Management of Chronic HCV Infection by PMDs

Rod RahimiOsler Journal Club

1-25-12

Outline

• Background on Hepatitis C• Barriers to treatment• ECHO (Extension for Community Healthcare

Outcomes) model• Cohort trial: PMD v. Specialists• Conclusions• Time for questions/discussion

Hepatitis C

• 170 million people worldwide (3%) are hepatitis C positive (3.2 million in the US)

cdc.gov

Hepatitis C treatment

Hepatitis C treatment

Hepatitis C treatment

• Pegylated interferon and ribavirin are available and cost-effective

• HCV genotype 1 cure rate 45%

• HCV genotype 2 and 3 cure rate 75%

Are patients receiving treatment?

• Antiviral treatment rates are <30%• Even among eligible patients treatment rates

range from only 45-75%• Rates even lower in rural areas and prisons• In New Mexico, 40% of the 6000 inmates are

infected with HCV. As of 2003 not a single one had received antiviral treatment

Barriers to Treatment

• Treatment is currently complex• Most PMDs lack training– Complex side effects from treatment including flu-

like symptoms, cytopenias, hemolysis, autoimmunity, depression

• In New Mexico, patients had to travel up to 250 miles to the UNM medical center, having to make an average of 18 trips during treatment

The University of New Mexico

• The ECHO (Extension for Community Healthcare Outcomes) Model

• http://www.youtube.com/watch?feature=player_embedded&v=2lBfyOlL4_s

The ECHO Model

Arora S et al. N Engl J Med 2011;364:2199-2207.

Arora S et al. N Engl J Med 2011;364:2199-2207.

Arora S et al. N Engl J Med 2011;364:2199-2207.

Arora S et al. N Engl J Med 2011;364:2199-2207.

Conclusions

• PMDs treating HCV infection with assistance of the ECHO model are as effective in achieving SVR as specialists

• No difference in serious adverse events between PMDs and specialists

Critical Appraisal Discussion

• What comparison is being made?

• Does the comparison make clinical sense?

• What are the potential selection biases?

Critical Appraisal Discussion

• No comparison group comprising patients treated by PMDs without ECHO– No PMDs treating HCV independently– Unethical to randomize PMDs to treating HCV

without ECHO• The study was not large enough to establish

equivalence between PMDs with ECHO and specialists

Telemedicine Discussion

• Advantages– Increase clinical knowledge among PMDs– Increase clinical access to specialist treatments– Cost-effective

• Disadvantages– Delay referrals– Potentially demanding on specialists– Potential for adverse events

References• Arora et al. Outcomes of Treatment for Hepatitis C Virus Infection by

Primary Care Providers. N Engl J Med. 2011 June 9;364(23):2199-2207.

• Fried et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med. 2002 Sep 26;347(13):975-82.

• Swain et al. A sustained virologic response is durable in patients with chronic hepatitis C treated with peginterferon alfa-2a and ribavirin. Gastroenterology. 2010 Nov;139(5):1593-601.

• Kanwal et al. Predictors of treatment in patients with chronic hepatitis C infection - role of patient versus nonpatient factors. Hepatology 2007 Dec;46(6):1741-9.