Telemedicine improves HCV treatment in underserved populations

Primary care clinicians who participated in a telemedicine training program – the Extension for Community Healthcare Outcomes (ECHO) model – managed hepatitis C virus infections just as effectively as specialty clinicians, researchers found.

Patients with chronic HCV infection who were treated in rural and prison primary care settings achieved similar rates of sustained virologic response compared with those treated at an academic medical center (58.2% vs. 57.5%; 95% CI: -9.2-10.7; P=0.89), data indicate.

Sanjeev Arora, MD, of the University of New Mexico in Albuqurque and colleagues compared HCV outcomes among 407 previously untreated patients at the university's HCV clinic (n=146) and at 21 ECHO sites (n=261) in the prospective cohort study.

They found that even among patients with difficult-to-treat HCV genotype 1 infection, there were no significant differences in treatment outcomes between the two groups – 45.8% of patients treated at the HCV clinic (38 of 83) achieved a sustained viral response vs. 49.7% at the ECHO sites (73 of 147; P=0.57).

Furthermore serious adverse event rates were lower among ECHO patients vs. those treated in the HCV clinic (6.9% vs. 13.7%).

With the ECHO program primary care clinicians participated in weekly discussions via video or teleconference with specialists in hepatology, infectious disease and pharmacology at the University of New Mexico.

These sessions gave community clinicians an opportunity to ask questions and plan patient care according to evidence-based guidelines.

“Implementation of this model would allow other states and nations to treat a greater number of patients infected with HCV than they are currently able to treat,” the researchers wrote in the New England Journal of Medicine.

Before the program was adopted, patients with chronic HCV in rural New Mexico waited up to 6 months for an appointment at a specialty HCV clinic and traveled up to 250 miles, according to the researchers.

Despite recent advances in treatment, much of the problem is due to the complexity of medication regimens and the potential for serious side effects with pegylated interferon and ribavirin (Copegus, Rebetol).

“The barriers to treatment are so formidable and concerns for safety so great that in 2004 almost no patients with HCV infection in rural and frontier areas of New Mexico were receiving treatment,” they wrote.

In an accompanying editorial, Thomas D. Sequist, MD, MPH of the division of general medicine and primary care at Brigham and Women's Hospital in Boston, wrote, “the hesitancy of primary care physicians to provide complex specialty treatment” is “understandable.”

He cited scarce resources, limited opportunities to interact with specialist colleagues and small clinical caseloads as barriers to specialty care in remote and isolated settings, and called the ECHO project an “important step forward.”

Insuring that adequate health information technology infrastructure is available, incentivizing commitments on the part of academic medical centers through community outreach recognition and developing models to finance telemedicine programs are key to ensuring the success of such programs, according to Sequist.

Currently, the ECHO program has been expanded to 255 additional sites to address other complex health issues, including substance abuse, cardiac risk factors, chronic pain and asthma.

Arora S et al. N Engl J Med. 2011; 146: 675-681.

Sequist TD. N Engl J Med. 2011; 146: 682.

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