Project ECHO Expands Access to Diabetes Knowledge
By Devanshi Gupta
diaTribe spoke with Dr. Nick Cuttriss, founding director of the ECHO Diabetes Action Network (EDAN), to learn how Project ECHO Diabetes and EDAN use telementoring to address health system failures for people with diabetes in vulnerable communities.
People with diabetes are often advised to see endocrinologists (“endos”), – a medical doctor who specializes in the treatment of diabetes, among many other conditions. Unfortunately, in the United States there is only about one endocrinologist for every 6,500 people with diabetes.
Instead of receiving care from a specialist, most people depend on their primary care physicians (PCPs) for diabetes care. Unfortunately, PCPs may be under-equipped and over-burdened, which may prevent them from having the same knowledge and providing equal quality care as specialists.
Project ECHO Diabetes, which started at Stanford University, aims to address that gap in knowledge by mentoring PCPs so they can deliver high-quality diabetes care to people who may not have access to a specialist. diaTribe spoke to Dr. Nick Cuttriss, a pediatric endocrinologist, the founding director and CEO of Echo Diabetes Action Network (EDAN), and former director of Project ECHO Diabetes.
What is Project ECHO?
Nick Cuttriss explained how Project ECHO, which stands for “Extension for Community Healthcare Outcomes,” uses telementoring to make specialty knowledge more accessible and improve health outcomes for underserved people living with chronic conditions.
“At the heart of ECHO is the lack of confidence of primary care professionals managing complex conditions,” Cuttriss said. “[These healthcare professionals] feel like it’s beyond their scope of work, and refer people to a specialist who is better equipped to address their concerns, whereas frontline healthcare providers are the ones who have the most access and touchpoints to patients with chronic conditions.”
Having high quality primary care is especially important for people living in rural areas, where people with diabetes may have to wait for months to get an appointment with an endocrinologist. Not to mention the other barriers such as having to travel hundreds of miles to visit their nearest diabetes specialists, or risk losing their job so they can take time off to seek necessary care.
This creates huge disparities in diabetes outcomes. For example, people at federally qualified healthcare centers (FQHCs) – or community-based healthcare providers that receive funds to provide services in underserved areas – have twice the rate of diabetes as that of the general population.
Considering the many barriers that prevent people from accessing a specialist in the first place, combined with the fact that people rarely see immediate results, people often do not consistently return to their specialty care clinic.
“If you’re not seeing outcomes when you put in all that work, why would people come back and take the time to do a follow-up?” said Cuttriss.
Originally started to address the high rate of disparities among people with Hepatitis C in New Mexico, the ECHO model is now used to share knowledge on several chronic conditions such as HIV, chronic pain, opioid addiction, and cancer. EDAN evolved from the ECHO model to focus even more closely on diabetes.
How does Project ECHO work?
Project ECHO uses telementoring to allow an exchange of information between a team of multidisciplinary healthcare professionals, the “hub,” and the frontline primary care professionals, the “spokes.”
“ECHO is a form of telehealth, but it’s not traditional telemedicine,” said Cuttriss. “It’s more of an amplification – you could use telemedicine, but the idea is to provide telementoring to frontline primary care centers.” This method aims to educate PCPs, who can then positively impact all of the people they treat with improved care, as opposed to trying to educate individual people with diabetes.
These telementoring sessions, or “clinics,” recognize the complexity of diabetes and educate PCPs on different aspects of the diabetes experience. The ‘hub’ teams consist of several health professionals: an endocrinologist, a behavioral health specialist, a diabetes care and education specialist, a nephrologist (kidney specialist), a community health worker, a diabetes advocate, a pharmacist, and a nurse. This team delivers training sessions for the PCPs. This allows information about the diabetes experience to travel from the hub team to the spokes. It also allows practical tips to be shared between the spokes, whose members are often recruited to this effort by large primary care professional organizations.
The clinics have a two part approach: they start with a lecture component on an essential aspect of diabetes care, such as diabetes devices, Time in Range, or how to limit the use of stigmatizing language. This is followed by case-based presentations that allow PCPs to learn how to implement the guidelines in practice. It also teaches them how to deliver the best care even when there are external factors affecting a person’s diabetes management, such as food insecurity, stigma and shame, or substance abuse.
Dr. Miriam Chang, a PCP based in Hawaii, has been attending ECHO programs for years and has found that the sessions have helped her identify which tests and treatments are the best for her patients.
“There was one test for kidney function, the protein/creatinine ratio, that I didn’t realize was a better test for my patients. But once it was presented in the session, it was like a lightbulb went off!” said Chang.
Additionally, the ECHO sessions allow providers in rural settings to connect with other providers at different clinics across the United States and learn about what care practices work best for them. At Chang’s clinic, a federally-qualified community health center, there are only a few providers with limited time to discuss cases with.
“It’s the ability to communicate with, and hear from, other physicians that I appreciate the most,” said Chang. “With ECHO, if I have a question about a certain drug I can put it out there in real time and learn from others in the Zoom room.”
What’s next for Cuttriss and the EDAN?
For Cuttriss, the goal of tackling disparities in diabetes care remains front and center when he thinks about the future of EDAN.
Part of that includes the launch of the first component of a program within EDAN called “Addressing Disparities in Diabetes with Project ECHO,” which kicked off in January. The program began with a four-month long series focused on diabetes and chronic kidney disease (CKD) in collaboration with medical education partner, Med-IQ; diatribe team members are participating as faculty. PCPs who participate in the program will receive continuing medical education credits, which is supported by an educational grant from Bayer HealthCare Pharmaceuticals.
“One in three people with diabetes have CKD, and three in four people with diabetes-related CKD who are Stage 3 and 4 don’t even know they have it,” said Cuttriss. “And if you look at racial disparities, you see three to four times the risk of end-stage kidney disease among Black Americans compared to whites, and two to three times for Asian Americans and Hispanics. For Native Americans as well, the risk is almost doubled.”
He hopes this series will be a “call-to-action” to improve the quality of care and reduce disparities. Once the series on CKD comes to a close, other series on diabetes devices, stigma and behavioral health, and cardiometabolic health are planned.
The long-term goal of EDAN is to increase the number of hubs running diabetes-related programs.
“We want to make diabetes-related programming more sustainable, and to also leverage other resources out there to address the lack of use, or under-utilization, of diabetes devices and technology,” he said. “It’s really a collaborative initiative so we can pay attention to disparities in care in the primary care setting and increase access overall. ”
PCPs can sign up for the CKD EDAN program here. If you are a person with diabetes who receives most of your care from a PCP, share this resource with them and encourage them to sign up. Additionally, you can share some of the other programs that EDAN is planning with them, which can be found here.
