Karla Thornton

Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers

BACKGROUND The Extension for Community Healthcare Outcomes (ECHO) model was developed to improve access to care for underserved populations with complex health problems such as hepatitis C virus (HCV) infection. With the use of video-conferencing technology, the ECHO program trains primary care providers to treat complex diseases. METHODS We conducted a prospective cohort study comparing treatment for HCV infection at the University of New Mexico (UNM) HCV clinic with treatment by primary care clinicians at 21 ECHO sites in rural areas and prisons in New Mexico. A total of 407 patients with chronic HCV infection who had received no previous treatment for the infection were enrolled. The primary end point was a sustained virologic response. RESULTS A total of 57.5% of the patients treated at the UNM HCV clinic (84 of 146 patients) and 58.2% of those treated at ECHO sites (152 of 261 patients) had a sustained viral response (difference in rates between sites, 0.7 percentage points; 95% confidence interval, -9.2 to 10.7; P=0.89). Among patients with HCV genotype 1 infection, the rate of sustained viral response was 45.8% (38 of 83 patients) at the UNM HCV clinic and 49.7% (73 of 147 patients) at ECHO sites (P=0.57). Serious adverse events occurred in 13.7% of the patients at the UNM HCV clinic and in 6.9% of the patients at ECHO sites. CONCLUSIONS The results of this study show that the ECHO model is an effective way to treat HCV infection in underserved communities. Implementation of this model would allow other states and nations to treat a greater number of patients infected with HCV than they are currently able to treat. (Funded by the Agency for Healthcare Research and Quality and others.).

Expanding access to hepatitis C virus treatment—Extension for Community Healthcare Outcomes (ECHO) project: Disruptive innovation in specialty care†

The Extension for Community Healthcare Outcomes (ECHO) Model was developed by the University of New Mexico Health Sciences Center as a platform to deliver complex specialty medical care to underserved populations through an innovative educational model of team‐based interdisciplinary development. Using state‐of‐the‐art telehealth technology, best practice protocols, and case‐based learning, ECHO trains and supports primary care providers to develop knowledge and self‐efficacy on a variety of diseases. As a result, they can deliver best practice care for complex health conditions in communities where specialty care is unavailable. ECHO was first developed for the management of hepatitis C virus (HCV), optimal management of which requires consultation with multidisciplinary experts in medical specialties, mental health, and substance abuse. Few practitioners, particularly in rural and underserved areas, have the knowledge to manage its emerging treatment options, side effects, drug toxicities, and treatment‐induced depression. In addition, data were obtained from observation of ECHO weekly clinics and database of ECHO clinic participation and patient presentations by clinical provider. Evaluation of the ECHO program incorporates an annual survey integrated into the ECHO annual meeting and routine surveys of community providers about workplace learning, personal and professional experiences, systems and environmental factors associated with professional practice, self‐efficacy, facilitators, and barriers to ECHO. The initial survey data show a significant improvement in provider knowledge, self‐efficacy, and professional satisfaction through participation in ECHO HCV clinics. Clinicians reported a moderate to major benefit from participation. We conclude that ECHO expands access to best practice care for underserved populations, builds communities of practice to enhance professional development and satisfaction of primary care clinicians, and expands sustainable capacity for care by building local centers of excellence. (HEPATOLOGY 2010)

Partnering Urban Academic Medical Centers And Rural Primary Care Clinicians To Provide Complex Chronic Disease Care

Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need because of various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions, and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have collaborated on more than 10,000 specialty care consultations for hepatitis C and other chronic diseases.

Project ECHO: Linking University Specialists with Rural and Prison-Based Clinicians to Improve Care for People with Chronic Hepatitis C in New Mexico

Project Extension for Community Healthcare Outcomes (Project ECHO) is a telemedicine and distance-learning program designed to improve access to quality health care for New Mexicans with hepatitis C. Project ECHO links health-care providers from rural clinics, the Indian Health Service, and prisons with specialists at the University of New Mexico. At weekly clinics, partners present and discuss patients with hepatitis C with specialists. Partners can receive continuing education credits for participating. Since June 2003, 173 hepatitis C clinics have been conducted with 1,843 case presentations. Partners have received 390 hours of training and 2,997 hours of continuing education credits. And in 2006, the State Legislature approved

Comparison of Neuropsychiatric Side Effects in an Observational Cohort of Efavirenz- and Protease Inhibitor-Treated Patients

1.5 million in annual funding for the project. Project ECHO has increased access to state-of-the art hepatitis C virus care for patients living in rural areas or prisons. Because of its success with hepatitis C, this project is being expanded to other chronic medical conditions.

Project ECHO (Extension for Community Healthcare Outcomes): A new model for educating primary care providers about treatment of substance use disorders

Abstract Purpose: To compare the extent of neuropsychiatric disturbances in two similar groups of HIV-infected patients treated for >4 weeks with either efavirenz (EFV) or protease inhibitors (PIs) as part of their antiretroviral therapy (ART). Method: A cross-sectional, questionnaire-based cohort of HIV patients who received two nucleoside reverse transcriptase inhibitors combined with either EFV (n = 75) or one or more PIs (n = 77) for at least 4 weeks and were tolerating therapy. The extent of neuropsychiatric disturbances was evaluated based on self-reported symptoms using the psychological evaluation test SCL-90-R. Treatment duration was broken down into quartiles of 30-198 days, >198-365 days, >365-637 days, and >637 days. Results: In the first 6 months of therapy, significantly higher (worse) scores were seen in 39/75 (52%) of the patients receiving EFV. The EFV-treated group had significantly higher scores for somatization, anxiety, obsessive-compulsive behavior, the Global Severity Index, and the Positive Symptom Distress Index, with trends for higher scores in paranoid ideation and depression symptom subcategories. Over the following 6 to 12 months of therapy, the EFV group scored higher than the PI group in somatization, anxiety, obsessive-compulsive behavior, hostility, depression, the Global Severity Index, and the Positive Symptom Total, but the differences were not significant. After 12 months of therapy, the EFV group had significantly lower scores than the PI group for somatization, interpersonal sensitivity, Global Severity Index, and Positive Symptom Total. Conclusion: EFV-induced neuropsychiatric symptoms can last up to 200 days after treatment initiation. However, symptom severity appears to decline over time in EFV-treated patients versus patients treated with a PI-based ART.

Demonopolizing Medical Knowledge

ABSTRACT Background: Project ECHO (Extension for Community Healthcare Outcomes) trains and mentors primary care providers (PCPs) in the care of patients with complex conditions. ECHO is a distance education model that connects specialists with numerous PCPs via simultaneous video link for the purpose of facilitating case-based learning. This article describes a teleECHO clinic based at the University of New Mexico Health Sciences Center that is focused on treatment of substance use disorders (SUDs) and behavioral health disorders. Methods: Since 2005, specialists in treatment of SUDs and behavioral health disorders at Project ECHO have offered a weekly 2-hour Integrated Addictions and Psychiatry (IAP) TeleECHO Clinic focused on supporting PCP evaluation and treatment of SUDs and behavioral health disorders. We tabulate the number of teleECHO clinic sessions, participants, and CME/CEU (continuing medical education/continuing education unit) credits provided annually. This teleECHO clinic has also been used to recruit physicians to participate in DATA-2000 buprenorphine waiver trainings. Using a database of the practice location of physicians who received the buprenorphine waiver since 2002, the number of waivered physicians per capita in US states was calculated. The increase in waivered physicians practicing in underserved areas in New Mexico was evaluated and compared with the rest of the United States. Results: Since 2008, approximately 950 patient cases have been presented during the teleECHO clinic, and more than 9000 hours of CME/CEU have been awarded. Opioids are the substances discussed most commonly (31%), followed by alcohol (21%) and cannabis (12%). New Mexico is near the top among US states in DATA-2000 buprenorphine-waivered physicians per capita, and it has had much more rapid growth in waivered physicians practicing in traditionally underserved areas compared with the rest of the United States since the initiation of the teleECHO clinic focused on SUDs in 2005. Conclusion: The ECHO model provides an opportunity to promote expansion of access to treatment for opioid use disorder and other SUDs, particularly in underserved areas.

Project ECHO (Project Extension for Community Healthcare Outcomes): A National and Global Model for Continuing Professional Development.

In the past 100 years, there has been an explosion of medical knowledge-and in the next 50 years, more medical knowledge will be available than ever before. Regrettably, current medical practice has been unable to keep pace with this explosion of medical knowledge. Specialized medical knowledge has been confined largely to academic medical centers (i.e., teaching hospitals) and to specialists in major cities; it has been disconnected from primary care clinicians on the front lines of patient care. To bridge this disconnect, medical knowledge must be demonopolized, and a platform for collaborative practice amongst all clinicians needs to be created. A new model of health care and education delivery called Project ECHO (Extension for Community Healthcare Outcomes), developed by the first author, does just this. Using videoconferencing technology and case-based learning, ECHOs medical specialists provide training and mentoring to primary care clinicians working in rural and urban underserved areas so that the latter can deliver the best evidence-based care to patients with complex health conditions in their own communities. The ECHO model increases access to care in rural and underserved areas, and it demonopolizes specialized medical knowledge and expertise.

Treating hepatitis C in American Indians/Alaskan Natives: A survey of Project ECHO® (Extension for Community Healthcare Outcomes) utilization by Indian Health Service providers

Chronic disease management requires ongoing consultation between community providers and experts from medical specialties that are often limited in underserved rural and urban areas inNewMexico, patients from rural areas often wait many months for an appointment and travel up to 250 miles for an office visit. The Extension for Community Healthcare Outcomes (ECHO) model was developed at the University of New Mexico Health Sciences Center (UNMHSC) as a platform for teaching community providers to deliver best-practicemedical services to underserved populations with chronic complex conditions. Project ECHO has expanded from its initial focus on hepatitis C (2003) to teleECHO clinics that address numerous complex health problems. The objective of this report is to describe how as a best-practice model for continuing professional development, Project ECHO has grown statewide, nationally, and globally.

Iatrogenic Cushing's syndrome after triamcinolone plus ritonavir-boosted atazanavir

Background: American Indians/Alaskan Natives have a high mortality associated with hepatitis C virus, yet treatment rates are low. The ECHO (Extension for Community Healthcare Outcomes) model™, a videoconferencing technology for primary care providers, is underutilized at Indian Health Service facilities. Purpose: To ascertain Indian Health Service providers’ benefit of and barriers to utilizing hepatitis C virus TeleECHO clinics. Methods: We electronically sent an Active Participant Survey to Indian Health Service providers utilizing hepatitis C virus TeleECHO clinic and a Non-Participant Survey to other Indian Health Service providers interested in this clinic. Results: In total, 100% of Active Participant Survey respondents perceive moderate to major benefit of hepatitis C virus TeleECHO clinic in managing hepatitis C virus, and 67% of Non-Participant Survey respondents reported lack of administrative time as the major barrier to utilizing this resource. Conclusion: Indian Health Service providers participating in hepatitis C virus TeleECHO clinic perceive this resource as highly beneficial, but widespread utilization may be impractical without allocating time for participation.