PRIMARY CARE HEPATITIS C TREATMENT OUTCOMES USING PROJECT ECHO MODEL CHRIS BOYLE 3/26/2013 Hepatitis C.

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 training

Hepatitis 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

Nome

Brevig Mission

Boise

Pocatello

Nampa

Grangeville

Lewiston

Grangeville

Missoula

Kalamath Falls

Spokane

Forks

Cle Elum

Chehalis

Pasco

Okanogan

Friday HarborSequi

m

Sumner

Ellensburg

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