Project ECHO^TM & PARSA HealthNet ECHO Pakistan Collaboration

Extension for Community Care Outcomes is (ECHO) is an innovative model to ensure capacity building at community and academic healthcare centers. ECHO enhances skills, work force development and practical experiences for primary care providers by de-monopolizing knowledge, advanced training and ensuring the best practices. PARSA HealthNet ECHO Pakistan was established in collaboration with University of New Mexico, Albuquerque in November, 2017 with Hub at Gujranwala, Pakistan. It was second ECHO Program initiated in Pakistan by Dr. Asad Ali Choudhry, that time. Using high quality plug and play videoconference technology, PARSA HealthNet ECHO Pakistan brings together experts from well renowned Medical Institutes of Pakistan and abroad in partnership with community-based health care providers to engage in case-based learning and disease management for communities with limited resources.

Current Programs:

Hepatitis & Liver Cirrhosis ECHO

Viral Hepatitis is the eighth highest cause of mortality globally and was responsible for an estimated 1.34 million deaths in 2015, a toll comparable to that of HIV and Tuberculosis. Globally, approximately 257 million persons are chronically infected with Hepatitis B and 71 million with Hepatitis C. At this rate, an estimated 20 million deaths will occur between 2015 and 2030.

Over 10 million Pakistanis are currently living with Hepatitis. The majority of people catch this infection in health care settings without being aware of it. The disease is called a silent killer because many patients remain undiagnosed and untreated for many years before developing complications and dying. With emergence of new drug treatments for Hepatitis, it is even easier for primary care providers to treat patients with Hepatitis. These treatments are simpler and significantly more effective than previous treatments for patients especially in case of Hepatitis C if primary care providers learn about best practices and evidence-based treatment for:'

• 1) Screening and diagnosis
• 2) Managing cirrhosis
• 3) Drug-drug interactions

PARSA HealthNet ECHO Pakistan curriculum in Hepatitis (Hepatitis B, Hepatitis C & Liver Cirrhosis) is designed to expand primary care capacity for evidenced based care at community health centers in underserved communities. Early Detection and treatment of Hepatitis in primary care setting can contribute to lower rates of morbidity and mortality, reduce risk of disease progression, and maximize the benefits of emerging treatment options. We provide primary care providers with knowledge to identify persons at risk for Hepatitis and Liver Cirrhosis and conduct risk assessments, tests, diagnose, counsel, stage, monitor and treat.

Faculty:

• 1) Dr. Asad Ali Choudhry
• 2) Prof. (Retd.) Altaf Alam
• 3) Prof. Kashif Malik
• 4) Prof. Javed Iqbal Farooqi
• 5) Bilal Hameed
• 6) MD, Dr. Bushra Ali
• 7) Dr. Najam Ud Din
• 8) Dr. Farooq Khan
• 9) Dr. Zeeshan Ali & Dr. Nadeem Teham

Curriculum Hepatitis C ECHO:

• 1) Epidemiology, Natural History & Whom to Screen
• 2) Clinical Presentation & Workup of the Patient
• 3) Starting AVT & On-treatment Monitoring
• 4) Acute Hepatitis C & Hepatitis B Coinfection
• 5) Treating a Patient with Liver Cirrhosis
• 6) Counselling a Patient with HCV & Benefits of SVR
• 7) HCV-Pregnancy & Breastfeeding; HCV in Children
• 8) Eliminating HCV
• 9) HBV – Epidemiology, Natural History & Screening
• 10) Clinical Features & Extra Hepatic Manifestations of HBV
• 11) HBV Serology – Tests and their Interpretations
• 12) Whom to Treat & How to Treat
• 13) Acute HBV Infection, HCV Coinfection
• 14) HBV – Pregnancy & Breastfeeding; HBV in Children
• 15) HBV – Immunotherapy/Chemotherapy
• 16) Counselling of HBV Patients & Benefits of Treatment

Curriculum – Liver Cirrhosis:

• 1) What is Liver Cirrhosis? An Overview
• 2) Portal Hypertension-Mechanism & Consequences
• 3) UGI Bleeding in Cirrhosis-General Principles of Management
• 4) Non-Variceal Esophago-Gastric Bleeding in Cirrhosis
• 5) Haemostasis & Coagulation cut-offs for Procedures in Cirrhosis
• 6) Vascular Thrombosis in Cirrhosis-Management
• 4) Prof. Javed Iqbal Farooqi
• 7) Hepatic Encephalopathy-Pathogenesis, Precipitants & Burden of Disease
• 8) Ascites in Cirrhosis-Evaluation & Management
• 9) Hepatorenal Syndrome
• 10) Spontaneous Bacterial Peritonitis
• 11) Management of Liver Diseases in Ramadan
• 12) Hepato-pulmonary & Porto-pulmonary Syndromes
• 13) Acute Hepatitis Case Based Learning
• 14) Case Based Discussion with Experts
• 15) Hepatocellular Carcinoma-An Overview
• 16) TIPS-Indications, Contraindications & Complications
• 17) Resection & Transplant for HCC
• 18) TACE/TAE for HCC, RFA/MWA for HCC
• 19) Systemic Therapy for HCC
• 20) Acute on Chronic Liver Failure-Definition, Causes & Management
• 21) Whom & When to Refer for Liver Transplant

Endocrine ECHO:

This activity was commenced under leadership of Prof. Imran Hasan Khan to help primary care physicians manage diabetes and it’s complications better in the community.

Faculty:

• 1) Dr. Muhammad Imran Hasan Khan
• 2) Dr. Kashif Aziz Ahmad
• 3) Dr. Muhammad Maqsood
• 4) Prof. Javed Iqbal Farooqi
• 5) Ms. Sabira Sharif
• 6) Dr. Hafiz Ehsan Ullah
• 7) Dr. Rizwan Ahmed
• 8) Dr. Maryam Khalid
• 9) Dr. Zeeshan Ali & Dr. Nadeem Teham

Curriculum Hepatitis C ECHO:

• 1) Epidemiology and Pathophysiology of Diabetes
• 2) Types of Diabetes and Features
• 3) Diagnostic tests
• 4) Role of Diet in Management
• 5) Role of Exercise in Management
• 6) Oral Hypoglycemic Agents, with special focus on new agents
• 7) Insulin, types and Practical Aspects
• 8) Acute Complication Hypoglycemia
• 9) Acute Complications, Ketoacidosis and Hyperosmolar Coma
• 10) Retinopathy – Features, investigations, management and when to refer
• 11) Neuropathy – Features, investigations, management and when to refer
• 12) Nephropathy – Features, investigations, management and when to refer
• 13) Autonomic Neuropathy – Features, investigations, management and when to refer
• 14) Diabetic Foot Disease – Features, investigations, management and when to refer
• 15) Other Macro-vascular Problems – Stroke and Cardiovascular Disease
• 16) Pregnancy and Diabetes
• 17) Surgery and Diabetes

Advanced Endoscopy ECHO:

In this series experts from Pakistan, USA and UK engage with the GI experts in Pakistan with a series of didactics, interesting cases and discussion on advanced endoscopy procedures. The interest has been immense and the activity is anticipated to upgrade the skills of the gastroenterologists across the country.

Faculty:

• 1) Dr. Saad Khalid Niaz (TI)
• 2) Prof. Ghias un Nabi Tayyab
• 3) Muhammad Khalid Hasan
• 4) MD, Dr. Nadeem Tehami
• 5) Dr. Mustafa Arain
• 6) Dr. Farooq Khan

Topics Covered:

• 1) Autoimmune Liver Disease
• 2) Endotherapy for Barrett’s – Applying RFA & EMR to Optimize Outcome
• 3) Abnormal Lesions in Oesophagus & Action Required
• 4) Corrosive Oesophageal Strictures

Palliative Care ECHO:

Another successful ECHO program about teaching primary care physicians how to provide palliation to terminally ill patients at home. This was the need of the hour, the participants are now much more comfortable offering such patients much needed end of life care.

Faculty:

• 1) Prof. Altaf Alam
• 2) Dr. Farooq Khan
• 3) Dr. Zeeshan Ali
• 4) Dr. Aqdas Kazi

Curriculum – Palliative Care ECHO:

• 1) Introduction to Palliative Care
• 2) Hepatic Encephalopathy
• 3) Palliative Management for Ascites & Hydrothorax
• 4) Palliative Care Management for GI Bleed
• 5) Palliative Management for Pain, Insomnia, Agitation & Pruritus
• 6) Palliative Management for Anorexia, Nutrition, Nausea, Vomiting, Constipation & Cough

PARSA ECHO COVID-19 Response:

Led by a panel of experts, PARSA HealthNet ECHO Pakistan, has been in the forefront helping to disseminate information and best practices for responding to the COVID-19 pandemic in Pakistan. Our organization, with the assistance of colleagues from around the world and Pakistan has been conducting a series of Interactive sessions with Pakistan’s healthcare stakeholders including medical practitioners, community workers and Government stakeholders and facilitating dialogue among clinicians about responding to COVID 19. The program is designed to assist Pakistan’s healthcare Stakeholders in the formulation of strategies to address challenges as a result of the pandemic. To date the number of registered participants of HealthNet Echo Pakistan COVID-19 program is more than 2500.

The objectives of this initiative being:

• 1) Professional Development: Participants gained skills and competencies for managing patients.
• 2) Creating Community focus: Providing a platform for clinical to increase professional interaction and decreasing isolation and creating a sense of community.
• 3) Increase Patient Outreach and accessibility: Patients can continue to work with their trusted clinician instead of traveling long distances to be seen by specialists.
• 4) Improve Dissemination of Information and practices: Healthcare professionals who participate in ECHO increase their knowledge and self-efficacy.

Curriculum – Palliative Care ECHO:

• 1) Introduction to Palliative Care
• 2) Hepatic Encephalopathy
• 3) Palliative Management for Ascites & Hydrothorax
• 4) Palliative Care Management for GI Bleed
• 5) Palliative Management for Pain, Insomnia, Agitation & Pruritus
• 6) Palliative Management for Anorexia, Nutrition, Nausea, Vomiting, Constipation & Cough

The awareness part of the COVID series comprised of twenty (20) sessions conducted from 18th March, 2020-8th May, 2020 (with up-to 400+ participants per session). The COVID Response part of the sessions were conducted with the objective of provision of training to doctors in primary care to diagnose COVOID-19, classify disease severity, provide home care to mild and moderate cases, and prompt referral of severe cases to hospitals and other health facilities in close liaison with the District administration. So far nine (9) have been conducted with up-to 800 participants per session. Other salient features in this regard include:

• 1) Developing simple flow charts and algorithms in line with the Government guidelines.
• 2) A panel of international And national experts has been training the frontline doctors and paramedical staff to deal
• 3) With the COVID cases through case-based discussions while keeping in mind availability of local resources.
• 4) A helpline (03-111-444-201/ 03-111-444-396) with expert back-up has also been setup as part of this initiative.
• 5) All patients are registered and proper data is being maintained in line with existing PARSA Trust policy.
• 6) The project is being supported by local philanthropy.
• 7) The training sessions held in collaboration with Project ECHO are open to all across Pakistan.