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Sanjeev Arora M.D. Professor of Medicine (Gastroenterology/Hepatology) Director Project ECHO Executive Vice Chairm PowerPoint Presentation
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Sanjeev Arora M.D. Professor of Medicine (Gastroenterology/Hepatology) Director Project ECHO Executive Vice Chairman Department of Medicine University of New Mexico Health Sciences Center, Tel: 505-272-2808 Fax: 505-272-4628 sarora@salud.unm.edu. MISSION. MISSION.

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slide1

Sanjeev Arora M.D.

Professor of Medicine (Gastroenterology/Hepatology)

Director Project ECHO

Executive Vice Chairman

Department of Medicine

University of New Mexico Health Sciences Center,

Tel: 505-272-2808

Fax: 505-272-4628

sarora@salud.unm.edu

slide2

MISSION

MISSION

The mission of Project ECHO is to

develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes.

Supported by Agency for Health Research and Quality HIT grant 1 UC1 HS015135-04, and MRISP, R24HS16510-02 and the New Mexico Legislature, Robert Wood Johnson Foundation

hepatitis c a global health problem
Hepatitis C: A Global Health Problem

170 Million Carriers Worldwide, 3-4 MM new cases/year

EAST

MEDITERRANEAN

20M

WEST

EUROPE

9 M

FAR EAST ASIA

60 M

U.S.A.

4 M

SOUTH EAST ASIA

30 M

AFRICA

32 M

SOUTH

AMERICA

10 M

AUSTRALIA

0.2 M

Source: WHO 1999

aasld practice guidelines diagnosis management and treatment of hepatitis c
AASLD Practice Guidelines: Diagnosis, Management, and Treatment of Hepatitis C
  • AASLD guidelines a key reference on best practices for care of hepatitis C patients
    • Previous guidelines issued in 2004,
    • 2009 guidelines recently published
      • Evidence-based recommendations approved by the AASLD, the Infectious Diseases Society of America, and the American College of Gastroenterology

Ghany MG, et al. Hepatology. 2009;49:1335-1374.

grading system for quality of aasld diagnostic treatment recommendations
Grading System for Quality of AASLD Diagnostic/Treatment Recommendations
  • Classification
    • Class I: evidence that diagnostic/treatment is beneficial, useful, and effective
    • Class II: conflicting evidence/divergence of opinion about usefulness/efficacy of diagnostic/treatment
    • Class IIa: evidence/opinion in favor of usefulness/efficacy
    • Class IIb: usefulness/efficacy less well established by evidence/opinion
    • Class III: evidence/general agreement that diagnostic/treatment is not useful/effective and may be harmful in some cases
  • Evidence level
    • Level A: data derived from multiple RCTs or meta-analyses
    • Level B: data derived from single RCT or nonrandomized studies
    • Level C: only consensus opinion of experts, case studies, or SOC

Ghany MG, et al. Hepatology. 2009;49:1335-1374.

aasld guideline recommendations for screening and counseling
AASLD Guideline Recommendations for Screening and Counseling

1. As part of a comprehensive health evaluation, all persons should be screened for behaviors that place them at high risk for HCV infection (Class I, level B).

2. Persons who are at risk should be tested for the presence of HCV infection (Class I, level B).

3. Persons infected with HCV should be counseled on how to avoid HCV transmission to others (Class I, level C).

Ghany MG, et al. Hepatology. 2009;49:1335-1374.

aasld guideline recommendations for screening and counseling7
AASLD Guideline Recommendations for Screening and Counseling

4. Patients suspected of having acute or chronic HCV infection should first be tested for anti-HCV (Class I, Level B).

5. HCV RNA testing should be performed in:

- Patients for whom antiviral treatment is being considered, using a sensitive quantitative assay (Class I, Level A)

- Patients with a positive anti-HCV test (Class I, Level B)

- Patients with unexplained liver disease whose anti-HCV test is negative and who are immunocompromised or suspected of having acute HCV infection (Class I, Level B).

Ghany MG, et al. Hepatology. 2009;49:1335-1374.

topics
Topics

Why screen for HCV

How to screen for HCV

Who should be tested for HCV

What laboratory tests should be used to test for HCV

How to counsel HCV-infected patients

hcv screening
HCV Screening

Why screen for HCV

How to screen for HCV

Who should be tested for HCV

What laboratory tests should be used to test for HCV

How to counsel HCV-infected patients

guidelines recommend risk factor screening in all patients
Guidelines Recommend Risk Factor Screening in All Patients
  • Potential for harm reduction
    • Alcohol intake, vaccinations, secondary transmission, treatment
  • Treatment reduces long-term adverse outcomes
  • Treatment benefit will improve further as SVR rates increase

Ghany MG, et al. Hepatology. 2009;49:1335-1374.

hcv testing and counseling
HCV Testing and Counseling

Why screen for HCV

How to screen for HCV

Who should be tested for HCV

What laboratory tests should be used to test for HCV

How to counsel HCV-infected patients

risk factors in 3 domains significantly associated with hcv infection
Risk Factors in 3 Domains Significantly Associated With HCV Infection

Domain

Odds Ratio (95% CI)

2.92

Medical history: blood transfusions, dialysis, elevated liver function tests results

5.92

Exposure: any blood contact

1.16

Work: job with high risk of HCV exposure

1.63

Personal history: sharing toothbrushes, receiving tattoos or piercings, acupuncture

8.15

Social history: illicit drug use, incarceration, past and current sexual activity

0.01

1.00

15.00

1000 randomly selected patients questioned about risk factors in 5 domains

83 were anti-HCV positive; 63 had at least one positive response

McGinn T, et al. Arch Intern Med. 2008;168:2009-2013.

hcv screening begins with risk factor assessment
HCV Screening Begins With Risk Factor Assessment

Ghany MG, et al. Hepatology. 2009;49:1335-1374. 1. Shehab TM, et al. Viral Hepat. 2001;8:377-383. 2. Kim WR. Hepatology. 2002;36:S30-S34.

  • Recommendation: Universal risk screening and focused testing (ref 1)
  • Survey of 4000 primary care physicians[2]
    • 59% of 1412 respondents asked all patients about HCV risk factors
  • As few as 25% of HCV infections are recognized[3]
practical models of hcv screening
Practical Models of HCV Screening
  • Include list of HCV risk factors in patient intake form
  • Have non physician review risk
  • Build risk screening into quality assurance
  • Veterans Affairs Medical Center example
    • 36,422 patients screened for HCV risk factors from January 2000 - December 2001
    • 12,485 patients (34%) at risk received anti-HCV testing
    • Anti-HCV was detected in 681 (5.4%)

Groom H, et al. J Clin Gastroenterol. 2008;42:97-106

hcv testing and counseling15
HCV Testing and Counseling

Why screen for HCV

How to screen for HCV

Who should be tested for HCV

What laboratory tests should be used to test for HCV

How to counsel HCV-infected patients

groups recommended for hcv testing by aasld and usphs
Groups Recommended for HCV Testing by AASLD and USPHS

Ghany MG, et al. Hepatology. 2009;49:1335-1374. Centers for Disease Control and Prevention. MMWR Recomm Rep. 1998;47:1-39.

  • Recent/past injection drug users—even if only used once
  • Groups with high HCV prevalence
    • HIV-infected individuals
    • Hemophiliacs treated with clotting factor concentrates before 1987
    • Hemodialysis recipients
    • Patients with unexplained aminotransferase abnormalities
  • Recipients of transfusion or transplantation before July 1992
  • Children born to women infected with HCV
  • Healthcare, public safety, and emergency medical personnel following needle injury or mucosal exposure to HCV-infected blood
  • Current sexual partners of individuals infected with HCV
  • Persons who have used illicit drugs by noninjection routes
hcv antibody testing is recommended for initial detection of hcv infection
HCV Antibody Testing Is Recommended for Initial Detection of HCV Infection

HCV antibody testing is sensitive and inexpensive

Positive results should be confirmed with repeat antibody test

Signal-to-cutoff ratio may be used to confirm that test is a true positive

Positive test results are often reportable

Ghany MG, et al. Hepatology. 2009;49:1335-1374.

slide18

HEPATITIS C IN

NEW MEXICO

HEPATITIS C IN NEW MEXICO

  • Estimated number is greater than 28,000
  • In 2004 Less than 5% had been treated
  • Without treatment 8,000 patients will develop cirrhosis between 2010-2015 with several thousand deaths
  • 2300 prisoners diagnosed in corrections system (expected number is greater than 2400) - None treated
  • Highest rate of chronic liver disease/cirrhosis deaths in the nation
sustained viral response cure rates with pegifn rbv according to genotype
Sustained Viral Response (Cure) Rates with PegIFN/RBV According to Genotype

76%-82%

42%-46%

Genotype Non-1

Genotype 1

Adapted from Strader DB et al. Hepatology. 2004;39:1147-1171.

slide20

HEPATITIS C TREATMENT

Good News:

Curable in 45-81% of cases

Bad News:

Severe side effects – anemia (100%), neutropenia >35%, depression >25%

slide21

Rural New Mexico

RURAL NEW MEXICO

  • Underserved Area for Healthcare Services
  • 32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUA’s)
  • 14 counties designated as Health Professional Shortage Areas (HPSA’s)
  • 121,356 sq miles
  • 1.83 million people
  • 42.1% Hispanic
  • 9.5% Native American
  • 17.7% poverty rate compared to 11.7% nationally
  • >22% lack health insurance
slide22

HEALTH CARE IN NEW MEXICO

HEALTHCARE IN

NEW MEXICO

  • 20% practice in rural or frontier areas

New Mexico Physician Survey 2001

slide23

GOALS

GOALS

  • Develop capacity to safely and effectively treat Hepatitis C in all areas of New Mexico and to monitor outcomes
  • Develop a model to treat complex diseases in rural locations and developing countries
slide24

PARTNERS

PROJECT ECHO

  • University of New Mexico School of Medicine Dept of Medicine, Telemedicine and CME
  • NM Department of Corrections
  • NM State Health Department
  • Indian Health Service
  • Community Clinicians with interest in Hepatitis C and Primary Care Association
slide25

METHOD

METHOD

  • Use Technology (telemedicine and internet) to leverage scarce healthcare resources
  • Disease Management Model focused on improving outcomes by reducing variation in processes of care and sharing “best practices”
  • Case based learning: Co-management of patients with UNMHSC specialists
  • Centralized database HIPAA compliant to monitor outcomes
slide26

STEPS

STEPS

  • Train physicians, nurses, pharmacists, educators in Hepatitis C
  • Train to use web based software “ihealth”
  • Conduct telemedicine clinics – “Knowledge Network”
  • Initiate co-management – “Learning loops”
  • Collect data and monitor outcomes centrally
  • Assess cost and effectiveness of programs
slide27

BENEFITS TO RURAL CLINICIANS

COMMUNITY PARTNERS

  • No cost CME’s and Nursing CEU’s
  • Professional interaction with colleagues with similar

interest

– Less isolation with improved recruitment and retention

  • A mix of work and learning
  • Obtain HCV certification
  • Access to specialty consultation with GI, hepatology,

psychiatry, infectious diseases, addiction specialist,

pharmacist, patient educator

slide30

Technology

METHOD

  • Videoconferencing Bridge (Polycom RMX 2000)
  • Videoconferencing Recording Device (Polycom RSS 2000)
  • You Tube like Website (Polycom VMC 1000)
  • Webcam Interfacing Capacity (Polycom CMA 5000)
  • iHealth
  • Webinar
  • Customer Relation Management Solution
  • Software for Online Classes
slide31

DISEASE SELECTION

DISEASE SELECTION

  • Common diseases
  • Management is complex
  • Evolving treatments and medicines
  • High societal impact (health and economic)
  • Serious outcomes of untreated disease
  • Improved outcomes with disease management
slide32

BUILDING BRIDGES

HEALTHCARE IN NEW MEXICO

BUILDING BRIDGES

PARETTO’S PRINCIPLE

State Health Dept

Community Health Centers

Private Practice

UNM HSC

Hepatitis C

Asthma and COPD

Substance Use and Mental Health Disorders

slide33

KNOWLEDGE IMPORTANT - NOT TITLE

FORCE MULTIPLIER

HEALTHCARE IN NEW MEXICO

Use Existing Community Clinicians

Primary Care

Nurse Practitioners

Physician Assistants

Specialists

Hepatitis C

Asthma and COPD

Substance Use and Mental Health Disorders

slide34

KNOWLEDGE IMPORTANT - NOT TITLE

FORCE MULTIPLIER

HEALTHCARE IN NEW MEXICO

Chronic Disease Management is a Team Sport

Community Health Worker

Medical Assistant

Primary Care

Nurse

Hepatitis C

Asthma and COPD

Substance Use and Mental Health Disorders

changes in hba1c with chw as sole diabetes educator
Changes in HbA1c with CHW as sole Diabetes Educator

% Change from Baseline

20

15

10

5

0

–5

–10

–15

–20

20

15

10

5

0

–5

–10

–15

–20

FullParticipation

Full Participation

Partial Participation

Partial Participation

6 Months

12 Months

Culica JH. Care for the Poor & Underserved. 2008;19:1076-1095.

slide36
Community Based Care for Cardiac Risk Factor Reduction was More Effective than Enhanced Primary Care

Becker Circulation. 2005;111:1298-1304.

slide37

Why is a CHW Intervention Effective?

DISEASE SELECTION

  • Live in Community
  • Understand Culture
  • “Have Walked Two Moons in The Patient’s Moccasins”
  • Appreciate Economic Limitations of Patient and Know Community Resources Available to Patient
  • Often Know Family and can engage other Social Resources for Patient
  • Spend More Time with Patient
slide38

CHW Training – TWO TRACKS

DISEASE SELECTION

  • CHW Specialist Training
      • Diabetes, Obesity, Hypertension, Cholesterol, Smoking Cessation, Exercise Physiology
      • Substance Use Disorders
      • Hepatitis C
  • CHW Basic Training
      • Computer Use, Human Behavior and Social Environment, Healthcare Delivery Systems, Payment Systems, Ethics, HIPAA
      • Medical Terminology, Human Anatomy, Patient Care Skills, Medical Record Keeping, Interpersonal Communication, Client Advocacy, Cultural Competence, Stages of Change Motivational Interviewing, Understanding Poverty, Family Dynamics and Family Systems Theories, Nutrition and Healthy Eating, Tobacco Risks and Cessation, Substance Abuse and Healthcare
slide39

Specialty CHW Program

DISEASE SELECTION

  • Use Low Cost Technology to Take Specialty Training to the CHWs, Promotoras, CHRs, Medical Assistants Where They Live
  • Narrow Focus- Deep Knowledge
  • Standardized Curriculum
  • Ongoing Support via Knowledge Networks
  • Part of Disease Management Team
  • Warm Handoff
slide40

Basic CHW Training

DISEASE SELECTION

  • Use Low Cost Technology to Take Basic Training to Individuals Where They Live
  • Standardized Curriculum
  • Ongoing Support via Knowledge Networks
  • Develop a Certification Program in Collaboration with DOH and Organizations that Represent CHWs
  • Collaborate with DOH and CHW Organization to Develop a Process and Criteria to Grandfather Existing CHWs
slide41

Why Do We Need An Army of CHWs?

DISEASE SELECTION

  • The Baby Boomers Are Aging
  • There will be a Tsunami of Chronic Disease
  • They Have a High Expectation for Service
  • There is a Severe Shortage of Primary Care Clinicians with No Visible Solutions in the Short Term
  • Primary Care Clinicians Need Support
slide42

ECHO Model Overcomes Many Barriers for Training & Development

KNOWLEDGE MODEL

  • Existing Methodologies for Training and Development of Widely Distributed Learners Have Significant Limitations
    • Expensive
    • Out of Sight-Out of Mind
    • Applying Knowledge is a Whole New Thing
    • Employee Turnover
    • Knowledge Becomes Obsolete
slide43
Community Health Workers in PrisonThe New Mexico Peer Education ProgramPilot training cohort, CNMCF Level II, July 27-30, 2009

First day of peer educator training

Photo consents on file with Project ECHO and CNMCF

slide44
Graduation Ceremony of First CohortThe New Mexico Peer Education ProgramPilot training cohort, CNMCF Level II, July 27-30, 2009

Graduation as Peer Educators

Photo consents on file with Project ECHO and CNMCF

slide47

How well has model worked for Hepatitis C ?

  • 375 HCV Telehealth Clinics have been conducted
  • 3534 patients entered HCV disease management program
  • CME’s/CE’s issued:
  • 5100 CME/CE hours issued to ECHO Clinicians for Hep C. Total CME hours 8500 at no cost
  • 237 hours of HCV Training conducted at rural sites
  • National Recognition as Model for Complex Disease Care
slide48

Project ECHO Clinicians HCV Knowledge Skills and Abilities (Self-Efficacy)scale: 1 = none or no skill at all 7= expert-can teach others

project echo clinicians hcv knowledge skills and abilities self efficacy50
Project ECHO Clinicians HCV Knowledge Skills and Abilities (Self-Efficacy)

Cronbach’s alpha for the BEFORE ratings = 0.92 and Cronbach’s alpha for the TODAY ratings = 0.86 indicating a high degree of consistency in the ratings on the 9 items

objectives
Objectives
  • To train primary care Clinicians in rural areas and prisons to deliver hepatitis C treatment to rural populations of New Mexico
  • To show that such care is as safe and effective as that given in a University Clinic
  • To show that Project ECHO improves access to hepatitis C care for minorities
participants
Participants
  • Study sites
    • Intervention (ECHO)
      • Community-based clinics: 14
      • New Mexico Department of Corrections: 7
    • Control: University of New Mexico (UNM) Liver Clinic
  • Subjects meeting inclusion / exclusion criteria
    • Community cases seen by primary care physicians
    • Consecutive University patients
study design
Study Design
  • Prospective cohort study
    • Participation determined by available technology
    • Randomization by patient, Clinician, or site not feasible
  • Advantages
    • Uniform eligibility criteria
    • Standardized treatment
    • Prospective measurement of end-points
  • Limitation: groups unbalanced with respect to patient covariates
principal endpoints
Principal Endpoints
  • Sustained viral response (SVR): no detectable virus 6 months after completion of treatment
  • Non-response: < 2 log drop in Hepatitis C viral load at 12 weeks or presence of virus at 24 wks
  • Significant adverse event (SAE): major side-effect
  • Completion of treatment: full course of prescribed therapy
developing new standards of practice for hepatitis c
Developing New Standards of Practice for Hepatitis C
  • 384 hepatitis C patients met inclusion and exclusion criteria
    • Age: 43.0 ± 10.0 years
    • Men: 63.3%
    • Minority: 65.2%
    • Genotype 1: 57.0%
    • Log10 viral load: 5.89 ± 0.95
    • Treatment sites
      • UNMH: 127 (33.1%)
      • ECHO site: 257 (66.9%)
conclusions
Conclusions
  • Rural primary care Clinicians deliver hepatitis C care under the aegis of Project ECHO that is as safe and effective as that given in a University clinic
  • Project ECHO improves access to hepatitis C care for New Mexico minorities
slide62

Potential Benefits

DISEASE SELECTION

  • Quality and Safety
  • Access for Rural and Underserved Patients
  • Workforce Training and Force Multiplier
  • Improving Professional Satisfaction/ Retention
  • Cost Effective Care- Avoid Excessive Testing and Travel
  • Prevent Cost of Untreated Disease (eg: Liver Transplant)
  • Integration of Public Health
slide64
Applications sought for Disruptive Innovations in Healthcare – New Models that would change healthcare nationally and globally (2007)

Project ECHO selected a winner amongst 307 Applications from 27 countries

ehealth Inititative award (2008)

Computerworld Award (2008)

US Long Distance Education Award (2008)

Ashoka Foundation Award for Social Entrepreneurship (2009)

Awards for ECHO Team

KNOWLEDGE MODEL

slide65

Use of telemedicine, best practice protocols, co-management of patients with case based learning (the ECHO model) is a robust method to to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes.

Supported by Agency for Health Research and Quality HIT grant 1 UC1 HS015135-04, and MRISP, R24HS16510-02 and the New Mexico Legislature, Robert Wood Johnson Foundation