- Telemedicine program patients taking direct-acting antiviral drugs had a comparable cure rate (95%) to patients seen at the outpatient clinic
- Community “Fibroscan blitzes” increased the uptake of fibrosis assessments
- The telemedicine program successfully provided care to people with hepatitis C living in remote communities
The introduction of new oral direct-acting antiviral drugs (DAAs) has simplified the treatment and cure of hepatitis C. However, people living in rural and remote areas often have limited access to hepatitis C care and treatment because they do not have easy access to centres that provide care and treatment services.
The Ottawa Hospital and Regional Viral Hepatitis Program’s Telemedicine Program was developed to reduce barriers to specialist hepatitis care for people with hepatitis C living in rural areas of Eastern Ontario through the Ontario Telemedicine Network (OTN).
A study compared clinical outcomes between patients in the Telemedicine Program (TM) and the Ottawa Hospital Viral Hepatitis Outpatient Clinic (non-TM). The researchers found that the Telemedicine Program was successful at providing care and treatment to patients with hepatitis C who live in remote communities. The new era of DAA treatment for hepatitis C has found increasing numbers of TM patients initiating treatment with equivalent cure rates between TM and non-TM patients.
The study
Using patient charts and electronic medical records in the Ottawa Hospital Viral Hepatitis Clinic database, researchers conducted an analysis of patients with chronic hepatitis C infection who were seen at least once between January 2012 and August 2016. Non-TM patients were seen at the Ottawa Hospital outpatient clinic. TM patients used the OTN video and audio system for the majority of their clinic visits. In total, 157 TM and 1,130 non-TM patients were included in this study.
The researchers compared clinical and socio-economic characteristics of the two groups. Each group was assessed for the following treatment outcomes:
- pre-treatment access to biopsy
- Fibroscan to measure stage of fibrosis
- initiation and type of hepatitis C treatment
- successful treatment – achieved a cure, with a sustained virological response at 12 weeks (SVR12). Only the most recent treatment outcome was considered in those who had undergone multiple hepatitis C treatments.
Since the study was conducted between 2012 and 2016, treatments included both interferon-ribavirin and DAAs. New DAA treatments cause far fewer side effects, need to be taken for a shorter duration and are more effective than treatment with interferon-ribavirin.
Results
People in both groups had broadly similar characteristics overall. They were of similar age (average 49 years), gender (64% male) and fibrosis stage (24% had cirrhosis).
There were some differences between the two groups. Compared to non-TM patients, TM patients were more likely to have a history of injection drug use (70% vs. 55%), excess alcohol use (69% vs. 57%) and incarceration (47% vs. 36%). They were also more likely to be Indigenous (7% vs. 2%) and have genotype 3 infection (26% vs. 16%).
Compared to TM patients, non-TM patients had a longer duration of hepatitis C infection (27 years vs. 21 years) and were more likely to have HIV co-infection (7% vs. 1%).
Hepatitis C outcomes
Measurement of fibrosis:
- TM patients were less likely than non-TM patients to have undergone biopsy (16% vs. 39%).
- With the introduction of a travelling Fibroscan assessment, both groups became equally likely to have undergone Fibroscan assessment (TM: 59%; non-TM: 62%).
Treatment:
- TM patients were less likely than non-TM patients to have started interferon-ribavirin therapy (5% vs. 20%).
- With combined interferon-ribavirin/DAA treatment, only 27% of TM patients started treatment compared to 54% of non-TM patients.
- With the introduction of DAA-only treatments, the gap between the two groups started to close, with 22% of TM patients starting treatment compared to 34% of non-TM patients.
Cure achieved:
- With DAA-only treatments, the cure rate was similar in both groups (TM: 95%; non-TM: 95%).
- There was reduced likelihood of therapeutic success if patients were Indigenous or had genotype 3 infection.
Telemedicine successfully provides care
The results of this study show that telemedicine programs can successfully provide care and achieve a cure in hepatitis C patients who live in remote communities, especially in the new DAA treatment era. This includes patients traditionally thought to have barriers to successful treatment, such as substance use and a history of imprisonment.
To measure the degree of liver inflammation and fibrosis, either a biopsy or Fibroscan can be performed. This study found that fewer patients in rural populations had liver biopsies because of the need to travel to Ottawa to have the procedure done. However, the introduction of “Fibroscan blitzes”—in which the TM team takes Fibroscan equipment to smaller communities where 15 to 30 patients can have fibrosis assessments at one time—has improved the uptake of fibrosis assessment. This has removed one of the barriers to care in this population.
The TM program reached a higher proportion of Indigenous patients than the non-TM clinic but the cure rate with DAAs was lower for this population. This suggests that more needs to be done for Indigenous populations. Possible methods of improving engagement include the use of Indigenous peer navigators to help with hepatitis C education and adherence and also the introduction of hepatitis C education and delivery of care think tanks with members of the Indigenous community.
Resource
Ontario Hepatitis C Team: The Ottawa Hospital and Regional Hepatitis Program – The Programming Connection
—Zak Knowles
REFERENCE
Cooper CL, Hatashita H, Corsi DJ, et al. Direct-acting antiviral therapy outcomes in Canadian chronic hepatitis C telemedicine patients. Annals of Hepatology. 2017;16(6):874–880. Available from: https://publisherspanel.com/api/files/view/213830.pdf