Common, complex, and often co-occurring chronic illnesses, such as major depression and ischemic heart disease, are fast becoming the leading causes of death worldwide.1 In North America, primary care providers (PCPs) are at the forefront of caring for these patients and are typically the point of referral to subspecialist consultation. However, specialists are often affiliated with tertiary care or academic health centers located in urban settings2; access to specialist care for patients and primary care physicians in rural areas can be a challenge. Moreover, rapidly evolving evidence for best practices in the management of these conditions outpaces PCPs’ ability to remain current. One potential mechanism for increasing the capacity of PCPs to manage these complex and chronic conditions is through the use of education to increase and maintain their competence in specialty areas.
Project Extension for Community Healthcare Outcomes (Project ECHO), a program developed in 2003 to help PCPs in rural New Mexico manage the hepatitis C virus (HCV), is one such innovative solution. Project ECHO’s virtual hub-and-spoke educational model harnesses telemedicine to facilitate rural PCPs’ learning and supervision by experts at academic health centers, thus increasing their ability to manage complex medical cases. The goals of Project ECHO are to use tele-education to provide access to scarce health care resources; to share best practices and reduce variation in care; to develop specialty expertise in PCPs, allowing them to practice within the full scope of their role; and to improve and monitor patient outcomes.3
Project ECHO participants, including clinicians, pharmacists, and nurse practitioners, initially receive one day of training from the HCV treatment team at the University of New Mexico School of Medicine. They then participate in weekly two-hour teleconference sessions, which consist of a combination of didactic lectures and anonymized case presentations of patients managed by the remote sites to facilitate learning. Community health care providers become familiar with managing patients with complex health needs. Arora and colleagues4 termed these learning opportunities “learning loops,” which facilitate PCPs’ learning through three main methods:
- Co-management of patients with specialists;
- Learning during sessions from other community-based PCPs, who practice in similar settings with comparable barriers to accessing care; and
- Learning from didactic presentations geared towards specific issues that arise during the telehealth clinic.
The effectiveness of the initial HCV Project ECHO program was evaluated. Patients treated by community-based PCPs trained under the ECHO model had the same health outcomes—specifically, comparable sustained virological response (“cure”) rates—as those treated at large academic health centers.3,5 Since this seminal work, Project ECHO has attracted attention both from members of the scientific community and from government agencies, and efforts have been made to adopt this model for a variety of other medical conditions including rheumatology, dermatology, musculoskeletal disease, asthma, chronic pain, palliative care, inflammatory bowel disease, women’s health, complex regional pain syndrome, dementia, diabetes, epilepsy, hypertension, liver disease, mental health, and transgender care.6–20
Amidst the global proliferation of Project ECHO programs, literature describing program development and related provider and patient outcomes has emerged. However, to date, no systematic review has summarized Project ECHO program results. The purpose of this systematic review was to examine the evidence from all Project ECHO models. We evaluated Project ECHO outcomes in terms of the impact on participant and patient outcomes and cost-effectiveness.
Data sources and identification of studies
We performed a broad search of the English-language literature included in five electronic databases: PubMed, MEDLINE, EMBASE, PsycINFO, and ProQuest. The keywords used in our search were “Project ECHO” and “Project Extension for Community Healthcare Outcomes.” We limited our search to literature published from January 2000 to August 2015 as the initial HCV pilot program was launched in 2003. Two authors (C.Z., S.S.) independently reviewed each of the identified abstracts to remove duplicates. Additional studies were identified through searches of the reference lists of the identified review articles related to Project ECHO.
Study inclusion and exclusion criteria
We selected studies for this review using the following inclusion criteria:
- English-language source;
- Peer-reviewed journal article or indexed abstract;
- Published from January 2000 to August 2015; and
- Primary focus on Project ECHO.
We included both qualitative and quantitative research. Studies were excluded if they were editorials or commentaries because of their subjective nature, non-peer-reviewed articles, or gray literature. We included studies that used the same data pool so long as they analyzed it for different outcomes (i.e., cost-effectiveness vs. patient outcome comparisons). All other duplicate studies were removed. The systematic utilization of these inclusion and exclusion criteria resulted in no disputes between the authors regarding study selection.
Data extraction and classification
This study followed the PRISMA guidelines for conducting a systematic review. Using our search criteria, we initially identified 387 articles and abstracts. Two additional articles were identified through reference list searches. Two authors (C.Z., S.S.) independently reviewed each abstract and removed duplicate articles. After this review, a total of 39 original studies met the inclusion criteria and were included for full-text review (see Figure 1).
Data were extracted by a single researcher (C.Z.). Data extraction categories included location of Project ECHO sites, type of education technology, instructional methods, frequency of sessions, chronic disease focus, and a brief summary of the findings.
We also aimed to assess the fidelity of each replication of the original HCV program. Our assessment criteria were:
- Initial training on Project ECHO model received by participants prior to the learning sessions;
- The duration of each teleconference learning session (two hours);
- The use of a combination of didactic material and case presentations at each session; and
- The frequency of sessions (weekly).
Projects that adhered to all four criteria were rated “high” in fidelity to the original model. Those that adhered to two to three criteria were rated “mid” in fidelity. Those that adhered to less than two and/or did not include enough descriptive data for assessment were rated as “low/insufficient information.”
We assigned each of the 39 included studies to a level of evidence in Moore’s continuing medical education (CME) evaluation framework (see Table 1).21 Moore’s framework is an ideal tool to assess current evidence from Project ECHO studies because it was developed to assess the impact of CME programs by focusing on the target outcomes of CME events with the goal of iteratively modifying the design of the event to achieve the intended results. Moore’s framework organizes outcome categories into seven levels, from Level 1 studies that simply describe the number of health care professionals who participated in the CME activity to Level 7 studies that describe the impact of the CME event on the health outcomes of a community.
We discussed the methodology and limitations of the included studies according to each level of Moore’s evaluation framework. We first discussed our findings pertaining to the motivating factors and barriers to participation in Project ECHO programs. We also described the studies that did not fit into any level of Moore’s framework, such as learning theories behind Project ECHO and the cost–benefit analysis of Project ECHO. Efforts were made to synthesize the available evidence to comment on the clinical effectiveness, feasibility, and meaningfulness of the program.
We calculated descriptive statistics for all extracted data and summarize them and the quality assessment data in the text below and in Appendix 1.
We included 39 studies in this review.3–5,7,9–20,22–44 Study characteristics and target populations are described first, followed by a description of study outcomes using Moore’s evaluation framework (see Appendix 1).
Project ECHO had 462 local programs in New Mexico, 13 national programs in the United States, and 5 international programs.45
Twenty-two studies contained Project ECHO models where the hubs (academic health centers) and spokes (remote locations) were located in the same U.S. state, most often New Mexico.3–5,7,9,11,14,16,17,25–27,29,31–33,35–37,39,40,42 Eight studies described a Project ECHO model with a central hub but multiple spokes from different states.10,13,18–20,28,34,41 Three recently developed programs in inflammatory bowel disease and transgender medicine employed a decentralized hub of subspecialists across multiple U.S. states.13,15
Thirty studies included civilian populations living in remote areas.3–5,7,9,11,12,14,16,17,20,22–40 Seven studies focused on veterans.10,13,15,19,34,41,42 Other special populations studied included indigenous Americans,3–5,18,22 prison inmates,3–5,18,25 and long-term care facility residents.9,26 A recent epilepsy initiative was the first Project ECHO program to include pediatric patients.20
Fidelity of subsequent Project ECHO programs to the original HCV Project ECHO program
We assessed 30 studies for their fidelity to the original model. Two met our criteria for high fidelity,23,36 11 had midlevel fidelity,7,15,16,18,25,27,29,35,38,39,42 and 17 were deemed to have low fidelity or contained insufficient information for assessment.9–11,13,14,17,19,20,26,28,30–33,37,40,41
Project ECHO program outcomes and quality assessment
Of the 39 included studies, 28 reported at least one outcome from Moore’s evaluation framework.3,5,7,9,10,12–19,22–24,26–28,32,33,35,37–42
Level 1: Number of participants.
Twelve studies reported the number of Project ECHO participants, which ranged from 9 to 710.7,9,13,17–19,22,24,33,35,39,41 The median number of participants was 38, and the interquartile range was 65.
Level 2: Health care providers’ satisfaction.
Thirteen studies contained data from surveys and/or semistructured interviews with PCPs involved in Project ECHO.4,10,12,15–17,19,23,24,27,28,35,37 In all 13 studies, participants indicated a high level of satisfaction with the educational program.
There may have been selection bias in these studies, as PCPs who completed the surveys presumably had at least a baseline interest in Project ECHO because they joined the program on a volunteer basis.12,24 Another limitation of these studies was the small number of survey respondents.12,24 The number of participants ranged from 8 to 83 (median of 27).
Level 3: Changes in health care providers’ knowledge.
Four studies assessed Project ECHO’s impact on PCPs’ knowledge with a pre-/posttest comparison.14,17,23,38 One study used multiple-choice questions to test PCPs’ knowledge of treatment-resistant hypertension and showed a significant increase in knowledge after Project ECHO participation.17 Other studies comparing self-reported level of knowledge before and after Project ECHO participation found similar results.14,23,38
Whereas multiple-choice questions are objective measures of declarative knowledge, self-reported survey responses may lack validity. Specifically, participants may be unwilling to disclose at baseline a lack of knowledge on a particular topic. Second, knowing that a program aims to increase knowledge, participants may overrate the extent of their knowledge increase after the program. Both scenarios could have produced bias that influenced the study results.46
Level 4: Health care providers’ competence.
Eight studies focused on PCPs’ competence after participating in Project ECHO.7,10,14,16,17,23,27,28 These studies used survey rating scales and semistructured interviews to measure the change in participants’ confidence. Seven reported an increase in self-confidence.7,10,16,17,23,27,28 The eighth study found no significant difference in participants’ confidence when comparing a pre–post Project ECHO self-efficacy survey, despite participants reporting a significant increase in their knowledge and skills.14 The authors attributed the negative results to participants’ inflated self-efficacy ratings at baseline due to their failure to appreciate their knowledge gaps in pain and headache management.
These self-reported surveys had the same potential biases as those previously discussed for the Level 3 studies.46 It is also unclear whether self-reported confidence is a good measure of clinical competence.
Level 5: Health care providers’ performance.
One study assessed participants’ performance.13 Frank et al13 longitudinally evaluated the Specialty Care Access Network (SCAN)-ECHO program for pain management to find the association between Project ECHO consultation and (1) the delivery of different types of outpatient care and (2) medication initiation. The authors found that an ECHO pain management consultation was associated with increased use of only physical medicine services (not mental health, substance disorder, or pain medicine services) and initiation of nonopioid medications among patients with chronic noncancer pain. Limitations included a lack of control group.
Level 6: Patient health.
Seven studies measured the change in patients’ health status after Project ECHO implementation.3,5,26,32,39,40,42 These studies focused on three diseases: HCV, dementia/behavioral issues, and diabetes.
Two studies contained results from the original HCV program.3,5 A prospective cohort study found that HCV-positive patients treated by Project ECHO PCPs had similar sustained viral response rates as patients treated by specialists.3 The other study found no significant difference in the number of serious adverse events between both groups.5 Two other studies replicating the HCV program showed similar results.39,40
Two studies focused on the Project ECHO-AGE program, which targeted long-term care residents with dementia and behavioral issues.26,32 In one study, Catic et al26 followed the outcomes of 44 long-term care residents who were patients of Project ECHO-AGE PCPs. When the ECHO recommendations were followed, 74% of patients improved, compared with 20% of patients when the recommendations were not followed because of provider judgment or family resistance. Limitations of this study included low statistical power. Gordon et al32 subsequently conducted a matched cohort study (Project ECHO-AGE patients vs. patients from a non–Project ECHO consultation service) using the same patient population and found that participating nursing homes reported significantly lower restraint levels than those in the control group.
Watts et al42 showed that, following Project ECHO training, the mean hemoglobin A1c values of patients in a diabetes clinic significantly decreased from 10.2 to 8.4 (P < .001) over five months. This decrease was not explained by system-wide improvements, as two clinics of non–Project ECHO PCPs saw a 4% to 15% increase in the percentage of patients with A1c values over 9 during the same period.42 Limitations of this study and the original HCV study included the lack of randomization in the study design, resulting in an inability to account for confounding factors.5,42
Level 7: Community health.
We found no studies with Level 7 outcomes.
Additional outcomes: Cost–benefit analysis.
Two studies looked at the financial benefits of Project ECHO.19,43 One discussed the cost-effectiveness of the original HCV program.43 The authors found that Project ECHO increased quality-adjusted life expectancy by 3.8 (standard deviation 1.4) years per patient. The mean savings from Project ECHO compared with conventional treatment were $1,352 per person or $352,872 for 261 patients. Project ECHO cost an average of $8,300 (standard deviation $7,800) per quality-adjusted life year gained, which was well below the standard U.S. willingness-to-pay threshold of $50,000 per quality-adjusted life year gained. The study deemed the HCV Project ECHO program cost-effective. A second study on the SCAN-ECHO model for chronic liver disease showed that patients saved an average of 187 travel miles per person, for a total of 28,597 miles saved.19
Motivating factors and barriers to Project ECHO participation
Some studies qualitatively analyzed motivating factors for Project ECHO participation using surveys or focus groups.28,41 The most common motivating factors were to increase one’s knowledge base, apply new knowledge to future patients, save patients traveling time, and increase collaboration with specialists. Other reasons for participating included obtaining CME credits, decreasing health care and patient costs, preventing professional isolation, sharing new knowledge with colleagues, and trying something new.41 The main barrier to participation was lack of time.28,41 Less important barriers included not receiving CME credit, lack of a financial incentive, and the inability to access the videoconferencing technology.41
On the basis of our knowledge and review of the literature, we believe that this is the first systematic review of the published literature on Project ECHO programs and their outcomes. Our review showed that evaluations of Project ECHO programs predominantly have been limited to Levels 1 to 4 of Moore’s framework. Preliminary data from seven studies suggest that Project ECHO can change PCPs’ behavior and patient outcomes.3,5,26,32,39,40,42 Moreover, emerging data from the HCV Project ECHO program indicate that this model is potentially cost-effective and can save patients the burden and cost of traveling to receive specialist care.19,43
Research also suggests that Project ECHO’s effectiveness as a CME program may be explained by several learning theories, specifically social cognitive theory, situated learning theory, and communities of practice.44 Social cognitive theory proposes that, for effective learning to occur, individuals must believe the benefits of performing the new behavior, have confidence in their own ability to perform it, and be positively reinforced to change.47 Situated learning theory postulates that effective teaching requires interesting and manageable tasks that motivate learners to extend their current skills and knowledge to perform the idealized version of the task.48 Communities of practice are founded on the premise that learning is more effective when one participates as part of a group of learners.49,50 Although we propose that these learning theories explain the study outcomes observed in our review, further research is needed to clearly elucidate the salient learning mechanisms and factors responsible for the observed Project ECHO outcomes.
The use of a teleconference-based model contributes to the potential cost-effectiveness and accessibility of Project ECHO because it saves the need for patients to travel long distances for specialist care and takes advantage of existing technology. However, the limited evidence available on the cost-effectiveness of Project ECHO focused only on the initial HCV program and cannot be generalized to other medical conditions. This lack of generalizability exists because other factors, such as the specific illness and the complexity of the patient’s condition, also could influence the cost-effectiveness of an intervention. A recent Cochrane Review could not draw definitive conclusions on the cost-effectiveness of telemedicine,51 but it is important to distinguish telemedicine from Project ECHO. In most telemedicine models, specialists from academic health centers personally manage patients and provide direct care using teleconferencing technology. In contrast, Project ECHO uses an indirect care model and the co-management of patients—specialists support and collaborate with PCPs working in remote locations to manage complex patients. In the Project ECHO model, specialists spending one hour collaborating with PCPs can potentially lead to better management of hundreds of patients.
Other care models are being developed as novel ways to improve patient outcomes, such as collaborative or integrated care approaches that engage interprofessional teams made up of a specialist, a primary care physician who retains overall clinical responsibility for the patient, and a case manager who follows up with the patient and assesses her or his adherence to the prescribed treatments.52 Collaborative care models have been shown to produce better patient outcomes than routine care under a PCP.52 However, these outcomes have not been compared with those from Project ECHO. Also separating collaborative care models from Project ECHO programs is the fact that collaborative care does not specifically target patients living in remote geographical settings, as Project ECHO does.
Project ECHO has shown great promise for improving the management of common chronic illnesses within primary care. As a result, government agencies and other funders have increased the resources dedicated to Project ECHO programs and extended its scope of practice to additional diseases. In 2003, Project ECHO was first implemented to address HCV—a complex yet common disease with a large societal burden. Since then, its effects on the management of less common conditions have been studied, including complex regional pain syndrome,35 transgender medicine,15 and pediatric epilepsy.20 The expansion of the scope of Project ECHO may reflect the ability of teleconference technology to bring current medical knowledge to any geographical location.
This review has several limitations. First, we used an inclusive approach to Project ECHO research, irrespective of study quality. For example, studies assessing outcomes from Levels 2 and 3 of Moore’s framework included a small number of survey respondents24,41 and contained self-selection bias.24,30 Second, studies comparing Project ECHO patient outcomes with those of subspecialist care alone have been limited to HCV, and few have looked beyond Level 5 outcomes. This is problematic, given that 17 of the studies contained low/insufficient information to assess fidelity to the original HCV program. As such, the effects of the original Project ECHO program on patient health outcomes cannot be generalized to many subsequent programs. Next, although studies often state that they are implementing “evidence-based” treatment methods, little verification has been done to ensure that this is the case for those Project ECHO programs without studies that yield outcomes at the higher levels of Moore’s framework. Further, although we included 39 studies in our review, none used a randomized controlled trial methodology. These limitations are reflective of the current state of Project ECHO research. Despite the growth of Project ECHO’s application in addressing HCV and its expansion to other medical conditions, quality studies are lacking. The existing research often includes heterogeneous methodologies that make it difficult to compare studies. Finally, our review consisted of searches of the PubMed, MEDLINE, EMBASE, PsycINFO, and ProQuest databases and could be subject to limitations related to publication bias.
Irrespective of these limitations, Project ECHO is being implemented widely and has shown promise addressing a critically important issue affecting the equity of health care delivery, and an overview of the available literature to synthesize the current evidence supporting its implementation is timely and useful.
Future research directions and challenges
Although we included 39 studies related to Project ECHO in this review, more research that addresses outcomes from Moore’s Level 5 (health care providers’ performance) and higher is needed to substantiate the claim that Project ECHO is an effective educational innovation. Research focusing on process measures (i.e., provider adherence to protocols, treatment algorithms, and care pathways) is needed to evaluate Project ECHO as a clinical innovation. Randomized controlled trials or additional trial methodologies are needed to further compare the patient and participant outcomes of Project ECHO programs. More studies are also needed to analyze the cost-effectiveness of Project ECHO.
Key barriers still exist to widespread Project ECHO implementation, including a lack of time and financial incentives for health care providers.27,41,53 Whether the Project ECHO model can be replicated with fidelity to ensure consistent quality learning is another important consideration that has not been addressed in the current literature. By overcoming these barriers and integrating Project ECHO into health systems planning, we can minimize the duplication of services and ensure that this model is delivered where it is most needed and most impactful.
In this review, we found preliminary evidence that Project ECHO is an effective and potentially cost-saving model that increases participant knowledge and patient accessibility to quality health care in remote locations, through improving the capacity of PCPs to manage more complex health conditions. Studies suggest that Project ECHO can narrow knowledge gaps to support the provision of evidence-based care in remote communities and increase self-efficacy in participants’ ability to provide up-to-date health care to more individuals in remote areas. As Project ECHO expands to address more medical conditions, further research examining its efficacy is needed to support its widespread use as an education and practice improvement initiative.
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