hepatitis c
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Hepatitis C. Primary Care Hepatitis C Treatment Outcomes Using Project ECHO model Chris Boyle 3/26/2013. Outline. Discuss Chronic Hepatitis C Describe Project ECHO Discuss a the prior study which was the model for our project Discuss my research. Chronis Hepatitis C. - PowerPoint PPT PresentationTRANSCRIPT
PRIMARY CARE HEPATITIS C TREATMENT OUTCOMES USING PROJECT ECHO MODEL
CHRIS BOYLE3/26 /2013
Hepatitis C
Outline
Discuss Chronic Hepatitis CDescribe Project ECHODiscuss a the prior study which was the
model for our projectDiscuss my research
Chronis Hepatitis C
Chronic Hepatitis C is a COMMON problem 3.3 million chronically infected persons
in the US (1.2% of US population) 180 million worldwide (2.5% of global
population) HCV is the most common blood-borne
infection in the US17,000 new HCV infections occurring/year in
the US
Chronis Hepatitis C
Chronic Hepatitis C is an EXPENSIVE problem #1 cause of death from liver disease #1 reason for liver transplantation 15,106 deaths/year attributed to HCV
which is expected increase over the next 20 years with ~200,000 deaths this decade
Total cost of HCV is $11 billion in medical expenses and about $54 billion in societal costs.
HCV and primary care treatment
Rarely being done Reasons providers
give for not treating are: Complex disease
management Lack of expertise Lack of access to
trained specialist A particular
problem in rural areas
HCV and primary care treatment
Drug assistance programs attempted by Pharma but failed
Should PCPs be treating complex chronic diseases in isolation? Many studies have
shown that patients with complex chronic medical diseases do better when comanaged by a specialist
Project ECHO
Project Extension for Community Health care Outcomes Project ECHO
4 pillarsUse Telehealth to leverage scarce health
resources and provide expertise to rural providers in the management of complex, but common chronic diseases
Disease management model that uses best practicesCase-based learning with specialty
comanagementOutcome monitoring
1 telemedicine
clinic/week, per discipline 10-15 min didactic De-identified cases sent
in advance Primary care physicians
present cases to
specialist panel Multi-specialty
co-management “Learning loops”
Project ECHO: How it Works
Project ECHO: Why Hepatitis C?
Chronic HCV was the 1st disease treated through the Project ECHO model
It was chosen because is has all six of the major issues that were identified as making a disease amenable to treatment using the Project ECHO model It is common. It has complex management. Treatment is changing; thus requires continuous learning. It has a high societal impact. There are serious consequences for failing to treat it. Improved outcomes can be obtained with appropriate care.
Slide about the ACA and Project ECHO
Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs
Prospective cohort studyCompared treatment for
HCV infection at the University of New Mexico HCV clinic with treatment by primary care clinicians at Project ECHO sites
407 treatment naïve patients enrolled
Primary end point was SVR
Secondary end point was major adverse events
Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs
Inclusion criteria Evidence of active
HCV viremia 18-65 years old Treatment naïve Initiated HCV therapy
during their study window
Exclusion criteria ANC <1500 Platelets <75 Creatinine >2.0 Co-infection with HBV
or HIV History of solid organ
transplant Decompensated liver
disease
Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs
Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs
Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs
Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs
Fried M, et al. N Engl J Med 2002; 347:975-82.Rodriguez-Torres M, et al. N Engl J Med 2009; 360:257-67.
Treatment by primary care clinicians via Project ECHO is as safe and effective as by specialists
Highest cure rates seen in community, higher even than registration trials
High proportion of minorities in Project ECHO sites, reversing health disparity
Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs:
Conclusions
Sites Clinicians Started Cases Hours of trainingHepatitis C 23 263 May 2009 399 unique 1500
Chronic Pain 97 390 Mar 2011 101 unique 600
Addiction and Psychiatry
16 239 Nov 2010 105 unique 400
HIV/AIDS 13 56 Jan 2012 50 75
Project ECHO: Accomplishments to Date
36-month Program Over 100 unique
sites 500 clinicians
Project ECHO Sites Alaska
IdahoOregon
MontanaWashington
Anchorage
NomeBrevig Mission
Boise
Pocatello
Nampa
Grangeville
Lewiston
Grangeville
Missoula
Kalamath Falls
Spokane
Forks
Cle Elum
Chehalis
Pasco
Okanogan
Friday HarborSequi
m
SumnerEllensburg
Twisp
White Salmon
Port Townsend
Moses Lake
Newport
South Bend
PuyallupLacy
Point Roberts
Quincy
Belfair
Olympia
Tacoma
Poulsbo
Yakima
North Bend
Cusick
Stevenson
Wellpinit
Maple Valley
Woodinville
Inchelium
Carnation
Curlew
Taholah
Orville
Kingston
Othello
Warm Springs
Neah Bay
Mossy Rock
Tokeland
ECHO - Chronic Pain27 sites
ECHO - Integrated Addiction and Adult Psychiatry, 42 sites
ECHO – HCV, 19 sites
ECHO – HIV, 12 sites
Vancouver
Eugene
Springfield
Medford
Twin Falls
Butte
Kalispell
Bozeman
Hypothesis
A multidisciplinary telemedicine co-management structure (Project ECHO) will lead to similar SVR and adverse event rates to those seen by Arora et al.
Project ECHO HCV treatment Harborview Medical Center
Our study aimed to validate the results from Arora et al using a replicated model at Harborview Medical Center which serves a rural population throughout the Northwest.
We conducted a retrospective cohort study reviewing de-identified patient data collected from Project ECHO
Primary end point of SVR ratesSecondary end point of major adverse
events
Methods
Inclusion criteria Evidence of active
HCV viremia 18-65 years old Treatment naïve Initiated HCV therapy
between 01/01/2010 and 5/12/2011 (the day before FDA approval of Boceprevir )
Exclusion criteria ANC <1500 Platelets <75 Creatinine >2.0 Co-infection with HBV
or HIV History of solid organ
transplant Decompensated liver
disease
Methods
Results
HMC data Arora et al.
Results
HMC data Arora et al.
Results
Results
Primary Endpoints
Secondary Endpoints
Adverse events Currently under review3 (5.3%) had treatment related adverse events which led to discontinuation of therapy
Limitations
Limited number of total patients treated during this period
Very few minority patientsSmaller number of genotype 1 patients
Discussion
Use of Project ECHO model at Harborview Medical Center appears to be comparable to prior Project ECHO experiences and to standard practice for HCV treatment in: Rates of obtained SVR in both Genotype 1 and non-
Genotype 1 chronic HCV patients Rates of adverse events
Thank you!!
A special thank you to Dr. John Scott for his mentorship