NEJM Study: Primary Care Clinicians Can Treat Hepatitis C as Effectively as Specialists Through New Delivery Model

University of New Mexico's Project ECHO poised to spread best practices, eliminate barriers to treatment and improve health care quality across the United States.

Under a completely new way of providing health care, primary care clinicians in remote villages, prisons and poor urban neighborhoods who were trained to treat patients with hepatitis C achieved excellent results identical to those of specialists at a university medical center.

These findings, from an evaluation of Project ECHO (Extension for Community Healthcare Outcomes), were published today online by the New England Journal of Medicine and will appear in the June 9 print edition. They demonstrate that primary care providers anywhere can be trained via videoconferencing technology to manage complex chronic conditions formerly outside their expertise, thus expanding their ability to treat very sick patients. Project ECHO is based at the University of New Mexico Health Sciences Center (UNMHSC) in Albuquerque.

“By producing what we call a ‘force multiplier effect,’ Project ECHO transforms the dynamics—and the capacity—for health care delivery and spread of best practices,” said Sanjeev Arora, M.D., the hepatologist at UNMHSC who created Project ECHO. “This model empowers primary care clinicians to provide high-quality specialty care locally, and holds promise for dramatically changing clinical practice and medical education nationally.”

Using real-time videoconferencing technology and best-practice medicine, Project ECHO teams primary care clinicians with specialists at academic medical centers, who train them in new areas of care delivery and co-manage patients with them. Project ECHO is not traditional telemedicine that facilitates a one-to-one remote connection between a doctor and a patient. In fact, no patient is ever seen during an ECHO teleclinic. Instead, through Project ECHO, primary care providers can treat many more patients with serious illnesses right in their communities.

Although the findings from the NEJM evaluation focus exclusively on treatment of hepatitis C, the Project ECHO model is being used to train primary care clinicians to locally treat patients with a dozen other chronic conditions.

Risa Lavizzo-Mourey, M.D., M.B.A., president and CEO of the Robert Wood Johnson Foundation (RWJF), which has provided a three-year, $5 million grant to Project ECHO, called the ECHO model “the future of health care for those who aspire to excellence.” The ECHO model, she said, “demonstrates how health care providers everywhere can—and should—work collaboratively to provide better care.”

“Project ECHO has the potential to transform health care as we know it,” Lavizzo-Mourey said. “What began as a truly disruptive innovation in New Mexico for treatment of hepatitis C has the capacity to re-engineer health care delivery and training across the health care system.”

RWJF’s funding aims to bring the ECHO model to “industrial strength” within New Mexico and spread it to health care providers nationwide. Replications are underway in Washington state and Chicago, and other potential sites are actively exploring the model. Several government agencies have expressed strong interest in ECHO as well.

The NEJM evaluation assessed cure rates among 407 patients with hepatitis C who had received no previous treatment for infection. Project ECHO enrolled 261 patients and UNMHSC enrolled 146. Cure rates were 58.2 percent for patients treated through Project ECHO and 57.5 percent for the group treated at UNMHSC. Results for both groups were significantly higher than cure rates achieved in previous community-based treatment studies for hepatitis C. The evaluation also showed that the ECHO model can reduce—and even eliminate—racial and ethnic disparities in treatment outcomes by bringing more services to minority communities.

In an editorial accompanying the evaluation, Thomas D. Sequist, M.D., associate professor of medicine and of health care policy at Harvard Medical School and Brigham and Women’s Hospital, called Project ECHO a “promising step” toward overcoming barriers to health care delivery and encouraged “expanding such innovative care models throughout the U.S. health care system.”

“The key to this study is that technology helped local physicians and other providers deliver safe, high-quality care within their own—in most cases, underserved—communities,” said Carolyn M. Clancy, M.D., director of the federal Agency for Health Care Quality and Research (AHRQ), which funded the evaluation. “We’ve known that geography can play a role in timely and appropriate treatment, especially managing complex conditions such as hepatitis C. However, it doesn’t have to mean destiny.”

Hepatitis C a Launching Pad for Other Treatment Clinics

Arora created Project ECHO to combat hepatitis C in New Mexico, which has very high rates of hepatitis C. As a specialist, Arora could only treat 70 to 90 patients a year in his clinic, yet more than 30,000 New Mexicans had the disease.

At the time, few physicians in New Mexico were trained to treat hepatitis C. For patients who don’t have access to a specialist where they live, it can be extremely difficult—if not impossible—to get the specialty care they need. The treatment regimen is grueling and requires 12 to 18 visits a year to a specialist. Yet, contrary to popular belief, hepatitis C can be cured.

Under the ECHO model, primary care clinicians—including physicians, nurses, physician assistants and community health workers—are organized into knowledge networks that meet weekly via videoconference to present patient cases. These “virtual grand rounds” are led by UNMHSC specialists who review and discuss the cases with primary care providers and also share best practices with them. Web-based disease management tools facilitate consults, and specialists and primary care providers jointly manage complex chronic illness care for patients. Primary care providers then treat patients in their own communities.

Project ECHO launched its hepatitis C clinic in 2003. Today, Project ECHO’s videoconferencing clinics address asthma, mental illness, chronic pain, diabetes and cardiovascular risk reduction, hepatitis C, high-risk pregnancy, HIV/AIDS, pediatric obesity, rheumatology and substance abuse.

Within New Mexico, more than 1,000 doctors, nurses, nurse practitioners, physician assistants and community health workers have participated in Project ECHO’s clinics and trainings, and Project ECHO has performed more than 10,000 case consultations through its knowledge networks. In this way, many thousands of patients in New Mexico have received much-needed specialty care.

In addition to funding from RWJF’s Pioneer Portfolio and AHRQ, Project ECHO enjoys strong support from the New Mexico Legislature, the University of New Mexico and the New Mexico Department of Health.

About the Robert Wood Johnson Foundation and the Pioneer Portfolio

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. Projects in the Pioneer Portfolio are future-oriented and look beyond conventional thinking to explore solutions at the cutting edge of health and health care.

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