dr. schaninger- hcv telehealth training - ky chfs€¦ · milestones in hcv therapy 0 10 20 30 40...
TRANSCRIPT
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HCV Telehealth Training ProgramChallenges and benefits of integrating hepatitis C
care into a primary care setting
Takako Schaninger, MDProgram Director
Southern Central AIDS Education TelehealthTraining Center
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Learning objectives
• To understand the need for more HCVproviders
• To understand the challenges and benefits ofimplementing a telehealth model of care forHCV in a primary care setting
• To review and understand a telehealth trainingmodel in HCV care: SCAETTC
• To review the implementation process ofSCAETTC
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InterferonologistsHeadaches Depression
Flu like symptoms
Myalgia Arthralgia
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Interferonologists
IncreasedIrritability
Thyroiditis
Bonemarrowsuppression
Poor appetite
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First DAA in 2011
Serious skin rash and more anemia
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The second wave in 2013
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Milestones in HCV therapy
0
10
20
30
40
50
60
70
80
90
100 1986 1998 2001 2002 2011 2013 2015
AASLD practice guideline: Hepatology, 39(4), 2004
Cure%
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2014/2015
DAA Ribavirin
Genotype 1
Genotype 2
Genotype 3
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A silver bullet for HCV
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WHY SHOULD PRIMARY CAREPROVIDERS LEARN ABOUT HCV?
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The Need2.7-3.9 million Americans are
infected with HCV
MMWR, 2012; 61(4): 1-32
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Prevalence of HCV by year of birth
Ann Int Med 2006; 144(10):705-14
Baby Boomers
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Current risk based testingis not working
#1 Increase Screening Rates
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CDC Recommendations
• TestingAdults born during 1945 to 1965 should receiveone time testing for HCV without priorascertainment of HCV risk
• Linkage to CareAll persons identified with HCV infection shouldreceive a brief alcohol screening and interventionas clinically indicated, followed by referral toappropriate care and treatment services for HCVinfection and related conditions as indicated
MMWR 2012; 61(4): 1-32
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80% of patients never make itto the specialist
NH Afdhal, MD, Viral Hepatitis Congress 2013
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Multiple barriers
A. Structural
– Not enough specialists
– Insufficient staffing: case managers and socialworkers
– Lack of integrated care models
– Limited reimbursement for HCV care
– High proportion of uninsured
NH Afdhal, MD, Viral Hepatitis Congress2013
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Multiple Barriers
B. Providers
– Lack of knowledge and experience
– Concerns about drug use and risk of reinfection
C. Patients
– Lack of symptoms
– Lack of knowledge/fears about treatment
– Unstable: substance use, lack of social support,housing, and income
– Lack of access to substance abuse treatment program
NH Afdhal, MD, Viral Hepatitis Congress2013
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Multiple barriers
A. Structural
– Not enough specialists Primary Care Providers
– Insufficient staffing: case managers and social workers
Much less resource intensive
– Lack of integrated care models Telehealth
– Limited reimbursement for HCV care
– High proportion of uninsured Affordable Care Act
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Multiple Barriers
B. Providers– Lack of knowledge and experience simple nontoxic
highly effective regimens– Concerns about drug use and risk of reinfection
C. Patients– Lack of symptoms
– Lack of knowledge/fears about treatment well toleratedtherapy
– Unstable: substance use, lack of social support, housing, andincome less relevant
– Lack of access to substance abuse treatment program
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#2 Increase access to treatmentoptions for underserved patients
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Natural history of HCV
Kerla Thornton, MD; Project ECHO
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The peak of the impact is in 2030
Digestive and Liver Disease 2011;43:66-72
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PastMultiple (2 or 3) visits were required beforemaking a therapeutic decision
HCV RNA levels
HCV genotype
Screening for Hepatitis A, B, and HIV Staging IL28B genotype
Referral to psychiatry and ophthalmology autoimmune diseases, DM, cardio-
pulmonary condition
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It took a very committed patient to make itfrom screening to initiation of therapy
HCV ab test
Taking history
HCV RNAHCV genotype
Hostcharacterization
Referral
TherapeuticDiscussion
NH Afdhal, MD, Viral Hepatitis Congress 2013
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Late 2014/2015
We need to assess
Presence of HCV RNA
HCV genotype
Assess cirrhosis (biomarkers, cbc, US)
Screening for viral hepatitis and HIV
Hb/Hct, if ribavirin used
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2016?
We need to assess
Presence of HCV RNA
Assess cirrhosis (biomarkers, cbc, US)
Screening for viral hepatitis and HIV
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#3 Cost effective care
• Rural patients can stay in their localcommunities and not travel long distances
• Patients can be diagnosed and treated earlier:improved outcomes and prevention of costlycomplications
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Project ECHO
• 28,000 HCV in NewMexico
• In 2004, 6 monthswaiting for HCV clinic atthe UNM
• Patients had to travelup to 250 miles
NEJM 2011:364(23):2199-2207
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Method
• Use technology: video conference and internet
• Focus on improving outcome
– Sharing best practices
• Case-based learning: co-management withspecialists (learning by doing)
NEJM 2011:364(23):2199-2207
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ECHO
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Results
NEJM 2011:364(23):2199-2207
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Integrated Primary Care Model
• Advantages
– One stop shopping
– Improving link-to-care (they are already linked)
– No need for on-site expensive specialists
– Increased trust helps patient be adherent to Rx
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Integrated Primary Care Model
• Disadvantages
– The workload is high
– Specialists’ backup may be needed to answerquestions
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Southern Central AIDS EducationTelehealth Training Center
A HRSA-funded program that is administered by theUniversity of Kentucky, Division of Infectious Diseases
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Mission
To expand access to care and improve the healthcare outcomes of hard-to-reach individualsinfected with HIV in Kentucky and beyond
SCAETTC integrates a team of experts in thefields of HIV, HCV, HBV, and Behavioral Health toprovide you with education and teleconsultation
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HCV death rates exceed HIV
Annals Internal Medicine, 2012; 156:271-278
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Milestones in HIV therapy
http://depts.washington.edu/hivaids/arvrx/case2/discussion.html
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Single-pill HIV regimens
Coming soon
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New HIV diagnosis in KY
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How we doLive distant learning sessions
15-20 min focusedtopic lecture
A variety of topics
– Case presentations bylearners/ instructor forconsultation anddiscussion
– 15-25 min
– Learn from real cases
– Learn from others
– Co-management• Learning by doing
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Topics
• HIV epidemiology andtesting
• Care to newlydiagnosed HIV+ patient
• Antiretroviral therapy
• Hepatitis C basis
• Hepatitis C treatment
• Hepatitis Cmanagement of adverseeffects
• Mental health
• Illicit drug use
• Motivational interview– Improve adherence
– Drug addiction
• Hepatitis B
• STD and management
• Metaboliccomplications
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SCAETTC Speakers
Frank RomanelliCurtis CaryNicole LeedyDerek ForsterKeith HaasJennifer HavenMichael LofwallAndrew Hoellein
Karen KriggerPaula Peyrani
Stephen Raffanti (TN)Lamis IbrahimJonathan MoormanJames Sacco (GA)
Melissa Osborn (OH)Warren Liang
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SCAETTC Participants
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Benefits
• No cost CEUs for MD, PA, NP, pharmacy,dentist
• Professional interactions with colleagues withsimilar interests– Less isolated, improve recruitment and retention
• Easier access to consultation with infectiousdiseases, hepatologist, pharmacy,psychologist, other subspecialists, SW
• Equipment for distance learning
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Virtual Clinic
• 1 preceptor- 1 preceptee
• Real clinic observation and hands-onexperience
• Co-management
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Telehealth Training Process
Increase knowledge and co-manage with experts
Identify patientManage patient
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HCV care in future
Primary Care Providers
• Test HCV
• Manage easy-to-treatpopulation by themselves
• Co-manage more complexpatients with experts
Specialists
• Treat complex patients
• Determine an indication,initiate treatment, and referback to PCP (a shared-caremodel)
• Surveillance and managementof cirrhotic patients
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THANK YOU