Telementoring to Support Community Providers in HCV Treatment

Chronic hepatitis C virus (HCV) infection affects approximately 71 million people worldwide, with an estimated prevalence of 50% to 60% among people who inject drugs.^1,2 However, people who inject drugs and other difficult to access populations (DTAPs) — such as indigenous groups and individuals with co-occurring psychiatric disorders — face multiple “barriers to treatment in Tertiary Liver Clinics (TLCs), possibly stemming from poor health literacy, discrimination, criminalization and stigmatization of drug use,” according to a 2018 study published online in the Internal Medicine Journal.³

“DTAPS may be socially isolated, have limited resources, psychiatric comorbidities, or competing social challenges which take precedence over HCV treatment,” wrote the authors. Additionally, these patients may not be aware of the availability of direct-acting antivirals (DAAs), and thus may have misconceptions regarding treatment due to the serious side effects and low efficacy associated with interferon-based therapies.⁴

These issues underscore the need for alternative modes of treatment delivery for these populations. The study authors note that the ideal clinicians to provide HCV treatment for DTAPs are those who already have relationships with these patients. To that end, they investigated the use of a telementoring approach⁵ called Project ECHO^® (Extension for Community Healthcare Outcomes; PE), which “uses video conference supported, de-identified, case-based learning to share knowledge between specialists and community doctors” to enable the latter to provide HCV treatment to their own patients.³

PE has been validated in 24 countries since it was launched in New Mexico. This model is distinct from telemedicine-based care in that treatment is administered by the community practitioner rather than delivered remotely by a specialist.

The current study examined the effectiveness of PE in a sample of Australian patients. A group of participants (n=100) who received PE-based treatment was compared with a group treated at TLCs (n=100). The PE patients were referred by 42 community prescribers, including drug and alcohol physicians, general practitioners, and sexual health clinicians.

During weekly videoconferences, the specialty group (comprised of a hepatologist, advanced trainee in gastroenterology, pharmacist, clinic nurse consultant, social worker, and administrative assistant) and the community clinician discussed case details and agreed on a treatment plan to be implemented by the community provider.

The study results show similar characteristics between the 2 groups in terms of age, gender, proportion of treatment-naive patients, and rates of cirrhosis, psychiatric disorders, and psychotropic medication use.

Several differences were observed between groups: the PE group demonstrated higher rates of ongoing substance abuse (44% vs 17%; P <.001), polysubstance abuse (26% vs 7%; P <.001), active intravenous drug use (32% vs 17%; P <.001), and opioid substitution therapy (74% vs 20%; P <.001). Additionally, there were a greater number of indigenous patients in the PE group (15% vs 5%; P =.018).

Of the original sample, 69 PE patients and 70 TLC patients completed treatment, with sustained virologic response confirmed in 60 and 67 of these individuals, respectively. Many of the remaining patients who completed treatment were lost to follow-up and thus sustained virologic response could not be determined.  

“Our study shows that PE facilitates the transfer of expertise from specialists to community prescribers who have an established relationship with DTAPs, but may not have the skills in treatment,” the authors concluded. “PE offers a great opportunity to build expertise using modern technology and utilise specialist time for tele-mentoring rather than direct health care delivery.”

To learn more about this model, Infectious Disease Advisor interviewed study co-author Miriam Levy, MBBS, FRACP, PhD, associate professor and head of the department of gastroenterology and hepatology at Liverpool Hospital at the University of New South Wales in the United Kingdom.

Infectious Disease Advisor: Why is there a need for an approach like PE in the treatment of patients with HCV?

Dr Levy: PE is a telementoring educational platform that bridges specialists with primary health care providers and other community health care workers so that patients can be managed without requiring a direct specialist consultation. Patients with HCV may have strong relationships with their drug health doctors who support them with counseling or opioid substitution medications. Patients are sometimes reluctant to attend specialist clinics because they fear stigma or are unable or unwilling to engage in the hospital environment. There may be geographic or socioeconomic obstacles.

These patients can safely be treated by their primary care or drug health doctors only if those community clinicians have the confidence to treat HCV. PE provides the support and education to allow this, using a unique case-based learning approach where de-identified but specific cases can be discussed in a group learning environment. This can remove the requirement of the patient to go see the specialist and may facilitate treatment for a much larger number of patients. We have supported the treatment of more than 350 patients, and only a minority of these [had to physically] attend our clinic.

Patients supported by PE are more likely to have ongoing substance abuse, including intravenous drug use and polysubstance abuse, and were far more likely to be taking opioid substitution therapy — patients who notoriously find it difficult to attend scheduled specialist clinic appointments in large quaternary referral hospitals. A high proportion of patients treated through PE were indigenous, suggesting that these patients also were more likely to attend and be treated by their own health care workers rather than our specialist clinic.

Many primary care and community clinicians attended numerous sessions until they felt confident and sufficiently supported to treat patients on their own. This has leveraged our capacity significantly.

Infectious Disease Advisor: Regarding your findings, what are the top takeaways for clinicians?

Dr Levy: PE is a fabulous platform to support the treatment of difficult to access patients, who represent a significant proportion of patients with HCV. PE provides a platform for relationship building and mentoring between specialists and clinicians in the community. Specialists do spend a lot of time educating trainee specialists, but perhaps not enough time sharing their knowledge with clinicians in the community. PE provides an extremely practical solution to address this gap and build bridges between specialists and community clinicians.  

Infectious Disease Advisor: What can providers and other stakeholders do to adopt and support a telementoring model like PE for use in this population?

Dr Levy: Specialists should consider it part of their daily business to support primary care clinicians. If that premise is accepted, then providers and stakeholders will find the infrastructure and concepts of PE highly efficacious toward achieving that end. Specialists will need some quarantine time to support the model, and [they will need to] consider the financial consequences, which in some settings may include reduced activity of the specialist in billable face-to-face patient care.

The specialist also needs the support of team members to create a multidisciplinary hub. Team members might include clinicians from other disciplines, a technology person to support the video conferencing, and case management to support the communication and correspondence on the de-identified cases.

The clinicians who will be learning from the specialists need to have dedicated time and willingness to increase their responsibility in managing HCV instead of referring the patient for the specialist to manage. Those who do this have found the empowerment rewarding, and despite their solitary work practice, the community providers feel confident and supported by this model. Again, if they are in a fee-for-service environment, the business model must be considered for them to participate fully.

Infectious Disease Advisor: What should be next steps in this area in terms of research or otherwise?

Dr Levy: Each country’s health system has economic drivers that influence the ability of both specialists and primary care clinicians to participate. Payers and providers need to identify the benefits of the model and determine solutions to allow its operation, such as overcoming remuneration structures and workplace job descriptions that do not currently incorporate such a model.

References

1. Hajarizadeh B, Grebely J, Dore GJ. Epidemiology and natural history of HCV infection. Nat Rev Gastroenterol Hepatol. 2013;10:553-562.
2. Doab A, Treloar C, Dore GJ. Knowledge and attitudes about treatment for hepatitis C virus infection and barriers to treatment among current injection drug users in Australia. Clin Infect Dis. 2005;40(Suppl 5):S313-S320.
3. Mohsen W, Chan P, Whelan M, et al. Hepatitis C treatment for difficult to access populations: can telementoring (as distinct from telemedicine) help? Intern Med J. 2019;49(3):351-357.[CM1]
4. McGowan CE, Fried MW. Barriers to hepatitis C treatment. Liver Int. 2012;32 Suppl 1(0 1):151-156.
5. Arora S, Kalishman S, Thornton K, et al. Expanding access to HCV treatment—Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care.Hepatology. 2010;52(3):1124-1133.