Primary care physicians with telemedicine support can manage hepatitis C virus (HCV) infection as effectively as specialty clinics, researchers found.
Viral suppression outcomes for rural and prison system primary care clinicians were similar to those achieved by their academic medical center colleagues who provided consultation and video- or teleconferencing support in a prospective cohort study led by Sanjeev Arora, MD, of the University of New Mexico in Albuquerque.
Sustained viral response rates were 58.2% and 57.5%, respectively (P=0.89), Arora's group reported online in the New England Journal of Medicine.
These rates matched those in the pivotal clinical trials for HCV treatments and represented a huge turnaround for the rural and underserved population treated, they noted.
Before the program, rural patients in New Mexico had to wait up to six months for an HCV clinic appointment and then travel up to 250 miles 18 times on average during the course of treatment.
"Barriers to treatment are so formidable and concerns for safety so great that in 2004 almost no patients with HCV infection in rural and frontier areas of New Mexico were receiving treatment," Arora's group wrote in the paper.
Safety concerns center on the serious side effects of pegylated interferon and ribavirin (Copegus, Rebetol), which require aggressive management by multidisciplinary experts, they explained.
Hesitancy on the part of primary care physicians to provide complex treatment for HCV is understandable, Thomas D. Sequist, MD, MPH, of Brigham and Women's Hospital and Harvard in Boston, commented in an accompanying editorial.
Encouraging primary care physicians to treat HCV without any training or assistance wouldn't be ethical, the researchers cautioned.
Sequist agreed with them that the type of program used in the study, with health information technology plus strong commitment to support on the part of academic medical centers, is needed to extend the model to other areas and for other chronic health issues.
Improved access to specialty care in a program like that could do much to address disparities in healthcare, Sequist pointed out.
Minorities -- predominantly Hispanics -- accounted for two-thirds of those treated at the 16 rural community sites and five prisons in the study but less than half of those at the University of New Mexico HCV clinic. Virologic response to treatment didn't differ between Hispanic and non-Hispanic patients in the study.
Community clinicians at the sites connected to weekly discussions via video- or teleconferencing through the Extension for Community Healthcare Outcomes (ECHO) program to ask questions and plan patient care according to evidence-based protocols.
Among the total of 407 patients with previously untreated chronic HCV infection, about 56% treated at both the HCV clinic and at the primary care sites were infected with HCV genotype 1.
Again, sustained viral response rates among the genotype 1 patients didn't show a significant difference by treatment site type either (45.8% for those at the HCV clinic and 49.7% treated by primary care providers, P=0.57).
Serious adverse events were actually less common at community or prison sites compared with the HCV clinic (6.9% versus 13.7%, P=0.02).
After adjustment for patient characteristics, the primary endpoint of sustained virologic response rates remained similar between site types (odds ratio 1.04 for primary care versus HCV clinic, 95% CI 0.67 to 1.60).
The researchers cautioned about the lack of a community group without telemedicine support for comparison, the possibility of residual confounding, and the broad confidence intervals that couldn't rule out a substantial difference in outcome of care between groups in the study.
But given the success in HCV treatment, the ECHO program has been expanded to 255 sites addressing a variety of complex health problems, including substance abuse, chronic pain, asthma, and rheumatologic conditions, they noted.
"The ECHO model has the potential for being replicated elsewhere in the U.S. and abroad, with community providers and academic specialists collaborating to respond to an increasingly diverse range of chronic health issues," they concluded in the paper.
MedPage Today
http://www.medpagetoday.com/InfectiousDisease/Hepatitis/26806
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