Transcript Cohort
Management of Chronic HCV Infection by PMDs Rod Rahimi Osler Journal Club 1-25-12 Outline • Background on Hepatitis C • Barriers to treatment • ECHO (Extension for Community Healthcare Outcomes) model • Cohort trial: PMD v. Specialists • Conclusions • Time for questions/discussion Hepatitis C • 170 million people worldwide (3%) are hepatitis C positive (3.2 million in the US) cdc.gov Hepatitis C treatment Hepatitis C treatment Hepatitis C treatment • Pegylated interferon and ribavirin are available and cost-effective • HCV genotype 1 cure rate 45% • HCV genotype 2 and 3 cure rate 75% Are patients receiving treatment? • Antiviral treatment rates are <30% • Even among eligible patients treatment rates range from only 45-75% • Rates even lower in rural areas and prisons • In New Mexico, 40% of the 6000 inmates are infected with HCV. As of 2003 not a single one had received antiviral treatment Barriers to Treatment • Treatment is currently complex • Most PMDs lack training – Complex side effects from treatment including flulike symptoms, cytopenias, hemolysis, autoimmunity, depression • In New Mexico, patients had to travel up to 250 miles to the UNM medical center, having to make an average of 18 trips during treatment The University of New Mexico • The ECHO (Extension for Community Healthcare Outcomes) Model • http://www.youtube.com/watch?feature=play er_embedded&v=2lBfyOlL4_s The ECHO Model Arora S et al. N Engl J Med 2011;364:2199-2207. Arora S et al. N Engl J Med 2011;364:2199-2207. Arora S et al. N Engl J Med 2011;364:2199-2207. Arora S et al. N Engl J Med 2011;364:2199-2207. Conclusions • PMDs treating HCV infection with assistance of the ECHO model are as effective in achieving SVR as specialists • No difference in serious adverse events between PMDs and specialists Critical Appraisal Discussion • What comparison is being made? • Does the comparison make clinical sense? • What are the potential selection biases? Critical Appraisal Discussion • No comparison group comprising patients treated by PMDs without ECHO – No PMDs treating HCV independently – Unethical to randomize PMDs to treating HCV without ECHO • The study was not large enough to establish equivalence between PMDs with ECHO and specialists Telemedicine Discussion • Advantages – Increase clinical knowledge among PMDs – Increase clinical access to specialist treatments – Cost-effective • Disadvantages – Delay referrals – Potentially demanding on specialists – Potential for adverse events References • Arora et al. Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers. N Engl J Med. 2011 June 9;364(23):2199-2207. • Fried et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med. 2002 Sep 26;347(13):975-82. • Swain et al. A sustained virologic response is durable in patients with chronic hepatitis C treated with peginterferon alfa-2a and ribavirin. Gastroenterology. 2010 Nov;139(5):1593-601. • Kanwal et al. Predictors of treatment in patients with chronic hepatitis C infection - role of patient versus nonpatient factors. Hepatology 2007 Dec;46(6):1741-9.