug coverage for eligible individuals, subject to an annual deductible based on total household net income.