In this community-based study, we were able to demonstrate high rates of cure for HCV treatment delivered through the ECHO model. The SVR rates in our ECHO cohorts of 58% overall and 48% in genotype 1 patients were similar to those observed in our study's comparison group treated at the academic medical center and the rates reported in licensing trials for HCV treatment.9,10,11
Previous community-based treatment studies have failed to replicate the results of licensing trials. For example, the SVR rate was 34% for genotype 1 patients in the Weight-Based Dosing of Peginterferon alfa 2-b and Ribavirin (WIN-R) trial.20
The Veteran's Affairs experience at 121 facilities showed an SVR rate of 20% for genotype 1 patients.21
Our study cohort, particularly at the ECHO sites, was predominately Hispanic. We met our goal of increasing treatment for underserved and minority patients. A recent study by the Latino Study Group showed significantly lower rates of SVR in Hispanic genotype 1 patients compared to non-Hispanics (34% vs. 49%).22
We did not see a similar ethnic difference in SVR. Recent research suggests that disparities in treatment for minorities may be due to geography and location of the patient. 23,24,25
Treatment through ECHO overcomes this barrier by bringing expertise and clinical resources to the rural clinician that may not otherwise be widely available, positively affecting outcomes.
The study design has three principal limitations. First, there was no comparison group of patients being treated in rural settings without the ECHO model. The barriers to treatment are so formidable and concerns for safety so great that almost no cases are currently treated in rural and frontier areas of New Mexico. The second limitation was an inability to randomize providers to ECHO and active control groups because we could not ethically encourage control providers to treat HCV without training; and patients could not be randomized due to the nature of the study. Third, multivariate models can adjust for differences in patient variables that are measured but do not address those that are not or cannot be measured.
Although the inclusion of practice site (Project ECHO versus University) was not significant in the multivariate model for SVR, the confidence interval for its odds ratio was quite broad. These results are consistent with a substantial difference in outcomes in ECHO compared with University care. The study was not large enough to establish equivalence.
The results of this study demonstrate that the ECHO model is an effective way to treat HCV in rural and underserved communities. By implementing this model other states and nations can potentially treat a much higher portion of patients infected with HCV, thereby preventing an enormous burden of illness and death. There are a number of potential explanations for this success. Community providers, particularly CHCs, provide coordinated, patient-centered care in facilities proximate to their patients. Patients are likely to have greater trust with local providers who can be culturally competent for their specific communities. This may enhance patient adherence, allow more frequent in-person visits and otherwise allow greater direct contact with the clinician. As a result, providers may be better able to comply with best practice protocols, ensure close lab test assessment, offer tailored patient education, and provide greater and timelier management of side effects. In addition, the fact that hepatitis and primary care are delivered by the same clinician ensures better integration and fewer communication challenges.
As a result of the success of the model for HCV, ECHO has now expanded to 255 sites. These clinics address common and complex health issues including substance use disorders, cardiac risk reduction, chronic pain, asthma, rheumatology and multiple other diseases. The project demonstrates that technology and inter-disciplinary collaboration can be used to leverage scarce specialty care resources.
In conclusion we have shown that treating a complex disease such as HCV using the ECHO model has similar effectiveness as treatment at an AMC. ECHO represents a needed change in conventional paradigms of AMCs and specialist care being available only in urban areas. ECHO has potential for replication in the United States and abroad as community providers and academic specialists partner to respond to an increasingly diverse range of chronic health issues.