Dr Sanjeev Arora

Earlier this year, the World Health Organization reported that its goal of eliminating viral hepatitis as a global public health threat by 2030 has come well within reach, with 194 governments committed to hepatitis elimination; drastic price reductions in medicines through the use of generics; and effective harm reduction, screening, and treatment approaches currently available. Close to 3 million people have been able to access treatment for hepatitis C over the past 2 years, and 2.8 million people started lifelong treatment for hepatitis B in 2016 alone. Yet yearly rates of new infections continue to increase worldwide. Rapid global scale-up of screening, prevention, and treatment services – putting knowledge of those services into the hands of the frontline healthcare providers who serve communities and patients most at risk – is crucial if the dream of eliminating hepatitis is ever to be fully realized.1

Project ECHO (Extension for Community Healthcare Outcomes) is an innovative tool for the dissemination of medical knowledge to providers in medically underserved areas, which has the potential to tip the scales of worldwide efforts to halt the advance of hepatitis. It is not “telemedicine,” wherein a specialist assumes the care of a patient; rather, it enables primary care providers to care more effectively for patients in their own communities.

Project ECHO was initially developed in 2003 by Dr. Sanjeev Arora, a liver specialist in the Department of Internal Medicine at the University of New Mexico Health Sciences Center, to address disparities in access to hepatitis C treatment among New Mexico’s rural populations. At the time, while over 28,000 patients in New Mexico were diagnosed with hepatitis C, fewer than 5% had received treatment with interferon and ribavirin (best practice at that time). The waiting list at Dr. Arora’s clinic in Albuquerque was 8 months long. Many of his patients had to travel hundreds of miles to get care, resulting in lost work time and income, childcare expenses, and travel costs. Low-income patients would often delay seeking care (and develop increased complications) or not seek treatment at all. People were dying from a curable disease.

In response, Dr. Arora devised the ECHO model as a solution to the problem of inadequate access to hepatitis C care in New Mexico’s rural and underserved communities. He based the ECHO model on four principles:

· Use of technology (multipoint videoconferencing and the internet) to leverage scarce healthcare resources, in this case Dr. Arora and the expert pharmacists and psychiatrists at the University of New Mexico
· Sharing of clinical best practices and guidelines for treatment
· Case-based learning: learners receive guided practice and support from a multidisciplinary expert team and master issues of complexity
· Evaluation of outcomes

Dr. Arora and his team set up 21 hepatitis C Centers of Excellence across New Mexico (16 in community health centers, 5 in state prisons), each run by primary care providers committed to becoming experts in hepatitis C prevention and treatment. Using a simple videoconference platform, Dr. Arora’s hepatitis C ECHO program connected his team of specialists at UNM (the “hub”) with those providers (the “spokes”) for weekly two-hour teleECHO sessions in which the hub team guided the spoke participants through didactic presentations and discussion of participants’ deidentified patient cases.2 The case presentations and shared discussions highlighted another key aspect of the ECHO model: all-teach, all-learn. The primary care clinicians presenting cases and the hub specialists were all viewed as experts in their own right, helping to contribute knowledge and understanding that lead to better patient care.

A teleECHO session in progress

Within two years of the launch of Dr. Arora’s Hepatitis C ECHO program, wait times at his clinic decreased to two weeks. Participating providers’ sense of self-efficacy improved. Their knowledge of the disease and how to prevent, screen for, and treat it increased. They reported feelings of reduced isolation and increased professional satisfaction.3 A prospective cohort study, published in 2011 in the New England Journal of Medicine, demonstrated that the rural primary care providers who participated in the program could treat hepatitis C just as effectively as the specialists at UNM could.4

Since this initial success, Dr. Arora and his team – now the ECHO Institute – expanded the use of the model to other common, complex conditions for which effective treatments existed and/or were rapidly developing and changing. ECHO programs are now conducted for chronic pain, diabetes, mental health, substance use disorders, rheumatology, tuberculosis, and HIV. The ECHO Institute also holds monthly training sessions for hub partners around the world; over 163 hubs now replicate the ECHO model across 24 countries for over 50 disease areas.5,6,7,8

In addition to the initial hepatitis C program in New Mexico, 21 global partners are leveraging ECHO to combat liver diseases. The ECHO Institute works with the US Center for Disease Control and Prevention (CDC) and the government of Georgia to provide training and clinical support for providers as part of that country’s hepatitis C elimination program. The ECHO team also collaborates with the United States Department of Health and Human Services for a national program addressing perinatal transmission of hepatitis B. The University of California, San Francisco, is leveraging the ECHO model for the microelimination of hepatitis C in San Francisco, and ECHO is being deployed for the CDC’s initiative to eliminate HCV in the Cherokee Nation. The University of Utah uses the ECHO model to help providers navigate patient complications due to cirrhosis, and to triage patients for liver transplant evaluation. In India, ECHO partners including the Post Graduate Institute of Medical Education and Research and the Indian National Association for the Study of the Liver are also using the model to fight hepatitis C.

Research continues to demonstrate the effectiveness of the ECHO model against hepatitis C. A recent study of providers participating in a US Veterans Affairs ECHO program for hepatitis C treatment showed that patients of those providers received significantly higher rates of antiviral treatment compared to patients of nonparticipating providers.9 Another study, presented at the 2017 EASL international conference, assessed the impact of a multi-pronged approach to hepatitis C treatment in Punjab, involving generic drugs and ECHO programs training providers in the use of those drugs. The study demonstrated a 93% cure rate across over 30,000 patients.10

As the World Health Organization has reported, we are close to the global elimination of hepatitis C, with new approaches and treatments, and more affordable medications increasingly available to aid us in reaching this goal. These approaches, medications, and treatments are useless if they do not reach the underserved populations who need them most. Project ECHO is a powerful tool that democratizes medical knowledge and improves care for those underserved patients and populations. We invite EASL members to join the ECHO movement and explore how the ECHO model can help combat hepatitis C and liver disease in their countries and regions. For more information see the Project ECHO website (https://echo.unm.edu) or contact Dr. Sanjeev Arora (sarora@salud.unm.edu).

References

(Over 70 research publications demonstrate the effectiveness of the ECHO model across a range of diseases and conditions. For a full bibliography, see https://echo.unm.edu/wp-content/uploads/2017/09/Project-ECHO-Bibliography.pdf)

 

  1. World Health Organization, “Close to 3 million people access hepatitis C cure,” http://www.who.int/mediacentre/news/releases/2017/hepatitis-c-cure/en/
  2.  Arora S, Thornton K, Komaromy M, Kalishman S, Katzman J, and Duhigg D. (2014) Demonopolizing Medical Knowledge. Academic Medicine 89 (1): 30-2.
  3. Arora S, Kalishman S, Thornton K, Dion D, Murata G, Deming P, et al. (2010) Expanding Access to hepatitis C virus treatment – Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology 52 (3):1124-33.
  4.  Arora S, Thornton K, Murata G, Deming P, Kalishman S, Dion D, et. al. (2011) Outcomes of treatment for hepatitis C virus infection by primary care providers. New England Journal of Medicine 364(23):2199-207.
  5. Arora S, Kalishman S, Dion D, Som D, Thornton K, Bankhurst A, et. al. (2011) Partnering urban academic medical centers and primary care clinicians to provide complex chronic disease care. Health Affairs 30(6):1176-84.
  6. Komaromy M, Duhigg D, Metcalf A, Carlson C, Kalishman S, Hayes L, et. al. (2016) Project ECHO (Extension for Community Healthcare Outcomes): A new model for educating primary care providers about treatment of substance use disorders. Substance Abuse 37(1):20-24.
  7. Struminger B, Arora S, Zalud-Cerrato S, Lowrance D, Ellerbrock T. (2017) Building virtual communities of practice for health. The Lancet 390 (10095): 632-34.
  8. Frank J, Carey E, Fagan K, Aron D, et. al. (2015) Evaluation of a telementoring intervention for pain management in the Veterans Health Administration. Pain Medicine 16 (6): 1090-1100.
  9. Beste L, Glorioso T, Ho P, Au D, Kirsh S, et. al. (2017) Telemedicine specialty support promotes hepatitis C treatment by primary care providers in the Department of Veterans Affairs. American Journal of Medicine 130 (4):432-438.
  10. Premkumar M, Gagandeep S, Dhiman R (2017) Chronic hepatitis C: Do generics work as well as branded drugs? Journal of Clinical and Experimental Hepatology 7(3):253-261.