Published April 1, 2020
The Hepatology Clinic at the Erie County Medical Center (ECMC) continues to gain national and international recognition for its unique approach and exceptional cure rate for hepatitis C.
Under the direction of Anthony D. Martinez, MD, associate professor of medicine, the clinic, affectionately known as “La Bodega,” is seen as a novel, co-localized model for the management of viral hepatitis and addiction disorders.
“Since 2016, we have treated close to 3,000 patients and the cure rate is 98.6 percent. We are pretty proud of that,” Martinez says.
“This is a comprehensive hepatology clinic, but we built into it an addiction medicine program because a lot of liver disease and addiction disorders are travel partners — they are married to each other.”
Martinez says health care providers are seeing a shift in the patient population.
“In the old days, it was primarily baby boomers who had hep C, but now the population is getting younger. As they start experimenting with drugs, they acquire the virus — so it leads to this dual syndemic,” he says. “This program is designed to take care of those patients. It’s comprehensive. We do everything from fatty liver disease to hepatitis B and liver cancer, but really hep C is our backbone.”
The term “bodega” is Spanish in origin and refers to the grocery stores that are common gathering places on street corners in residential neighborhoods.
Martinez wanted his clinic to convey that same sense of comfort and community — and was struck by the fact the metal roll down security gate over the ECMC clinic’s reception desk window made it resemble a New York City bodega.
Some of the clinic’s traditions provide that community feel — when patients are cured from hep C they write their name and a message on the wall. There is a also a cowbell that they get to ring to signify they have been cured.
“It’s a very tangible feeling to come in and see all these names — those are people who have been cured,” Martinez says. “They are turning a page on a chapter in their life that they are trying to leave behind.”
Also displayed on one of the clinic’s walls is a pennant that reads “Come One, Come All,” which Martinez says “that’s kind of our motto, what the whole thing is built on.”
“La bodega is not a physical space, it’s an ideology, a concept for a model,” he says. “It’s a very forgiving model. We are not run in a very conventional way. About 30 percent of our referrals come from patients themselves. They bring family members or people they know in the community who are looking for help.”
Martinez says the clinic works hard to see patients the same day they are referred. In 2019, the clinic hosted 3,200 visits.
“A lot of these patients have a lot of challenges in their daily lives so part of it is understanding and meeting them where they are at,” he says. “Many of these patients have all the complications — the liver disease, the substance use, there are social issues — it’s all one constellation of things. We do our best to co-manage all of it, not just treat this and say the rest is somebody else’s problem.”
“We get really heavily invested in them. All these patients have our cellphone numbers. They know how to get to us,” Martinez says. “It’s a nice model. It’s hard to quantify when you try to produce the data because you can produce outcomes data, but we constantly get asked how it works.”
“You get fixed up, you ring a bell, you write your name on the wall, the doctor’s covered in tattoos and wears jeans. I don’t know how you quantify it.”
Martinez notes the model is a co-localized approach, which utilizes an outreach team of social workers who partner with a number of addiction facilities.
The social workers remain in constant contact with individuals who have screened positive for hep C, facilitating the linkage with the clinic to help patients overcome barriers such as transportation issues.
“When they come here to the bodega, they can immediately begin medically-assisted therapy if they are opiate dependent and they begin hep C treatment almost simultaneously,” Martinez says.
That differs from past protocols, when individuals had to be abstinent from drugs and alcohol for six months before being eligible for hep C treatment.
“We have changed that mentality and are treating these patients quicker,” Martinez says. “Now we have newer agents, new hep C medications available that have minimal side effects and the duration is very short, anywhere between 8 and 12 weeks.”
“We’ve changed the whole paradigm where we no longer wait for the patient to become abstinent because during that time period is when they are the highest risk to spread the infection through sharing needles or whatever the case may be.”
Martinez says almost 50 percent of the bodega’s hep C patients begin treatment for opiate dependency and stop their active drug use.
“By treating the hep C it’s almost like a gateway to deal with the addiction,” he notes.
The model continues to receive recognition from a number of entities, both nationally and globally.
It has received the New York State World AIDS Day Commissioner’s Special Recognition Award. The clinic has also been designated as a center for drug user health in New York State.
Martinez says the model has been exported and presented in grand rounds programs throughout the country.
“We’ve got versions of this clinic in about 10 different states — Louisiana, Washington, Nevada, California and Texas among them. There are versions of this that we have helped to promote and develop,” he says. “It’s good to know the model can be replicated.”
In New York State, the program has received funding for a “mini residency,” where it is opened up to providers in the addiction community.
“It’s very flexible. They come here and can spend anywhere from a day to a week,” Martinez says. “We cover all their travel expenses and teach them how to do this. We put together a management guideline and put in all the new information we have. We try to update it every year and it is basically a ‘how to’ that is very pragmatic.”
Martinez says about 25 providers have been trained to begin treatment on their own — and they have come from disparate locations — ranging from outlying rural areas to New York City.
The program also hosts one of the highest rated elective rotations — a mix of hepatology and addiction — at the Jacobs School of Medicine and Biomedical Sciences.
“We try to educate medical students, residents and fellows to interact with these patients and get past some of the stigma associated with addiction,” Martinez says.
By 2019, Martinez felt that he had enough data to write up what the model looks like and get it out into the world.
Submissions to the annual Liver Meeting of the American Association for the Study of Liver Diseases (AASLD) last November in Boston were accepted and one of the abstracts made it into the presidential plenary session, which is a high-level presentation on the items the AASLD felt were most impactful and meaningful.
“Our poster was included in the hep C wrap-up so the work that was done here in the bodega actually made it into that,” Martinez says.
The program also had an international audience when it presented at the International Conference on Hepatitis Care in Substance Users in Montreal.
This year, Martinez was invited to present at the International Hepatology Exchange in Amsterdam.
“I was the only American there and met with a number of people from Portugal and Saudi Arabia who expressed interest in the models we’ve implemented here to try and help and develop some of their elimination programs,” he said.
Martinez also met with Portuguese delegates at the AASLD meeting in Boston, which he described as “high-level talks and assessment” in terms of identifying infrastructure and needs.
Martinez notes he started programs in a few places around the country before he came to Buffalo and says the biggest common denominator throughout is the human interaction.
“Meeting patients where they are at is essential. If you are embedded in the community and have a good understanding of how people live, it makes you that much more effective,” he says.
Martinez notes the “La Bodega” team has seven members — evidence that such programs do not require large numbers of health care professionals.
“If you have a good understanding of your resources and how to allocate them, you can develop a model that is very lean, but very efficient,” he says. “It has to be mobile — reaching the patients at where they are. The team needs to be fluid and mobile enough that a piece of the bodega can get to them and access them.”
“As a result we can then facilitate the linkage. It is a hybrid of outreach, conventional referral and co-localization,” Martinez says. “It is utilizing all of the tools that we have in the toolbox to capture as many of these patients as we can to provide treatment.”
While Buffalo is not the first program of this kind that Martinez has implemented, it is the one that he says has fully hit its stride.
“I think as it gains global recognition, my vision is that Buffalo becomes the hub for this,” Martinez says. “I have had requests from all over the country from people to come and see how this works and how they can implement it. I can envision the same thing happening overseas.”
“We still have a lot of work to do here despite having a cure rate close to 100 percent. We are busier than we’ve ever been, which is great because it means we are doing something right, but it’s scary because it means the problem is persisting.”
The World Health Organization has a target to eliminate hepatitis C by 2030, but the United States has a long way to go in increasing the number of cases treated.
“Of all the people with hep C in 2018 I think only 6 percent in the United States got treatment so we are lagging behind,” Martinez says. “For the future, I would like to see this Buffalo bodega model be implemented in more places nationally so we can catch up with the rest of the world in terms of eradication.”
Martinez points out there are three main factors why the program caught on in Buffalo:
Martinez says he is proud that medical students and residents who rotate in the bodega want to work there.
“I think that is a testament to the work itself, but also the support that they see from the hospital and the university. They see this as a place where they can be supported professionally, be developed and stay on long term.”
Martinez also notes the surrounding community has been a huge factor in the program’s success.
“I cannot say enough about Buffalo. I am not from here, but I have been here eight years now, and there is something about the people in this community,” he says. “Whether it’s the patients, their families or the community partners, I fell in love with this place eight years ago and it grows by leaps and bounds every year.”
“I would love to see the revitalization of Buffalo. Part of me hopes that what we’ve done here has some little contribution to the greater mission — the revitalization of this amazing Rust Belt American city.”