Clinical outcomes of hepatitis C treated with pegylated interferon and ribavirin via telemedicine consultation in Northern California

TeleHCV: A single-visit protocol and minimal passive remote monitoring are sufficient to achieve high SVR with a sofosbuvir-velpatasvir regimen

AIM

Chronic Hepatitis-C Virus (HCV) treatment has evolved significantly in recent years with Direct-Acting Antivirals (DAAs). The traditional care cascade includes several steps that limit its impact, and simplification protocols have emerged. Therefore, the authors explore a simplified treatment strategy for HCV in a healthcare system with limited access to specialized care.

SUBJECT AND METHODS

Chronic HCV, DAA-naïve patients waiting for in-person specialized care were invited to a single-arm non-inferiority trial to evaluate a simplified treatment protocol with a single face-to-face appointment and minimal monitoring of antiviral therapy. The unique visit consisted of an HCV presentation followed by individual medical consultation, blood tests, and delivery of sofosbuvir-velpatasvir pills for a 12-week treatment. Patients were remotely monitored without scheduled on-treatment appointments or phone calls. After treatment, teleconsultation using video was offered. The primary outcome was Sustained Virological Response (SVR) 12-weeks post-treatment. It was analyzed with Intention-To-Treat (ITT) and Per-Protocol (PP) approaches.

CLINICALTRIALS

gov: NCT04039698.

RESULTS

The authors included 144 patients, of which 54.2 % were male, mean age was 52 years. Most individuals (84.7 %) had an APRI score < 1. All patients received at least one dose of DAA, 139 completed antiviral therapy, and 131 had SVR evaluation. The ITT SVR rate was 90.3 % (130/144 patients; 95 % CI 84.2 %‒94.6 %), and the PP SVR was 99.2 % (130/131 patients; 95 % CI 95.8 %‒100 %). Eighty-three adverse events were reported, and 93 % were handled with remote care.

CONCLUSION

This simplified strategy achieved a high SVR rate in a population with restricted access to specialized care. Telehealth tools and minimal monitoring are promising components for policies aimed at HCV elimination.

Elimination of HCV Infection: Recent Epidemiological Findings, Barriers, and Strategies for the Coming Years

Hepatitis C is a disease for which in approximately 30 years we have gone from the discovery of the causative agent in 1989, to the introduction of direct-acting antiviral (DAAs) therapies starting from 2011, and to a proposal for its elimination in 2016, with some countries being on track for this goal. Elimination efforts, in the absence of a vaccine, rely on prevention measures and antiviral therapies. However, treatment rates have declined in recent years and are not considered adequate to achieve this goal at a global level. This poses a great epidemiological challenge, as HCV in many countries still causes a significant burden and most infected people are not yet diagnosed. Consequently, efforts are needed at different levels with common purposes: to facilitate access to screening and diagnosis and to improve linkage to care pathways. In this review, we discuss the latest epidemiological findings on HCV infection, the obstacles to its elimination, and strategies that are believed to be useful to overcome these obstacles but are applied unevenly across the world.

Perceived barriers and facilitators to the adoption of telemedicine infectious diseases consultations in southeastern Missouri hospitals

INTRODUCTION

Telemedicine infectious diseases consultations (tele-ID consults) improves access to healthcare for underserved/resource-limited communities. However, factors promoting or hindering implementation of tele-ID consults in low-resource settings are understudied. This study sought to fill this gap by describing perceived barriers and facilitators tele-ID consults at three rural hospitals in southeastern Missouri.

METHODS

Twelve in-depth, semi-structured interviews were conducted with a purposively sampled group of information-rich hospital stakeholders from three rural, southeastern Missouri hospitals with partial or no on-site availability of ID physicians. Our literature-informed interview guide elicited participants' knowledge and experience with tele-ID consults, perceptions on ID consultation needs, and perceived barriers to and facilitators of tele-ID consults. Interview transcripts were coded using an iterative process of inductive analysis to identify core themes related to barriers and facilitators.

RESULTS

Perceived barriers to adopting and implementing tele-ID consults included logistical challenges, technology and devices, negative emotional responses, patient-related factors, concerns about reduced quality of care when using telemedicine, lack of acceptance or buy-in from physicians or staff, and legal concerns. Key facilitators included perceived need, perceived benefits to patients and physicians, flexibility and openness to change among staff members and patients, telemedicine champions, prior experiences, and enthusiasm.

DISCUSSION

Our findings demonstrate that rural hospitals need tele-ID consults and have the capacity to implement tele-ID consults, but operational and technical feasibility challenges remain. Adoption and implementation of tele-ID consults may reduce ID-physician shortage-related service gaps by permitting ID physician's greater geographic reach.

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

INTRODUCTION

Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare.

METHODS

We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes.

RESULTS

Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples.

DISCUSSION

Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

More than Just Buying a Van: Lessons Learned from a Mobile Telehealth HCV Testing and Treatment Study

Hepatitis C virus (HCV) disproportionately affects people who inject drugs (PWID). Although HCV has become universally curable since the arrival of direct-acting antivirals, barriers exist to facilitating care and cure in this historically hard-to-reach population, including limited testing and healthcare services and healthcare stigma, issues that are compounded in rural areas. Telehealth is effective in increasing access to HCV care and cure, but innovative approaches of testing and care are required to fully address the need among rural PWID, which led to our study examining a mobile telehealth model for treating HCV. In this commentary, we discuss lessons learned delivering telehealth on a mobile unit, important factors for consideration when designing a mobile intervention, and we suggest an ideal model to increase access to HCV testing and treatment and other services for rural PWID.

Small molecule drug discovery targeting the JAK-STAT pathway

The Janus kinase-signal transducer and activator of transcription (JAK-STAT) pathway functions as a central hub for transmitting signals from more than 50 cytokines, playing a pivotal role in maintaining hematopoiesis, immune balance, and tissue homeostasis. Dysregulation of this pathway has been implicated in various diseases, including immunodeficiency, autoimmune conditions, hematological disorders, and certain cancers. Proteins within this pathway have emerged as effective therapeutic targets for managing these conditions, with various approaches developed to modulate key nodes in the signaling process, spanning from receptor engagement to transcription factor activation. Following the success of JAK inhibitors such as tofacitinib for RA treatment and ruxolitinib for managing primary myelofibrosis, the pharmaceutical industry has obtained approvals for over 10 small molecule drugs targeting the JAK-STAT pathway and many more are at various stages of clinical trials. In this review, we consolidate key strategies employed in drug discovery efforts targeting this pathway, with the aim of contributing to the collective understanding of small molecule interventions in the context of JAK-STAT signaling. We aspire that our endeavors will contribute to advancing the development of innovative and efficacious treatments for a range of diseases linked to this pathway dysregulation.

United States Provider Experiences with Telemedicine for Hepatitis C Treatment: A Nationwide Survey

Background

Hepatitis C virus (HCV) elimination requires treatment access expansion, especially for underserved populations. Telehealth has the potential to improve HCV treatment access, although data are limited on its incorporation into standard clinical practice.

Methods

We conducted a cross-sectional, e-mail survey of 598 US HCV treatment providers who had valid email addresses and 1) were located in urban areas and had written ≥20 prescriptions for HCV treatment to US Medicare beneficiaries in 2019-20 or 2) were located in non-urban areas and wrote any HCV prescriptions in 2019-20. Through email, we notified providers of a self-administered electronic 28-item survey of clinical strategies and attitudes about telemedicine for HCV.

Results

We received 86 responses (14% response rate), of which 75 used telemedicine for HCV in 2022. Of those 75, 24% were gastroenterologists/hepatologists, 23% general medicine, 17% infectious diseases, and 32% non-physicians. Most (82%) referred patients to commercial laboratories, and 85% had medications delivered directly to patients. Overwhelmingly, respondents (92%) felt that telehealth increases healthcare access, and 76% reported that it promotes or is neutral for treatment completion. Factors believed to be "extremely" or "very" important for telehealth use included patient access to technology (86%); patients' internet access (74%); laboratory access (76%); reimbursement for video visits (74%) and audio-only visits (66%). Non-physician licensing and liability statutes were rated "extremely" or "very" important by 43% and 44%, respectively.

Conclusions

Providers felt that telehealth increases HCV treatment access. Major limitations were technological requirements, reimbursement, and access to ancillary services. These findings support the importance of digital equity and literacy to achieve HCV elimination goals.

Review article: Telecare in gastroenterology-Within the COVID-19 pandemic and beyond

BACKGROUND

Telehealth is a growing model of care, greatly accelerated with the demands of the COVID-19 pandemic. Telecare is a synchronous audio-visual or audio-only format of health delivery.

AIMS

To evaluate the existing literature on telecare within adult gastroenterology subspecialties to determine if outcomes are comparable to traditional in-person consultations and to highlight the Pokapū Network, a local initiative in the Lakes Region of New Zealand, amongst these international findings.

METHODS

We completed an OVID MEDLINE search using the terms gastroenterology, endoscopy, digestive system, inflammatory bowel disease, functional, hepatology, liver, telemedicine, telehealth, videoconferencing, remote consultation, video clinic and telephone clinic.

RESULTS

Patients showed positive attitudes towards telecare and, in several reports, would elect to have telecare consults in the future. Telecare reduces travel time and out-of-pocket costs for patients and the need for patients to take time off work. Generally, patients engaging with telecare show equivalent health outcomes to patients engaging with traditional models of care. Patients from ethnic minority groups or lower socio-economic backgrounds, or who are older, are less likely to complete a 'successful' telecare consult.

CONCLUSION

Telecare is a useful model of care to allow gastroenterology centres to function within the context of COVID-19 isolation and beyond. It has significant benefits for patients who face geographical and financial barriers to accessing healthcare. Telecare models such as the Pokapū Network hold promise in reducing inequities for gastroenterology patients. Such models must be introduced with consideration of digital disparities that exist amongst patients to avoid worsening the digital divide.

A nurse-led, telehealth-driven hepatitis C management initiative in regional Victoria: Cascade of care from referral to cure

INTRODUCTION

Elimination of hepatitis C virus stands as an unresolved World Health Organization target, and is associated with complications including cirrhosis and hepatocellular carcinoma. Hepatitis C virus management has been revolutionised following the widespread availability of direct-acting antiviral agents in Australia since 2016; however, large proportions of the population remain untreated. Telehealth-based service delivery is an accessible and effective alternative, and we aimed to assess qualitative and clinical outcomes in a clinical nurse consultant-led regional telehealth model.

METHODS

A prospective cohort analysis of all patients referred to a Victorian regional hospital's hepatitis C virus telehealth clinic between 1 April 2017 and 10 June 2020 was conducted. Data were collated from outpatient and electronic medical records.

RESULTS

Fifty-five out of 71 referred patients were booked, with 44 patients (80%) attending at least one appointment. A history of alcohol use disorder and psychiatric comorbidity was seen in 25 (54%) and 24 (52%) patients, respectively. Twenty-one out of 24 (88%) eligible patients had direct-acting antiviral agent treatment and 14 out of 21 (67%) successfully completed the treatment. An average of 46.5 km, 54.6 min and $AUD30.70 was saved per patient for each visit. Observed benefits included: increased medical engagement, adherence to and completion of HCV treatment and cirrhosis monitoring. Telehealth-driven hepatocellular carcinoma surveillance was successful in the cirrhotic subgroup.

CONCLUSION

Clinical nurse consultant-led hepatitis C virus management via telehealth allows access to marginalised regional populations. Clinical outcomes were comparable to other cohorts with additional cost-benefit, efficiency gains and carbon footprint reduction amongst a previously unreported regional Victorian hepatitis C virus population.

A contactless cure: Leveraging telehealth to improve hepatitis C treatment at a safety-net hospital

Hepatitis C virus (HCV) causes significant mortality worldwide. HCV is highly curable but access to care is limited for many patients. The Grady Liver Clinic (GLC), a primary care-based HCV clinic, utilizes a multidisciplinary team to provide comprehensive care for a medically underserved patient population in Atlanta, Georgia. The GLC added a telehealth option for HCV treatment at the start of the COVID-19 pandemic. We describe the outcomes of utilizing telehealth in this population. We performed a retrospective chart review of patients who initiated HCV treatment from March 2019 to February 2020 (pre-pandemic) and March 2020 to February 2021 (pandemic). Charts were abstracted for patient demographics and characteristics, treatment regimen, and treatment outcomes. Our primary outcome was HCV cure rate of the pre-pandemic compared to the pandemic cohorts and within the different pandemic cohort visit types. We performed an intention-to-treat (ITT) analysis for all patients who took at least one dose of a direct-acting antiviral (DAA) regardless of therapy completion, and a per-protocol (PP) analysis of those who completed treatment and were tested for HCV cure. SVR12 rates were >95% on ITT analysis, with no significant difference between pre-pandemic and pandemic cohorts. There was also no significant difference within the pandemic group when treatment was provided traditionally, via telehealth, or via a hybrid of these. Our findings support the use of telehealth as a tool to expand access to HCV treatment in a medically underserved patient population.

Telehealth interventions in patients with chronic liver diseases: A systematic review

BACKGROUND AND AIM

Telehealth interventions may improve access to care, disease-specific, and quality outcomes in chronic liver diseases (CLDs). We aimed to systematically evaluate outcomes of telehealth interventions in CLDs.

MATERIALS AND METHODS

We used key terms and searched PubMed/EMBASE from inception to January 10, 2022. Two authors independently screened abstracts. Disagreements were resolved by a third reviewer. We included any type of CLD, including posttransplant patients, and extracted outcomes as defined by authors for each etiology of CLD (sustained virological response in HCV or weight loss in NAFLD). Meta-analysis was not performed because of the heterogeneity of data. Quality assessment was performed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias tool for clinical trials.

RESULTS

Of 4250 studies screened, 43 met the inclusion criteria. Of these, 28 reported HCV treatment outcomes. All studies showed no statistically significant differences between sustained virological response rates in TH groups compared with control groups or historic cohorts. Eight studies evaluating liver transplant-related processes and outcomes demonstrated improved rates of transplant evaluation and referrals and decreased short-term readmission rates. Three randomized controlled trials and 1 observational study on NAFLD showed improved weight loss outcomes. One retrospective study showed reduced mortality risk in CLD patients with at least 1 TH encounter.

CONCLUSIONS

TH interventions in patients with CLDs consistently show equivalent or improved clinical outcomes compared with traditional encounters. TH in CLDs can bridge the gap in access while maintaining the quality of care for underserved populations.

Are We on the Right Track for HCV Micro-Elimination? HCV Management Practices in Dialysis Centers in Poland-A National Cross-Sectional Survey

Chronic hepatitis C (CHC) is prevalent in the hemodialysis-dependent population. Currently, all patients with CHC should be considered for treatment; however, many hemodialysis-dependent patients are still left untreated. Following HCV cure, accurate surveillance is mandatory to reduce liver-related mortality and prevent reinfection. We aimed to establish HCV management practices and barriers to HCV elimination in dialysis centers in Poland. Polish dialysis centers were surveyed via email. The HCV management strategies were investigated. Representatives of 112 dialysis centers responded, representing 43.1% of all dialysis centers in Poland and 43.4% of hemodialysis-dependent patients' volume. Most respondents were Heads of hemodialysis centers and board-certified nephrologists. The study demonstrated that in the vast majority of hemodialysis centers (91.6%), subjects are considered for antiviral treatment (AVT); however, many obstacles preventing patients from being prescribed AVT were identified; patients' reluctance to undergo AVT was most reported (60%). The majority of dialysis units neither evaluate patients with CHC for liver fibrosis (60.4%) nor screen them for hepatocellular carcinoma (53.5%). In conclusion, the presented study demonstrates that HCV management practices across Polish dialysis centers vary substantially. There is a need to optimize and streamline the HCV management infrastructure in the hemodialysis population in Poland.

Telemedicine in Hepatology: Current Applications and Future Directions

Telemedicine refers to the use of information and communication technologies for providing health care at a distance. Through the use of telecommunication technologies such as cell phones, computers, and other electronic devices, health care providers are able to conduct patient visits, mentor/train other providers, and monitor patients' chronic diseases remotely, potentially hundreds or thousands of miles away. Over the past 2 decades, the use of telemedicine has grown in the field of hepatology. In this review, we provide a focused primer on telemedicine and its current applications in hepatology. In particular, we discuss the use of telemedicine in the management of chronic hepatitis C, the complications of liver disease, as well as preliver transplantation evaluation and posttransplantation care. In addition, we provide a synopsis of the effect of the coronavirus disease 2019 (COVID-19) pandemic on the use of telemedicine in hepatology.

You Can't Have One Without the Other: Innovation and Ethical Dilemmas in Gastroenterology and Hepatology

Medical innovation and ethical dilemmas are intertwined in gastroenterology and hepatology. This narrative review explores direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) as a touchstone example of how medical innovation breeds ethical dilemmas. A few quandaries-informed consent as well as informed deferral during the first wave of DAA approvals, sobriety restrictions from payors, and high DAA costs for patients-are addressed through the lens of the foundational principles of clinical medical ethics: autonomy, beneficence, non-maleficence, justice, and utility. By placing these issues within a medical ethics framework, we hope not only to focus on the solutions that the gastroenterology and hepatology community developed in the advent of DAA therapy, but to highlight an ethical paradigm that can be applied to similar dilemmas that will be faced as new therapies for other gastrointestinal diseases are approved.

eHealth Technologies for Screening, Diagnosis, and Management of Viral Hepatitis: A Systematic Review

BACKGROUND & AIMS

Chronic viral hepatitis is a leading cause of worldwide liver-related morbidity and mortality, despite the availability of effective treatments that reduce or prevent complications in most patients. Electronic-health (eHealth) technologies have potential to intervene along the whole cascade of care. We aimed to summarize available literature on eHealth interventions with respect to conventional screening, diagnostic and treatment outcomes in chronic hepatitis B (HBV) and hepatitis C (HCV).

METHODS

We systematically reviewed MEDLINE, EMBASE, Cochrane Library and international conference abstracts, including studies published from 2009 - 2020. Overall 80 studies were included, covering electronic medical record (EMR) interventions (n=39), telemedicine (n=20), mHealth (n=5), devices (n=4), clinical decision support (n=3), web-based (n=5), social media (n=1) and electronic communication (n=3).

RESULTS

Compared to standard care, EMR alerts increase screening rates in eligible populations including birth cohort screening in HCV, universal HCV screening in Emergency Departments, ethnic groups with high HBV prevalence, and HBV screening prior to immunosuppression. Direct messaging alerts to providers and automated testing may have a greater effect. No significant difference was found in sustained virological response outcomes between telemedicine and face-to-face management for community, rural and prison cohorts in HCV in the direct acting antiviral era of treatment, with higher patient satisfaction in telemedicine groups.

CONCLUSIONS

EMR alerts significantly increase screening rates in eligible cohorts in both chronic HBV and HCV. Telemedicine is equally efficacious to face-to-face care in HCV treatment. Other eHealth technologies show promise; however rigorous studies are lacking.

The value of physical examination in the era of telemedicine

Telemedicine use has expanded rapidly to cope with increasing demand on services by delivering remote clinical review and monitoring of long-term conditions. Triaging individual patients to determine their suitability for telephone, video or face-to-face consultations is necessary. This is crucial in the context of COVID-19 to ensure doctor-patient safety. Telemedicine was shown to be safe and feasible in managing certain chronic diseases and providing patient education. When reviewing newly referred or long-term patients, different specialty clinics have different requirements for physical examination. Clinicians prefer face-to-face consultations at the initial visit to establish a doctor-patient relationship; telephone or video consultations are reasonable options for long-term patients where physical examination may not be needed. Video consultations, often aided by sophisticated devices and apps or medical assistants, are useful to facilitate remote physical examination. Most patients prefer telemedicine as it saves time and travel cost and provides better access to appointments.

Telehealth as an Important Player in the Management of Hepatitis C Virus

Background: Hepatitis C virus (HCV) is a global public health issue that can cause both acute and chronic liver diseases. There is a high risk of HCV burden, but limited access and cost remain a challenge for proper diagnosis and treatment. Leveraging eHealth technology may indicate a viable solution for the management of HCV patients. Objective: To review the literature regarding the role of eHealth, including telemedicine, in the management of HCV. Methods: Databases including PubMed, Google Scholar, Medline, Web of Science, and Science Direct were searched from 1 January 2008 to 30 June 2020 to identify different types of eHealth interventions used for the management of adult HCV patients. Our search also determined the role of telehealth for HCV patients in the current pandemic. Results: Four main categories emerged from this scoping review that includes improving treatment rates via utilizing telehealth services, satisfaction with the telehealth services, disease management, health promotion, and similarity between telehealth and traditional modalities. Conclusion: Current evidence suggests that telemedicine is a cost-effective and unique platform to improve patients’ access to quality services that curb the increasing burden of this silent killer in developing countries. This modality can certainly be utilized in the current crisis to manage care for HCV patients efficiently.

We Must Do Better: Addressing HCV Treatment Barriers in Persons Who Inject Drugs in the United States

The opioid epidemic in the United States, along with a lack of adequate harm reduction services, has contributed to a sharp rise in hepatitis C virus (HCV) infections. Despite considerable evidence of the effectiveness of HCV treatment in people who inject drugs (PWID), and recommendations from clinical guidelines to prioritize treatment in PWID, there are multiple barriers to broad uptake of HCV treatment. These barriers exist at the systems level, as well as at the level of medical providers and patients. Interventions to remove treatment barriers in the United States include harm reduction services, simplifying HCV testing algorithms, improved linkage to HCV care services, and application of new treatment models including colocating services at substance use disorder treatment programs. By following the lead of other countries who have addressed the barriers to HCV treatment, the United States has opportunities to do better in addressing the consequences of the opioid epidemic, including chronic HCV infection.

Framework for community-based models for treating hepatitis C virus

Objective Although community-based models for treating hepatitis C virus (HCV) are widely recognised for reaching more people who require treatment, little is known about their organisational and operational elements. This study aimed to address this gap and develop a framework for designing, implementing and evaluating community-based models for treating HCV. Methods This study was a systematic review in which 17 databases were searched for published and unpublished studies. The final search of databases was performed in September 2017. A qualitative inductive thematic approach was used to extract and categorise organisational and operational elements of community-based models for treating HCV. Results Data analysis yielded 13 organisational and operational elements that were categorised into three domains: support for patients, support for healthcare providers and service delivery facilitation. In the support for patients domain, support was categorised into four elements: peer support, psychological assessment and support, social assessment and support and adherence support. In the support for healthcare providers domain, the elements included the provision of educational opportunities for HCV care providers, specialist mentoring, decision making support and rewarding and recognition for HCV care providers. Finally, the service delivery facilitation domain included seven elements that target service-level enablers for community-based HCV treatment, including essential infrastructure, policy implementation and collocation and collaboration with other related services. Conclusion This framework for understanding the components of models of community-based HCV treatment may be used as a guide for designing, implementing and evaluating models of care in support of HCV elimination. HCV care providers and patients need to be supported to improve their engagement with the provision of community-based treatment. In addition, evidence-based strategies to facilitate service delivery need to be included. What is known about the topic? Community-based models for treating HCV are widely recognised as having the advantage of reaching more people who require treatment. These types of models aim to remove barriers related to accessibility and acceptability associated with tertiary centre-based HCV treatment. What does this paper add? Community-based models for treating HCV use various organisational and operational elements to improve the accessibility, effectiveness and acceptability of these services. The elements we identified target three main domains: support for patients with HCV, support for HCV care providers and service delivery facilitation. The importance of these organisational and operational elements designed to improve health and health services outcomes of community-based models for treating HCV is strongly influenced by context, and dependent on both the setting and target population. What are the implications for practitioners? Health policy makers and practitioners need to consider a patient’s psychosocial and economic status and provide support when needed. To successfully deliver HCV treatment in community settings, HCV care providers need to be trained and supported, and need to establish linkages, collaborations or colocations with other related services.

Comparison of hepatitis C treatment outcomes between telehepatology and specialty care clinics in the era of direct-acting antivirals

INTRODUCTION

Telehealth technologies for rural patients are increasingly being used to deliver care within the Department of Veterans Affairs (VA), and treatment of hepatitis C virus (HCV) is no exception. However, data evaluating outcomes with telehealth compared with specialty clinics in the era of direct-acting antiviral (DAA) agents is sparse.

METHODS

In a retrospective analysis, we compared treatment outcomes for patients receiving DAAs followed solely in a telehepatology clinic (telehealth) versus an in-person specialty care clinic (standard of care) at the VA Eastern Colorado Health Care System. Patients with decompensated cirrhosis (CTP-B or CTP-C) were excluded from the study as they were exclusively followed via standard of care. Provider overlap occurred between clinics and consisted of physician specialists (hepatology and infectious diseases), physician assistants and clinical pharmacists.

RESULTS

From 1 January 2014 to 31 December 2017, we treated 764 veterans for HCV infection. Standard of care was provided to 629 patients representing 654 treatment courses, and telehealth was provided to 135 patients representing 138 treatment courses. Sustained virologic response rates were not significantly different between the two clinics when looking at total treatment courses (93% telehepatology vs 89% specialty care, p = 0.203) and individual patients treated (95% telehepatology vs 93% specialty care, p = 0.377).

DISCUSSION

Hepatitis C treatment utilizing telehealth technologies to improve access to care does not negatively impact treatment outcomes when compared with specialty care clinics in the era of DAAs.

Outcomes of a tertiary-based innovative approach to engage primary care providers in provision of hepatitis C treatment in community settings

Background

Australia is committed to eliminating the hepatitis C virus (HCV) by 2030. Despite regulations in Australia that enable the prescription of subsidised direct acting antiviral (DAA) by primary health care providers, the number of providers who treat patients for HCV remains low and this limits the prospect of HCV elimination. The Prince Charles Hospital, Brisbane, Australia, implemented an innovative program called Cure-It aimed at engaging primary care providers in community-based HCV treatment. This paper aims to describe initial experiences and short-term patient outcomes of this program.

Methods

A formative evaluation was conducted using program data for the period March 2016 to April 2018. Descriptive statistics were used to report the number of engaged primary care providers, patients’ baseline characteristics, treatment plans, and treatment outcomes.

Results

Thirty primary care providers from different settings were engaged in HCV treatment. Among 331 patients eligible for community-based treatment, 315 (95.2%) commenced treatment, the completion rate was 92.4 and 66.5% achieved sustained virological response at 12 weeks (SVR12). The SVR12 had not been documented for 26.8% of patients. Among patients whose SVR12 was documented, 98.2% achieved SVR12. Only 1.3% of patients experienced treatment failure.

Conclusion

A flexible tertiary-led model can improve primary care providers and patients’ engagement with provision of HCV treatment. Tertiary centres need to play their role to improve the accessibility of HCV treatment through providing training and on-going support for primary care providers while enabling those providers to become more confident in providing treatment independently.

Clinical effectiveness, cost effectiveness and acceptability of community-based treatment of hepatitis C virus infection: A mixed method systematic review

Several community-based models for treating hepatitis C virus (HCV) infection have been implemented to improve treatment accessibility and health outcomes. However, there is a lack of knowledge regarding how well these models achieve the desired goals. We conducted a mixed-method systematic review of quantitative and qualitative evidence about clinical effectiveness, cost effectiveness and acceptability of community-based HCV treatment models. Seventeen databases were researched for published and unpublished studies. Methodological quality was assessed using The Joanna Briggs Institute Critical Appraisal tools. Quantitative findings were synthesized in narrative form and qualitative findings were synthesized using meta-synthesis. Forty-two quantitative and six qualitative studies were included. No relevant cost effectiveness studies were found. Five categories of community-based models were identified: telehealth, integration of HCV and addiction services, integration of HCV and HIV services, integration of HCV and primary care, and implementation by a home care and health care management company. The range of reported outcomes included; end of treatment response: 48.7% to 96%, serious side effects: 3.3% to 27.8%, sustained virological response: 22.3% to 95.5%, relapse: 2.2% to 16.7%, and treatment completion: 33.4% to 100%. Inconsistent measures of uptake and adherence were used; uptake ranged from 8.3% to 92%, and 68.4% to 100% of patients received ≥80% of prescribed doses. Patient reported experiences included trusted and supportive care providers, safe and trusted services, easily accessible care, and positive psychological and behavioural changes. The clinical effectiveness and acceptability reported from the included studies are similar to or better than reported outcomes from systematic reviews of studies in tertiary settings. Studies of the cost effectiveness of community-based models for treating HCV are needed.

Telemedicine: An Evolving Field in Hepatology

Healthcare delivery has been dramatically changing in recent times with advances in technology. One area of expansion has been the use of telemedicine due to progression in communication technologies. Telemedicine offers the opportunity to overcome barriers of access, improve patient satisfaction, improve healthcare outcomes and streamline communication between patients and providers. The primary modalities of telemedicine can be grouped into categories of ‘remote monitoring,’ ‘store and forward’ and ‘interactive telemedicine.’ These modalities of telemedicine have been practiced and explored within the scope of hepatology such as in liver transplantation, hepatocellular carcinoma and management of chronic hepatitis C (CHC). There are numerous telemedicine‐based CHC management studies and programs that have developed in New Mexico, the Department of Veterans Affairs, as well as globally in Australia and Canada. In Northern California, the University of New Mexico telemedicine‐based model of ‘ECHO’ has been extended to develop community‐based champions to screen‐link‐treat CHC patients with the goal to eliminate hepatitis C. Despite the advantages to telemedicine, there are still many barriers to seamless integration due to reimbursement and up‐front cost. Nevertheless, it remains an essential part in providing world‐class care to liver patients across geographic and economic barriers.

Virtual Consultations Through the Veterans Administration SCAN-ECHO Project Improves Survival for Veterans With Liver Disease

Access to specialty care has been associated with improved survival in patients with liver disease but universal access is not always feasible. Methods of care delivery using virtual modalities including the SCAN-ECHO (Specialty Access Network-Extension of Community Healthcare Outcome) program were implemented by the Veterans Health Administration (VHA) to address this need but limited data are available on patient outcomes. We sought to evaluate the efficacy of a SCAN-ECHO visit within the context of a regional cohort of patients with liver disease in the VHA (n = 62,237) following implementation in the Ann Arbor SCAN-ECHO Liver Clinic from June 1, 2011, to March 31, 2015. The effect of a SCAN-ECHO visit on all-cause mortality was compared with patients with no liver clinic visit. To adjust for the differences among patients who had a SCAN-ECHO visit versus those with no visit, propensity score matching was performed on condition factors that affect the likelihood of a SCAN-ECHO visit: demographics, geographic location, liver disease diagnosis, severity, and comorbidities. During the study period, 513 patients who had a liver SCAN-ECHO visit were found within the cohort. Patients who had completed a virtual SCAN-ECHO visit were more likely younger, rural, with more significant liver disease, and evidence for cirrhosis. Propensity-adjusted mortality rates using the Cox Proportional Hazard Model showed that a SCAN-ECHO visit was associated with a hazard ratio of 0.54 (95% confidence interval 0.36-0.81, P = 0.003) compared with no visit. Conclusion: Improved survival in patients using SCAN-ECHO suggests that this approach may be an effective method to improve access for selected patients with liver disease, particularly in rural and underserved populations where access to specialty care is limited.

Building a Hepatitis C Clinical Program: Strategies to Optimize Outcomes

PURPOSE OF REVIEW

An increasing number of specialists and non-specialists are developing clinical programs to treat and cure hepatitis C virus (HCV). The goal of this paper is to evaluate and describe optimal strategies to improve outcomes related to HCV care delivery.

RECENT FINDINGS

Screening and diagnosis of HCV should be guided by established recommendations. Given the recognized disparity in HCV diagnosis and linkage to care, a multi-modal approach involving care coordination and technology resources should be used to improve patient engagement. Access to HCV treatment may be optimized through systematic documentation, prior authorization, and appeal processes. Treatment monitoring should emphasize medication adherence, side effect and drug interaction management, as well as elimination of practical barriers. Finally, post-treatment engagement to promote liver health and reduce the risk of complications or reinfection maximizes the benefit of HCV treatment.

SUMMARY

The landscape of HCV treatment has evolved from a specialist-driven model with few patients qualifying for treatment to an opportunity for non-specialists and other providers to provide curative therapies in most patients. Innovative practice models that employ a multidisciplinary approach will likely improve screening, diagnosis, engagement, and treatment outcomes.

Direct-Acting Antiviral Therapy Outcomes in Canadian Chronic Hepatitis C Telemedicine Patients

INTRODUCTION

Many of the 300,000 HCV-infected Canadians live in under-served and remote areas without access to HCV healthcare specialists. Telemedicine (TM) and advances in HCV management can facilitate linkage of these marginalized patients to healthcare.

MATERIALS AND METHODS

A cohort database analysis was performed on patients followed at The Ottawa Hospital and Regional Viral Hepatitis Program between January 2012 and August 2016. We compared patient characteristics, fibrosis work-up and antiviral treatment outcomes in TM (n = 157) and non-TM (n = 1,130) patients (The Ottawa Hospital Viral Hepatitis Outpatient Clinic) residing in Eastern Ontario.

RESULTS

TM patients were more often infected with genotype 3 (25.9% vs. 16.4%), were more commonly Indigenous (7.0% vs. 2.2%) had a history of injection drug use (70.1% vs. 54.9%) and incarceration (46.5% vs 35.5%). Groups were comparable in age (48.9 years), gender (63.7% male) and cirrhotic stage (24.0%). 59.2% of TM patients underwent transient elastography during regional outreach blitzes compared to 61.8% of non-TM patients (p = 0.54). Overall, half as many TM patients initiated antiviral therapy as non-TM patients (27.4% vs. 53.8%, p &lt; 0.001). The introduction of DAA regimens is bridging this gap (22.2% of TM patients vs. 34.3% of non-TM patients). SVR rates with interferon-free, DAA regimens were 94.7% and 94.8% in TM and non-TM groups (p = 0.99).

CONCLUSION

Our TM program engages and retains a population that faces many barriers to effective HCV treatment. TM patients initiated HCV therapy and achieved High SVR rates comparable to those obtained using traditional models of care.

Expansion of Treatment for Hepatitis C Virus Infection by Task Shifting to Community-Based Nonspecialist Providers: A Nonrandomized Clinical Trial

Background

Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection has resulted in high rates of disease cure; however, not enough specialists currently are available to provide care.

Objective

To determine the efficacy of HCV treatment independently provided by nurse practitioners (NPs), primary care physicians (PCPs), or specialist physicians using DAA therapy.

Design

Nonrandomized, open-label clinical trial initiated in 2015. (ClinicalTrials.gov: NCT02339038).

Setting

13 urban, federally qualified health centers (FQHCs) in the District of Columbia.

Patients

A referred sample of 600 patients, of whom 96% were black, 69% were male, 82% were treatment naive, and 20% had cirrhosis. Seventy-two percent of the patients had HCV genotype 1a infection. The baseline characteristics of patients seen by each provider type were similar.

Intervention

Patients were assigned in a nonrandomized but specified manner to receive treatment from 1 of 5 NPs, 5 PCPs, or 6 specialists. All providers underwent an identical 3-hour training session based on guidelines. Patients received treatment with ledipasvir-sofosbuvir, which was provided on site, according to U.S. Food and Drug Administration labeling requirements.

Measurements

Sustained virologic response (SVR).

Results

516 patients achieved SVR, a response rate of 86% (95% CI, 83.0% to 88.7%), with no major safety signals. Response rates were consistent across the 3 provider types: NPs, 89.3% (CI, 83.3% to 93.8%); PCPs, 86.9% (CI, 80.6% to 91.7%); and specialists, 83.8% (CI, 79.0% to 87.8%). Patient loss to follow-up was the major cause of non-SVR.

Limitation

Nonrandomized patient distribution; possible referral bias.

Conclusion

In a real-world cohort of patients at urban FQHCs, HCV treatment administered by nonspecialist providers was as safe and effective as that provided by specialists. Nurse practitioners and PCPs with compact didactic training could substantially expand the availability of community-based providers to escalate HCV therapy, bridging existing gaps in the continuum of care for patients with HCV infection.

Primary Funding Source

National Institutes of Health and Gilead Sciences.

Use of telehealth to treat and manage chronic viral hepatitis in regional Queensland

For regional and rural Queenslanders, chronic viral hepatitis treatment is a major unmet health need, with restricted access to specialists outside of tertiary, largely metropolitan hospitals. To increase treatment of chronic viral hepatitis in regional Queensland, a team-based telehealth model was expanded. This expansion embedded an initial nursing consultation prior to specialist telehealth consultation. We conducted a retrospective audit of the introduction and expansion of hepatology telehealth services. Activity from July 2014-June 2015 (pre-expansion) was compared with July 2015- June 2016 (post-expansion). Interviews were conducted with key staff to determine factors contributing to success of the service and identify ongoing challenges to the service model. A greater than four-fold increase in clinical consultation was observed (131 telehealth consultations pre-expansion vs 572 post-expansion; p < 0.001). The failure to attend rate decreased (13.0% vs 6.5%, pre vs post-expansion respectively; p = 0.030), suggesting engagement with the service increased. Staff cited nurse-conducted primary assessment prior to specialist consultation and personalised patient treatment packs as key contributors to increased patient flow and engagement. This expanded team approach appears effective in delivering specialised treatment to an underserved area in regional Central Queensland. It may serve as a model to further expand telehealth management of chronic disease for regional Queenslanders.

Frequency of and Factors Associated with Receipt of Liver-Related Specialty Care Among Patients with Hepatitis C in the Chronic Hepatitis Cohort Study

BACKGROUND

Linking persons with hepatitis C virus (HCV) to care and treatment is critical to reduction in disease burden; typically, this entailed referral to a specialist. However, data regarding the frequency and factors associated with referral among patients in healthcare organizations (HCOs) are lacking.

METHODS

Among persons in four US HCOs with newly diagnosed HCV during 2006-2011, we determined the frequency of liver-related specialist care after diagnosis. We also identified sociodemographic and clinical characteristics associated with such care by multivariate analysis, adjusted for all variables.

RESULTS

Among 3592 patients with newly diagnosed HCV, 57 % (range among sites 45-90 %) received specialist care; of these, 57 % received care within 90 days of diagnosis. Patient characteristics associated with receipt of specialist care included: affiliation with one of the study sites [adjusted odds ratio (aOR) 4.8 vs. the referent site); having Medicare plus private insurance (aOR 1.6 vs. Medicaid); and having elevated alanine aminotransferase (ALT) (aOR 1.6 vs. normal ALT) or lower platelet values (aOR 1.4 vs. normal platelet level). Specialist care within 90 days of diagnosis was associated with private insurance (aOR 1.5 vs. Medicaid), elevated ALT levels (aOR 1.3-2.3 vs. normal), and having ≥2 comorbid conditions (aOR 1.4 vs. no comorbid conditions). Compared to patients not referred, those referred were more likely to be treated (aOR 3.5).

CONCLUSIONS

Receipt of specialist care among persons with newly diagnosed HCV varied among HCOs. Clinical evidence of liver disease and having private insurance were associated with prompt receipt of specialist care and HCV treatment.

State of the Art, Unresolved Issues, and Future Research Directions in the Fight against Hepatitis C Virus: Perspectives for Screening, Diagnostics of Resistances, and Immunization

Hepatitis C virus (HCV) still represents a major public health threat, with a dramatic burden from both epidemiological and clinical points of view. New generation of direct-acting antiviral agents (DAAs) has been recently introduced in clinical practice promising to cure HCV and to overcome the issues related to the interferon-based therapies. However, the emergence of drug resistance and the suboptimal activity of DAAs therapies against diverse HCV genotypes have been observed, determining treatment failure and hampering an effective control of HCV spread worldwide. Moreover, these treatments remain poorly accessible, particularly in low-income countries. Finally, effective screening strategy is crucial to early identifying and treating all HCV chronically infected patients. For all these reasons, even though new drugs may contribute to impacting HCV spread worldwide a preventive HCV vaccine remains a cornerstone in the road to significantly reduce the HCV spread globally, with the ultimate goal of its eradication. Advances in molecular vaccinology, together with a strong financial, political, and societal support, will enable reaching this fundamental success in the coming years. In this comprehensive review, the state of the art about these major topics in the fight against HCV and the future of research in these fields are discussed.

A systematic review of community based hepatitis C treatment

BACKGROUND

Hepatitis C virus (HCV) treatment uptake globally is low. A barrier to treatment is the necessity to attend specialists, usually in a tertiary hospital. We investigate the literature to assess the effect of providing HCV treatment in the community on treatment uptake and cure.

METHODS

Three databases were searched for studies that contained a comparison between HCV treatment uptake or sustained virologic response (SVR) in a community site and a tertiary site. Treatment was with standard interferon with or without ribavirin, or pegylated interferon and ribavirin. A narrative synthesis was conducted.

RESULTS

Thirteen studies fulfilled the inclusion criteria. Six studies measured treatment uptake; three demonstrated an increase in uptake at the community site, two demonstrated similar rates between sites and one demonstrated decreased uptake at the community site. Nine studies measured SVR; four demonstrated higher SVR rates in the community, four demonstrated similar SVR rates, and one demonstrated inferior SVR rates in the community compared to the tertiary site.

CONCLUSION

The data available supports the efficacy of HCV treatment in the community, and the potential for community based treatment to increase treatment uptake. Whilst further studies are required, these findings highlight the potential benefit of providing community based HCV care - benefits that should be realised as interferon-free therapy become available. (PROSPERO registration number CRD42015025505).

Statewide hepatitis C model of care for rural and remote regions

The evolution of management of hepatitis C virus (HCV) has seen a majority of patients treated being regarded as cured. Despite this development, uptake of treatment remains low in Australia, and this is particularly true in rural and remote areas. The largest state in Australia, Western Australia (WA), covers an area of 2500 km(2). As the rural and remote population of WA is scattered in small areas rather than major centers, poor accessibility to remote areas and lack of adequate of medical and nursing resources pose major problems in providing equity of care to patients with chronic HCV. A statewide hepatitis model of care, established in 2009, has led to an increase in identification and treatment of patients living with HCV. Strategies used to facilitate these changes include telehealth, a nurse practitioner model, and general practitioner shared-care model. The statewide program will be modified to meet the changing needs of patients as all-oral treatment regimens become available, with further emphasis being placed on the role of rural and remote health professionals in identifying patients with HCV and initiating and monitoring treatment.

Use of telemedicine technologies in the management of infectious diseases: a review

Telemedicine technologies are rapidly being integrated into infectious diseases programs with the aim of increasing access to infectious diseases specialty care for isolated populations and reducing costs. We summarize the utility and effectiveness of telemedicine in the evaluation and treatment of infectious diseases patients. The use of telemedicine in the management of acute infectious diseases, chronic hepatitis C, human immunodeficiency virus, and active pulmonary tuberculosis is considered. We recapitulate and evaluate the advantages of telemedicine described in other studies, present challenges to adopting telemedicine, and identify future opportunities for the use of telemedicine within the realm of clinical infectious diseases.