The use of telemedicine to link primary caregivers to the specialized medical resources of an academic medical center proved to be extremely effective for treating chronic hepatitis C in rural and underserved regions, according to a report published online June 1 in the New England Journal of Medicine.
In a prospective cohort study involving 407 HCV patients who had never received treatment for the disease, the proportion of patients who achieved a sustained virologic response to therapy was no different between the 261 treated at remote sites using the Extension for Community Healthcare Outcomes (ECHO) model and the 146 who were treated at a university HCV clinic, said Dr. Sanjeev Arora of the University of New Mexico, Albuquerque, and his associates.
<a href="http://polldaddy.com/poll/5103589/">Can you see yourself using the ECHO model to manage your patients with hepatitis C?</a><span style="font-size:9px;"><a href="http://polldaddy.com/features-surveys/">survey software</a></span>The treatment response was not only equivalent between the two study groups, it also was equivalent to that reported in controlled trials of HCV therapy, even though the ECHO patients in this study were impoverished minorities. "By implementing this model, other states and nations can potentially treat many more patients infected with HCV than are currently receiving treatment, thereby reducing the enormous burden of illness and associated mortality," the investigators said.
"ECHO represents a needed change from the conventional approaches in which specialized care and expertise are available only at academic medical centers in urban areas," they noted.
At present, "very few persons with chronic HCV infection are receiving treatment," and it is estimated that under the conventional approach, therapy will prevent "only 14% of potential liver-related deaths caused by HCV infection between 2002 and 2030," Dr. Arora and his colleagues said.
"Community-based health centers are often the most culturally appropriate and accessible choices for care, particularly in rural areas, and providers at these centers can establish trust through ongoing relationships with patients. Therefore, these centers can be ideal places to provide complex care for HCV infection, if they have access to the needed expertise," said Dr. Arora, who is also director of the ECHO Project at the university, and his associates.
The ECHO program began in 2003 and involves 16 community sites and 5 prisons. It provides weekly HCV clinics via video conferencing or teleconferencing in which primary care providers at these sites present cases to, and ask questions of, hepatology, infectious disease, psychiatry, and pharmacology specialists at the university. "These case-based discussions are supplemented with short didactic presentations by interdisciplinary experts to improve content knowledge" and teach skills, the investigators wrote.
Dr. Arora and his associates assessed treatment outcomes in patients who were initially treated in 2004-2008 and followed through the end of 2009. The primary end point was the rate of sustained virologic response 24 weeks after the conclusion of treatment.
This rate was 58.2% at the ECHO sites, which was not significantly different from the 57.5% rate at the university clinic.
These rates are similar to those reported in licensing trials of peginterferon and ribavirin.
Nearly twice as many patients at the university clinic (13.7%) as in the ECHO program (6.9%) developed serious adverse events, and more than twice as many (8.9% vs. 4.2%) developed a serious adverse event necessitating termination of treatment, the researchers said (N. Engl. J. Med. 2011 June 1 [doi:10.1056/NEJMoa1009370]).
The findings demonstrate that chronic HCV infection, a complex disease, "can be managed as effectively at a center that uses the ECHO model as at an academic medical center," Dr. Arora and his associates wrote. It is likely that the ECHO program accomplished this by facilitating more clinician visits; greater adherence to treatment; closer assessment of lab test results; and better, more timely management of side effects.
The study was supported by the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the New Mexico Department of Health, and the New Mexico State Legislature. Dr. Arora reported ties to ZymoGenetics, Genentech, Vertex Pharmaceuticals, Tibotec, Human Genome Sciences, Wyeth, and Schering-Plough.