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Project ECHO: Building capacity to manage complex conditions in rural, remote and underserved areas
Abstract
There is a need to bring specialized medical expertise to rural and remote areas. Project ECHO offers a method to move knowledge from specialists in academic centres using videoconference, case-base learning, and best-practices knowledge sharing. Ontario has implemented ECHO since 2014 and has demonstrated favourable outcomes among primary care clinicians.
... 53,54 This underscores the need for effective distance education strategies to bring medical expertise to remote and/or underserved regions. 55 A dissemination plan and the simultaneous use of complementary education approaches/tools and repetition can help to increase awareness and implementation of guidelines among target populations. 56 In addition, the experts suggested the establishment of central service points that could offer PN expertise to other centers. ...
... 53 The Extension for Community Healthcare Outcomes areas. 55,59 A systematic review has found that the ECHO model and similar tele-education models of healthcare delivery improve provider-and/or patient-related outcomes (eg, for patients with hepatitis C, chronic pain, dementia, and type 2 diabetes). 60 Based on the ECHO model, the Learn Intestinal Failure Tele-ECHO (LIFT-ECHO) project was launched in 2019 to support the treatment and management of patients with intestinal failure relying on long-term PN in the US. ...
Purpose
This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit (held November 8-10, 2021, at Charleston, SC, and Bad Homburg, Germany) and aims to raise awareness concerning unresolved issues associated with the PN process and potential future directions, including a greater emphasis on patients’ perspectives and the role of patient support.
Summary
Ensuring that every patient in need receives adequate PN support remains challenging. It is important to have a standardized approach to identify nutritional risk and requirements using validated nutritional screening and assessment tools. Gaps between optimal and actual clinical practices need to be identified and closed, and responsibilities in the nutrition support team clarified. Use of modern technology opens up opportunities to decrease workloads or liberate resources, allowing a more personalized care approach. Patient-centered care has gained in importance and is an emerging topic within clinical nutrition, in part because patients often have different priorities and concerns than healthcare professionals. Regular assessment of health-related quality of life, functional outcomes, and/or overall patient well-being should all be performed for PN patients. This will generate patient-centric data, which should be integrated into care plans. Finally, communication and patient education are prerequisites for patients’ commitment to health and for fostering adherence to PN regimes.
Conclusion
Moving closer to optimal nutritional care requires input from healthcare professionals and patients. Patient-centered care and greater emphasis on patient perspectives and priorities within clinical nutrition are essential to help further improve clinical nutrition.
... In 2018, an expert panel reviewed the evidence base for the effectiveness of the ECHO and ECHO-like models, confirming their utility [55]. Project ECHO has been particularly successful in building capacity for managing complex clinical cases in rural and underserved areas, making a significant impact on healthcare delivery [56][57]. ...
Background: The advent of telemedicine marks a significant transformation in healthcare delivery, leveraging technology to improve accessibility and efficiency for both providers and patients. From early methods of distant communication to modern innovations like telehealth and mobile health, telemedicine has evolved alongside technological advancements. Aim: This article explores the historical development, current applications, and future potential of telemedicine, emphasizing its role in enhancing healthcare delivery and access. Methods: The article reviews the evolution of telemedicine, beginning with early communication methods and progressing through significant milestones such as the development of the stethoscope, handwashing practices, and modern technologies like 5G networks, artificial intelligence (AI), and electronic health records (EHRs). It also examines the integration of robotics, mobile health, and sensors in telemedicine. Results: The review highlights telemedicine's impact across various medical disciplines, including surgery, emergency care, and chronic disease management. The integration of advanced technologies has enhanced the capabilities of telemedicine, enabling real-time communication, remote monitoring, and improved patient outcomes. Conclusion: Telemedicine represents a paradigm shift in healthcare, offering solutions to challenges in accessibility and efficiency. Its continued evolution, driven by technological advancements, promises to further revolutionize healthcare delivery, making it more responsive to the needs of providers and patients alike.
... Remote education strategies can help to bring medical expertise to underserved regions. 69 For example, the Extension for Community Healthcare Outcomes (ECHO) model uses videoconferencing technology to move specialized medical knowledge from academic centers to primary care providers in the community. 67 Many institutions are still using handwritten PN orders and must transcribe them multiple times (into the electronic health record and then into the ACD), and in other hospitals electronic health records do not interface with ACDs, so transcription of orders into the compounder must occur. ...
Purpose
The International Safety and Quality of Parenteral Nutrition (PN) Summit consisted of presentations, discussions, and formulation of consensus statements. The purpose here is to briefly summarize the summit and to present the consensus statements.
Summary
There was a high degree of consensus, with all statements approved by all authors/summit experts. These consensus statements should be regarded not as formal guidelines but rather as best-practice guidance intended to complement national and international nutrition society evidence-based guidelines and position statements. This article also summarizes key discussion topics from the summit, encompassing up-to-date knowledge and practical guidance concerning PN safety and quality in various countries and clinical settings, focusing on adult patients. Clear geographical differences exist between practices in Europe and the United States, and different approaches to improve the safety, quality, and cost-effectiveness of PN vary, particularly with regard to the delivery systems used. Discussion between experts allowed for an exchange of practical experience in optimizing PN use processes, opportunities for standardization, use of electronic systems, potential improvements in PN formulations, better management during PN component shortages, and practical guidance to address patients’ needs, particularly during long-term/home PN.
Conclusion
The consensus statements are the collective opinion of the panel members and form best-practice guidance. The authors intend that this guidance may help to improve the safety and quality of PN in a variety of settings by bridging the gap between published guideline recommendations and common practical issues.
... Training clinicians to provide specialist-level care to children and youth with mental health and neurodevelopmental conditions is another approach for promoting best practices in antipsychotic laboratory monitoring of children and youth. This approach has been implemented in Ontario through Project Extension of Community Health Outcomes (ECHO) (56,57). Project ECHO Ontario uses a continuing professional education model to train health care providers throughout Ontario to provide specialist-level care to children and youth with mental health and neurodevelopmental conditions. ...
Background
In 2011, the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) published guidelines for the metabolic monitoring of antipsychotic-treated children and youth. Population-based studies examining adherence to these guidelines are needed to ensure the safe use of antipsychotics in children and youth.
Methods
We conducted a population-based study of all Ontario residents aged 0 to 24 who were newly dispensed an antipsychotic between April 1, 2018, and March 31, 2019. We estimated prevalence ratios (PRs) and 95% confidence intervals (CI) associating sociodemographic characteristics with the receipt of baseline and follow-up (3- and 6-month) laboratory testing using log-Poisson regression models.
Results
Overall, 6,505 of 27,718 (23.5%) children and youth newly dispensed an antipsychotic received at least one guideline-recommended baseline test. Monitoring was more prevalent among individuals aged 10 to 14 years (PR 1.20; 95% CI 1.04 to 1.38), 15 to 19 years (PR 1.60; 95% CI 1.41 to 1.82), and 20 to 24 years (PR 1.71; 95% CI 1.50 to 1.94) compared to children under the age of 10. Baseline monitoring was associated with mental health-related hospitalizations or emergency department visits in the year preceding therapy (PR 1.76; 95% CI 1.65 to 1.87), a prior diagnosis of schizophrenia (PR 1.20; 95% CI 1.14 to 1.26) or diabetes (PR 1.35; 95% CI 1.19 to 1.54), benzodiazepine use (PR 1.13; 95% CI 1.04 to 1.24), and receipt of a prescription from a child and adolescent psychiatrist or developmental pediatrician versus a family physician (PR 1.41; 95% CI 1.34 to 1.48). Conversely, monitoring was less frequent in individuals co-prescribed stimulants (PR 0.83; 95% CI 0.75 to 0.91). The prevalence of any 3- and 6-month follow-up monitoring among children and youth receiving continuous antipsychotic therapy at these time points was 13.0% (1,179 of 9,080) and 11.4% (597 of 5,261), respectively. Correlates of follow-up testing were similar to those of baseline monitoring.
Conclusion
Most children initiating antipsychotic therapy do not receive guideline-recommended metabolic laboratory monitoring. Further research is needed to understand reasons for poor guideline adherence and the role of clinician training and collaborative service models in promoting best monitoring practices.
... It has demonstrated improvement in health outcomes and addressed mostly geographical barriers to healthcare access [14] . In that space, the ECHO model provides a unique pedagogical approach that empowers accessible primary health workers through the extrapolation of knowledge at an interactive platform so that people in rural areas with limited access to specialists can receive almost similar specialized care [15] . ...
Background:
A robust emergency care system is a cost-effective method of reducing preventable death and disability, especially in low-and middle-income countries. To scale emergency care expertise across the country, the Uganda Ministry of Health and Seed Global Health established the Emergency Medical Services (EMS) ECHO program. We describe the process of establishing the program in a resource-limited setting, best practices, and lessons learned in Uganda.
Methods:
Investigators conducted a mixed-methods evaluation to assess the initial 4 months' implementation of the EMS ECHO. We conducted pre/post-program assessments of healthcare worker knowledge, self-efficacy, and professional's satisfaction with the program. The analysis compared the differences between pre/post-test scores descriptively.
Results:
The EMS ECHO was initiated in November 2021. A phased curriculum was developed with the initial phase focusing on the ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) approach to the emergency patient. This phase reached 2,030 health workers cumulatively across 200 health facilities. The majority of the participants were medical doctors (n = 751, 37%), and nurses (n = 568, 28%). Majority of participants (95%) rated the sessions as informative. On whether the ECHO sessions diminished professional isolation, 66% agreed or strongly agreed.
Conclusions:
Similar to other ECHO program evaluation results, Uganda's EMS ECHO program improved knowledge, skills, and the development of a virtual community of practice thereby diminishing professional isolation. It also demonstrates that through a planned stepwise process, virtual learning and telementorship can be used efficiently to improve healthcare worker knowledge,skills and multiply the limited number of emergency care experts available in the country.
... Clinician education and training programs enabling concordance with treatment guidelines and best practices are alternative approaches for optimizing psychotropic drug use in children and youth, with several programs in the United States demonstrating improved prescribing appropriateness for stimulants and antipsychotics [64,65]. A similar approach has been implemented in Ontario through Project Extension of Community Health Outcomes (ECHO) [66]. Project ECHO Ontario uses an innovative continuing professional education model to train health care providers throughout the province to provide specialist-level care to children and youth with mental health and neurodevelopmental conditions, with over 700 providers being trained since 2016. ...
Background
Population-based research examining geographic variability in psychotropic medication dispensing to children and youth and the sociodemographic correlates of such variation is lacking. Variation in psychotropic use could reflect disparities in access to non-pharmacologic interventions and identify potentially concerning use patterns.
Methods
We conducted a population-based study of all Ontario residents aged 0 to 24 years who were dispensed a benzodiazepine, stimulant, antipsychotic or antidepressant between January 1, 2018, and December 31, 2018. We conducted small-area variation analyses and identified determinants of dispensing using negative binomial generalized estimating equation models.
Results
The age- and sex-standardized rate of psychotropic dispensing to children and youth was 76.8 (range 41.7 to 144.4) prescriptions per 1000 population, with large variation in psychotropic dispensing across Ontario’s census divisions. Males had higher antipsychotic [rate ratio (RR) 1.40; 95% confidence interval (CI) 1.36 to 1.44) and stimulant (RR 1.75; 95% CI 1.70 to 1.80) dispensing rates relative to females, with less use of benzodiazepines (RR 0.85; 95% CI 0.83 to 0.88) and antidepressants (RR 0.81; 95% CI 0.80 to 0.82). Lower antipsychotic dispensing was observed in the highest income neighbourhoods (RR 0.72; 95% CI 0.70 to 0.75) relative to the lowest. Benzodiazepine (RR 1.12; 95% CI 1.01 to 1.24) and stimulant (RR 1.11; 95% CI 1.01 to 1.23) dispensing increased with the density of mental health services in census divisions, whereas antipsychotic use decreased (RR 0.82; 95% CI 0.73 to 0.91). The regional density of child and adolescent psychiatrists and developmental pediatricians (RR 1.00; 95% CI 0.99 to 1.01) was not associated with psychotropic dispensing.
Conclusion
We found significant variation in psychotropic dispensing among young Ontarians. Targeted investment in regions with long wait times for publicly-funded non-pharmacological interventions and novel collaborative service models may minimize variability and promote best practices in using psychotropics among children and youth.
... 9 It is a guided practice model that uses case-based learning to help participants manage their own cases and acquire generalizable knowledge to provide specialized care to patients locally. 10,11 HHS ASPR, in collaboration with Project ECHO, more than 20 medical professional societies, and the National Emerging Special Pathogens Training and Education Centers (NETEC), launched a series of Project ECHO COVID-19 Clinical Rounds (COVID-19 Clinical Rounds) on March 24, 2020. The purpose of COVID-19 Clinical Rounds is peer-to-peer, real-time sharing of COVID-19 clinical care challenges and successes, as circumstances rapidly evolve. ...
As COVID-19 was declared a health emergency in March 2020, there was immense demand for information about the novel pathogen. This paper examines the clinician-reported impact of Project ECHO COVID-19 Clinical Rounds on clinician learning. Primary sources of study data were Continuing Medical Education (CME) Surveys for each session from the dates of March 24, 2020 to July 30, 2020 and impact surveys conducted in November 2020, which sought to understand participants’ overall assessment of sessions. Quantitative analyses included descriptive statistics and Mann-Whitney testing. Qualitative data were analyzed through inductive thematic analysis. Clinicians rated their knowledge after each session as significantly higher than before that session. 75.8% of clinicians reported they would ‘definitely’ or ‘probably’ use content gleaned from each attended session and clinicians reported specific clinical and operational changes made as a direct result of sessions. 94.6% of respondents reported that COVID-19 Clinical Rounds helped them provide better care to patients. 89% of respondents indicated they ‘strongly agree’ that they would join ECHO calls again.COVID-19 Clinical Rounds offers a promising model for the establishment of dynamic peer-to-peer tele-mentoring communities for low or no-notice response where scientifically tested or clinically verified practice evidence is limited.
... The ECHO approach has successfully trained primary care providers in geriatrics (Bennett et al., 2018) and contributed to increased provider comfort and confidence in their skills (Furlan et al., 2019). This model may help address shortages in HIV specialists and gerontologists in rural communities by providing consultation services to primary care providers, helping them to address clinical challenges associated with aging, comorbidities, or managing multiple medications (Harris et al., 2020). ...
People living with HIV in rural parts of the Southern United States face poor outcomes along the HIV care continuum. Additionally, over half of people with diagnosed HIV are age 50 and older. Older adults living with HIV in the rural South often have complex health and social needs associated with HIV, aging, and the rural environment. Research is needed to understand what support organizations and clinics need in providing care to this population. This qualitative study examines the challenges health and social service providers face in caring for older patients living with HIV. In 2020–2021, we interviewed 27 key informants who work in organizations that provide care to older adults with HIV in the seven states with high rural HIV burden: Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina. Our findings highlight how racism and poverty; culture, politics, and religion; and a lack of healthcare infrastructure collectively shape access to HIV care for older adults in the South. Rural health and social service providers need structural-level changes to improve their care and services.
... 8 Other providers have noted that ECHO is likely not a 'panacea for access to specialty care,' but rather a 'force multiplier' for skills transfer. 9 It, therefore, is important to capture and disseminate quality improvement data to determine the ways in which ECHO programmes best can serve providers' specialty healthcare training needs. ...
... Project ECHO (Extension for Community Health care Outcomes) uses case-based telementoring to support community clinicians to deliver best-practice care. 18 McDonnell Elder et al 19 describe how 1 PBRN has created a statewide network for ECHO programs. The PBRN facilitated a unique funding stream for the ECHO programs by partnering with payers and health care systems. ...
The COVID-19 outbreak is a stark reminder of the ongoing challenge of emerging and reemerging disease, the human cost of pandemics and the need for robust research.¹ For primary care, the advent of COVID-19 has forced an unprecedented wave of practice change. In turn, Practice-Based Research Networks (PBRNs) must rapidly pivot to address the changing environment and the critical challenges faced by primary care. The pandemic has also impacted the ability of PBRNs to deploy traditional research methods such as face-to-face patient and provider interactions, practice facilitation, and stakeholder engagement. Providers need more relevant, patient-centered evidence and the skills to effect change. These skills will become more important than ever as primary care practices evolve in response to the current COVID-19 pandemic and the disparities in health outcomes highlighted by COVID-19 and the global Black Lives Matter social movement for justice. Throughout this issue, authors detail the work conducted by PBRNs that demonstrate many of these evolving concepts. Articles explore how PBRNs can evaluate COVID-19 in primary care, the role of PBRNs in quality improvement, stakeholder engagement, prevention and chronic care management, and patient safety in primary care.
Objectives
The objective of this study was to compare and contrast the experiences of interdisciplinary attendees (spokes) and experts (hub members) from three Extension for Community Healthcare Outcomes (ECHO) programmes: hepatitis C, chronic pain and concurrent mental health and substance use disorders.
Design
Prospective qualitative study.
Setting
Single-centre in tertiary care.
Participants
The team conducted 30 one-on-one interviews with spokes and 4 focus groups with hub members from three ECHO programmes.
Analyses
Three analysts were involved to perform a reflexive thematic analysis.
Results
Our results showed the benefits and limitations of the three ECHOs, varying according to specificities of targeted chronic conditions. Three overarching themes were identified from the data analysis: (1) perceived impacts of an interprofessional educational setting; (2) nature of disease and interprofessional interactions as determinants of clinical practice changes in diagnoses and treatments and (3) impacts on patient engagement and care pathways.
Conclusions
The extent to which a chronic disease relies on a biopsychosocial approach, the degree of interdisciplinary care required and the simplicity/complexity of treatment algorithms influence perceived benefits and barriers to participating in ECHO programmes. These points raised by our study are important in the understanding of the successes and limitations of implementing an ECHO programme. They are essential as they provide key information for tailoring Project ECHO to the chronic disease it addresses.
Primary care providers (PCPs) report insufficient capacity for child and youth mental health care (CYMH). The telementoring program Project ECHO (Extension for Community Healthcare Outcomes) can build capacity, but 75- to 120-minute sessions are a participation barrier. Using a Lean health care paradigm, we designed a 60-minute session, and compared self-reported CYMH capacity strengthening (10 constructs) and satisfaction between 60- and 90-minute sessions. Pre-post (n = 139) and post-cycle (n = 146) survey data were analyzed using generalized linear mixed-effects logistic regression. Capacity strengthening was demonstrated when analyzing both groups together (all Ps ≤ .002). Session duration did not affect capacity strengthening for 9/10 constructs (all Ps > .05), but medication management development was higher with 90-minute sessions ( P = .002). Satisfaction was high in both groups. The 60-minute ECHO CYMH sessions can be used without negative learning outcomes, but more mentoring may be needed to build capacity for psychopharmacologic treatment.
Project Extension for Community Healthcare Outcomes (ECHO) enables healthcare providers to share knowledge and best practices via telementoring. The ECHO model builds provider capacity and improves care for patients with a variety of health conditions. This study describes a Canada-wide National ECHO pilot project in the area of geriatric mental health and reports on the program's impact on providers' care practices. A mixed-methods approach was used to analyze surveys completed by participating healthcare providers. Program evaluation measured satisfaction, achievement of learning objectives, awareness of issues related to geriatric mental health, and comfort and self-efficacy working with older adults. The program led to a statistically significant increase in participants' awareness of issues related to support for older adults with mental illness and comfort and self-efficacy in managing these patients in their own practice. The National ECHO pilot project was successful in building healthcare providers' capacity to care for older adults with mental health issues and positively impacting their practice. These findings support using the ECHO model to provide ongoing geriatric mental health education for clinicians from across Canada and beyond.
The ECHO (Extensions Community Healthcare Outcomes) model of healthcare delivery has grown rapidly since its establishment and increased in popularity in recent years. This expansion has developed alongside the growing incidence of chronic diseases and the need to better manage them. The increasing uptake in ECHO has presented a requirement to assess its true value as healthcare costs are increasing globally, resulting in a growing demand by governments and policy makers to ensure chronic disease management strategies provide true value. Therefore, the aim of this review is to examine the impact that ECHO has on clinical practice and how such impacts are measured or evaluated. A narrative literature review is carried out to examine the outcomes assessed in ECHO-related studies. Three key academic databases were utilised for the literature search: Web of Science, PubMed, and Medline. Keywords relating to the review were chosen and searched for. Papers were screened using specified inclusion and exclusion criteria relating to years of publication (2000–2020), type of publication (original research, review papers and meta-analyses) and language requirements (English language only). This review found that while the ECHO model is expanding, and improving the so-called “knowledge gap” between specialists and primary care physicians, there is also a gap in the ways value is examined within ECHO. Most studies on ECHO lack an examination of patient reported health outcomes and appropriate, comparative costing methods. Current ECHO-related studies lack vital components that demonstrate the value of the model. Such components include patient reported health outcomes and detailed costing comparisons between the ECHO model and the traditional care pathway it is replacing.
Background
In recent years, virtual communities of practice (VCoP) have been used to bridge the knowledge and expertise gap between resourceful health centres and underserved communities. VCoP have the potential to promote learning in the Interprofessional Education (IPE) domain. There is a need to evaluate the quality and effectiveness of VCoP concerning the IPE domain.
Purpose
To develop and test an observational tool for assessing IPE in VCoP.
Methods
An interprofessional research team created a twenty-item tool based on a literature review, and developed over multiple iterations. The Virtual Interprofessional Education (V-IPE) tool underwent testing by two trained independent observers who represented the target audience of research assistants and users of the tool. They each assessed 21 recorded sessions of three VCoPs offered in Ontario, Canada, focused on chronic pain, liver diseases, and rheumatology. Overall agreement and reliability between observers are reported for each item.
Results
The agreement and inter-rater reliability were acceptable. Agreement varied from 23.8% to 100%, and inter-rater reliability varied from −0.33 to 0.64.
Discussion
This tool can be applied as a quality improvement measure to monitor and improve the quality of IPE delivered in VCoPs.
Conclusion
This novel tool can be used as a starting point for developing a more sophisticated and reliable tool to assess IPE delivered in VcoPs.
Introduction:
There is an enormous need for pain education among all health care professions before and after licensure. The study goal was to explore generic and chronic pain-specific factors that influenced uptake of a continuous education program for chronic pain, the Project Extension for Community Health Outcomes (ECHO) CHUM Douleur chronique.
Methods:
The study team conducted 20 semistructured virtual interviews among participants of the program. Interviews were transcribed verbatim, and two analysts used a reflexive thematic analysis approach to generate study themes.
Results:
Five aspects facilitating engagement, continued participation, and uptake of the Project ECHO were identified: rapid access to reliable information, appraising one's knowledge, cultivating meaningful relationships, breaking the silos of learning and practice, and exponential possibilities of treatment orchestrations for a complex condition with no cure. Although participants' experiences of the program was positive overall, some obstacles to engagement and continued participation were identified: heterogeneity of participants' profiles, feelings of powerlessness and discouragement in the face of complex incurable pain conditions, challenges in applying recommendations, medical hierarchy, and missed opportunity for advocacy.
Discussion:
Many disease-specific and contextual factors contributed to an increased motivation to participate in the ECHO program. Some elements, such as the complexity of diagnosis and treatment, and the multidisciplinary requirements to manage cases were identified as elements motivating one's participation in the program but also acting as a barrier to knowledge uptake. These must be understood in the broader systemic challenges of the current health care system and lack of resources to access allied health care.
El presente trabajo se ubica dentro del campo de la neuroestética: el estudio científico de las bases neuronales de la contemplación y creación de una obra de arte . Se analiza el papel que desempeñan las neuronas espejo (NE) en la experiencia estética. Se parte del concepto de enacción de Francisco Varela –“la representación mental creativa de la acción potencial que un ser realiza en el mundo”–, y del de empatía –la “posibilidad de entrar en el sentir de otro”– con sustrato neurológico en el grupo neuronal precitado. Las NE, descritas por G. Rizzolati en 1996, se vinculan con la experiencia estética del creador, permitiendo la anticipación mental al acto creativo que dará origen a su obra, y con la del espectador, participando en la capacidad para conmoverse frente al acto creativo del primero. También se muestran otras perspectivas: las neuronas Gandhi (Ramachandran) que participan en la vinculación del yo con las experiencias del otro, y los hallazgos de Gallagher, quien aprecia las NE como un sistema básico para lograr la simulación interna de las expresiones artísticas de otra persona. Se apela a la idea de “representaciones globales previas” de Changeux, que se activan para poder vincular la historia personal con la experiencia estética del presente, idea que conecta con la teoría de la consciencia central y la consciencia ampliada de Di Masio. Se revisa la Teoria Seleccional de Grupos Neuronales de Edelman, para explicar la relación entre memoria y consciencia y la generación de los qualia. Finalmente, se desarrolla el concepto de exocerebro, de Bartra, entendido como una gran prótesis funcional de contenidos simbólicos que inciden en los circuitos cerebrales y logran variaciones en sus funciones según el contexto cultural donde se desenvuelva el ser humano. Se concluye que las NE son el punto de partida para una comprensión distinta de la experiencia estética, pero cuyo estudio no se agota en las mismas, dada su propia complejidad.
El presente trabajo se ubica dentro del campo de la neuroestética: el estudio científico de las bases neuronales de la contemplación y creación de una obra de arte . Se analiza el papel que desempeñan las neuronas espejo (NE) en la experiencia estética. Se parte del concepto de enacción de Francisco Varela –“la representación mental creativa de la acción potencial que un ser realiza en el mundo”–, y del de empatía –la “posibilidad de entrar en el sentir de otro”– con sustrato neurológico en el grupo neuronal precitado. Las NE, descritas por G. Rizzolati en 1996, se vinculan con la experiencia estética del creador, permitiendo la anticipación mental al acto creativo que dará origen a su obra, y con la del espectador, participando en la capacidad para conmoverse frente al acto creativo del primero. También se muestran otras perspectivas: las neuronas Gandhi (Ramachandran) que participan en la vinculación del yo con las experiencias del otro, y los hallazgos de Gallagher, quien aprecia las NE como un sistema básico para lograr la simulación interna de las expresiones artísticas de otra persona. Se apela a la idea de “representaciones globales previas” de Changeux, que se activan para poder vincular la historia personal con la experiencia estética del presente, idea que conecta con la teoría de la consciencia central y la consciencia ampliada de Di Masio. Se revisa la Teoria Seleccional de Grupos Neuronales de Edelman, para explicar la relación entre memoria y consciencia y la generación de los qualia. Finalmente, se desarrolla el concepto de exocerebro, de Bartra, entendido como una gran prótesis funcional de contenidos simbólicos que inciden en los circuitos cerebrales y logran variaciones en sus funciones según el contexto cultural donde se desenvuelva el ser humano. Se concluye que las NE son el punto de partida para una comprensión distinta de la experiencia estética, pero cuyo estudio no se agota en las mismas, dada su propia complejidad.
El presente trabajo se ubica dentro del campo de la neuroestética: el estudio científico de las bases neuronales de la contemplación y creación de una obra de arte . Se analiza el papel que desempeñan las neuronas espejo (NE) en la experiencia estética. Se parte del concepto de enacción de Francisco Varela –“la representación mental creativa de la acción potencial que un ser realiza en el mundo”–, y del de empatía –la “posibilidad de entrar en el sentir de otro”– con sustrato neurológico en el grupo neuronal precitado. Las NE, descritas por G. Rizzolati en 1996, se vinculan con la experiencia estética del creador, permitiendo la anticipación mental al acto creativo que dará origen a su obra, y con la del espectador, participando en la capacidad para conmoverse frente al acto creativo del primero. También se muestran otras perspectivas: las neuronas Gandhi (Ramachandran) que participan en la vinculación del yo con las experiencias del otro, y los hallazgos de Gallagher, quien aprecia las NE como un sistema básico para lograr la simulación interna de las expresiones artísticas de otra persona. Se apela a la idea de “representaciones globales previas” de Changeux, que se activan para poder vincular la historia personal con la experiencia estética del presente, idea que conecta con la teoría de la consciencia central y la consciencia ampliada de Di Masio. Se revisa la Teoria Seleccional de Grupos Neuronales de Edelman, para explicar la relación entre memoria y consciencia y la generación de los qualia. Finalmente, se desarrolla el concepto de exocerebro, de Bartra, entendido como una gran prótesis funcional de contenidos simbólicos que inciden en los circuitos cerebrales y logran variaciones en sus funciones según el contexto cultural donde se desenvuelva el ser humano. Se concluye que las NE son el punto de partida para una comprensión distinta de la experiencia estética, pero cuyo estudio no se agota en las mismas, dada su propia complejidad.
Project ECHO (Extension for Community Healthcare Outcomes) uses videoconferencing technology to support and train healthcare professionals (HCPs) remotely. A 4‐month fortnightly ECHO programme was developed and implemented to enhance palliative care provision by primary care therapists. Teaching and case‐based discussions were facilitated by palliative care specialists. A mixed‐methods cohort study was used to evaluate the project. ECHO participants completed pre‐ and post‐programme questionnaires regarding their knowledge and skills across key palliative care domains. Focus groups were held before programme commencement to explore participants' attitudes and experiences of palliative care and after programme conclusion to explore their experiences of ECHO. Twenty‐six primary care HCPs commenced the ECHO programme. Mean scores in self‐rated confidence in knowledge and skill improved significantly (p < .002) following the programme. Twenty‐one primary care HCPs completed the post‐ECHO surveys and scores of self‐rated confidence in knowledge and skills were significantly higher than pre‐ECHO scores. Ninety‐five percent of participants (n = 19) reported ECHO met their learning needs and was an effective format to enhance clinical knowledge. Eighty‐five percent of participants (n = 17) would recommend ECHO to their colleagues. Project ECHO improved palliative care knowledge and skills of primary care HCPs in Ireland, with potential to address the growing need for integrated palliative care services.
Imagine a world without technology. What would we do? How would we survive? What would we do without our smartphones? Well, humanity did pretty good for thousands of years, even though there were some significant challenges put in front of our ancestors. Advances in telecommunications, computing power, data storage, and a variety of mechanical devices have helped healthcare, medicine, and public health reach new levels. The integration of these various tools has permitted telemedicine, telehealth, e-health, m-health, and telepresence to become common place and fully entrenched in commerce and all human activity. This chapter presents some of these technological advances at a very high level. A complete or exhaustive list would fill numerous volumes of several compendiums. The important points to remember are that these technological advances continue to amaze us. They become significant and I dare say vital to our way of life and our ability to enable better healthcare.
Introduction:
Inadequate knowledge and training of healthcare providers are obstacles to effective chronic pain management. ECHO (extension for community healthcare outcomes) uses case-based learning and videoconferencing to connect specialists with providers in underserved areas. ECHO aims to increase capacity in managing complex cases in areas with poor access to specialists.
Methods:
A pre-post study was conducted to evaluate the impact of ECHO on healthcare providers' self-efficacy, knowledge and satisfaction. Type of profession, presenting a case, and number of sessions attended were examined as potential factors that may influence the outcomes.
Results:
From June 2014 to March 2017, 296 primary care healthcare providers attended ECHO, 264 were eligible for the study, 170 (64%) completed the pre-ECHO questionnaire and 119 completed post-ECHO questionnaires. Participants were physicians (34%), nurse practitioners (21%), pharmacists (13%) and allied health professionals (32%). Participants attended a mean of 15 ± 9.19 sessions. There was a significant increase in self-efficacy (p < 0.0001) and knowledge (p < 0.0001). Self-efficacy improvement was significantly higher among physicians, physician assistants and nurse practitioners than the non-prescribers group (p = 0.03). On average, 96% of participants were satisfied with ECHO. Satisfaction was higher among those who presented cases and attended more sessions.
Discussion:
This study shows that ECHO improved providers' self-efficacy and knowledge. We evaluated outcomes from a multidisciplinary group of providers practicing in Ontario. This diversity supports the generalisability of our findings. Therefore, we suggest that this project may be used as a template for creating other educational programs on other medical topics.
Background
Urban environments can influence many aspects of health and well-being and access to health care is one of them. Access to primary health care (PHC) in urban settings is a pressing research and policy issue in Canada. Most research on access to healthcare is focused on national and provincial levels in Canada; there is a need to advance current understanding to local scales such as neighbourhoods.
Methods
This study examines spatial accessibility to family physicians using the Three-Step Floating Catchment Area (3SFCA) method to identify neighbourhoods with poor geographical access to PHC services and their spatial patterning across 14 Canadian urban settings. An index of spatial access to PHC services, representing an accessibility score (physicians-per-1000 population), was calculated for neighborhoods using a 3km road network distance. Information about primary health care providers (this definition does not include mobile services such as health buses or nurse practitioners or less distributed services such as emergency rooms) used in this research was gathered from publicly available and routinely updated sources (i.e. provincial colleges of physicians and surgeons). An integrated geocoding approach was used to establish PHC locations.
Results
The results found that the three methods, Simple Ratio, Neighbourhood Simple Ratio, and 3SFCA that produce City level access scores are positively correlated with each other. Comparative analyses were performed both within and across urban settings to examine disparities in distributions of PHC services. It is found that neighbourhoods with poor accessibility scores in the main urban settings across Canada have further disadvantages in relation to population high health care needs.
Conclusions
The results of this study show substantial variations in geographical accessibility to PHC services both within and among urban areas. This research enhances our understanding of spatial accessibility to health care services at the neighbourhood level. In particular, the results show that the low access neighbourhoods tend to be clustered in the neighbourhoods at the urban periphery and immediately surrounding the downtown area.
Rurality can contribute to the vulnerability of people with chronic diseases. Qualitative research can identify a wide range of health care access issues faced by patients living in a remote or rural setting.
To systematically review and synthesize qualitative research on the advantages and disadvantages rural patients with chronic diseases face when accessing both rural and distant care.
This report synthesizes 12 primary qualitative studies on the topic of access to health care for rural patients with chronic disease. Included studies were published between 2002 and 2012 and followed adult patients in North America, Europe, Australia, and New Zealand.
Qualitative meta-synthesis was used to integrate findings across primary research studies.
THREE MAJOR THEMES WERE IDENTIFIED: geography, availability of health care professionals, and rural culture. First, geographic distance from services poses access barriers, worsened by transportation problems or weather conditions. Community supports and rurally located services can help overcome these challenges. Second, the limited availability of health care professionals (coupled with low education or lack of peer support) increases the feeling of vulnerability. When care is available locally, patients appreciate long-term relationships with individual clinicians and care personalized by familiarity with the patient as a person. Finally, patients may feel culturally marginalized in the urban health care context, especially if health literacy is low. A culture of self-reliance and community belonging in rural areas may incline patients to do without distant care and may mitigate feelings of vulnerability.
Qualitative research findings are not intended to generalize directly to populations, although meta-synthesis across a number of qualitative studies builds an increasingly robust understanding that is more likely to be transferable. Selected studies focused on the vulnerability experiences of rural dwellers with chronic disease; findings emphasize the patient rather than the provider perspective.
This study corroborates previous knowledge and concerns about access issues in rural and remote areas, such as geographical distance and shortage of health care professionals and services. Unhealthy behaviours and reduced willingness to seek care increase patients' vulnerability. Patients' perspectives also highlight rural culture's potential to either exacerbate or mitigate access issues.
People who live in a rural area may feel more vulnerable-that is, more easily harmed by their health problems or experiences with the health care system. Qualitative research looks at these experiences from the patient's point of view. We found 3 broad concerns in the studies we looked at. The first was geography: needing to travel long distances for health care can make care hard to reach, especially if transportation is difficult or the weather is bad. The second concern was availability of health professionals: rural areas often lack health care services. Patients may also feel powerless in "referral games" between rural and urban providers. People with low education or without others to help them may find navigating care more difficult. When rural services are available, patients like seeing clinicians who have known them for a long time, and like how familiar clinicians treat them as a whole person. The third concern was rural culture: patients may feel like outsiders in city hospitals or clinics. As well, in rural communities, people may share a feeling of self-reliance and community belonging. This may make them more eager to take care of themselves and each other, and less willing to seek distant care. Each of these factors can increase or decrease patient vulnerability, depending on how health services are provided.
The purpose of this study is to determine whether an innovative interactive distance training program is an effective modality to train community health workers (CHWs) to become members of the diabetes health care team. The University of New Mexico Health Sciences Center has developed a rigorous diabetes training program for CHWs involving both distance and hands-on learning as part of Project ECHO™ (Extension for Community Healthcare Outcomes).
Twenty-three diverse CHW participants from across New Mexico were enrolled in the first training session. Participants completed surveys at baseline and at the end of the program. They attended a 3-day hands-on training session, followed by weekly participation in tele/video conferences for 6 months. Wilcoxon signed-rank statistics were used to compare pre- and posttest results.
Participants demonstrated significant improvements in diabetes knowledge (P = .002), diabetes attitudes (P = .04) and confidence in both clinical and nonclinical skills (P < .001 and P = .04, respectively). Additionally, during focus group discussions, participants reported numerous benefits from participation in the program.
Community health worker participation in the Project ECHO diabetes training program resulted in significant increases in knowledge, confidence, and attitudes in providing care to patients with diabetes. Studies are ongoing to determine whether the training has a positive impact on patient outcomes.
The Extension for Community Healthcare Outcomes (ECHO) model was developed to improve access to care for underserved populations with complex health problems such as hepatitis C virus (HCV) infection. With the use of video-conferencing technology, the ECHO program trains primary care providers to treat complex diseases.
We conducted a prospective cohort study comparing treatment for HCV infection at the University of New Mexico (UNM) HCV clinic with treatment by primary care clinicians at 21 ECHO sites in rural areas and prisons in New Mexico. A total of 407 patients with chronic HCV infection who had received no previous treatment for the infection were enrolled. The primary end point was a sustained virologic response.
A total of 57.5% of the patients treated at the UNM HCV clinic (84 of 146 patients) and 58.2% of those treated at ECHO sites (152 of 261 patients) had a sustained viral response (difference in rates between sites, 0.7 percentage points; 95% confidence interval, -9.2 to 10.7; P=0.89). Among patients with HCV genotype 1 infection, the rate of sustained viral response was 45.8% (38 of 83 patients) at the UNM HCV clinic and 49.7% (73 of 147 patients) at ECHO sites (P=0.57). Serious adverse events occurred in 13.7% of the patients at the UNM HCV clinic and in 6.9% of the patients at ECHO sites.
The results of this study show that the ECHO model is an effective way to treat HCV infection in underserved communities. Implementation of this model would allow other states and nations to treat a greater number of patients infected with HCV than they are currently able to treat. (Funded by the Agency for Healthcare Research and Quality and others.).
Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need because of various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions, and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have collaborated on more than 10,000 specialty care consultations for hepatitis C and other chronic diseases.
Inadequate access to care for mentally ill children and their families is a persistent problem in the United States. Although promotion of pediatric primary care clinicians (PCCs) in detection, management, and coordination of child mental health care is a strategy for improving access, limitations in training, time, and specialist availability represent substantial barriers. The Massachusetts Child Psychiatry Access Project (MCPAP), publicly funded with 6 regional consultation teams, provides Massachusetts PCCs with rapid access to child psychiatry expertise, education, and referral assistance.
Data collected from MCPAP teams measured participation and utilization over 3.5 years from July 1, 2005, to December 31, 2008. Data were analyzed for 35,335 encounters. PCC surveys assessed satisfaction and impact on access to care.
The MCPAP enrolled 1341 PCCs in 353 practices covering 95% of the youth in Massachusetts. The MCPAP served 10,114 children. Practices varied in their utilization of the MCPAP, with a mean of 12 encounters per practice per quarter (range: 0-245). PCCs contacted the MCPAP for diagnostic questions (34%), identifying community resources (27%), and consultation regarding medication (27%). Provider surveys revealed improvement in ratings of access to child psychiatry. The rate of PCCs who reported that they are usually able to meet the needs of psychiatric patients increased from 8% to 63%. Consultations were reported to be helpful by 91% of PCCs.
PCCs have used and value a statewide system that provides access to teams of psychiatric consultants. Access to child mental health care may be substantially improved through public health interventions that promote collaboration between PCCs and child mental health specialists.
Background :
Geriatrics training is essential for future primary care providers. The Extension for Community Healthcare Outcomes (ECHO) model improves access to specialty care via case-based videoconferencing, but Project ECHO has not previously been designed to target residents.
Objective :
We designed Project ECHO-Geriatrics to deliver geriatrics education to primary care trainees using the ECHO model and evaluated self-rated geriatrics competency of trainees from the University of Washington Family Medicine Residency Network programs who participated between January 2016 and March 2017.
Methods :
We assessed outcomes of Project ECHO-Geriatrics through anonymous surveys. Participants rated didactics, case discussions, and geriatrics-specific knowledge before and after sessions on a 5-point scale (1, low, to 5, high). Participants were asked whether they planned to do anything differently in their practice and, if yes, to describe this change.
Results :
Fifteen sessions were held with 204 unique participants from 12 sites, with an average of 28 (range, 13-41) participants per session. From the 9 of 29 (31%) Family Medicine Residency Network programs that enrolled, 63% percent (116 of 184) of eligible residents attended. Sessions were highly rated (89% of responses were 4 or 5). Self-reported geriatrics-specific knowledge increased significantly (before 3.3 [SD = 0.89] versus after 4.0 [SD = 0.60], P < .001). Sixty-five percent (118 of 181) of participants reported plans to change their practice.
Conclusions :
Project ECHO-Geriatrics is an innovative, feasible way to train the future primary care workforce in geriatrics and grow the capacity to provide high-quality care to older adults.
Background:
The referral-consultation process can be difficult to navigate. Electronic consultations (eConsults) can help streamline referrals by facilitating inter-provider communication.
Objective:
We evaluated the potential effect of eConsult on specialist referral rates in Ontario among family physicians providing comprehensive care.
Methods:
We conducted a retrospective 1:3 matched cohort study examining total referrals and referrals to all available medical specialties from primary care providers between 1 April 2014 and 31 March 2015. We used multivariable random effects Poisson regression analysis to compare referral rates between eConsult and non-eConsult users while adjusting for relevant patient and provider characteristics. Referral rates were expressed per physician, per 100 patients and per 100 patient encounters.
Results:
There were 113197 referrals across all medical specialties made by 119 eConsult physicians and 352 matched controls. Referral rates per physician were significantly lower in the eConsult group for all specialty groupings [unadjusted rate ratio (RR) = 0.87, 95% confidence interval (CI) = 0.80-0.95; adjusted RR = 0.92, 95% CI = 0.85-1.00]. Referral rates per patient were lower among eConsult physicians (unadjusted RR = 0.91, 95% CI = 0.84-0.98) but this difference was not statistically significant after adjustment (adjusted RR = 0.96, 95% CI = 0.90-1.02). No statistically significant difference was observed when referrals were expressed per 100 patient encounters.
Conclusion:
This is the first Canadian study to examine the potential effect of eConsult on overall referrals at a population level. Our findings demonstrate that using eConsult service is associated with fewer referrals from primary to specialist care, with considerable potential for cost savings to our single-payer system.
Equitable access and distribution of health care services for rural and remote populations is a substantial challenge for health workforce planners and policy makers. Geospatial examination of access to health care considers both need and supply dimensions together to determine spatial access scores which contribute to a greater understanding of potential inequity in accessibility. This geospatial investigation explores geographic variation in accessibility to primary health care services utilizing combined access scores for family physicians and nurse practitioner services in urban and rural communities in the Canadian Prairie provinces of Saskatchewan and Alberta. An index of access scores was developed using a floating catchment area framework and a census subdivision geographic unit. Information about family physician and nurse practitioner practice locations and spatial population data were obtained from the Canadian Institute for Health Information and Statistics Canada respectively. Alberta has a better overall provincial access score than Saskatchewan for family physicians and nurse practitioners combined (11.37 vs. 9.77). The results demonstrate that nurse practitioner services are likely addressing primary care access gaps due to reduced numbers of family physician services in certain geographical areas. Combined access scores reveal inequalities in the distribution of primary health care services relative to the proportion of population aged 65 + across both provinces, particularly in rural and remote communities. This study contributes to health services research by exploration of combined access scores for family physician and nurse practitioner services in relation to the distribution of seniors. These findings provide insight into which areas may be in need of increased primary health care services with a focus on both of these health professional groups. The findings of this research will serve as a foundational model for future expansion of the methods to other health care provider groups and to other population health need indicators provincially and nationally.
Objective:
Family physicians in Canada receive little training in chronic pain management; concomitantly, they face increasing pressure to reduce their prescribing of opioids. Project ECHO Ontario Chronic Pain/Opioid Stewardship (ECHO) is a telementoring intervention for primary care practitioners that enhances their pain management skills. This qualitative study reports participants' experiences and assessment of ECHO.
Design:
An opportunistic sample of multidisciplinary primary care providers attending one of three residential weekend workshops participated in focus group discussions.
Setting:
University or hospital facilities in Toronto, Thunder Bay, and Kingston, Ontario, Canada.
Subjects:
Seventeen physicians and 20 allied health professionals.
Methods:
Six focus group discussions were conducted at three different sites during 2014 and 2015. Transcripts were analyzed using a qualitative-descriptive approach involving analytic immersion in the data, reflection, and achieving consensus around themes discerned from transcribed discussions.
Results:
Findings resolved into five main themes: 1) challenges of managing chronic pain in primary care; 2) ECHO participation and improvement in patient-provider interaction and participant knowledge; 3) the diffusion of knowledge gained through ECHO to participants' colleagues and patients; 4) ECHO participation generating a sense of community; and 5) disadvantages associated with participating in ECHO.
Conclusions:
Managing patients with chronic pain in primary care can be difficult, particularly in remote or underserved practices. Project ECHO offers guidance to primary care practitioners for their most challenging patients, promotes knowledge acquisition and diffusion, and stimulates the development of a "community of practice."
Background:
A pilot program using the Project Extension for Community Healthcare Outcomes (ECHO) model was conducted for multiple sclerosis (MS) clinicians in the Pacific Northwest. The pilot was a collaboration between the National Multiple Sclerosis Society and faculty at the University of Washington. The goal was to determine the feasibility of using this telehealth model to increase the capacity and capability of clinicians in rural areas to treat people with MS.
Methods:
Thirteen practice sites with 24 clinicians were recruited to participate. Videoconferencing was used to conduct weekly sessions consisting of brief didactics followed by case consultations.
Results:
Most participants completing the outcome survey (10 of 15) indicated that they were more confident in treating patients with MS. They were satisfied with the training, felt better able to care for their patients, and had made changes in their treatment based on the case consultations and didactic content. They valued the case studies and case-based didactics and learned from each other as well as from the team.
Conclusions:
The pilot MS Project ECHO warrants further investigation regarding its potential effect on access to MS care delivery for underserved populations.
Objective:
Project Extension for Community Healthcare Outcomes (Project ECHO©) addresses urban-rural disparities in access to specialist care by building primary care provider (PCP) capacity through tele-education. Evidence supporting the use of this model for mental health care is limited. Therefore, this study evaluated a mental health and addictions-focused ECHO program. Primary outcome measures were PCP knowledge and perceived self-efficacy. Secondary objectives included: satisfaction, engagement, and sense of professional isolation. PCP knowledge and self-efficacy were hypothesized to improve with participation.
Methods:
Using Moore's evaluation framework, we evaluated the ECHO program on participant engagement, satisfaction, learning, and competence. A pre-post design and weekly questionnaires measured primary and secondary outcomes, respectively.
Results:
Knowledge test performance and self-efficacy ratings improved post-ECHO (knowledge change was significant, p < 0.001, d = 1.13; self-efficacy approached significance; p = 0.056, d = 0.57). Attrition rate was low (7.7%) and satisfaction ratings were high across all domains, with spokes reporting reduced feelings of isolation.
Discussion:
This is the first study to report objective mental health outcomes related to Project ECHO. The results indicate high-participant retention is achievable, and provide preliminary evidence for increased knowledge and self-efficacy. These findings suggest this intervention may improve mental health management in primary care.
Objectives:
To implement the ECHO telementoring model for hepatitis C and to evaluate its outcomes in the health providers.
Methods:
Following the ECHO model, an hepatitis C teleECHO clinic was established at the Hospital Italiano in Argentina. The teleECHO clinic provides support and training to physicians from Patagonia who treat patients with hepatitis C. In order to evaluate the teleECHO clinic outcomes, physicians completed a survey focused on skills and competence in hepatitis C before and after six months of participating in the project. The survey consisted of 10 questions, which participants rated from 1 to 7 (1 no ability; 7 highest ability). To analyze the difference before and after participation in the project, Wilcoxon signed-rank test was used.
Results:
During the first six months of implementation of the model, a total of 14 physicians from 12 sites in Patagonia agreed to participate in the survey. The median age of the participants was 42 years. Participants' primary specialties were Hepatology (55%), Infectious Diseases (25%), General Practice (10%), and other (10%). A significant improvement was observed in all the evaluated fields after six month of the participation in the teleECHO clinic, namely fibrosis staging, determining appropriate candidates for treatment, and selecting appropriate HCV treatment. In addition, their general interest in hepatitis C increased.
Conclusions:
We successfully replicated and implemented the first teleECHO clinic in Argentina. Physicians improved their ability to provide best practice care for patients with Hepatitis C. This article is protected by copyright. All rights reserved.
Purpose:
Project Extension for Community Healthcare Outcomes (ECHO) uses tele-education to bridge knowledge gaps between specialists at academic health centers and primary care providers from remote areas. It has been implemented to address multiple medical conditions. The authors examined evidence of the impact of all Project ECHO programs on participant and patient outcomes.
Method:
The authors searched PubMed, MEDLINE, EMBASE, PsycINFO, and ProQuest from January 2000 to August 2015 and the reference lists of identified reviews. Included studies were limited to those published in English, peer-reviewed articles or indexed abstracts, and those that primarily focused on Project ECHO. Editorials, commentaries, gray literature, and non-peer-reviewed articles were excluded. The authors used Moore's evaluation framework to organize study outcomes for quality assessment.
Results:
The authors identified 39 studies describing Project ECHO's involvement in addressing 17 medical conditions. Evaluations of Project ECHO programs generally were limited to outcomes from Levels 1 (number of participants) to 4 (providers' competence) of Moore's framework (n = 22 studies, with some containing data from multiple levels). Studies also suggested that Project ECHO changed provider behavior (n = 1), changed patient outcomes (n = 6), and can be cost-effective (n = 2).
Conclusions:
Project ECHO is an effective and potentially cost-saving model that increases participant knowledge and patient access to health care in remote locations, but further research examining its efficacy is needed. Identifying and addressing potential barriers to Project ECHO's implementation will support the dissemination of this model as an education and practice improvement initiative.
Chronic pain is a prevalent and serious problem in the province of Ontario. Frontline primary care providers (PCPs) manage the majority of chronic pain patients, yet receive minimal training in chronic pain. ECHO (Extension for Community Healthcare Outcomes) Ontario Chronic Pain & Opioid Stewardship aims to address the problem of chronic pain management in Ontario. This paper describes the development, operation, and evaluation of the ECHO Ontario Chronic Pain project. We discuss how ECHO increases PCP access and capacity to manage chronic pain, the development of a community of practice, as well as the limitations of our approach. The ECHO model is a promising approach for healthcare system improvement. ECHO's strength lies in its simplicity, adaptability, and use of existing telemedicine infrastructure to increase both access and capacity of PCPs in underserviced, rural, and remote communities.
Telepsychiatry has clinical efficacy with children, but questions remain about cost-effectiveness. State agencies and health systems need to know if a child telepsychiatry consult system can address system concerns and improve care quality while lowering costs.
To assist care in a rural state with few child and adolescent psychiatrists, an academic center coordinated a consult system of (1) televideo consults for high-needs children with Medicaid and state Multidisciplinary Team (MDT)/foster care involvement, (2) remote medication reviews for beyond guidelines prescribing, and (3) elective community provider telephone-based consults. Consult service data were collected and analyzed with Wyoming's Medicaid and Foster Care Divisions between the program start in January 2011 until March 2013.
There were 229 televideo MDT/foster care consults, 125 mandatory medication reviews, and 277 elective phone consultations supporting community providers during this period. Following implementation, the number of Medicaid children ≤5 years of age using psychotropic medications decreased by 42% (p<0.001), and the number of children using psychotropic doses >150% of the Food and Drug Administration maximum decreased by 52% (p<0.001). Televideo consults redirected 60% of children slated by caseworkers for a psychiatric residential treatment facility admission into alternative community treatment and placements. A financial return on investment was 1.82 to 1 for combined services.
This coordinated child telepsychiatry consult system for a state Medicaid division reduced outlier pediatric psychiatric medication prescribing, supported local community-delivered treatments, and reduced unnecessary hospitalizations in a financially advantageous manner that was well received by the practice community.
Objective
Project TEACH provides training, consultation and referral support to build child and adolescent mental health (MH) expertise among primary care providers (PCPs) . This study describes how TEACH engages PCP, how program components lead to changes in practice, and how contextual factors influence sustainability.
Method
30 PCPs randomly selected from 139 trained PCPs and 10 PCPs from 143 registered with TEACH but not yet trained completed semi-structured interviews. PCP selection utilized purposeful sampling for region, rurality and specialty. Interviews were recorded, transcribed and analyzed using grounded theory.
Results
PCP participation was facilitated by perceived patient needs,lack of financial and logistic barriers and continuity of PCP-program relationships from training to ongoing consultation. Trained PCPs reported more confidence interacting with families about MH, assessing severity, prescribing medication, and developing treatment plans. They were encouraged by satisfying interactions with MH specialists and positive feedback from families. Barriers included difficulties implementing screening, time constraints, competing demands, guarded expectations for patient outcomes and negative impressions of the MH system overall.
Conclusions
Programs like TEACH can increase PCP confidence in MH care and promoteincreased MH treatment in primary care and through collaboration with specialists. Sustainability may depend on the PCP practice context and implementation support.
Project ECHO Pain, the innovative telementoring program for health professionals, was developed in 2009 at the University Of New Mexico Health Sciences Center to fill considerable gaps in pain management expertise. Substantive continuing education for clinicians who practice in rural and underserved communities convenes weekly by means of telehealth technology. Case-based learning, demonstrations, and didactics are incorporated into the interprofessional program that helps to improve pain management in the primary care setting.
Three different approaches were used to evaluate the program over a 3-year period: (1) evaluation of all weekly continuing medical education surveys; (2) aggregation of annual clinic data; and (3) assessment of practice change in clinicians who joined Project ECHO Pain for at least 1 year.
Between January 2010 and December 2012, 136 Project ECHO Pain clinics were held, with 3835 total instances of participation, representing 763 unique individuals from 191 different sites. Sixty percent self-identified as advanced practice or other nonphysician health professional. Statistically significant improvements in participant self-reported knowledge, skills, and practice were demonstrated. Focus group analyses of 9 subjects detailed specific practice improvements.
Project ECHO Pain is a successful continuing professional development program. The telementoring model closes the large knowledge gap in pain education seen in primary care and other settings. Expertise is delivered by implementing effective, evidence-based, and work-based education for diverse health professionals. Project ECHO Pain serves as a model for interprofessional collaborative practice.
In the past 100 years, there has been an explosion of medical knowledge-and in the next 50 years, more medical knowledge will be available than ever before. Regrettably, current medical practice has been unable to keep pace with this explosion of medical knowledge. Specialized medical knowledge has been confined largely to academic medical centers (i.e., teaching hospitals) and to specialists in major cities; it has been disconnected from primary care clinicians on the front lines of patient care. To bridge this disconnect, medical knowledge must be demonopolized, and a platform for collaborative practice amongst all clinicians needs to be created. A new model of health care and education delivery called Project ECHO (Extension for Community Healthcare Outcomes), developed by the first author, does just this. Using videoconferencing technology and case-based learning, ECHO's medical specialists provide training and mentoring to primary care clinicians working in rural and urban underserved areas so that the latter can deliver the best evidence-based care to patients with complex health conditions in their own communities. The ECHO model increases access to care in rural and underserved areas, and it demonopolizes specialized medical knowledge and expertise.
Very little literature exists on rural specialists as a unique group and how best to meet their needs. We sought to provide some baseline information on specialists practising in rural and remote Canada to better understand their reasons for working rurally, their workload and how supported they felt, as well as their sources of advice and satisfaction with continuing medical education (CME).
The Society of Rural Physicians of Canada mailed a survey to specialists working in rural and remote Canada. Specialists were identified based on databases of the Canadian Medical Association (CMA) and the provincial colleges. The survey focused on reason(s) for working in a rural or remote setting, level of support and CME.
The survey was sent to 1500 physicians and yielded a 19% response rate. Although 85% of respondents felt supported overall, less than 20% felt supported by the CMA or by the Royal College of Physicians and Surgeons of Canada (RCPSC). Conversely, most felt supported by immediate colleagues (85%) and their community (78%). Most wished they had access to more training, with close to 90% agreeing that additional training should be available if they had worked for several years in a rural or remote area and a need was demonstrated.
The CMA and the RCPSC may wish to work with rural specialists to foster a more supportive relationship and better meet their needs. Additionally, efforts should be made to provide rural specialists with better access to relevant CME.
Psychiatric disorders are hard to detect in a primary care setting. The vocational training for general practitioners (GPs) of the University of Maastricht, the Netherlands, intends to create a new comprehensive programme on diagnosing psychiatric disorders.
We consulted the literature to obtain an answer to the question: is evidence available for the effectiveness of specific educational methods to teach GP trainees psychiatric diagnostic skills?
We searched in four databases for studies on a variety of search terms (39) referring to primary care, psychiatry, diagnosis, education and quality. As selection criterium for outcome measure we took change in diagnostic competence.
From a number of 769 articles 27 methodologically sound studies remained. This article presents several of their research characteristics. No conclusive evidence has been found for the effectivity of an isolated educational method. The combination of methods seems promising. However, no specific mix of methods is a guarantee for success.
We made some recommendations for training psychiatric diagnostic competency. The literature endorses our own idea that education in this field should include reflection on attitude and barriers.
The authors conducted a critical review of the literature on interventions to improve provider recognition and management of mental disorders in primary care, searching the MEDLINE database for relevant articles published from 1966 through May 1998 and finding 48 usable controlled studies (27 randomized controlled trials and 21 quasi-experimental studies). Improved diagnosis of mental disorders was reported in 18 of 23 (78%) of the studies examining this outcome and improved treatment in 14 of 20 studies (70%); clinical improvement in psychiatric symptoms or functional status was documented in 4 of 11 and 4 of 8 (36% and 50%, respectively). Considerable study heterogeneity precluded subjecting the literature synthesis to a formal meta-analysis of pooled results; the authors were therefore unable to demonstrate an association between efficacy of an intervention and any specific variables. A variety of interventions and further research may be effective in improving the recognition and management of mental disorders in primary care.
The authors describe an innovative academic health center (AHC)-led program of health care delivery and clinical education for the management of complex, common, and chronic diseases in underserved areas, using hepatitis C virus (HCV) as a model. The program, based at the University of New Mexico School of Medicine, represents a paradigm shift in thinking and funding for the threefold mission of AHCs, moving from traditional fee-for-service models to public health funding of knowledge networks. This program, Project Extension for Community Health care Outcomes (ECHO), involves a partnership of academic medicine, public health offices, corrections departments, and rural community clinics dedicated to providing best practices and protocol-driven health care in rural areas. Telemedicine and Internet connections enable specialists in the program to comanage patients with complex diseases, using case-based knowledge networks and learning loops. Project ECHO partners (nurse practitioners, primary care physicians, physician assistants, and pharmacists) present HCV-positive patients during weekly two-hour telemedicine clinics using a standardized, case-based format that includes discussion of history, physical examination, test results, treatment complications, and psychiatric, medical, and substance abuse issues. In these case-based learning clinics, partners rapidly gain deep domain expertise in HCV as they collaborate with university specialists in hepatology, infectious disease, psychiatry, and substance abuse in comanaging their patients. Systematic monitoring of treatment outcomes is an integral aspect of the project. The authors believe this methodology will be generalizable to other complex and chronic conditions in a wide variety of underserved areas to improve disease outcomes, and it offers an opportunity for AHCs to enhance and expand their traditional mission of teaching, patient care, and research.
- M O Mazurek
- R Brown
- A Curran
- K Sohl
- Echo
Mazurek MO, Brown R, Curran A, Sohl K. ECHO autism. Clin
Pediatr (Phila) 2017;56:247-56.
Quality Improvement in Maternity Care via Project
AMCHP. Quality Improvement in Maternity Care via Project
[Downloaded free from http://www.cjrm.ca on Monday, September 23, 2019, IP: 10.232.74.27]
ECHO; 2017. Available from: http://www.amchp.org/
programsandtopics/BestPractices/InnovationStation/ISDocs/IS_
Project%20ECHO.pdf. [Last accessed on 2019 Jun 05].
, Boyle JF, Duhigg D, Shelley B, Olivas C, et al. Innovative telementoring for pain management: Project ECHO pain
- Katzman