Telemedicine Program Matches Outcomes of Specialty Center

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Primary care physicians in  remote New Mexico communities received training and support via teleconferencing to treat chronic hepatitis C patients.Remote patients and prison inmates treated for hepatitis C by primary care physicians with telemedicine help from a university specialty clinic achieved equal viral suppression as patients treated at the university clinic, a new study shows.

Maintaining a rigorous schedule of up to 18 treatments over a prolonged time at a specialty clinic is one of the significant barriers to effective management of HCV. The prospective telemedicine cohort study led by Dr. Sanjeev Arora of the University of New Mexico, Albuquerque, compared treatment outcomes of patients who were up to 250 miles away from the university clinic to patients treated by the specialists at the clinic.

"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," Arora's group wrote in the paper published in the June 1, 2011 New England Journal of Medicine.

The Extension for Community Healthcare Outcomes (ECHO) program was developed to improve access to care for complex chronic diseases such as hepatitis C virus. The program uses video-conferencing technology to train and support primary care providers in remote and underserved populations. Community clinicians at the sites connected to weekly discussions via video- or teleconferencing to ask questions and plan patient care according to evidence-based protocols.

In the study 407 patients with chronic HCV infection, who had undergone no previous treatment, were treated by primary care physicians at 21 ECHO sites with telemedicine support from specialists at the University of New Mexico HCV clinic. The researchers compared the outcomes of 261 patients at the ECHO sites with outcomes of 146 patients treated at the UNM specialty clinic.

The end point of the study was a sustained viral suppression. In the university-treated group, 84 patients (57.5 percent) achieved a sustained viral response compared to 152 patients (58.2 percent) treated at the remote sites. Among 83 patients with HCV-1 infection at the university clinic, 38 (45.8 percent) achieved a sustained viral response compared to 73 of 147 HCV-1 patients (49.7 percent) at the ECHO sites.

Genetic diversity of HCV is one reason that it has been difficult to develop an effective vaccine since a vaccine must protect against all genotypes. There are at least six distinctly different strains of the virus, which have different genetic profiles (genotypes). In the U. S. genotype 1 is the most common form of HCV. Serious adverse events occurred in 13.7 percent of the patients at the UNM HCV clinic and in 6.9 percent of the patients at ECHO sites.

In an accompanying editorial, Dr. Thomas Sequist, of Brigham and Women’s Hospital noted that safety is one of the reasons primary care physicians are often reluctant to treat HCV patients. The primary treatment for HCV is pegylated interferon and ribavirn, which require aggressive management by multidisciplinary experts. It is so difficult to manage, the study authors noted that encouraging primary care physicians to treat HCV without training or assistance would not be ethical.

Sequist agreed with that assessment saying that the type of program used in the study with training and telemedicine support from academic medical centers is essential to extending the success of the study to other areas with limited access to specialists.

With the success in HCV treatment, the ECHO program has been expanded to 255 sites addressing a variety of complex health problems, including substance abuse, chronic pain, asthma, and rheumatologic conditions.

"The ECHO model has the potential for being replicated elsewhere in the U.S. and abroad,” the researchers wrote. “With community providers and academic specialists collaborating to respond to an increasingly diverse range of chronic health issues.”

By Michael O’Leary, contributing writer, Health Imaging Hub


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