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

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 HS and New Mexico Legislature MISSION

Underserved Area for Healthcare Services Rural New Mexico 121,356 sq miles 1.83 million people 42.1% Hispanic 9.5% Native American 17.7% poverty rate compared to 11.7% nationally >22% lack health insurance 32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUA’s) 14 counties designated as Health Professional Shortage Areas (HPSA’s) RURAL NEW MEXICO

HEALTHCARE IN NEW MEXICO ~20% practice in rural or frontier areas New Mexico Physician Survey 2001 HEALTH CARE 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 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 HEPATITIS C IN NEW MEXICO

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 GOALS

PROJECT ECHO ~ 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 PARTNERS

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 METHOD

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 STEPS

COMMUNITY PARTNERS ~ No cost CME’s and Nursing CEU’s ~ 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 BENEFITS TO RURAL PROVIDERS

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 DISEASE SELECTION

HEALTHCARE IN NEW MEXICO UNM HSC State Health Dept Private Practice Community Health Centers Hepatitis C HIV Hepatitis B BUILDING BRIDGES PARETTO’S PRINCIPLE

HEALTHCARE IN NEW MEXICO Specialists Primary Care Pharmacists Nurse Practitioners Hepatitis C HIV Hepatitis B KNOWLEDGE IMPORTANT - NOT TITLE Use Existing Community Providers KNOWLEDGE IMPORTANT - NOT TITLE

COMMUNITY HEALTH EXTENSION AGENT University of New Mexico State Department of Health Community Providers CHEA COMMUNITY HEALTH EXTENSION AGENT

ROLE OF KNOWLEDGE NETWORK Learning Capacity Time Increasing Gap “Expanding the Definition of Underserved Population” A KNOWLEDGE NETWORK IS NEEDED

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

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

How well has model worked? 173 HCV Telehealth Clinics have been conducted 3016 patients managed CME’s/CE’s 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

KNOWLEDGE MODEL Robert Wood Johnson Changemaker Award 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

VISION FOR THE FUTURE MonTueWedThursFri 8-10 AM Hepatitis C Cardiac Risk Reduction Clinic AsthmaPrevention of Teenage Suicide Mental Health Disorders AM Rhuema- tology Neurology Substance Abuse GeriatricsEndocrine 2-4 PM GastroCardiologyHeart Failure Childhood Obesity Orthopedics 28 VISION FOR THE FUTURE

Perceived Benefits to Providers scale: 1 = none or no skill at all 7= expert-can teach others N=19 BEFORE Participation MEAN (SD) TODAY MEAN (SD) Paired Difference MEAN (SD) p-value 1. Ability to identify suitable candidates for treatment for HCV. 3.2 (1.3) 5.7 (0.8) 2.5 (1.0)< Ability to assess severity of liver disease in patients with Hepatitis C. 3.7 (1.0) 5.6 (0.8) 1.9 (0.9) Ability to treat HCV patients and manage side effects. 2.3 (1.3) 5.5 (0.8) 3.2 (1.5)<0.0001

Perceived Benefits to Providers scale: 1 = none or no skill at all 7= expert-can teach others BEFORE Participation MEAN (SD) TODAY MEAN (SD) Paired Difference MEAN (SD) p-value 4. Ability to assess and manage psychiatric co- morbidities in patients with Hepatitis C. 2.7 (1.3) 5.3 (0.9) 2.5 (1.4) Serve as local consultant within my clinic and in my area for HCV questions and issues. 2.8 (1.2) 6.0 (0.9) 3.2 (1.3)< Overall Competence (average of 9 items above) 3.2* (1.0) 5.7* (0.6) 2.5 (1.0)< Cronbach’s alpha for the BEFORE ratings = 0.93 and Cronbach’s alpha for the TODAY ratings = 0.90 indicating a high degree of consistency in the ratings on the 9 items

Project ECHO Annual Meeting Survey Mean Score Range 1-5 Project ECHO has diminished my professional isolation 4.3 My participation in Project ECHO has enhanced my professional satisfaction 4.8 Collaboration among agencies in Project ECHO is a benefit to my clinic 4.9 Project ECHO has expanded access to HCV treatment for patients in our community 4.9 Access to in general to specialist expertise and consultation is a major area of need for you and your clinic 4.9 Access to HCV specialist expertise and consultation is a major are of need for you and your clinic 4.9 September 23, 2006

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

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

Interim Results GroupNumberPercent * All patients488 Enrolled to trial % Treatment ended % Full course of treatment % 6-month follow-up7858.2% Sustained viral response6785.9% * Of the preceding row

ECHO Sites Serve Minorities ECHOUNMP-value Minorities66.5%49.4%0.010 Hispanics57.4%36.5%0.002

Outcomes by Site ECHOUNMP-value Non-response21.9%15.3%NS SAE*8.2%25.4%0.003 * Excludes subjects stopping treatment for other reasons

Outcomes by Minority Status MinorityNHWP-value Non-response22.8%14.7%NS SAE*15.1%14.9%NS * Excludes subjects stopping treatment for other reasons

Factors Affecting Response VariableNon-response (n=47) All others (n=193) P-value Genotype 185.1%51.8%<0.001 SGOT85 ± 5466 ± Uric Acid6.7 ± ± Platelets168 ± ± MCV92 ± 591 ±

Factors Affecting SAE VariableSAE (n=24) Rx Completed (n=136) P-value Age (years)48.9 ± ± Women70.8%39.0%0.004 High school45.8%69.1%0.027 IV drug use33.3%57.4%0.030 Liver disease37.5%15.4%0.011 Depression58.3%33.8%0.022

Factors Affecting SAE VariableSAE (n=24) Rx Completed (n=136) P-value Albumin3.87 ± ± Creatinine0.78 ± ± Hgb14.9 ± ± Hct42.6 ± ± RBC4.63 ± ±

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

Supported by Agency for Health Research and Quality grant 1 UC1 HS and New Mexico Legislature 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.