ECHO 1. Appreciate the concept and approach of ECHO in general and - PDF document

Dis isclosures Jordan Feld: • Research: Abbott, Abbvie, Gilead, Janssen, Merck Introduction to o Liv Liver Disea Diseases s & • Consulting: Abbvie, Contravir, Gilead, Merck ECHO Ontar ario Liv Liver Hemant Shah: • Consulting Fees: Abbvie, Gilead, Merck, Intercept, Lupin Hemant Shah MD MScCH Jordan J Feld MD MPH HPTE Toronto Centre for Liver Disease Sandra Rotman Centre for Global Francis Family Liver Clinic Health @hepatoMD Learn arning Obje bjectives ECHO 1. Appreciate the concept and approach of ECHO in general and ECHO Liver in particular (Extension for Community Health Outcomes) 2. Gain a general understanding of the hepatitis C virus and the burden of illness caused by chronic hepatitis C virus infection The father of ECHO Mod Modest Goa oals “At ECHO, our mission is to democratize medical knowledge and get best practice care to underserved people all over the world.” Our goal is to touch the lives of 1 billion people by 2025. Sanjeev Arora 1

Th The Mo Model It wor orks • Compared outcomes in patients treated in rural NM vs UNM • Similar cure rates despite tougher-to-cure pop’n in rural areas • Has spread widely and been replicated throughout the US Mad Made in in Ne New Me Mexi xico The Me Th Methods Project ECHO  Use Technology to leverage scarce resources - Linking PCPs to specialists - Facilitates linkage  Sharing “best practices” to reduce disparities to care Nurses - Allows people to be treated by  Case based learning to master complexity Other care providers people and in Primary Care MDs settings they know  Web-based database to monitor outcomes & trust Perfected in Canada! Arora S, Acad Med. 2007 Feb;82(2): 154-60. Arora NEJM 2011 ECH CHO in in Ca Canada The ECHO Hub Th Hub Team am • First proposed to do ECHO Hepatitis in Canada • Hepatology: Jordan Feld & Hemant Shah - Toronto • Limited interest and no support from MOH • Family Medicine/Addiction: Craig Kuhn - Niagara • Developed HepC Net program – Hemant Shah – similar model to support HCV treatment teams around Ontario • Nursing: Magdalena Kuczynski • 2014 – ECHO Pain • Pharmacist: Ruifen Su • Chronic pain team led by Andrea Furlan • Support from MOH • ECHO Team: Rhonda Mostyn – Project Manager • Highly successful Ralph Fabico – Program Coordinator • 2016 – Add ECHO Hepatitis + Rheumatology…more in Jane Zhao – Research Coordinator the works! Ashley Grilo - Admin Assistant • 2018 – ECHO Hepatitis C becomes ECHO Liver Shamini Martin – Education Coordinator 2

‘Curriculum’ The Sess Th Sessions Date Topic Presenter S1 – 23-Jul-18 Introduction to Liver Disease and ECHO Liver Dr. Jordan Feld S2 – 30-Jul-18 Who is at risk? Natural History, Screening & Diagnosis Dr. Hemant Shah 6-Aug-18 No Session S3 – 13-Aug-18 • ‘Didactic session’ Initial Assessment, Data Gathering Dr. Jordan Feld S4 -20-Aug-18 Cirrhosis: Management of Key Complications Part 1 Dr. Jordan Feld 27-Aug-18 No Session (Summer break) • Liver curriculum – 17 topics 3-Sep-18 No Session (Summer break) Key Areas S5 -10-Sep-18 Cirrhosis: Management of Key Complications Part 2 Dr. Hemant Shah • Hub + ‘guest’ speakers – 20-40 min + discussion S6 – 17-Sep-18 Epidemiology of Hep B & C &NAFLD in Canada Dr. Hemant Shah • Cirrhosis S7 – 24-Sep-18 Hep C: Treatment Decision Making, Readiness and Principles, Ontreatment Dr. Jordan Feld • Case presentations Monitoring • HCV S8 – 1-Oct-18 Hep C: Best Practice Management of Genotype 1 Dr. Hemant Shah 8-Oct-18 No Session • HBV • Community site S9 -15-Oct-18 Hep C: – Best Practice Management of Genotype 2-6 Dr. Jordan Feld • Fatty Liver S10 – 22-Oct-18 Hep C: After Hep C Therapy – Long Term Monitoring & Follow up • Key points and clear question Dr. Hemant Shah S11 – 29-Oct-18 Hep B: What do the tests mean & Vaccination Dr. Hemant Shah • Alcohol • Discussion – community sites + hub S12 – 5-Nov-18 Hep B: Treatment Options (acute & chronic) Dr. Jordan Feld 12-Nov-18 No Session • Collective consensus on best strategies S13 – 19-Nov-18 Hep B: Pregnancy, Children & Immune Suppression Dr. Hemant Shah S14 – 26-Nov-18 Alcoholic liver disease Dr. Jordan Feld • Follow-up of previous cases S15 – 3-Dec-18 Fatty Liver: Diagnosis, Treatment & Management Dr. Jordan Feld Symptom Management – Side effects of medications and resources needed Ruifen Su & Magdalena • Pre + Post questionnaires + survey S16 – 10-Dec-18 for successful treatment Kuczynski Treatment Management – Motivational Interviewing: Engaging patients to go S17 – 17-Dec-18 Richard Yanofsky on and stay on treatment 24-Dec-18 No Session (Christmas) HCV - Hepatitis C HBV - Hepatitis B Af After the he Cu Curr rriculum • Welcome to join any time! Qu Questions ab about • Bring cases or just participate in the discussion ECHO Liver? • With time…the goal is that everyone becomes a local Liver expert but still value in joining the sessions • Updates from meetings • New literature • Challenging cases Con Concern rning trends Trend in cirrhosis deaths by region 1980 to 2010 Intr In tro to to the Liv Liver Mokdad BMC Medicine 2014 3

Why did did we foc ocus on n these se dise disease ses? Sho Should the he big big 3 3 be be the he big big 4? 4? Deaths (millions) in 2013 HCV (0.70) HBV (0.69) A&E (0.06) Viral hepatitis HIV/AIDS Tuberculosis Malaria Mokdad BMC Medicine 2014 Global Burden of Disease Study 2013, Lancet 2015 Moving in in the he wrong dir directio ion Liver is a Synthetic Factory Liver Colorectal Pancreas Lung Male Female Prostate Breast Stomach • Protein production – Albumin/clotting factors • -3 -2 -1 0 1 2 3 Drug detoxification • Bile production – digestion/absorption % change annually Cancer Care Ontario 2015 Many cau Man auses of of liv liver r dise disease … Wha hat do do you call all the hese tests? • Acute • Viral (Hep A-E, CMV, EBV … ) • ALT (Alanine aminotransferase) • Toxin (Drug, alcohol) • AST (Aspartate aminotransferase) • Ischemia (inflow/outflow) • ALP (Alkaline phosphatase ) • Autoimmune (autoimmune hepatitis) • GGT (Gamma-glutamyl transferase) • Chronic • Viral (B, C) • Fatty liver (NAFLD, Alcohol) Liver enzymes  NOT LFTs • Inherited (Hemochromatosis, Wilson, A1AT) More • Autoimmune (AIH, PBC, PSC) important Hep – Hepatitis | CMV - Cytomegalovirus | EBV - Epstein – Barr virus AIH – autoimmune hepatitis | PBC - primary biliary cirrhosis | PSC - primary sclerosing cholangitis 4

Why? Liver Assessment 56 yo man awaiting liver transplant • Liver enzymes are not LFTs ALT 17 • ALT/AST: rate of hepatocellular injury AST 27 • ALP/GGT: indication of cholestasis GGT 43 • Liver function tests ALP 93 • INR/Albumin: liver synthesis “LFTs” are “Normal”!! • Conjugated Bilirubin: transport to caniliculus • Assessment of portal hypertension • Platelets: hypersplenism/portal hypertension Actually – not true – LFTs VERY abnormal INR 2.4 Bilirubin 98 umol/L Albumin 28 g/L INR - International normalized ratio Cirrhosis matters: What we are From the Patient’s Perspective… trying to prevent  Patients feel perfectly fine!!  Almost always entirely asymptomatic …until it’s too late Cirrhosis  Even if they have cirrhosis Esophageal Jaundice HCV/HBV/ Varices NASH Hepatic Liver Fluid Retention Encephalopathy Cancer Ascites Liver disease catches you by Recognizing Cirrhosis surprise Which one has cirrhosis? Obvious Not So Obvious 5