Building on Project ECHO® methods to develop capacity for hepatitis C elimination

HPEC 2024 Oral Abstract for Innovations in Education

Title: Building on Project ECHO® methods to develop capacity for hepatitis C elimination

Author: Daniel Saltman, MD FACP

Affiliations: Department of Medicine, John A. Burns School of Medicine, University of Hawai`i Project ECHO: Hawai`i Learning Groups

Context: Hawaii has one of the highest rates of liver cancer incidence and mortality in the US, primarily caused by viral hepatitis. Safe and effective treatments exist to cure hepatitis C infection (HCV). Hawaii has a statewide goal aligned with a national initiative to eliminate HCV by 2030. Hawaii’s island geography makes access to quality care difficult for isolated populations, including those in rural areas, incarcerated, or among people who use drugs.
Both local and national experience has identified treatment of hard to reach populations as a bottleneck in HCV elimination efforts. Hepatitis C is transmitted through blood-blood contact. Risk factors include injections overseas, blood transfusions prior to 1992, low hygiene tattoos, and injection drug use. Early screening efforts targeted those born between 1945 and 1965 as at risk with many unaware of their chronic infection. Current recommendations are for one- time screening everyone over age 18 and anyone with ongoing risk factors. New infections are increasing among young people who use injection drugs.
The ECHO model was identified as a best practice to develop a localized network of treating providers using case-based, inter-disciplinary, collaborative learning with hepatitis experts.
The ECHO model leverages video-conferencing to develop a sustainable hub-and-spoke program of mentorship and guided practice. The hub is composed of specialists and content experts, and the spokes are primary care providers and their teams.
We recently completed a third series centered on hepatitis evaluation and treatment. In 2021, we produced a 16-week series focused on HCV; in 2022, 16-weeks focused on hepatitis B (HBV) and in 2023, 12-weeks focused on HCV.

Objectives: Our goal is to build capacity for the evaluation and treatment of chronic HCV.

Description of Innovation: From January 2021 through October 2023, we produced 44 clinics. Forty-six de-identified patients were presented and discussed.
We emphasize the primacy of case-based learning by typically starting each session with the patient case. Recent sessions had 45 minutes for case presentation and discussion and 40 minutes for a didactic with Q&A. The program leads model inclusivity and a team-based approach to promote interdisciplinary learning.
A Case Presentation Form was designed to communicate clinical content and to focus discussions.
A facilitation method is used that separates the patient background, history and physical exam from the expert recommendations. This promotes participation, a patient-centered approach to care, and helps level disparate backgrounds of participants. All participants are invited to ask questions after the presentation to gain a deeper understanding of the patient’s case. A facilitator summarizes this background and confirms the accuracy with the presenter. The content experts and others are then invited to provide recommendations regarding further evaluation and treatments and the expert recommendations are summarized to the group. The expression “all teach, all learn” becomes manifest in these discussions.
We are accredited to offer continuing education awards to physicians, nurses, pharmacists and social workers. We collect evaluation surveys after each session using REDCap (Research Electronic Data Capture) and deliver a participant- and session- specific, printable CE certificate upon completion.
Presentation slides, references and resources are posted on the HLG webpages after each session to provide greater depth of learning for interested participants.
Through REDCap, we distributed pre- and post- series questionnaires. Twenty-six questions were grouped by Self-efficacy, Access, Clinical Benchmarks, Series Evaluation, and Comfort with practical practice goals like vaccination, screening, lab interpretation, and use of standing orders.

Evaluation of Innovation: We had 1455 hours of attendance by 197 individuals. Fifty-nine physicians, 30 pharmacists, and 56 nurses participated from zip codes across all the Hawaiian Islands.
Average attendance increased over the 3 years (45 to 95 to 115) to include providers from the Hawaii Dept of Public Safety prison system, Community Health Centers, pharmacies, drug treatment programs and insurance carriers.
For the years 2021, 2022, and 2023, respectively, of those non-faculty who completed the questionnaires:
8/11 (73%), 30/37 (81%), and 25/28 (89%) Agreed or Strongly Agreed their participation reduced the need for travel for their patients.
8/11 (73%), 24/37 (65%), and 14/28 (50%) Agreed or Strongly Agreed their prescribing practice will change as a result of what they learned.
7/11 (64%), 27/37 (73%), and 19/28 (68%) Agreed or Strongly Agreed their referral pattern will change as a result of what they learned.
After participating in the 2023 HCV ECHO series, 68% of respondents agreed or strongly agreed with the statement: “Compared to other providers, I can manage primary care liver problems very well” compared to 36% before participating in the training(s) – a 32% increase.

Discussion/ Key Message: This year, the Medicaid Quest plans eliminated prior authorization requirements for prescribing direct-acting antiviral treatments for HCV and explicitly recognized the value of this HCV ECHO program therein.
A program of mentorship and intentional education for primary care participants was shown to increase the capacity for the management and treatment of HCV. Ongoing efforts like these are essential to hepatitis C elimination plans in Hawai`i. Centering patients and provider experience by emphasizing case-sharing as the primary learning method has resulted in strong engagement. Participants reported changes in prescribing and referral practices, expressed improved confidence in managing liver conditions, and strong program satisfaction.
We hope for further recognition that evaluation and treatment of hepatitis C with a shared practical goal of elimination is an ideal model for how to leverage technology in the primary care setting to further broad public health goals. Hepatitis C is a teaching case for developing population-based care using screening protocols and standing orders, decision support and reporting standards.

Target Audience: Educators, primary care providers, pharmacists, health care systems, public health workforce

References:
National Elimination Plan: JAMA. 2023;329(15):1251-1252. doi:10.1001/jama.2023.3692 Hawai`i Elimination Plan: https://www.hepfreehawaii.org/hep-free-2030
HCV ECHO 2023 Resources: https://www.hawaiilearning.org/hcv-2023-resources/