Miriam Komaromy

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)

Unmet mental health needs of women in public-sector gynecologic clinics

OBJECTIVE We examined the mental health needs of poor young women seen in public-sector gynecologic settings. STUDY DESIGN Participants were 205 ethnically diverse women, mean age 29 years, seen by gynecologists at San Francisco General Hospital, all either uninsured or receiving public medical assistance. An interview with an instrument designed to diagnose mood, anxiety, alcohol, and eating disorders in medical patients, the Prime-MD, was used to assess current mental disorders. Any history of sexual or other physical assault was recorded. Receipt of primary care was scored for comprehensiveness. RESULTS The rates of current psychiatric disorders were extremely high; 21.5% had current major depression. The prevalence of anxiety disorders was also elevated among these women. Many had a history of sexual trauma, and 28% had been the victims of unwanted intercourse. Finally, many reported behaviors that pose serious health risks. For example, 32% smoked and 2% used illicit drugs. Fewer than half had access to comprehensive primary medical care. CONCLUSIONS Young, poor women who seek care in public-sector gynecologic clinics would benefit from comprehensive medical care addressing their psychosocial needs.

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

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.

Demonopolizing Medical Knowledge

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.

Coping with HIV Infection: Why People Delay Care

Excerpt To the Editors:Many persons infected with the human immunodeficiency virus (HIV) delay initiating care until their disease is advanced (1). We investigated factors associated with delay in ...

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

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.

Enhanced Primary Care Treatment of Behavioral Disorders With ECHO Case-Based Learning

The Extension for Community Healthcare Outcomes (ECHO) model offers a way for primary care providers to develop expertise in addressing behavioral health issues of primary care patients. It provides an alternative to traditional continuing medical education (CME) for ongoing training and support for health care providers. ECHO uses videoconferencing to connect multiple primary care teams simultaneously with academic specialists and builds capacity via mentorship and case-based learning. ECHO aims to expand access to care by developing capacity to treat common, complex conditions in underserved areas. Participants in an integrated addictions and psychiatry teleECHO program reported that when they presented a patient case, the feedback they received was highly valuable and led them to change their care plans more than 75% of the time. ECHO is an effective model for teaching primary care teams about behavioral health and may be more effective than traditional CME approaches.

Knowledge Networks for Treating Complex Diseases in Remote, Rural, and Underserved Communities

Project ECHO (Extension for Community Healthcare Outcomes) is an innovative healthcare program developed to address the treatment of patients with chronic and complex diseases in rural and underserved areas of New Mexico. Through the use of technology and iterative, case-based discussion with ongoing support, the model used in Project ECHO bridges the gap between academic healthcare specialists and providers in rural and underserved settings. Its prime foci are the provision of workplace learning, evidence-based practices, and the delivery of best quality care to patients with chronic diseases. Collaboration between academic specialists and community-based providers enables patients to receive state-of-the-art healthcare from the professionals they know and trust in their own communities. For local providers, co-management of the often lengthy and involved treatments gives them additional expertise in competencies associated with chronic disease and involves them in continuing communication and patient management. As they learn more about specific chronic diseases, the community-based providers become engaged with expanded networks of providers and organizations, become more satisfied in their work, and experience less professional isolation. With continued involvement, community-based providers become highly skilled in the treatment of these chronic and complex diseases, thus creating centers of excellence in their own communities. This chapter describes the activities and outcomes associated with the collaborative, iterative, and workplace-focused care of patients with Hepatitis C, the first chronic disease to be addressed, and how new modes of collaboration were forged between specialists in academic settings and community-based primary care providers in rural and underserved communities. Work on other chronic diseases is now being organized using a similar approach to developing expanded expertise in rural and underserved areas of the state.

Technology Enhanced Learning in Addiction Mental Health: Developing a Virtual Knowledge Network: NIMHANS ECHO

Addiction or Substance Use Disorders (SUD) is a growing public health problem in India. There are very few trained health professionals to provide evidence based care for these conditions. We initiated a weekly tele-ECHO clinic to train health professionals in the recognition and management of Alcohol and tobacco use disorders. The preliminary results points towards the feasibility as well as acceptability of the ECHO model of training in addiction mental health. There is a need for more involvement of the health care providers in future NIMHANS ECHO Programs.