Telemedicine Puts HCV Care in Hands of PCPs
By Crystal Phend, Senior Staff Writer, MedPage Today
June 01, 2011
Primary care physicians with telemedicine support can manage hepatitis C
virus (HCV) infection as effectively as specialty clinics, researchers
found.
Viral suppression outcomes for rural and prison system primary care
clinicians were similar to those achieved by their academic medical center
colleagues who provided consultation and video- or teleconferencing support
in a prospective cohort study led by Sanjeev Arora, MD, of the University of
New Mexico in Albuquerque.
Sustained viral response rates were 58.2% and 57.5%, respectively (P=0.89),
Arora's group reported online in the New England Journal of Medicine.
These rates matched those in the pivotal clinical trials for HCV treatments
and represented a huge turnaround for the rural and underserved population
treated, they noted.
Before the program, rural patients in New Mexico had to wait up to six
months for an HCV clinic appointment and then travel up to 250 miles 18
times on average during the course of treatment.
"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.
Safety concerns center on the serious side effects of pegylated interferon
and ribavirin (Copegus, Rebetol), which require aggressive management by
multidisciplinary experts, they explained.
Hesitancy on the part of primary care physicians to provide complex
treatment for HCV is understandable, Thomas D. Sequist, MD, MPH, of Brigham
and Women's Hospital and Harvard in Boston, commented in an accompanying
editorial.
Encouraging primary care physicians to treat HCV without any training or
assistance wouldn't be ethical, the researchers cautioned.
Sequist agreed with them that the type of program used in the study, with
health information technology plus strong commitment to support on the part
of academic medical centers, is needed to extend the model to other areas
and for other chronic health issues.
Improved access to specialty care in a program like that could do much to
address disparities in healthcare, Sequist pointed out.
Minorities -- predominantly Hispanics -- accounted for two-thirds of those
treated at the 16 rural community sites and five prisons in the study but
less than half of those at the University of New Mexico HCV clinic.
Virologic response to treatment didn't differ between Hispanic and
non-Hispanic patients in the study.
Community clinicians at the sites connected to weekly discussions via video-
or teleconferencing through the Extension for Community Healthcare Outcomes
(ECHO) program to ask questions and plan patient care according to
evidence-based protocols.
Among the total of 407 patients with previously untreated chronic HCV
infection, about 56% treated at both the HCV clinic and at the primary care
sites were infected with HCV genotype 1.
Again, sustained viral response rates among the genotype 1 patients didn't
show a significant difference by treatment site type either (45.8% for those
at the HCV clinic and 49.7% treated by primary care providers, P=0.57).
Serious adverse events were actually less common at community or prison
sites compared with the HCV clinic (6.9% versus 13.7%, P=0.02).
After adjustment for patient characteristics, the primary endpoint of
sustained virologic response rates remained similar between site types (odds
ratio 1.04 for primary care versus HCV clinic, 95% CI 0.67 to 1.60).
The researchers cautioned about the lack of a community group without
telemedicine support for comparison, the possibility of residual
confounding, and the broad confidence intervals that couldn't rule out a
substantial difference in outcome of care between groups in the study.
But given 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, they
noted.
"The ECHO model has the potential for being replicated elsewhere in the U.S.
and abroad, with community providers and academic specialists collaborating
to respond to an increasingly diverse range of chronic health issues," they
concluded in the paper.
The study was supported by the Agency for Healthcare Research and Quality,
the Robert Wood Johnson Foundation, the New Mexico Department of Health, and
the New Mexico State Legislature.
Arora reported 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.
Sequist reported having no conflicts of interest to disclose.