Expanding Primary Care Capacity to Treat Hepatitis C Virus Infection Through an Evidence-Based Care Model — Arizona and Utah, 2012–2014

Kiren Mitruka, MD; Karla Thornton, MD; Susanne Cusick; Christina Orme; Ann Moore; Richard A. Manch, MD; Terry Box, MD; Christie Carroll, Deborah Holtzman, PhD; John W. Ward, MD

Disclosures

Morbidity and Mortality Weekly Report. 2014;63(18):393-398. 

In This Article

Introduction

Hepatitis C virus (HCV) infection is the leading reason for liver transplantation and a common cause of hepatocellular carcinoma, the most rapidly increasing cause of cancer-related deaths in the United States.[1,2] Of the approximately 3 million persons living with HCV infection in the United States, an estimated 38% are linked to care, 11% are treated, and 6% achieve cure.[3] Recent development of highly effective and well-tolerated medications, such as sofosbuvir and simeprevir, to treat chronic HCV infection shows promise in curbing rising HCV-related morbidity and mortality, with the potential to cure >90% of patients. To fully benefit from these new treatments, improvement in linkage to care and treatment is urgently needed.* Lack of provider expertise in HCV treatment and limited access to specialists are well-documented barriers to HCV treatment.[4,5] In September 2012, CDC funded programs in Utah and Arizona to improve access to primary care providers with the capacity to manage and treat HCV infection. Both programs were modeled on the Extension for Community Healthcare Outcomes (Project ECHO), developed by the University of New Mexico's Health Sciences Center in 2003 to build primary care capacity to treat diseases among rural, underserved populations through videoconferencing and case-based learning in "teleECHO" clinics. To assess the effectiveness of these programs in improving primary care provider capacity and increasing the number of patients initiating treatment, process and patient outcome data for each state program were analyzed. In both states, Project ECHO was successfully implemented, training 66 primary care clinicians, predominantly from rural settings. Nearly all (93%) of the clinicians had no prior experience in care and treatment of HCV infection. In both states combined, 129 (46%) of HCV-infected patients seen in teleECHO clinics received antiviral treatment, more than doubling the proportion of patients expected to receive treatment.[3] These findings demonstrate Project ECHO's ability to expand primary care capacity to treat HCV infection, notably among underserved populations.

Project ECHO was designed to build primary care clinicians' capacity to treat chronic, common, and complex diseases through weekly teleECHO clinics called "Knowledge Networks," in which primary care clinicians present their cases, through videoconferencing, to specialists who provide advice and clinical mentoring. Working together and supplemented with short didactic presentations (e.g., on HCV diagnosis and management) by interdisciplinary experts, the community-based providers and specialists manage patients following evidence-based protocols.

From September 30, 2012, to February 28, 2014, ECHO programs in Utah and Arizona recruited providers serving populations at increased risk for HCV infection (e.g., persons born during 1945–1965) and in areas with a shortage of HCV specialists. Providers with an interest in treating HCV infection and access to videoconferencing technology (e.g., access to a webcam and software provided by Project ECHO) were eligible to participate. Utah targeted community-based providers in seven neighboring states (Oregon, California, Idaho, Utah, Montana, Wyoming, and Colorado) with an estimated population of 10 million, 60% of whom resided in rural settings. Arizona recruited community-based providers within nine of Arizona's 15 counties, representing approximately 90% of the state's population of nearly 7 million.

Utah recruited providers throughout the project period via outreach at professional societies, departments of health, community-based organizations, and university-based referral clinics. Arizona recruited all providers within the first 3 months of the project through outreach at community health centers. In both states, Project ECHO staff initially visited providers to train them in HCV diagnosis and management and in the protocol for patient presentation. Providers then began weekly participation in teleECHO clinic sessions, following the Project ECHO format, and lasting about 1 to 1.5 hours. Providers were eligible to receive continuing medical education credits. Utah's team of specialists consisted of a hepatologist, psychiatrist, and pharmacist; Arizona's team consisted of a hepatologist and nurse practitioner. In Utah, teleECHO clinics were held once weekly.

After the initial case presentation, providers were encouraged to attend sessions at specific time intervals (4, 8, 12, 24, and 48 weeks, and 6 months post-treatment) based on standards for monitoring treatment; three to 14 primary care clinicians attended each session (median = six). In Arizona, teleECHO clinics were held once weekly and were site-specific; one to 21 primary care clinicians attended each session (median = seven). Providers at each site were asked to present every patient, those newly diagnosed and those on treatment, at the weekly teleECHO clinic sessions. A monthly synchronous cohort treatment initiation approach was followed, where patients at each site were started on treatment in like timeframes and managed together as a cohort to simplify monitoring. At larger provider sites, an HCV coordinator supported providers in patient management (i.e., medication adherence and insurance enrollment). In Utah, the program collaborated with the local health department to identify HCV-infected patients requiring linkage to care and those who were lost to follow-up. Data from each state Project ECHO program (e.g., types of providers, practice settings, patient characteristics, and clinical outcomes) are summarized in this report.

Over the 17-month period (September 30, 2012–February 28, 2014), a total of 90 unique attendees participated in teleECHO clinics in the two states; of these, 66 (73%) were primary care clinicians with practices in predominantly rural settings and at community health centers ( Table 1 ). A total of 280 unique cases of chronic HCV infection were presented in teleECHO sessions ( Table 2 ). In both states, cases were predominantly among persons who were U.S.-born, non-Hispanic white, and born during 1945–1965. A history of injecting drug use was known for 41.4% (116 of 280) of patients. A total 136 of patients seen were known to have health-care coverage; Medicaid was the most common type of coverage (61.8%) followed by private insurance (23.5%). HCV genotype 1 infection was the most common type of infection (62.9%). Of patients with an available aspartate aminotransferase (AST) to platelet ratio index (APRI) score, 41% (100 of 243) had a score ≥1, indicating the presence of advanced fibrosis or cirrhosis. Among 129 (46.1% of 280) patients who started treatment, 70.5% (91 of 129) were treated with an interferon-based regimen, and 26.4% (34 of 129) were treated with a regimen containing sofosbuvir, a drug approved in December 2013. Arizona and Utah started treatment with a sofosbuvir-based regimen in 35.8% (29 of 81) and 10.4% (five of 48) of patients, respectively, during December 2013–February 2014.

* Information available at http://www.hcvguidelines.org.
APRI calculated as (AST [IU/L]/upper limit of normal AST [IU/L])/platelets [109/L] x 100.

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