Access to care: Management of hepatitis C viral infection in remote locations


  • Potential conflict of interest: Nothing to report.


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ECHO, Extension for Community Healthcare Outcomes; HCV, hepatitis C virus; PCC, primary care clinician.

Since its recognition in 1989, hepatitis C virus (HCV) has continued to plague both developed and developing nations across the globe. It has been estimated that 130 million to 170 million people worldwide are chronically infected with HCV, and more than 350,000 people die annually.1 In the United States, 3.2 million people are estimated to be infected with chronic HCV, which causes approximately 12,000 deaths each year.2 A birth cohort–based screening strategy recommended by the Centers for Disease Control and Prevention would diagnose another 800,000 patients.3 Although new and more effective drug therapies have been developed to combat this growing disease, few patients have access to treatment.

In 2007, the American Association for the Study of Liver Diseases had 3362 dues-paying members, and 55% of these members considered their primary profession to be treating liver disease.4 In 2009, the association had 3500 members; this illustrates the slow growth in the number of practicing hepatologists.5 In addition, hepatologists practice primarily at academic medical centers, and this limits access to care for patients in remote locations away from academic medical centers.

Because of the complexity of HCV care and the limited access to liver disease specialists, many people in remote locations do not receive treatment. To help to address this growing disparity, Project ECHO (Extension for Community Healthcare Outcomes) was established in 2003 at the University of New Mexico Health Sciences Center. Using state-of-the-art telehealth technology, ECHO links remote primary care clinicians (PCCs) to a team of specialists at an academic medical center to help with the management of a patient's care. ECHO trains and supports PCCs and thus enables them to develop self-efficacy and gain knowledge about complex and chronic diseases not usually considered in their scope of practice. To accomplish this, ECHO operates regularly scheduled telehealth or tele-ECHO clinics called knowledge networks that community partners join by either video or audio. ECHO is not traditional telemedicine in which specialists interact with patients directly; instead, PCCs retain responsibility for patient care under the guidance of ECHO and its team of specialists. As PCCs gain more self-efficacy and experience in treating patients, they begin to operate with increasing independence and become experts themselves.

ECHO staff members conduct an onsite 1-day orientation for all new partners who want to begin treating HCV. During this orientation, the participants go over the HCV treatment protocol in detail, the technologies required for participation, and the format of the case-based presentations given at the weekly tele-ECHO clinics. After participation in the orientation, providers begin to present HCV cases to ECHO specialists in the fields of hepatology, infectious diseases, psychiatry, and pharmacology to gain expert advice and clinical mentoring (Fig. 1). The longitudinal comanagement of patients with specialists offers case-based learning and an opportunity to develop both content knowledge and self-efficacy.6 The ECHO model supports feedback from specialists and provides PCCs the opportunity to discuss treatment throughout the course of a patient's care. Short didactic presentations are also given to further improve disease knowledge. These case-based knowledge networks create learning loops in which PCCs learn from one another in addition to the experts to gain the skills necessary to treat complex HCV patients.6-8 In 2011, 31 community partners representing 19 partner sites, participated in the tele-ECHO HCV clinic.

Figure 1.

Screen shot of partner sites and the Project ECHO team participating in a tele-ECHO HCV clinic.

Table 1 shows previously published data illustrating significant improvements in providers' knowledge of HCV, self-efficacy, and professional satisfaction through their participation in ECHO HCV clinics.6 Clinicians reported a significant benefit from participation in ECHO. Table 2 shows the number of continuing medical education credits that participants have earned through their participation in ECHO HCV clinics. These credits are provided free of charge.

Table 1. 2008 Annual Survey of Clinicians Participating in the ECHO HCV Clinic (n = 23)
 Mean (Standard Deviation)
  1. This table is adapted with permission from Hepatology.6 The rating scale anchors are (1) not at all and (5) to a large degree.

Transfer of knowledge from ECHO clinics to clinical care 
 I am able to apply knowledge learned in ECHO clinics to patients with similar diseases in my clinic.4.7 (0.5)
 I am able to share knowledge with clinical staff about specific diseases discussed in the ECHO clinics that I attend.4.4 (0.7)
Local clinical environment 
 Clinicians and staff at my clinic are supportive of my involvement in ECHO.4.3 (0.8)
 Patients and their families support our involvement with ECHO.3.9 (0.9)
 Participating and learning about a complex chronic disease through ECHO is an effective way for our clinic to enhance its expertise.4.7 (0.6)
 Local health care professionals consult with us as local experts in specific diseases because of our ECHO participation.3.6 (1.1)
Patient safety/quality of care 
 I am confident as a provider that ECHO addresses patient safety issues promptly and effectively for each of the ECHO clinics in which I participate.4.8 (0.5)
 I am confident about my knowledge and skills to address patient safety issues associated with the patients whom I present at ECHO clinics.4.0 (0.8)
 ECHO specialists help me to identify potential patient safety/quality of care issues.4.7 (0.5)
Teaching best practices 
 I am confident/comfortable presenting patient cases during ECHO clinics.3.6 (1.4)
 I listen to and learn from providers who present their patient cases during ECHO clinics.3.8 (1.2)
 Didactic sessions during ECHO clinics are an effective way for me to learn the screening, treatment, and management of patients.4.2 (1.0)
 Site visits by ECHO staff are an effective way for clinical staff to learn ECHO disease-specific screening, management, and treatment protocols.4.2 (1.0)
 Multiple site visits at my clinic by ECHO staff would be a more effective way to learn ECHO protocol and procedures.3.4 (1.0)
Table 2. Continuing Medical Education Credit Totals for Project ECHO HCV Clinics: 2003 to February 2012
YearHCV Continuing Medical Education Credits (n)
Grand Total11,816

ECHO has been successful at increasing access to care for patients who previously had no access to experts. In a study published in 2011,7 ECHO demonstrated that HCV treatment provided by ECHO PCCs was as safe and effective as treatment provided by HCV experts at the dedicated HCV clinic of the University of New Mexico hospital. The standard treatment for HCV, which was clearly defined by the ECHO protocol, was given to all the patients who participated. In all, 58.2% of the patients treated at ECHO sites and 57.5% of the patients treated at the HCV clinic of the University of New Mexico Health Sciences Center had a sustained virological response.7 There was no statistical difference in the cure rates at the university clinic and the community partners. In addition, ECHO sites treated a greater percentage of minority patients (64.5% Hispanic) than the university clinic (41.5% Hispanic).7

Because of the success of the tele-ECHO HCV clinics, Project ECHO has expanded to other complex chronic disease areas, such as integrated addictions and psychiatry, chronic pain, diabetes and cardiovascular care, palliative care, human immunodeficiency virus/acquired immune deficiency syndrome, high-risk pregnancy, and rheumatology (Fig. 2). Project ECHO has also expanded from its original site in New Mexico to partner sites at the University of Washington, the University of South Florida, the University of Chicago, Beth Israel Deaconess Medical Center (Boston, MA), the University of Utah, the Institute of Liver and Biliary Sciences (New Delhi, India), and other places in India.

Figure 2.

Map of Project ECHO tele-ECHO clinics in New Mexico.

Globally, the incidence of liver disease is on the rise. Escalating levels of obesity around the world in conjunction with more sedentary occupations have resulted in an increase in the rate of nonalcoholic fatty liver disease in the developed world, whereas developing nations are seeing rising levels of alcoholic liver disease because of increased alcohol consumption.9 Despite this growing public health concern and the need for hepatologists, there continues to be an inadequate workforce to meet the demand, especially in underserved and remote areas. ECHO has the potential to significantly expand best practices for other liver diseases, in addition to HCV by utilizing the ECHO model to train PCCs. Expanding the number of providers who are able to treat liver disease is a solution to the growing need for treatment and the lack of available specialists to treat liver disease is a solution to the growing need for treatment and the lack of available specialists.