Education Columns

Crystal Zhou, PharmD, Andrea Jochim, MD, PhD, Christopher Behrens, MD Alvin Goo, PharmD, and Ying Zhang, MD, MPH, University of Washington

Introduction
Through Project ECHO (Extension for Community Healthcare Outcomes) and other primary care implementation projects, studies have shown that treatment of hepatitis C by primary care clinicians has been both safe and effective.^1,2 However, previous studies have not focused on family medicine provisions of hepatitis C treatment and training residents within family medicine residency clinics for hepatitis C management. There has been intent to build hepatitis C treatment training into family medicine residencies nationwide; however, this need is still unmet.³ The University of Washington’s (UW) Harborview Medical Center (HMC) Family Medicine Clinic (FMC) in Seattle, Washington incorporates a primary care-based model for treatment of hepatitis C virus (HCV) infection. This clinic is a hospital-based family medicine residency clinic serving urban underserved patients, and both pharmacy and physician residents learn alongside trained attending family medicine physicians and clinical pharmacists to treat hepatitis C patients. The HMC FMC uses an interdisciplinary model for the treatment of hepatitis C which incorporates physicians, pharmacists, pharmacy technicians, patient care coordinators, and residents. One of the family medicine attending physicians serves as the main HCV specialist (HCV physician) in the clinic. All of the learners and providers, including the HCV physician, complete comprehensive online training modules created by the UW prior to performing direct patient care activities. This family medicine-based interdisciplinary model for chronic HCV treatment provides a robust didactic and clinical practice based curriculum for family medicine residents and ambulatory care pharmacy residents to learn all of the important facets of care provision and medication management for patients.

Medical and Pharmacy Resident Training
During a scholarly work elective rotation or on their own time, the family medicine physician residents complete an online course focused on HCV diagnosis and treatment, including specific education on the newer direct acting antiviral agents for HCV, created by UW. The online course contains seven modules with two to six lessons in each module. Each lesson requires successful completion of a five-question quiz in order to move on to the next module.⁴ Table 1 shows the different modules covered in the online training. At the end of each module, there is a comprehensive self-assessment that also contains five questions. The quiz and self-assessment questions are all multiple-choice questions that do not include true/false options. A score of at least 80% on each quiz is required to pass. Each module takes 3 to 4 hours to complete and the entire course takes approximately 24 active hours. The course must be completed before beginning direct patient care activities. In addition to the online course, the physician residents are required to present five to seven of their hepatitis C patients at the UW Project ECHO weekly meeting. Similarly, the pharmacy residents complete the same online HCV course and manage hepatitis C patients with a supervising pharmacist at the hepatology clinic one half day per week for 6 months. Monthly topic discussions were facilitated by the hepatology pharmacists for the pharmacy residents. The HCV physician and the FMC clinical pharmacist supervises the family medicine residents and pharmacy residents, respectively, as they care for HCV patients. Table 2 shows an example of the HMC FMC HCV treatment protocol for a 12-week Harvoni course

Table 1: Outline of Hepatitis C Online Modules

Table 2: Example Harvoni 12-week Treatment Protocol

*Sustained virologic response 12 weeks after treatment

Conclusion
The interdisciplinary HCV treatment model at the HMC FMC in Seattle allows physicians and clinical pharmacists to collaborate and provide timely and effective management to HCV patients, which has increased educational opportunities for trainees and access to care for patients with HCV. While various HCV diagnosis and treatment training modules exist online, the UW’s online training program is a comprehensive approach to the diagnosis and treatment of HCV with funding from the Centers of Disease Control and Prevention.^5,6 Since the program is free of charge, other family medicine residency programs may incorporate this online training into their curricula, partner with hepatologists for more complex HCV patient consultations, and utilize clinical pharmacists, if available, for prescription and medication-related issues.

References 

1.  Kattakuzhy S, Gross C, Emmanuel B, ASCEND Providers, et al. Expansion of treatment for hepatitis C virus infection by task shifting to community-based nonspecialist providers: a nonrandomized clinical trial. Ann Intern Med. 2017;167(5):311-318. https://doi.org/10.7326/M17-0118. 
2. Yoo ER, Perumpail RB, Cholankeril G, Jayasekera CR, Ahmed A. Expanding treatment access for chronic hepatitis C with task-shifting in the era of direct-acting antivirals. J Clin Transl Hepatol. 2017;5(2):130-133. https://doi.org/10.14218/JCTH.2016.00059. 
3. Camminati CW, Simha A, Kolb NR, Prasad R. Intent to build hepatitis C treatment capacity within family medicine residencies: a nationwide survey of program directors: a CERA Study. Fam Med. 2016;48(8):631-634. 
4. Hepatitis C Online. About Hepatitis C Oline. http://www.hepatitisc.uw.edu/. August 18, 2017.
5. Edith Cowan University. Hepatitis Online Education. http://hepatitis.ecu.edu.au/hepc/index.php. Accessed October 16, 2017
6. US Department of Veterands Affairs. Evaluating Liver Test Abnormalities: Introduction.  https://www.hepatitis.va.gov/HEPATITIS/course/index.asp?page=/provider/courses/livertests/livertests-01&. Accessed October 16, 2017.