With special training, effective and safe hepatitis C therapy can be provided in primary care

Project ECHO care teams take part in a virtual care conference using teleconferencing to link remote primary care centres to the University of New Mexico
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Specially trained primary care providers can offer effective and safe treatment for hepatitis C infection, US investigators report in the New England Journal of Medicine.

Rates of sustained virological response were the same for patients who received therapy from primary care providers as individuals who received treatment at a specialist clinic.

The primary care providers were given specialist training and support using video and telephone conferencing. This training, called the Extension for Community Healthcare Outcomes (ECHO) model, was developed by doctors at the University of New Mexico (UNM) Health Sciences Center.

Glossary

hypothesis

A tentative explanation for an observation, phenomenon, or scientific problem. The purpose of a research study is to test whether the hypothesis is true or not.

clinician

A doctor, nurse or other healthcare professional who is active in looking after patients.

cure

To eliminate a disease or a condition in an individual, or to fully restore health. A cure for HIV infection is one of the ultimate long-term goals of research today. It refers to a strategy or strategies that would eliminate HIV from a person’s body, or permanently control the virus and render it unable to cause disease. A ‘sterilising’ cure would completely eliminate the virus. A ‘functional’ cure would suppress HIV viral load, keeping it below the level of detection without the use of ART. The virus would not be eliminated from the body but would be effectively controlled and prevented from causing any illness. 

They were concerned that a large proportion of patients in New Mexico with chronic hepatitis C were not receiving therapy for their infection. Especially low rates of treatment were seen in patients living in rural areas, as well as those from minority populations, and those in prison.

“In 2004, patients from rural areas had to wait up to 6 months for an appointment at the HNM HCV clinic and had to travel up to 250 miles,” comment the authors, adding, “as of 2003, not a single patient in the correctional system had received treatment for HCV infection.”

Using state-of-the-art video and teleconfering facilities, specialist staff from the UNM HCV clinic trained primary care providers to deliver hepatitis C therapy.

Investigators wished to see if treatment provided according to the ECHO model was as effective and safe as therapy delivered at the specialist UNM clinic.

They therefore compared treatment outcomes (the proportion of patients achieving a sustained virological response) between the two types of service providers, and also gathered information on the frequency of side-effects.

“Our hypothesis was that when treatment for hepatitis C infection is delivered in the community (or prison) with the use of the ECHO model, it is as effective as that provided by an academic medical center,” comment the investigators.

The study involved 407 adult patients whose hepatitis was treated between 2004 and 2008. A total of 246 of these patients received therapy at the 21 ECHO centres (five in prisons) that participated in the research.

Almost identical proportions of patients at the ECHO sites and specialist clinic achieved a sustained virological response (58.2% vs. 57.5%).

Treatment outcomes were also comparable for patients with the hard-to-treat genotype-1 infection (rate of sustained virological response: ECHO, 49.7% vs. clinic, 45.8%).

Serious side-effects were more common among patients treated at the clinic than those cared for at ECHO sites (13.7 vs. 6.9%, p = 0.02). In addition, clinic patients were more likely to have side-effects leading to the termination of therapy (8.9% vs. 4.2%, p = 0.05).

“We found that treatment for HCV infection delivered with the use of the ECHO model was associated with high rates of cure,” write the authors, who also note “we met our goal of increasing treatment for minority and other underserved patients.”

They believe that the ECHO model can bring “to the rural clinician the expertise and clinical resources that may not otherwise be available, thus positively affecting the outcomes.”

The investigators conclude: “The ECHO model has the potential for being replicated elsewhere in the United States and abroad, with community providers and academic specialists collaborating to respond to an increasingly diverse range of chronic health issues.”

References

Arora S et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. New England Journal of Medicine 364:2199-2207, 2011 (click here for the free abstract).