ACG 2006

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• Sanjeev Arora M.D., FACG
• Professor of Medicine
• Executive Vice Chairman
• Department of Medicine
• University of New Mexico School of Medicine

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MISSION
MISSION
The mission of Project ECHO is to develop the
capacity to safely and effectively treat chronic,
common and complex diseases in rural and
underserved areas and to monitor outcomes.
Supported by Agency for Health Research and
Quality grant 1 UC1 HS015135-03 and New Mexico
Legislature
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Rural New Mexico
RURAL NEW MEXICO
Underserved Area for Healthcare Services

• 32 of 33 New Mexico counties are listed as
  Medically Underserved Areas (MUAs)
• 14 counties designated as Health Professional
  Shortage Areas (HPSAs)

• 121,356 sq miles
• 1.83 million people
• 42.1 Hispanic
• 9.5 Native American
• 17.7 poverty rate compared to 11.7 nationally
• gt22 lack health insurance

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HEALTHCARE IN NEW MEXICO
HEALTH CARE IN NEW MEXICO

• 20 practice in rural or frontier areas

New Mexico Physician Survey 2001
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HEPATITIS C IN NEW MEXICO
HEPATITIS C IN NEW MEXICO

• Estimated number is greater than 32,000
• Less than 5 have been treated
• Without treatment 8,000 patients will develop
  cirrhosis between 2010-2015 with several thousand
  deaths
• 1978 prisoners diagnosed in corrections system
  (expected number is greater than 2400) - None
  treated
• Highest rate of chronic liver disease/cirrhosis
  deaths in the nation

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GOALS
GOALS

• Develop capacity to safely and effectively treat
  Hepatitis C in all areas of New Mexico and to
  monitor outcomes
• Develop a model to treat complex diseases in
  rural locations and developing countries

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PROJECT ECHO
PARTNERS

• University of New Mexico School of Medicine Dept
  of Medicine and Telemedicine
• NM Department of Corrections
• NM State Health Department
• Indian Health Service
• Community Providers with interest in Hepatitis C
  and Primary Care Association

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METHOD
METHOD

• Use Technology (telemedicine and internet) to
  leverage scarce healthcare resources
• Disease Management Model focused on improving
  outcomes by reducing variation in processes of
  care and sharing best practices
• Case based learning Co-management of patients
  with UNMHSC specialists
• Centralized database HIPAA compliant to monitor
  outcomes

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STEPS
STEPS

• Train providers, nurses, pharmacists, educators
  in Hepatitis C
• Install protocols and software on site
• Conduct telemedicine clinics Knowledge
  Network
• Initiate co-management Learning loops
• Collect data and monitor outcomes centrally
• Assess cost and effectiveness of programs

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BENEFITS TO RURAL PROVIDERS
COMMUNITY PARTNERS

• No cost CMEs and Nursing CEUs
• Professional interaction with colleagues with
  similar
• interest
• Less isolation with improved recruitment and
  retention
• A mix of work and learning
• Obtain HCV certification
• Access to specialty consultation with GI,
  hepatology,
• psychiatry, infectious diseases, addiction
  specialist,
• pharmacist, patient educator

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DISEASE SELECTION
DISEASE SELECTION

• Common diseases
• Management is complex
• Evolving treatments and medicines
• High societal impact (health and economic)
• Serious outcomes of untreated disease
• Improved outcomes with disease management

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BUILDING BRIDGES
HEALTHCARE IN NEW MEXICO
BUILDING BRIDGES
PARETTOS PRINCIPLE
State Health Dept
Community Health Centers
Private Practice
UNM HSC
Hepatitis C
HIV
Hepatitis B
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KNOWLEDGE IMPORTANT - NOT TITLE
KNOWLEDGE IMPORTANT - NOT TITLE
HEALTHCARE IN NEW MEXICO
Use Existing Community Providers
Primary Care
Nurse Practitioners
Specialists
Pharmacists
Hepatitis C
HIV
Hepatitis B
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COMMUNITY HEALTH EXTENSION AGENT
COMMUNITY HEALTH EXTENSION AGENT
CHEA
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ROLE OF KNOWLEDGE NETWORK
A KNOWLEDGE NETWORK IS NEEDED
Increasing Gap
Medical Knowledge
Learning Capacity
Time
Expanding the Definition of Underserved
Population
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KNOWLEDGE MODEL
KNOWLEDGE MODEL

• Patient specific knowledge on demand
• Access to Case-Specific Information like Access
  to Electricity

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PROJECT ECHO RURAL SITES
8/1/06
Colfax
Rio Arriba
San Juan
Taos
Union
Los Alamos
Mora
Harding
McKinley
Sandoval
Santa Fe
San Miguel
Quay
Bernalillo
Cibola
Guadalupe
Valencia
Torrance
Curry
De Baca
Roosevelt
Socorro
Catron
Lincoln
Chaves
Sierra
Lea
Grant
Otero
Eddy
Dona Ana
Luna
Federally Qualified Health Centers ( FQHC )
Hidalgo
Department of Corrections
Indian Health Service
( IHS )
Department of Health ( DOH )

Pending FQHC IHS

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• How well has model worked?
• 173 HCV Telehealth Clinics have been conducted
• 3016 patients managed
• CMEs/CEs issued
• 2917 CME/CE hours issued to ECHO providers at
• no-cost.
• 205 hours of HCV Training conducted at rural
  sites
• 6 Million Dollars of No Cost Drug Obtained
• National Recognition as Model for Complex Disease
  Care

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Robert Wood Johnson Changemaker Award
KNOWLEDGE MODEL

• Applications sought for Disruptive Innovations in
  Healthcare New Models that would change
  healthcare nationally and globally
• 307 Applications from 27 countries
• 9 finalists selected by a panel of Judges
• Project ECHO selected a winner by worldwide
  online voting

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VISION FOR THE FUTURE
VISION FOR THE FUTURE
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Perceived Benefits to Providersscale 1 none
or no skill at all 7 expert-can teach others
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Perceived Benefits to Providers scale 1 none
or no skill at all 7 expert-can teach others
Cronbachs alpha for the BEFORE ratings 0.93
and Cronbachs alpha for the TODAY ratings 0.90
indicating a high degree of consistency in the
ratings on the 9 items
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Project ECHO Annual Meeting Survey
September 23, 2006
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Objectives-Disease Outcomes

• To show that hepatitis C treatment delivered
  through Project ECHO is as safe and effective as
  care given at the University of New Mexico
• To show that Project ECHO improves delivery of
  hepatitis C care to minority populations
• To compare treatment outcomes for minority and
  non-Hispanic white subjects

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Methods

• Study design
• Prospective cohort study
• Site effect adjusted for patient covariates
• Study sites
• Project ECHO
• 14 community clinics
• NM Department of Corrections
• University of New Mexico Liver Clinic
• Subjects referred by their primary care providers

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Interim Results
Of the preceding row
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ECHO Sites Serve Minorities
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Outcomes by Site
Excludes subjects stopping treatment for other
reasons
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Outcomes by Minority Status
Excludes subjects stopping treatment for other
reasons
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Factors Affecting Response
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Factors Affecting SAE
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Factors Affecting SAE
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Disease Outcome Conclusions

• Project ECHO provides hepatitis C treatment that
  is as safe as care delivered at UNM
• Preliminary data suggests that Project ECHO
  delivers hepatitis C treatment that is just as
  effective
• Project ECHO treats a larger proportion of
  minorities than UNM
• The outcomes of treatment for minority and
  non-Hispanic white subjects are similar

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Use of telemedicine, best practice protocols,
co-management of patients with case based
learning (the ECHO model) is a robust method to
to safely and effectively treat chronic, common
and complex diseases in rural and underserved
areas and to monitor outcomes.
Supported by Agency for Health Research and
Quality grant 1 UC1 HS015135-03 and New Mexico
Legislature