Laura Rodriguez Research InstituteFamily Health Centers of San DiegoSan DiegoCA.
Institute of Public HealthSan Diego State University Research FoundationSan DiegoCA.
Hepatol Commun. 2020 Dec 21;5(3):412-423. doi: 10.1002/hep4.1617. eCollection 2021 Mar.
Hepatitis C virus (HCV) is a major cause of cirrhosis, liver cancer, and mortality in the United States. We assessed the effectiveness of decentralized HCV treatment delivered by nurse practitioners (NPs), primary care physicians (PMDs), or an infectious disease physician (ID MD) using direct-acting antivirals in a Federally Qualified Health Center (FQHC) in urban San Diego, CA. We conducted a cross-sectional analysis of 1,261 patients who received treatment from six NPs, 10 PMDs, and one ID MD practicing in 10 clinics between January 2014 and January 2020. Care was delivered based on the Extension for Community Healthcare Outcomes (Project ECHO) model with one hub and nine spokes. HCV was deemed cured if a patient had a sustained virologic response (SVR) after 12 weeks of treatment (SVR12). We evaluated differences in the prevalence of cure between provider types and hub or spoke status using Poisson regression. Patients were 34% Latino, 16% black, 63% were aged >50 years, and 59% were homeless; 53% had advanced fibrosis, 69% had genotype 1, and 5% were coinfected with human immunodeficiency virus. A total of 943 patients achieved SVR12 (96% per protocol and 73% intention to treat). Even after adjustment for demographics, resources, and disease characteristics, the prevalence of cure did not differ between the ID MD and PMDs (prevalence ratio [PR], 1.00; 95% confidence interval [CI], 0.95-1.04) or NPs (PR, 1.01; 95% CI, 0.96-1.05). Similarly, there were no differences between the hub and spokes (PR, 1.01; 95% CI, 0.98-1.04). Among a low-income and majority homeless cohort of patients at urban FQHC clinics, HCV treatment administered by nonspecialist providers was not inferior to that provided by a specialist.
丙型肝炎病毒（HCV）是导致美国肝硬化、肝癌和死亡的主要原因。我们评估了在加利福尼亚州圣地亚哥市的一家联邦合格的健康中心（FQHC）中，使用直接作用抗病毒药物由护士从业者（NP）、初级保健医生（PMD）或传染病医生（ID MD）进行分散式 HCV 治疗的效果。我们对 2014 年 1 月至 2020 年 1 月期间在 10 个诊所工作的 6 名 NP、10 名 PMD 和 1 名 ID MD 治疗的 1261 名患者进行了横断面分析。护理是根据社区医疗保健成果扩展（Project ECHO）模型提供的，该模型有一个中心和九个分支。如果患者在治疗 12 周后出现持续病毒学应答（SVR），则认为 HCV 已治愈（SVR12）。我们使用泊松回归评估了提供者类型和中心或分支状态之间治愈率的差异。患者中 34%为拉丁裔，16%为黑人，63%年龄>50 岁，59%无家可归；53%有晚期纤维化，69%为基因型 1，5%合并感染人类免疫缺陷病毒。共有 943 名患者达到 SVR12（96%按方案和 73%意向治疗）。即使在调整人口统计学、资源和疾病特征后，ID MD 和 PMD（患病率比 [PR]，1.00；95%置信区间 [CI]，0.95-1.04）或 NP（PR，1.01；95%CI，0.96-1.05）之间的治愈率差异无统计学意义。同样，中心和分支之间也没有差异（PR，1.01；95%CI，0.98-1.04）。在城市 FQHC 诊所的低收入和多数无家可归患者群体中，非专家提供者提供的 HCV 治疗并不逊于专家提供的治疗。
