ECHO HBV Global was submitted for consideration of the Outstanding Educational Collaboration Award because it was not only designed to address this important global health issue through education in regions with high prevalence of hepatitis B by collaborating with leaders in these regions, but also because the effects of this education may have a significant effect on the prevalence, morbidity and mortality of hepatitis B in affected regions.

Background

Hepatitis B (HBV) remains a major global public health problem. The World Health Organization (WHO) estimates that almost 300 million people around the world are living with chronic HBV infection, with 1.5 million new infections added each year.

The WHO has set targets of a 90% reduction of incidence of HBV, 65% reduction in mortality from 2015, 90% of cases will be diagnosed, and 80% of people with diagnoses who are eligible for treatment will be treated. However, gaps in knowledge and practice impede achievement of these goals.

The diagnosis and management of chronic HBV are complex. Most people are unaware they have contracted the virus, and illness may not be apparent for decades. While treatment is not recommended for all people with chronic HBV, all people with HBV should be counseled about the risk of transmission to others, the benefits of healthy lifestyle modifications (abstinence or no alcohol consumption and optimization of body weight), and the importance of lifelong monitoring to determine if an indication for treatment has developed. Monitoring tests and intervals vary, depending on the patient’s serology.

Globally, only 9% of people with chronic HBV are diagnosed, and only 5% of diagnosed patients who are eligible for treatment are receiving it. Without treatment, one in four people with chronic HBV will develop cirrhosis, and between 2% and 5% of them will develop hepatocellular carcinoma annually. The burden of missed diagnosis and deferred treatment is staggering: Over 800,000 deaths are attributed to HBV each year. The prevalence of HBV varies by region, with the largest burden in the WHO Western Pacific region. China alone contributes one-third of the world’s HBV cases.

Activity

DKBmed partnered with two international organizations to implement a program, ECHO (Extension for Community Healthcare Outcomes) HBV Global, to address and ameliorate the gaps that prevent diagnosis and proper management of HBV. The education was targeted to clinicians in China, Thailand, and the United States. The estimated prevalence of chronic HBV in the countries targeted by our proposed educational program is nearly 100 million, with 87 million people in China alone living with HBV, where about 80% are unaware of their infection.

ECHO HBV Global was based on the design of Project ECHO, which started 20 years ago to help clinicians who lacked expertise in hepatology treat their patients with hepatitis C. Over the past two decades, thousands of ECHO programs have been conducted, enabling local clinicians to retain management of their patients but with the guidance of specialist mentors.

In the past few years, DKBmed has developed several programs using the ECHO model for various disease states, including severe asthma, migraine, and HIV. Each ECHO program is unique. The model typically involves a short series of online video conference modules. These begin with a brief lecture (10-20 minutes), followed by a question-and-answer session and group discussion. During the discussion, participants can bring challenging cases to the expert faculty to seek guidance in management.

DKBmed developed the needs assessment, identified gaps and learning objectives, and created the content for expert faculty presentation. Each ECHO group, also referred to as “workshop,” met four times over the course of one month, with each of the four modules focused on one of the learning objectives. The learning objectives were:

1. Detect elements of stigma toward HBV within their countries and practices and recognize opportunities to screen patients for HBV.
2. Assess optimal timing for care treatment among patients with HBV to minimize risk for hepatocellular carcinoma.
3. Appraise the value of emerging and available medications used to treat chronic HBV.
4. Identify opportunities for screening patients with high risk for coinfection with HIV, hepatitis C or hepatitis D.

To effectively reach and educate learners in Thailand and China, DKBmed partnered with two organizations: the International Medical Exchange & Cooperation Committee (IMECC) and In Vivo Academy. IMECC, headquartered in Shanghai, is a branch committee of Chinese Non-government Medical Institutions Association (CNMIA). In Vivo Academy is a not-for-profit organization dedicated to providing accredited and independent medical education to healthcare professionals throughout Asia.

DKBmed had previously worked with both organizations and recognized that an alliance between them not only enables synergistic operations, but also allows for identification of local key opinion leaders to serve as faculty and expert mentors. Additionally, the collaboration aided in the recruitment of local learners. The regional faculty modified the educational content, in conjunction with the U.S.-based faculty, so that it was most appropriate for the learners in their regions.

In addition to the two workshops for learners in the United States, ECHO HBV Global included two workshops for learners in China and one for learners in Thailand. Each workshop group included participants from one of the three countries to facilitate a discussion of the specific challenges for the patient populations in their countries. These discussions were led by expert faculty members from each region.

Zoom facilitated interactivity between the expert faculty and the group’s participants. Learners were encouraged to participate by turning their cameras on and unmuting themselves during the question and answer and patient case segments. This allowed for an interactive session rather than a typical didactic lecture. Real-time polling was conducted, and the results were promptly shared, allowing the faculty to reveal the correct response and provide a rationale or reinforce any material if needed. With learners meeting at the same day and time for every module, this program becomes part of their schedule for a month. The small-group learning format established rapport among the learners and the expert faculty/mentor.

Outcomes

In total, the program reached 228 learners (148 in China, 25 in Thailand, and 53 in the U.S.). Post-activity assessment revealed that knowledge increased by 41% overall, competence increased by 64%, and confidence increased by 82%. Importantly, 96% of learners intended to change their practice or noted that the activity reinforced their current practice.

Learners expressed interest in a continuation of the program. Faculty members highlighted the program as “a perfect opportunity, especially for the junior-level physicians,” and commended the format, stating, “This format has impressed me. The audience is pre-arranged to submit their patient scenario prior to each module. This can help us properly understand how to help their HBV patients."

Limitations and Challenges

Developing and implementing a multinational program is challenging, with differences in language, time zone, and cultural norms. Communication between DKBmed and partnering organizations was difficult to schedule, with many meetings occurring outside of DKBmed’s normal working hours. DKBmed’s program manager responded to emails in the middle of the night rather than the next morning, which would delay the response by another day. However, all parties were adaptable and flexible, and the program was ultimately successful.

The involvement of multiple faculty members presented additional challenges. Although IMECC mainly managed the Chinese faculty and In Vivo coordinated with Thai faculty, DKBmed’s program manager oversaw and coordinated the entire process while also ensuring that the U.S.-based faculty would be able to attend their multiple modules.

The nature of ECHO programs, with several live interactive modules, limited the number of learners reached. The Chinese groups were quite large (ranging from 36 to 85 learners per module), though, and may have inhibited more active learner participation. However, insights revealed that Asian learners are not always comfortable sharing possible shortcomings in their practice, possibly impacting participation even in smaller groups.

Funding

Financial support was provided by Gilead Sciences, Inc., in the form of an independent educational grant.