title: Telemedicine Specialty Support Promotes Hepatitis C Treatment by Primary Care Providers in the Department of Veterans Affairs.
abstract: BACKGROUND
  The Department of Veterans Affairs is the largest US provider of hepatitis C treatment. Although antiviral regimens are becoming simpler, hepatitis C antivirals are not typically prescribed by primary care providers. The Veterans Affairs Extension for Community Health Outcomes (VA-ECHO) program was launched to promote primary care-based hepatitis C treatment using videoconferencing-based specialist support. We aimed to assess whether primary care provider participation in VA-ECHO was associated with hepatitis C treatment and sustained virologic response.
  
  
  METHODS
  We identified 4173 primary care providers (n = 152 sites) responsible for 38,753 patients with chronic hepatitis C infection. A total of 6431 patients had a primary care provider participating in VA-ECHO; 32,322 patients had an unexposed primary care provider. Exposure was modeled as a patient-level time-varying covariate. Patients became exposed after primary care provider participation in ≥1 VA-ECHO session. Multivariable Cox proportional hazards frailty modeling assessed the association between VA-ECHO exposure and hepatitis C treatment. Among treated patients, modified Poisson regression assessed the relationship between exposure and sustained virologic response.
  
  
  RESULTS
  After adjustment, exposed patients received significantly higher rates of antiviral treatment compared with unexposed patients (adjusted hazard ratio, 1.20; 95% confidence interval, 1.10-1.32; P <.01). The rate of primary care provider-initiated antiviral medication was 21.4% among treated patients reviewed on VA-ECHO teleconferences compared with 2.5% among unexposed patients (P <.01). No difference in adjusted rates of sustained virologic response was observed for patients with exposed primary care providers (P = .32), with similar crude rates for primary care providers versus specialists.
  
  
  CONCLUSIONS
  National implementation of VA-ECHO was positively associated with hepatitis C treatment initiation by primary care providers, without differences in sustained virologic response.
authors.affiliation: Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash; Department of Medicine, School of Medicine, University of Washington, Seattle; General Medicine Service, VA Puget Sound Health Care System, Seattle, Wash. Electronic address: Lauren.beste@va.gov.
authors.forename: Lauren A
authors.initials: LA
authors.lastname: Beste
authors.affiliation: VA Eastern Colorado Health Care System, Denver; Department of Biostatistics and Informatics, University of Colorado Denver, Aurora.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Glorioso
authors.affiliation: VA Eastern Colorado Health Care System, Denver; Department of Medicine, University of Colorado School of Medicine, Aurora.
authors.forename: P Michael
authors.initials: PM
authors.lastname: Ho
authors.affiliation: Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash; Department of Medicine, School of Medicine, University of Washington, Seattle; Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Wash.
authors.forename: David H
authors.initials: DH
authors.lastname: Au
authors.affiliation: Louis Stokes Cleveland VA Medical Center, Ohio; Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Office of Specialty Care Services, Veterans Health Administration, Washington, DC.
authors.forename: Susan R
authors.initials: SR
authors.lastname: Kirsh
authors.affiliation: Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Todd-Stenberg
authors.affiliation: Portland VA Medical Center, Ore; Department of Medicine, Division of Gastroenterology, Oregon Health & Sciences University, Portland.
authors.forename: Michael F
authors.initials: MF
authors.lastname: Chang
authors.affiliation: Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash; Department of Medicine, School of Medicine, University of Washington, Seattle; Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Wash.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Dominitz
authors.affiliation: Department of Medicine, School of Medicine, University of Washington, Seattle.
authors.forename: Anna E
authors.initials: AE
authors.lastname: Barón
authors.affiliation: Department of Veterans Affairs, Washington, DC; Department of Medicine, George Washington University, DC.
authors.forename: David
authors.initials: D
authors.lastname: Ross
mesh_terms: D000998:Antiviral Agents / Q000627:therapeutic use; D005260:Female; D019698:Hepatitis C, Chronic / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000379:methods / Q000458:organization & administration*; D015397:Program Evaluation; D017216:Telemedicine / Q000379:methods* / Q000458:organization & administration; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs / Q000458:organization & administration*
chemical_list: D000998:Antiviral Agents
keywords: Antiviral therapy; Project ECHO; Telemedicine