Project ECHO may improve outcomes in underserved rural patients with diabetes
Adults with type 1 or type 2 diabetes had lower HbA1c levels, body mass index, and diastolic blood pressure when their caregivers received weekly remote diabetes training from subspecialists, a recent study found.
Rural patients with diabetes may benefit from care provided by ECHO-trained primary care clinicians, according to a recent study.
Project ECHO is an initiative that supports implementation of guideline-recommended care in under-resourced areas with virtual communities, sharing of best practices, and case-based learning in subspecialty care for primary care clinicians. Researchers at the University of New Mexico, where Project ECHO originated, developed a program in which pairs of primary care physicians and community health workers at 10 clinics in rural areas were mentored weekly. Patients were eligible for the study if they were adults who had type 1 diabetes, had type 2 diabetes and were taking insulin, or had either type of diabetes and an HbA1c level above 9%.
Changes in cardiorenal risk factors were compared in patients treated by ECHO-trained clinicians versus retrospectively selected patients who had been treated by subspecialists at the University of New Mexico Diabetes Comprehensive Care Center. The primary outcome was change from baseline in HbA1c level, with changes in body mass index (BMI), blood pressure, cholesterol level, and urine albumin to creatinine ratio (UACR) as secondary outcomes. The results were published July 9 by the Journal of General Internal Medicine.
Overall, 856 patients were included in the ECHO cohort and 151 were included in the retrospective cohort. Age and sex were similar in the two groups at baseline, but those in the ECHO cohort had higher baseline BMI (32 kg/m2 vs. 30 kg/m2; P=0.002) and more commonly self-identified as Hispanic/Latino (59.3% vs. 49.7%; P<0.001). Median HbA1c level, diastolic blood pressure, and low-density lipoprotein cholesterol level also differed significantly between cohorts at baseline (P<0.001 for all comparisons).
After an average follow-up of 19.5 months and 16.9 months, respectively, the ECHO cohort had a larger reduction in HbA1c level than the retrospective cohort (−1.2% vs −0.6%; P=0.02 for difference in difference). BMI decreased in the ECHO group and increased in the retrospective cohort (−0.2 kg vs. 1.3 kg/m2; P=0.003 for difference in difference), while diastolic blood pressure decreased only in the ECHO cohort. Similar improvements in low-density lipoprotein cholesterol were seen in both groups, and UACR in both groups remained stable.
The authors noted that they used a retrospective comparison group and could not distinguish between patients with type 1 and type 2 diabetes, among other limitations. They concluded that using the Project ECHO model to mentor primary care clinicians and community health workers in rural, medically underserved communities helped build diabetes expertise; was associated with improvements in HbA1c, blood pressure, and cholesterol level; and allowed patients to receive the care in their own communities.
“These findings support the need for prospective, controlled trials evaluating the impact of the ECHO model on clinical outcomes for vulnerable populations with diabetes,” the authors wrote. “Healthcare professionals may consider the ECHO model as a potential solution for overcoming clinical inertia and improving diabetes-related health disparities affecting patients in rural communities with limited access to specialists.”