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Hepatitis C

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.

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Hepatitis C

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  1. Hepatitis C Primary Care Hepatitis C Treatment Outcomes Using Project ECHO model Chris Boyle 3/26/2013

  2. Outline Discuss Chronic Hepatitis C Describe Project ECHO Discuss a the prior study which was the model for our project Discuss my research

  3. 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 US • 17,000 new HCV infections occurring/year in the US

  4. 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.

  5. 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

  6. 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

  7. Project ECHO • Project Extension for Community Health care Outcomes • Project ECHO • 4 pillars • Use 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 practices • Case-based learning with specialty comanagement • Outcome monitoring

  8. Project ECHO: How it Works • 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-specialtyco-management • “Learning loops”

  9. 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.

  10. Slide about the ACA and Project ECHO

  11. Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs Prospective cohort study Compared 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

  12. 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

  13. Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs

  14. Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs

  15. Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs

  16. Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs

  17. Arora et al. Outcomes of Treatment for Hepatitis C Virus by PCPs: Conclusions • 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 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.

  18. Project ECHO: Accomplishments to Date • 36-month Program • Over 100 unique sites • 500 clinicians

  19. Project ECHO Sites Point Roberts Orville Curlew Okanogan Alaska Friday Harbor Neah Bay Montana Twisp Cusick Sequim Inchelium Port Townsend Washington Forks Newport Kingston Wellpinit Poulsbo Taholah Woodinville Brevig Mission Kalispell Belfair Carnation Spokane Nome North Bend Maple Valley Cle Elum Tacoma Quincy Sumner Moses Lake Puyallup Lacy Ellensburg Lewiston Olympia Anchorage Tokeland Othello Yakima Chehalis Missoula Mossy Rock South Bend Pasco Grangeville Butte Vancouver Stevenson White Salmon Bozeman Warm Springs Idaho Oregon ECHO - Chronic Pain 27 sites ECHO - Integrated Addiction and Adult Psychiatry, 42 sites ECHO – HCV, 19 sites ECHO – HIV, 12 sites Eugene Nampa Boise Springfield Twin Falls Pocatello Medford Kalamath Falls Grangeville

  20. 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.

  21. 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 rates Secondary end point of major adverse events

  22. 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

  23. Methods

  24. Results

  25. Results HMC data Aroraet al.

  26. HMC data Aroraet al.

  27. Results

  28. Results

  29. Primary Endpoints

  30. Secondary Endpoints • Adverse events • Currently under review • 3 (5.3%) had treatment related adverse events which led to discontinuation of therapy

  31. Limitations • Limited number of total patients treated during this period • Very few minority patients • Smaller number of genotype 1 patients

  32. 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 treatmentin: • Rates of obtained SVR in both Genotype 1 and non-Genotype 1 chronic HCV patients • Rates of adverse events

  33. Thank you!! A special thank you to Dr. John Scott for his mentorship

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