Evaluation of treatment access and scope of a multistate hepatitis C virus Extension for Community Healthcare Outcomes telehealth service in the US Indian Health System, 2017-2021

Abstract

Purpose: American Indians/Alaska Native (AI/AN) persons are disproportionately affected by hepatitis C virus (HCV). The Northwest Portland Area Indian Health Board Indian Country Extension for Community Healthcare Outcomes (ECHO) telehealth clinic supports primary care providers (PCPs) in treating HCV. We evaluated the extent to which Indian Country ECHO increases access to HCV treatment and holistically serves AI/AN patients.

Methods: We conducted a retrospective descriptive analysis of Indian Country ECHO treatment recommendations from 2017 to 2021. Recommendations were classified into the following categories: HCV treatment with direct-acting antiviral medication, prevention, substance use disorder treatment, lab or imaging orders, pharmacological considerations, behavior changes, other, and referral. Subanalysis of treatment recommendations was completed for patients with cirrhosis.

Findings: Of the 776 patients from 77 Indian Health System facilities who presented at Indian Country ECHO, 718 (93%) received treatment recommendations. Most patients (93%) received recommendations for HCV treatment by their PCP; only 3% received a recommendation for referral to a hepatologist or liver transplant center for additional care. Most patients received at least 1 recommendation beyond the scope of HCV treatment provision. Cirrhosis criteria were met by 8% of patients, of which 80% received recommendations for HCV treatment by their PCP and 25% received recommendations for referral to a specialist for additional care.

Conclusions: Most patients presented at the Indian Country ECHO received recommendations for HCV treatment by their PCP, along with recommendations beyond the scope of HCV. Indian Country ECHO telehealth clinic provides comprehensive recommendations to effectively integrate evidence-based HCV treatment with holistic care at the primary care level.

Keywords: American Indian/Alaska Native; Extension for Community Healthcare Outcomes (ECHO); access to care; hepatitis C; telehealth.

FIGURE 1

Histogram of the number of treatment recommendation per case. Most patients (95%) received at least 1 treatment recommendation that did not directly pertain to HCV treatment. Over half (56%) of the patients received between 3 and 6 treatment recommendations.

FIGURE 2

Distribution of patients meeting criteria for cirrhosis versus no cirrhosis based on Fib-4 score and platelet count. A small portion of patients (8%) met the study criteria for cirrhosis, while 40% had indeterminant fibrosis, and 52% had no evidence of fibrosis. Fibrosis-4 cutoffs were based on the previous literature showing that fibrosis-4 scores less than 1.45 had a negative predictive value of 90% to exclude advanced fibrosis and fibrosis-4 scores greater than 3.25 had a 97% specificity for advanced fibrosis. Platelet counts below 150 (x10⁹/L) are a known complication of cirrhosis and sign of decreased liver function. Patients were also considered to have cirrhosis if imaging, FibroSure^®, or FibroTest^® results indicated cirrhosis.