Synchronous Cohorts: A novel variation to the Project ECHO approach to Hepatitis C treatment
AASLD LiverLearning®. Moore A. Nov 5, 2013; 36991
Topic: Experimental Liver Transplantation and Liver Surgery
Ann Moore
Ann Moore
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BACKGROUND: The ECHO model as piloted by Sanjeev Arora, MD, hepatologist at University of New Mexico, allows for the treatment of hepatitis C by primary care providers in remote rural sites with ongoing teleconferencing support. Current therapy, particularly with the addition of protease inhibitors, involves increasingly complex management of response milestones and adverse event management. HCVNET Arizona is a Project ECHO site focused around a 14 site FQHC based in Flagstaff and has been involved in successfully treating Hepatitis C patients. Because of the rapid growth in patient numbers and treatment sites, it was elected to define specific starting dates at which all patients being readied for treatment would receive their first pegylated interferon injection. This allowed for each patient at each site to obtain their laboratory studies on the same day of the week and have their side effects managed and their treatment milestones coordinated simultaneously across the treatment network. This approach afforded the opportunity to coordinate all associated treatment activities such as pre-treatment work-up, patient training, and medication authorization. METHODS: A total of five cohorts among twelve sites have thus far been initiated at 2 month intervals with an average of 8 patients per cohort. No single clinic site had more than 3 patients starting at any one time. 70% of patients were genotype 1 and received telaprevir-based therapy. The hepatology team at St. Joseph’s Hospital and Medical Center teleconferences with all providers on a weekly basis every Wednesday. Patients generally had complete blood counts and chemistry panels drawn on the prior Mondays. Each patient is then reviewed with the local provider during the teleconference. RESULTS: Of 42 patients started on treatment, 35 were undetectable at week 4, 40 remained undetectable at week 12, and all who completed treatment have been undetectable at end of treatment. A total of 4 pts were discontinued prior to expected end of treatment (1 depression, 1 pneumonia, 1 unrelated trauma, and 1 who could not be reached for follow up). Adverse events were limited to anemia and rash (none serious), and were appropriately managed by the primary providers. CONCLUSIONS: The Synchronous Cohort approach to teleconferencing with primary care providers offered multiple advantages (1) Simultaneous treatment milestones and adverse event management, enhancing the learning experience for which the ECHO model is known to be effective. (2) Coordination of laboratory results (3) Focused work-ups and patient education based on synchronous treatment initiation (4) Less intrusive impact on the busy primary care focused clinics.
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