Current Hepatology Reports

, Volume 15, Issue 3, pp 178–186 | Cite as

Project ECHO: a Revolutionary Approach to Expanding Access to Modern Treatments for Hepatitis C

  • Karla Thornton
  • Paulina Deming
  • Bruce Struminger
  • Miranda Sedillo
  • Eric Castillo
  • Miriam Komaromy
  • Sarah Zalud-Cerrato
  • Sanjeev Arora
Hepatitis C (J Ahn, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Hepatitis C


Despite the introduction of direct-acting antivirals which simplified treatment and significantly increased cure rates, hepatitis C virus (HCV) treatment barriers persist. The number of HCV specialists is limited, particularly in rural and medically underserved areas, and patients often do not have access to care and treatment. Project ECHO was developed to increase the number of patients optimally treated for HCV through their local primary care clinics. Since its inception, the ECHO model has been used to improve HCV access across the USA and globally. Project ECHO and the ECHO model represent a revolutionary approach to expanding access to treatment for HCV.


Hepatitis C Project ECHO Underserved populations Prison health care Collaborative learning models Telementoring 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Edlin BR, Eckhardt BJ, Shu MA, Holmberg SD, Swan T. Toward a more accurate estimate of the prevalence of hepatitis C in the United States. Hepatology. 2015 Nov; 62(5):1353–63.Google Scholar
  2. 2.••
    Ly KN, Hughes EM, Jiles RB, et al. Rising mortality associated with hepatitis C virus in the United States, 2003–2013. Clin Infect Dis. 2016. doi:10.1093/cid/ciw111. Important study showing that mortality from hepatitis C in the USA has surpassed mortality from all other notifiable infectious diseases.
  3. 3.
    Ryerson AB, Eheman CR, Altekruse SF, et al. Annual Report to the Nation on the Status of Cancer, 1975–2012, featuring the increasing incidence of liver cancer. Cancer. 2016. doi:10.1002/cncr.29936.PubMedGoogle Scholar
  4. 4.
    van der Meer AJ, Veldt BJ, Feld JJ, et al. Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis. JAMA. 2012;24:2584–93.CrossRefGoogle Scholar
  5. 5.
    Ryerson AB, Eheman CR, Altekruse SF, Ward JW, Jemal A, Sherman RL, et al. Annual Report to the Nation on the Status of Cancer, 1975–2012, featuring the increasing incidence of liver cancer. Cancer. 2016;122(9):1312–37.Google Scholar
  6. 6.
    Holmberg SD, Spradling PR, Moorman AC, et al. Hepatitis C in the United States. N Engl J Med. 2013;20:1859–61.CrossRefGoogle Scholar
  7. 7.
    Denniston MM, Klevens RM, McQuillan GM, et al. Awareness of infection, knowledge of hepatitis C, and medical follow‐up among individuals testing positive for hepatitis C: National Health and Nutrition Examination Survey 2001–2008. Hepatology. 2012;55(6):1652–61.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Smith BD, Morgan RL, Beckett GA, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965. MMWR Recomm Rep. 2012;61(RR-4):1–32.PubMedGoogle Scholar
  9. 9.
    U.S. Preventive Services Task Force. Final Update Summary: hepatitis C: Screening. U.S. Preventive Services Task Force. July 2015.
  10. 10.
    Hill A, Cooke G. Hepatitis C can be cured globally, but at what cost. Science. 2014;345(6193):141–2.CrossRefPubMedGoogle Scholar
  11. 11.
    Arora S, Thornton K, Komaromy M, et al. Demonopolizing medical knowledge. Acad Med. 2014;89(1):30–2.CrossRefPubMedGoogle Scholar
  12. 12.
    U.S. Health Resources and Services Administration, HRSA medically underserved areas find. U.S. Health Resources and Services Administration. Data as of 4/7/2016. Available from:
  13. 13.
    Murphy SL, Xu J, Kochanek KD, Bastian BA. Deaths: final data for 2013. Natl Vital Stat Rep. 2016;64(2):1–119.PubMedGoogle Scholar
  14. 14.
    Arora S, Thornton K, Murata G, Deming P, Kalishman S, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364(23):2199–207.CrossRefPubMedGoogle Scholar
  15. 15.••
    Chhatwal J, Wang X, Ayer T, et. al. Hepatitis C disease burden in the United States in the era of oral direct‐acting antivirals. Hepatology. 2016. doi:10.1002/hep.28571 Describes an important mathematical model, which demonstrates that increased hepatitis C treatment capacity is essential in decreasing mortality and morbidity from hepatitis C in the era of direct-acting antivirals.
  16. 16.
    Nafisi S. Primary care physicians utilizing the ECHO model equally effective as subspecialist treating HCV using DAA-only regimens: results of the ECHO model. Poster presented at the European Association for the Study of the Liver Annual Meeting 2016 April 13–17, 2016 in Barcelona Spain.Google Scholar
  17. 17.
    He T, Li K, Roberts MS, Spaulding AC, Ayer T, Grefenstette JJ, Chhatwal, J. Prevention of hepatitis C by screening and treatment in US prisons. Ann Intern Med. 2015;164(2):84–92.Google Scholar
  18. 18.
    Varan AK, Mercer DW, Stein MS, Spaulding AC. Hepatitis C seroprevalence among prison inmates since 2001: still high but declining. Public Health Rep. 2014;129(2):187–95.Google Scholar
  19. 19.
    Indian Health Service. HIS 2015 Year Profile.
  20. 20.
    Surveillance for viral hepatitis—United States, 2011, (2014, accessed 27 March 2015).
  21. 21.
    Arora S, Kalishman S, Thornton K, et al. Expanding access to hepatitis C virus treatment—Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52(3):1123–33.CrossRefGoogle Scholar
  22. 22.
    Livingston SE, Townshend-Bulson LJ, Bruden DL, et al. Treatment eligibility in Alaska native and American Indian persons with hepatitis C virus infection. Int J CircumpolarHealth. 2012;71:1–7.Google Scholar
  23. 23.
    Reilley B, Leston J, Redd JT, et al. Lack of access to treatment as a barrier to HCV screening: a facility-based assessment in the Indian health service. J Public Health Manag Pract. 2014;20(4):420–3.CrossRefPubMedGoogle Scholar
  24. 24.
    Pindyck T, Kalishman S, Flatow-Trujillo L, Thornton K. Treating hepatitis C in American Indians/Alaskan Natives: A survey of Project ECHO®(Extension for Community Healthcare Outcomes) utilization by Indian Health Service providers. SAGE Open Med. 2015;3:2050312115612805.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Thornton K et al. Response guided therapy is not dead: low sustained virologic response (SVR) rates in patients with detectable hepatitis C virus (HCV) at week 4 of treatment with sofosbuvir (SOF)-containing Regimens” 50th Annual Meeting of the European Association for the Study of Liver International Liver Congress, Vienna, Austria, April 22–26, 2015. Poster Presentation.Google Scholar
  26. 26.
    Thornton K, et al. Low Sustained Virologic Response (SVR) Rates in Genotype (GT) 2 and 3 Patients with Quantifiable Hepatitis C Virus (HCV) at Week 4 of Treatment with Sofosbuvir (SOF)-containing Regimens. 51st Annual Meeting of the European Association for the Study of Liver International Liver Congress, Barcelona Spain, April 13–17, 2016. Poster Presentation.Google Scholar
  27. 27.
    Thornton K, et al. Is response guided therapy dead? Low cure rates in patients with detectable hepatitis C virus at week 4 of treatment? Accepted for publication in Hepatology International 2016;20:1–8.Google Scholar
  28. 28.
    Hirnschall G. Towards the Elimination of Hepatitis B and C by 2030 The draft WHO Global Health Strategy. Glasgow: World Hepatitis Summit; 2015. p. 2–5.Google Scholar
  29. 29.
    National Academies of Sciences, Engineering, and Medicine. Eliminating the public health problem of hepatitis B and C in the United States: Phase one report. Washington, DC: The National Academies Press; 2016.Google Scholar
  30. 30.
    Stvilia K, Tsertsvadze T, Sharvadze L, et al. Prevalence of hepatitis C, HIV, and risk behaviors for blood-borne infections: a population-based survey of the adult population of T’bilisi, Republic of Georgia. J Urban Health. 2006;83:289–98.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Mitruka K, Tsertsvadez T, Butsashvili M, Gamkrelidze A, Sabelashvili P, Adamia E. Launch of a Nationwide Hepatitis C Elimination Program—Georgia, MMWR Morb Mortal Wkly Rep. 2015;64(28):753–57.Google Scholar
  32. 32.
    Arora S et al. Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care. Health Aff. 2011;30(6):1176–84.CrossRefGoogle Scholar
  33. 33.
    Bankhurst A et al. Expanding access in rheumatology specialty care in new mexico via an innovative community outreach program. Arthritis Rheumatism. 2012;64:10.Google Scholar
  34. 34.
    Catic A, Mattison M, Lipsitz L. ECHO-AGE: a video-consultation program to bring geriatric expertise to long-term care. J Am Geriatr Soc. 2013;61:111.CrossRefGoogle Scholar
  35. 35.
    Catic A et al. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc. 2014;15(12):938–42.CrossRefPubMedGoogle Scholar
  36. 36.
    Colleran K et al. Building capacity to reduce disparities in diabetes training community health workers using an integrated distance learning model. Diabetes Educ. 2012;38(3):386–96.CrossRefPubMedGoogle Scholar
  37. 37.
    Cordasco KM et al. VHA’S comprehensive women’s health SCAN-ECHO program: lessons learned. J Gen Intern Med. 2014;29:233.Google Scholar
  38. 38.
    Deming P et al. Project ECHO: a novel model for clinical pharmacists in a multidisciplinary Telehealth care network for rural and underserved communities. Pharmacotherapy. 2013;33:10.Google Scholar
  39. 39.
    Davis R, et al. Air force diabetes center of excellence project ECHO: successful telemedicine with a global reach diabetes. Amer Diabetes Assoc. 2015;64:A197–A197.Google Scholar
  40. 40.
    Dubin RE, et al. ECHO Ontario Chronic Pain & Opioid Stewardship: providing access and building capacity for primary care providers in underserviced, rural, and remote communities. Studies in Health Technology and Informatics. 209 2014: 15–22Google Scholar
  41. 41.
    Frank J, et al. Evaluation of a telementoring intervention for pain management in the Veterans Health Administration. Pain Med. 2015;16(6):1090–100.Google Scholar
  42. 42.
    Gordon SE, et al. Project ECHO-AGE and nursing home quality of care. J Am Med Dir Assoc. 2015;16(3):B27–8.Google Scholar
  43. 43.
    Harkins M et al. Project ECHO: Improving asthma care in New Mexico with telehealth technology. CHEST J. 2011;140(4):861A.CrossRefGoogle Scholar
  44. 44.
    Ho M, et al. The VA’s specialty care transformational initiatives to improve access and delivery of specialty care. J Gen Intern Med. 2013;28:S447–8.Google Scholar
  45. 45.
    Katzman JG et al. UNM ECHO-pain and headache program. Headache. 2012;52:5.Google Scholar
  46. 46.
    Katzman JG. Making connections: using telehealth to improve the diagnosis and treatment of complex regional pain syndrome, an underrecognized neuroinflammatory disorder. J Neuroimmune Pharmacol. 2013;8(3):489–93.CrossRefPubMedGoogle Scholar
  47. 47.
    Katzman JG et al. Innovative telementoring for pain management: project ECHO pain. J Contin Educ Health Prof. 2014;34(1):68–75.CrossRefPubMedGoogle Scholar
  48. 48.
    Kauth MR et al. Teleconsultation and training of VHA providers on transgender care: implementation of a multisite hub system. Telemed E-Health. 2015;21(12):1012–8.CrossRefGoogle Scholar
  49. 49.
    Khatri K, Haddad M, Anderson D. Project ECHO: replicating a novel model to enhance access to hepatitis C care in a community health center. J Health Care Poor Underserved. 2013;24(2):850–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Knoefel J, Herman C. Dementia care training for primary care providers: Project ECHO™. Neurol Suppl. 2015;84(184):P6–182.Google Scholar
  51. 51.
    Marr L, Neale D. Project ECHO: bringing palliative care consultation to rural New Mexico through a novel telemedicine format. J Pain Symptom Manag. 2012;243(2):448–9.CrossRefGoogle Scholar
  52. 52.•
    Mitruka K et al. Expanding primary care capacity to treat hepatitis C virus infection through an evidence-based care model: Arizona and Utah, 2012–2014. MMWR Morb Mortal Wkly. 2014;63:393–8. One of the first published articles demonstrating the efficacy of the ECHO model for hepatitis C in a locale other than New Mexico.Google Scholar
  53. 53.
    Moore A, Manch R. Synchronous cohorts: a novel variation to the Project ECHO approach to hepatitis C treatment. Hepatology. 2013;58:111.Google Scholar
  54. 54.
    Salgia RJ et al. The educational impact of the specialty care access network–extension of community healthcare outcomes program. Telemed E-Health. 2014;20(11):1004–8.CrossRefGoogle Scholar
  55. 55.
    Scott JD et al. Project ECHO: a model for complex, chronic care in the Pacific Northwest region of the United States. J Telemed Telecare. 2012;18(8):481–4.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Socolovsky C et al. Evaluating the Role of Key Learning Theories in ECHO: A Telehealth Educational Program for Primary Care Providers Progress in community health partnerships: research, education, and action. 2013. p. 361–8.Google Scholar
  57. 57.
    Watts SA, et al. Improved glycemic control in veterans with poorly controlled diabetes mellitus using a Specialty Care Access Network-Extension for Community Healthcare Outcomes model at primary care clinics. J Telemed Telecare. 2015;22(4):221–4.Google Scholar
  58. 58.
    Wong JB, et al. Cost-effectiveness of hepatitis C treatment by primary care providers supported by the Extension for Community Healthcare Outcomes (ECHO) model. Hepatology. 2013;58:330A–330A.Google Scholar
  59. 59.
    Su GL, et al. Implementation of the first Department of Veterans Affairs Specialty Care Access Network-Extension of Community Healthcare Outcomes (SCAN-ECHO) program for chronic liver disease. Hepatology. 2012;56:259A–60A.Google Scholar
  60. 60.
    Lotvin A, Shrank W, Chang A. Harvoni® utilization in the weeks after launch: patterns and implications. 2014.Google Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Karla Thornton
    • 1
    • 2
    • 3
  • Paulina Deming
    • 3
    • 4
  • Bruce Struminger
    • 1
    • 2
    • 3
  • Miranda Sedillo
    • 3
  • Eric Castillo
    • 3
  • Miriam Komaromy
    • 2
    • 3
    • 5
  • Sarah Zalud-Cerrato
    • 3
  • Sanjeev Arora
    • 2
    • 3
    • 6
  1. 1.Division of Infectious DiseasesUniversity of New Mexico Health Sciences CenterAlbuquerqueUSA
  2. 2.Department of Internal MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueUSA
  3. 3.ECHO InstituteUniversity of New Mexico Health Sciences CenterAlbuquerqueUSA
  4. 4.College of PharmacyUniversity of New Mexico Health Sciences CenterAlbuquerqueUSA
  5. 5.Division of General Internal MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueUSA
  6. 6.Division of Gastroenterology and HepatologyUniversity of New Mexico Health Sciences CenterAlbuquerqueUSA

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