ECHO model effectively improved access to care for HCV in underserved populations

Arora S. N Engl J Med. 2011;doi:10.1056/NEJMoa1009370.

The Extension for Community Healthcare Outcomes model allowed primary care providers to manage hepatitis C infection in rural and underserved communities comparable to academic medical centers, according to new findings published in The New England Journal of Medicine.

“Currently, there are 16 community sites and five prisons in which treatment for HCV infection is delivered with the use of the [Extension for Community Healthcare Outcomes (ECHO)] model,” Sanjeev Arora, MD, of the department of internal medicine at the University of New Mexico, and colleagues wrote in the study. “Since ECHO’s inception in 2003, there have been more than 5,000 case presentations, and 800 patients have been treated.”

According to background information in the study, the model was developed to improve access to care for underserved populations with complex health problems such as HCV by training primary care providers through video-conferencing technology.

The researchers hypothesized that HCV treatment with the ECHO model delivered across 21 primary care clinics that utilized the ECHO model in the community or in prison in New Mexico would be as effective as the treatment provided at the University of New Mexico (UNM) HCV clinic.

Participants were aged 18 to 65 years, had chronic HCV infection and were not previously treated. Of the 407 participants included in the analysis, 261 were treated at ECHO sites and 146 were treated at the UNM clinic; all were treated for HCV based upon standard ECHO protocol. Primary outcome measure was sustained virologic response.

Both arms achieved sustained virologic response with similar rates of 57.5% of patients treated at the UNM clinic and 58.2% of patients treated at ECHO sites (95% CI, -9.2 to 10.7). Moreover, 45.8% of those with HCV genotype-1 infection treated at the UNM clinic had a sustained virologic response compared with 49.7% of those at ECHO sites (P=.57).

Serious adverse events were more commonly reported at the UNM clinic vs. those treated at ECHO sites (13.7% vs. 6.9%; P=.02).

“ECHO represents a needed change from the conventional approaches in which specialized care and expertise are available only at academic medical centers in urban areas,” the researchers wrote. “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.”

Disclosure: Dr. Arora reports receiving grant support from ZymoGenetics, Genentech, Vertex Pharmaceuticals, Tibotec, Human Genome Sciences, and Wyeth (now part of Pfizer); speaking fees from Schering-Plough (now part of Merck) and Genentech-Roche; and payment for advisory board membership from Vertex Pharmaceuticals.

Brian Montague, DO, MS, MPH

At least 5 million people are thought to be infected with HCV, a significant fraction of whom without treatment will progress to end stage liver disease in the next 10 to 20 years. Multiple studies have shown that referral based models of care lead to very low uptakes to treatment, with minorities and economically disadvantaged populations experiencing a large portion of the associated morbidity and mortality. Because the costs of treating persons with end-stage liver disease can be enormous, HCV therapy has been repeatedly and clearly shown to be a cost effective intervention. Innovative models of increasing access to HCV, particularly as new therapies are brought to market are critically needed. Despite the cited limitations, the program presented by Arora and colleagues is a remarkable example of just such a program, blending a clinical care program with capacity development for providers through their knowledge network. In this era of cost containment, support for innovative programs such as these will be critical to increase uptake to treatment for HCV and contain the economic and human costs of this epidemic.

Brian Montague, DO, MS, MPH
Brown University and The Miriam Hospital

Disclosure: Mr. Montague reports no relevant financial disclosures.

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