Model helps improve HCV care in underserved populations

A model developed to improve care for persons with complicated medical conditions in underserved areas helped provide safe, effective treatment for hepatitis C virus (HCV) infection, a new study has found.

Physicians in New Mexico developed the Extension for Community Healthcare Outcomes (ECHO) model to train primary care clinicians in rural or other underserved locations in providing appropriate care for complex medical problems. ECHO uses teleconferencing to train, support and advise clinicians via case presentations and lectures. Twenty-one sites in New Mexico, 16 rural communities and 5 prisons, currently use the ECHO model to treat HCV infection. The authors conducted a prospective cohort study to evaluate the safety and efficacy of ECHO-based treatment compared with treatment at the University of New Mexico's HCV clinic. Sustained virologic response, defined as undetectable HCV RNA 24 weeks after treatment stopped, was used as the primary end point. The study was published online June 1 by the New England Journal of Medicine.

Patients were eligible for the study if they were 18 to 65 years of age; had HCV RNA evidence of infection; hadn't been treated for HCV infection before Sept. 7, 2004; and began treatment between Sept. 7, 2004 and Feb. 29, 2008 if they had HCV genotype 1 or 4 infection or between Sept. 7, 2004 and Aug. 15, 2008 if they had HCV genotype 2 or 3 infection. Patients in the ECHO group were more likely to be male and Hispanic, while patients in the university clinic group were older. Most patients (about 56% in each group) had HCV genotype 1 infection. A definitive treatment outcome was determined for all patients by Dec. 31, 2009.

Four hundred seven patients were enrolled in the study, 146 who were treated at the university clinic and 261 who were treated at ECHO sites. Overall, 57.5% of patients treated at the university clinic and 58.2% of those treated at ECHO sites had a sustained virologic response to treatment (between-group difference, 0.7 percentage point; 95% CI, −9.2 to 10.7 percentage points; P=0.89). After the authors adjusted for differences in patient characteristics, the rate of sustained virologic response did not differ significantly for the ECHO sites compared with the university clinic (adjusted odds ratio, 1.04; 95% CI, 0.67 to 1.60). Rates of serious adverse events were 13.7% in university clinic patients and 6.9% in ECHO patients (P=0.02). University clinic patients were also more likely to have a serious adverse event that led to treatment withdrawal (8.9% vs. 4.2%; P=0.05).

The authors pointed out that they did not compare ECHO patients with patients receiving standard treatment in the same areas, and that ethical concerns precluded random assignment of rural and prison clinicians to use of the ECHO model or care without ECHO support. Patients could also not be randomly assigned to a treatment group.

Nevertheless, the authors concluded that the ECHO model of care led to effective treatment of HCV infection in patients living in underserved areas, comparable to the care provided at an academic medical center.

“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 authors wrote. They also noted that the model could be adapted and used to improve care for other chronic health conditions.