Arora S. N Engl J Med. 2011;doi:10.1056/NEJMoa1009370.
The Extension for Community Healthcare Outcomes model allowed primary
care providers to manage hepatitis C infection in rural and underserved
communities comparable to academic medical centers, according to new findings
published in The New England Journal of Medicine.
“Currently, there are 16 community sites and five prisons in which
HCV infection is delivered with the use of the
[Extension for Community Healthcare Outcomes (ECHO)] model,” Sanjeev
Arora, MD, of the department of internal medicine at the University of New
Mexico, and colleagues wrote in the study. “Since ECHO’s inception in
2003, there have been more than 5,000 case presentations, and 800 patients have
According to background information in the study, the model was
developed to improve access to care for underserved populations with complex
health problems such as HCV by training primary care providers through
The researchers hypothesized that HCV treatment with the ECHO model
delivered across 21 primary care clinics that utilized the ECHO model in the
community or in prison in New Mexico would be as effective as the treatment
provided at the University of New Mexico (UNM) HCV clinic.
Participants were aged 18 to 65 years, had chronic HCV infection and
were not previously treated. Of the 407 participants included in the analysis,
261 were treated at ECHO sites and 146 were treated at the UNM clinic; all were
treated for HCV based upon standard ECHO protocol. Primary outcome measure was
sustained virologic response.
Both arms achieved sustained virologic response with similar rates of
57.5% of patients treated at the UNM clinic and 58.2% of patients treated at
ECHO sites (95% CI, -9.2 to 10.7). Moreover, 45.8% of those with
HCV genotype-1 infection treated at the UNM clinic had
a sustained virologic response compared with 49.7% of those at ECHO sites
Serious adverse events were more commonly reported at the UNM clinic vs.
those treated at ECHO sites (13.7% vs. 6.9%; P=.02).
“ECHO represents a needed change from the conventional approaches
in which specialized care and expertise are available only at academic medical
centers in urban areas,” the researchers wrote. “The ECHO model has
the potential for being replicated elsewhere in the United States and abroad,
with community providers and academic specialists collaborating to respond to
an increasingly diverse range of chronic health issues.”
Disclosure: Dr. Arora reports receiving grant support from
ZymoGenetics, Genentech, Vertex Pharmaceuticals, Tibotec, Human Genome
Sciences, and Wyeth (now part of Pfizer); speaking fees from Schering-Plough
(now part of Merck) and Genentech-Roche; and payment for advisory board
membership from Vertex Pharmaceuticals.
Brian Montague, DO, MS, MPH
At least 5 million people are thought to be infected with HCV, a significant fraction of whom without treatment will progress to end stage liver disease in the next 10 to 20 years. Multiple studies have shown that referral based models of care lead to very low uptakes to treatment, with minorities and economically disadvantaged populations experiencing a large portion of the associated morbidity and mortality. Because the costs of treating persons with end-stage liver disease can be enormous, HCV therapy has been repeatedly and clearly shown to be a cost effective intervention. Innovative models of increasing access to HCV, particularly as new therapies are brought to market are critically needed. Despite the cited limitations, the program presented by Arora and colleagues is a remarkable example of just such a program, blending a clinical care program with capacity development for providers through their knowledge network. In this era of cost containment, support for innovative programs such as these will be critical to increase uptake to treatment for HCV and contain the economic and human costs of this epidemic.
Brian Montague, DO, MS, MPH
Brown University and The Miriam Hospital
Disclosure: Dr. Montague reports no relevant financial disclosures.