Project ECHO: A novel tele-mentoring service to aid hepatitis C treatment in difficult-to-access populations

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Introduction: Hepatitis C virus (HCV) is now curable with nationally funded direct-acting antivirals; however, its eradication faces many barriers as HCV commonly occurs in difficult-to-access populations (DTAPs), including those with active drug misuse and psychiatric comorbidities. Project ECHO (PE) is a novel “hub and spoke” tele-mentoring program that originated in New Mexico, USA, and was adopted by Liverpool Hospital in July 2016 to empower local clinicians and target DTAPs.

Aim: To examine if the PE model can more effectively identify and treat DTAPs with HCV in comparison to a patient cohort treated in an outpatient liver clinic.

Methods: This prospective study was approved by the Sydney South West Area Health Service ethics committee. Weekly PE video conference meetings were conducted with local clinicians, including drug and alcohol physicians, sexual health physicians, private methadone prescribers, and community general practitioners. Deidentified HCV cases were presented to a multidisciplinary team of gastroenterologists, nurses, and allied health staff. Information discussed and collected during PE meetings broadly encompassed relevant clinical and biochemical data for formulating treatment plans, psychosocial, and drug-related elements that were considered potential barriers, and treatment outcomes. PE patients were then retrospectively compared with 99 consecutive new HCV patients seen in Liverpool Hospital Liver Clinic since July 2016.

Results: Between July 2016 and April 2017, 99 cases of HCV were presented at the PE meetings by local clinicians in the South Western Sydney Local Health District. Thirteen were referred from a sexual health clinic, 68 from various drug health facilities, four from private methadone prescribers, and 14 from GPs. The PE cohort had a greater proportion of female patients (33.3% vs 25.3%) and were younger (median age, 45 years) compared with the liver clinic cohort (median age, 50 years). There were more Indigenous patients in the PE (n = 15) compared with the liver clinic cohort (n = 5). Ongoing substance misuse was prevalent in 43 of 99 PE patients, of whom 31 were active intravenous drug users and 25 had polysubstance misuse, compared with 17 of 99, 12 and 7, respectively, in the liver clinic. Of the 99 PE patients, 73 used opioid substitution therapy, of whom 38 (52.1%) required daily pickups (an indirect indicator of instability), while only 20 clinic patients used opioid substitution therapy, six of whom (30%) required daily pickups. Of the PE patients, 49 have a background of psychiatric illness, with 41 using psychotropic medications, compared with 44 clinic patients who have psychiatric comorbidities, 29 of whom are pharmacologically treated. Cirrhosis was present similarly in PE (13.1%) and liver clinic (18.1%) cohorts. Most were treatment-naive (95.0% and 90.9%, respectively). Genotypes 1, 2, and 3 proportions were similar between PE (44.4%, 6%, and 47.5%, respectively) and liver clinic (39.3%, 6%, and 37.3%, respectively) patients. Genotype 6 was not seen in PE patients, while it comprised 11.1% of liver clinic patients. As of May 2017, 18 of 18 patients in the PE cohort have completed therapy and achieved sustained virological response (SVR), while 46 patients are awaiting completion of treatment. Thirty-two patients did not initiate therapy (13 due to conflicting priorities and 19 were lost to follow-up), and three had treatment ceased early. In contrast, 34/35 liver clinic patients achieved SVR (one relapsed), 44 patients are awaiting completion, and 20 did not initiate therapy (six due to conflicting priorities, eight lost to follow-up, six awaiting future therapies).

Conclusion: PE provides an innovative model that facilitates community treatment of HCV in DTAPs who are cared for by other services and differ markedly from those who would attend liver clinics. Furthermore, the teaching approach of PE teleconferencing sessions effectively empowers referring clinicians to become independent prescribers.