Efficacy of an eConsult Service to Cure Hepatitis C in Primary Care

Jacey Nishiguchi; Anusha McNamara; Colleen S. Surlyn; Kellene Vokaty Eagen; Laura Feeney; Vivian Lian; David E. Smith

Disclosures

J Viral Hepat. 2022;29(1):21-25. 

In This Article

Discussion

There was no significant difference in achieving SVR12 in both the ITT and PP populations. This is likely attributable to the high efficacy of DAAs. A meta-analysis evaluating the efficacy of DAA therapy found an overall SVR rate of 93.7% in patients younger than 65 years and 92.8% in patients ≥65 years old.[9] Another small cohort study found no significant differences in treating HCV through trained community-based providers compared with specialists; patients achieved an overall SVR12 rate of 86%.[10] More than 90% of patients in both of our groups achieved SVR12, demonstrating a similarly high overall rate of cure (Table 2).

Given the high efficacy of DAAs, provider use of the eConsult system did not impact attainment of SVR12. Providers may have chosen not to use the eConsult service if they felt comfortable treating independently or if they were in a clinic with providers who were more experienced in treating HCV who could serve as resources. An additional confounding factor was that certain providers may have used the eConsult because they thought it was required to initiate treatment in primary care. The overall high cure rate suggests that the high efficacy of DAAs allows for providers regardless of treatment experience to successfully treat patients with HCV when provided assistance from more experienced providers.

The eConsult system has expanded access to HCV treatment in our patient population. Over a 31 month period, 242 patients were treated through this service. These patients may not have been treated otherwise due to provider unfamiliarity in treating HCV through primary care. A prior analysis of this eConsult service by Facente et al. confirmed increased access to care with a tripling of patients who received treatment over a 3 year period after the launch of the eConsult (8.9 patients per month vs. 18.9 patients per month post-intervention).[8] This study also found an increase in the total unique number of PCPs treating HCV and the number of clinics in which primary care-based treatment was available (five clinics preintervention to 12 post-intervention).[8] The ability of this service to expand access to care is in part, due to utilizing clinical pharmacists to review eConsults. Each pharmacist is able to support multiple providers, thereby increasing the number of providers treating HCV in primary care and total number of patients being treated.[8] Including pharmacists on the eConsult team has also aided in continuity of care since they often follow these patients in clinic throughout their treatment course. Similar success in expanding HCV treatment through primary care was also demonstrated in a randomized controlled trial in people who inject drugs. This study found that SVR12 rate was noninferior to historical controls and treatment initiation was significantly higher in the primary care arm than the standard of care (hospital based specialist care).[11]

Our secondary aim was to evaluate for differences in use of the eConsult system by sex, race, presence of cirrhosis, provider type, and medication selection. In both the ITT population (all patients initiated on treatment who met inclusion criteria) and PP population (excluded patients who did not obtain final SVR12 laboratories), there was a significant difference in use of the eConsult system by provider type and medication type. Certain providers may have had more training in HCV treatment, contributing to a difference in the type of providers who utilized the eConsult system (Table 1). There was also a difference in medication type used, which may be attributable to provider knowledge of new treatment options. For example, more patients were recommended to receive GLE-PIB when treated through an eConsult. Physicians and pharmacists who provide treatment recommendations through the eConsult system are up to date with the newest treatment options and guidelines and may have been more familiar with using GLE-PIB, a newer DAA that was FDA approved during the first year of our study period. In the ITT population, there were also significant differences in use of the eConsult system by sex and race. This is likely attributable to the location of clinics and their respective patient populations. For example, clinics that had more experienced providers who would not need the eConsult system were located in areas with a higher proportion of Black/African American patients in this urban safety net health system. The PP analysis did not have any significant differences in these characteristics, potentially due to differences in follow-up in certain patient populations.

There are many limitations to our study. First, using SVR12 as a marker of HCV cure may undercount patients who achieved cure but did not return for follow-up laboratories. Additionally, the high efficacy of DAAs made it difficult to find a difference in achieving SVR12 based on use of the eConsult system. Another limitation to this study is that given the retrospective nature, data regarding adherence, treatment dates, and prescriber type may not have been accurately or completely recorded in each patient's chart. This may have led to inaccurate assumptions about gaps in treatment. Additionally, due to the small sample size, this study was not powered to detect a difference in efficacy based on use of the eConsult. At its inception, the team that created the eConsult envisioned it would serve as an educational tool such that with time prescribers may no longer require using it to treat patients for HCV. However, there has not been a formal assessment of the educational value and impact of this tool, therefore, this study may not fully appreciate how use of eConsult changed over time for specific providers as they became more comfortable treating HCV. We were unable to identify trends in prescribing practices during the study period to assess for provider learning and change in use of the eConsult service over time.

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