1. Management of Chronic HCV Infection by PMDs Rod Rahimi Osler Journal Club 1-25-12

2. 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

3. Hepatitis C 170 million people worldwide (3%) are hepatitis C positive (3.2 million in the US) cdc.gov

4. Hepatitis C treatment

6. Pegylated interferon and ribavirin are available and cost-effective HCV genotype 1 cure rate 45% HCV genotype 2 and 3 cure rate 75%

7. 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

8. 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

9. The University of New Mexico The ECHO (Extension for Community Healthcare Outcomes) Model http://www.youtube.com/watch?feature=play er_embedded&v=2lBfyOlL4_s

10. The ECHO Model

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

15. 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

16. Critical Appraisal Discussion What comparison is being made? Does the comparison make clinical sense? What are the potential selection biases?

17. 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

18. 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

19. 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.