Clinical Outcomes of Rural Patients with Diabetes Treated by ECHO-Trained Providers Versus an Academic Medical Center.

BACKGROUND: Despite clinical practice guidelines prioritizing cardiorenal risk reduction, national trends in diabetes outcomes, particularly in rural communities, do not mirror the benefits seen in clinical trials with emerging therapeutics and technologies. OBJECTIVE: Project ECHO supports implementation of guidelines in under-resourced areas through virtual communities of practice, sharing of best practices, and case-based learning. We hypothesized that diabetes outcomes of patients treated by ECHO-trained primary care providers (PCPs) would be similar to those of patients treated by specialists at an academic medical center. DESIGN: Specialists from the University of New Mexico (UNM) launched a weekly diabetes ECHO program to mentor dyads consisting of a PCP and community health worker at ten rural clinics. PARTICIPANTS: We compared cardiorenal risk factor changes in patients with diabetes treated by ECHO-trained dyads to patients treated by specialists at the UNM Diabetes Comprehensive Care Center (DCCC). Eligible participants included adults with type 1 diabetes, type 2 diabetes on insulin, or diabetes of either type with A1c > 9%. MAIN MEASURES: The primary outcome was change from baseline in A1c in the ECHO and DCCC cohorts. Secondary outcomes included changes in body mass index (BMI), blood pressure, cholesterol, and urine albumin to creatinine ratio (UACR). KEY RESULTS: Compared to the DCCC cohort (n = 151), patients in the ECHO cohort (n = 856) experienced greater A1c reduction (-1.2% vs -0.6%; p = 0.02 for difference in difference). BMI decreased in the Endo ECHO cohort and increased in the DCCC cohort (-0.2 vs. +1.3 kg/m2; p = 0.003 for difference in difference). Diastolic blood pressure declined in the Endo ECHO cohort only. Improvements of similar magnitude were observed in low-density lipoprotein cholesterol in both groups. UACR remained stable in both groups. CONCLUSIONS: ECHO may be a suitable intervention for improving diabetes outcomes in rural, under-resourced communities with limited access to a specialist.

Comparison of Care Provided to Underserved Patients With Diabetes by a Telementoring Model of Care to Care Provided by a Specialty Clinic: Endo ECHO Versus an Academic Specialty Clinic.

PURPOSE: The purpose of the study was to examine differences among adult patients with diabetes who receive care through a telementoring model versus care at an academic specialty clinic on guideline-recommended diabetes care and self-management behaviors. METHODS: Endocrinology-focused Extension for Community Healthcare Outcomes (ECHO Endo) patients completed surveys assessing demographics, access to care, health care quality, and self-management behaviors at enrollment and 1 year after program enrollment. Diabetes Comprehensive Care Center (DCCC) patients completed surveys at comparable time points. RESULTS: At baseline, ECHO patients were less likely than DCCC patients to identify English as their primary language, have postsecondary education, and private insurance. One year postenrollment, ECHO patients visited their usual source of diabetic care more frequently. There were no differences in A1C testing or feet checking by health care professionals, but ECHO patients were less likely to report eye exams and smoking status assessment. ECHO and DCCC patients did not differ in consumption of high-fat foods and soda, physical activity, or home feet checks. ECHO patients were less likely to space carbohydrates evenly and test glucose levels and more likely to have smoked cigarettes. CONCLUSIONS: Endo ECHO is a suitable alternative to specialty care for patients in underserved communities with restricted access to specialty care. Results support the value of the Project ECHO telementoring model in addressing barriers to high-quality care for underserved communities.

Risk Assessment and Coronary Artery Calcium Scoring in Transgender and Gender-Diverse Individuals Receiving Gender-Affirming Hormone Therapy.

OBJECTIVE: To evaluate cardiovascular risk factors and prevalent coronary artery disease (CAD) using Coronary Artery Calcium (CAC) scoring in transgender and gender-diverse (TGD) individuals receiving gender-affirming hormone therapy (GAHT) and compare the CAC scores of TGD individuals with those of the general population. METHODS: TGD individuals aged ≥30 years, without known risk factors for cardiovascular disease (CVD), other than tobacco use and family history of CVD, on GAHT were recruited, and baseline information, including metabolic parameters, was collected. CAC scores were obtained and compared with those of a cisgender age-matched population. RESULTS: Of 25 transwomen recruited, 24 underwent CAC scans. Of them, 2 (8.3%) had a CAC score of >0 to 99 and 1 (4.1%) had a CAC score of ≥100. Of 22 transmen recruited, 16 underwent CAC scans. Of them, 26 (12.5%) had a CAC score of >0 to 99 and none had a CAC score of ≥100. Framingham Risk Scores were not correlated with the presence of CAC. CONCLUSION: The presence of CAC in this small cohort of TGD individuals on GAHT was similar to that in the cisgender age-matched population. CAC scoring is a means to assess the prevalence of CAD in TGD individuals and identify those in whom aggressive risk reduction is indicated.

The current role of telehealth in the management of patients with osteoporosis.

INTRODUCTION: Telehealth is the use of electronic technologies for communication, storage, and analysis of health-related information. Telemedicine is a form of telehealth that involves remote patient care. This is a review and update of the use of these modalities as they apply to the education of healthcare professionals who provide care for patients with osteoporosis and the delivery of their care. AREAS COVERED: This review focuses on technology-enabled collaborative learning and its prototype model, Project ECHO (Extension for Community Healthcare Outcomes). Bone Health TeleECHO and similar programs apply the ECHO model of learning to mentor healthcare professionals on implementation of best practice care for patients with osteoporosis and other skeletal diseases. Telemedicine, which has seen widespread uptake during the COVID-19 pandemic, is an alternative to in-person visits for patients with osteoporosis as well as for those with other conditions. EXPERT OPINION: Remote education of healthcare professionals and the remote delivery of patient care provides opportunities, as well as challenges, for achieving the goal of reducing the global burden of osteoporotic fractures.

A Project ECHO and Community Health Worker Intervention for Patients with Diabetes.

BACKGROUND: Both community health workers and the Project ECHO model of specialist telementoring are innovative approaches to support primary care providers in the care of complex patients with diabetes. We studied the effect of an intervention that combined these 2 approaches on glycemic control. METHODS: Patients with diabetes were recruited from 10 federally qualified health centers in New Mexico. We used electronic health record (EHR) data to compare HbA1c levels prior to intervention enrollment with HbA1c levels after 3 months (early follow-up) and 12 months (late follow-up) following enrollment. We propensity matched intervention patients to comparison patients from other sites within the same electronic health records databases to estimate the average treatment effect. RESULTS: Among 557 intervention patients with HbA1c data, mean HbA1c decreased from 10.5% to 9.3% in the pre- versus postintervention periods (P < .001). As compared to the comparison group, the intervention was associated with a change in HbA1c of -0.2% (95% confidence interval [CI] -0.4%-0.5%) and -0.3 (95% CI -0.5-0.0) in the early and late follow-up cohorts, respectively. The intervention was associated with a significant increase in percentage of patients with HbA1c <8% in the late follow-up cohort (8.1%, 95% CI 2.2%-13.9%) but not the early follow-up cohort (3.6%, 95% CI -1.5% to 8.7%) DISCUSSION: The intervention was associated with a substantial decrease in HbA1c in intervention patients, although this improvement was not different from matched comparison patients in early follow-up. Although combining community health workers with Project ECHO may hold promise for improving glycemic control, particularly in the longer term, further evaluations are needed.

Project ECHO Cancer Initiative: a Tool to Improve Care and Increase Capacity Along the Continuum of Cancer Care.

Solving health problems requires not only the development of new medical knowledge but also its dissemination, particularly to underserved communities. The barriers to effective dissemination also contribute to the disparities in cancer care experienced most everywhere. This concern is particularly acute in low and middle-income countries which already bear a disproportionate burden of cancer, a situation that is projected to worsen. Project ECHO (Extension for Community Healthcare Outcomes) is a knowledge dissemination platform that can increase workforce capacity across many fields, including cancer care by scaling best practices. Here we describe how Project ECHO works and illustrate this with existing programs that span the cancer care continuum and the globe. The examples provided combined with the explanation of how to build effective Project ECHO communities provide an accessible guide on how this education strategy can be integrated into existing work to help respond to the challenge of cancer.

Tele-rounds and Case-Based Training: Project ECHO Telementoring Model Applied to Complex Diabetes Care.

Lack of access to subspecialty care and persistent suboptimal outcomes for insulin-requiring patients with diabetes mandates development of innovative health care delivery models. The workforce shortage of endocrinologists in the United States results in primary care providers taking on the role of diabetes specialists despite lack of confidence and knowledge in complex diabetes management. The telementoring model Project ECHO amplifies and democratizes specialty knowledge to reduce disparities in care and improve health outcomes. Project ECHO can be applied to type 1 diabetes and other complex medical conditions to address health disparities and urgent needs of complex patients throughout the lifespan.

Commentary: An emerging role for household-based diabetes education.

The work of Aasbjerg et al. raises provocative questions about risks of diabetes among unrelated family members and the impact of social determinants on metabolic health. In this brief commentary, we will identify commonly reported household factors and how they predict metabolic health. We will also suggest a different approach to explore risks of diabetes among unrelated family members across generations and recommend what implications these findings have for clinical diabetes care and population health at large.

A Telementoring Intervention Leads to Improvements in Self-Reported Measures of Health Care Access and Quality among Patients with Complex Diabetes.

Individuals living with complex diabetes experience limited access to endocrine care due to a nationwide shortage of endocrinologists. Project ECHO (Extension for Community Healthcare Outcomes) is an innovative, scalable model of health care that extends specialty care to medically underserved areas through ongoing telementorship of community primary care providers. We evaluated the effects of an endocrine-focused ECHO program (Endo ECHO) on patients with type 1 and complex type 2 diabetes, and report here on changes in patient-reported measures of health care access and quality from baseline to one year aft er program enrollment. Patients were eligible for Endo ECHO if they were 18 years or older with complex diabetes. Aft er participating in Endo ECHO, access to health care and diabetes-related quality of care improved dramatically. Our results suggest that Endo ECHO may be a suitable intervention for extending best practices in diabetes care to medically underserved patients.

Impact of a Primary Care Provider Tele-Mentoring and Community Health Worker Intervention on Utilization in Medicaid Patients with Diabetes.

OBJECTIVE: The Endocrinology ECHO intervention utilized a tele-mentoring model that connects primary care providers (PCPs) and community health workers (CHWs) with specialists for training in diabetes care. We evaluated the impact of the Endo ECHO intervention on healthcare utilization and care for Medicaid patients with diabetes in New Mexico. METHODS: Between January 2015 and April 2017, patients with complex diabetes from 10 health centers in NM were recruited to receive diabetes care from a PCP and CHW upskilled through Endo ECHO. We matched intervention patients in the NM Medicaid claims database to comparison Medicaid beneficiaries using 5:1 propensity matching. We used a difference-in-difference (DID) approach to compare utilization and processes of care between intervention and comparison patients. RESULTS: Of 541 Medicaid patients enrolled in Endo ECHO, 305 met inclusion criteria and were successfully matched. Outpatient visits increased with Endo ECHO for intervention patients as compared to comparison patients (rate ratio, 1.57; 95% confidence interval [CI], 1.43 to 1.72). The intervention was associated with an increase in emergency department (ED) visits (rate ratio, 1.30; 95% CI, 1.04 to 1.63) but no change in hospitalizations (rate ratio, 1.47; 95% CI, 0.95 to 2.23). Among intervention patients, utilization of metformin increased from 57.1% to 60.7%, with a DID between groups of 8.8% (95% CI, 4.0% to 13.6%). We found similar increases in use of statins (DID, 8.5%; 95% CI, 3.2% to 13.8%), angiotensin-converting enzyme inhibitors (DID, 9.5%; 95% CI, 3.5% to 15.4%), or antidepressant therapies (DID, 9.4%; 95% CI, 1.1% to 18.1%). CONCLUSION: Patient enrollment in Endo ECHO was associated with increased outpatient and ED utilization and increased uptake of prescription-related quality measures. No impact was observed on hospitalization.

Empagliflozin-induced Diabetic Ketoacidosis Unmasking a Type 1 Diabetes Diagnosis.

Empagliflozin is a sodium glucose cotransporter-2 inhibitor that inhibits renal glucose reabsorption through an insulin-independent mechanism. This class of drugs is used in the management of type 2 diabetes. A 49-year-old female with type 2 diabetes treated with empagliflozin presented to the emergency department in diabetic ketoacidosis (DKA). This case report details the series of events leading to the diagnosis of drug-induced DKA, which led to a change in the patient's diagnosis from type 2 diabetes to type 1 diabetes.

ENDO ECHO IMPROVES PRIMARY CARE PROVIDER AND COMMUNITY HEALTH WORKER SELF-EFFICACY IN COMPLEX DIABETES MANAGEMENT IN MEDICALLY UNDERSERVED COMMUNITIES.

OBJECTIVE: To determine whether participation in a multidisciplinary telementorship model of healthcare delivery improves primary care provider (PCP) and community health worker (CHW) confidence in managing patients with complex diabetes in medically underserved regions. METHODS: We applied a well-established healthcare delivery model, Project ECHO (Extension for Community Healthcare Outcomes), to the management of complex diabetes (Endo ECHO) in medically underserved communities. A multidisciplinary team at Project ECHO connected with PCPs and CHWs at 10 health centers across New Mexico for weekly videoconferencing virtual clinics. Participating PCPs and CHWs presented de-identified patients and received best practice guidance and mentor-ship from Project ECHO specialists and network peers. A robust curriculum was developed around clinical practice guidelines and presented by weekly didactics over the ECHO network. After 2 years of participation in Endo ECHO, PCPs and CHWs completed self-efficacy surveys comparing confidence in complex diabetes management to baseline. RESULTS: PCPs and CHWs in rural New Mexico reported significant improvement in self-efficacy in all measures of complex diabetes management, including PCP ability to serve as a local resource for other healthcare providers seeking assistance in diabetes care. Overall self-efficacy improved by 130% in CHWs ( P<.0001) and by 60% in PCPs ( P<.0001), with an overall large Cohen's effect size. CONCLUSION: Among PCPs and CHWS in rural, medically underserved communities, participation in Endo ECHO for 2 years significantly improved confidence in complex diabetes management. Application of the ECHO model to complex diabetes care may be useful in resource-poor communities with limited access to diabetes specialist services. ABBREVIATIONS: CHW = community health worker; CME = Continuing Medical Education; ECHO = Extension for Community Healthcare Outcomes; FQHC = federally qualified health center; PCP = primary care provider.

Leveraging Scarce Resources With Bone Health TeleECHO to Improve the Care of Osteoporosis.

Osteoporosis is a common condition with serious consequences because of fractures. Despite availability of treatments to reduce fracture risk, there is a large osteoporosis treatment gap that has reached crisis proportions. There are too few specialists to provide services for patients who need them. Bone Health Extension for Community Health Care Outcomes (TeleECHO) is a strategy using real-time ongoing videoconferencing technology to mentor health care professionals in rural and underserved communities to achieve an advanced level of knowledge for the care of patients with skeletal diseases. Over the first 21 months of weekly Bone Health TeleECHO programs, there were 263 registered health care professionals in the United States and several other countries, with 221 attending at least 1 online clinic and typically 35 to 40 attendees at each session at the end of the reported period. Assessment of self-confidence in 20 domains of osteoporosis care showed substantial improvement with the ECHO intervention (P = 0.005). Bone Health TeleECHO can contribute to mitigating the crisis in osteoporosis care by leveraging scarce resources, providing motivated practitioners with skills to provide better skeletal health care, closer to home, with greater convenience, and lower cost than referral to a specialty center. Bone Health TeleECHO can be replicated in any location worldwide to reach anyone with Internet access, allowing access in local time zones and languages. The ECHO model of learning can be applied to other aspects of bone care, including the education of fracture liaison service coordinators, residents and fellows, and physicians with an interest in rare bone diseases.

Characterization of Cortisol Secretion Rate in Secondary Adrenal Insufficiency.

CONTEXT: In secondary adrenal insufficiency (SAI), chronic deficiency of adrenocorticotropin (ACTH) is believed to result in secondary changes in adrenocortical function, causing an altered dose-response relationship between ACTH concentration and cortisol secretion rate (CSR). OBJECTIVE: We sought to characterize maximal cortisol secretion rate (CSRmax) and free cortisol half-life in patients with SAI, compare results with those of age-matched healthy controls, and examine the influence of predictor variables on ACTH-stimulated cortisol concentrations. DESIGN: CSRmax was estimated from ACTH1-24 (250 µg)-stimulated cortisol time-concentration data. Estimates for CSRmax and free cortisol half-life were obtained for both dexamethasone (DEX) and placebo pretreatment conditions for all subjects. SETTING: Single academic medical center. PATIENTS: Patients with SAI (n = 10) compared with age-matched healthy controls (n = 21). INTERVENTIONS: The order of DEX vs placebo pretreatment was randomized and double-blind. Cortisol concentrations were obtained at baseline and at intervals for 120 minutes after ACTH1-24. MAIN OUTCOME MEASURES: CSRmax and free cortisol half-life were obtained by numerical modeling analysis. Predictors of stimulated cortisol concentrations were evaluated using a multivariate model. RESULTS: CSRmax was significantly (P < 0.001) reduced in patients with SAI compared with controls for both placebo (0.17 ± 0.09 vs 0.46 ± 0.14 nM/s) and DEX (0.18 ± 0.13 vs 0.43 ± 0.13 nM/s) conditions. Significant predictors of ACTH1-24-stimulated total cortisol concentrations included CSRmax, free cortisol half-life, and baseline total cortisol, corticosteroid-binding globulin, and albumin concentrations (all P < 0.05). CONCLUSIONS: Our finding of significantly decreased CSRmax confirms that SAI is associated with alterations in the CSR-ACTH dose-response curve. Decreased CSRmax contributes importantly to the laboratory diagnosis of SAI.

Are diabetes guidelines truly evidence based?

The global epidemic of obesity and diabetes underscores the urgency to develop strategies to prevent cardiovascular (CV) disease in this vulnerable population. Clinical guidelines are intended to help the clinician manage these patients, but guidelines are often discordant among professional organizations and not always evidence based. Clinicians must rely upon the best available evidence, and therefore we critically reviewed the evidence behind the American Diabetes Association (ADA) 2016 guidelines on the prevention of CV disease in diabetes. We believe the most robust evidence comes from randomized controlled trials specifically designed for diabetes with hard clinical endpoints such as mortality and CV events. Our analysis supports the ADA recommendations regarding a Mediterranean diet, glycemic control, and BP control, but we believe the evidence to support aspirin and statin therapy in diabetes is inconclusive. This discordance may be multi-factorial including the exclusion of some relevant studies and an over-reliance upon subgroup and meta-analysis. Given the lack of mortality benefit and inconsistent clinical benefits of aspirin and statins, it is essential that clinicians individualize treatment decisions while carefully weighing the risks and harms of any intervention.

Taking Telemedicine to the Next Level in Diabetes Population Management: a Review of the Endo ECHO Model.

Worldwide increases in diabetes prevalence in the face of limited medical resources have prompted international interest in innovative healthcare delivery models. Project ECHO (Extension for Community Healthcare Outcomes) is a "telementoring" program which has been shown to increase capacity for complex disease management in medically underserved regions. In contrast to a traditional telemedicine model which might connect a specialist with one patient, the ECHO model allows for multiple patients to benefit simultaneously by building new expertise. We recently applied the ECHO model to improve health outcomes of patients with complex diabetes (Endo ECHO) living in rural New Mexico. We describe the design of the Endo ECHO intervention and a 4-year, prospective program evaluation assessing health outcomes, utilization patterns, and cost-effectiveness. The Endo ECHO evaluation will demonstrate whether and to what extent this intervention improves outcomes for patients with complex diabetes living in rural New Mexico, and will serve as proof-of-concept for academic medical centers wishing to replicate the model in underserved regions around the world.

Bone Health ECHO: telementoring to improve osteoporosis care.

Extension for Community Healthcare Outcomes creates knowledge networks that enable a transition from centralized specialty care at academic institutions to empowerment of primary care providers to provide more highly skilled care closer to home.

Iatrogenic Cushing's syndrome after triamcinolone plus ritonavir-boosted atazanavir.

OBJECTIVE: To describe a case of iatrogenic Cushing's syndrome (ICS) following a triamcinolone injection for subscapular bursitis in an HIV-positive patient receiving an antiretroviral regimen that included ritonavir boosted-atazanavir. SETTING: University outpatient HIV clinic. CASE SUMMARY: A 60-year-old HIV-positive man on a ritonavir-boosted, atazanavir-containing antiretroviral regimen was diagnosed with subscapular bursitis. The patient received two intrabursal injections with 1% lidocaine plus triamcinolone 20 mg. Four weeks after the injections, the patient experienced symptoms of Cushing's syndrome with a pronounced drop in his CD4+ T-cell count, requiring treatment of oral candidiasis and prophylaxis for opportunistic infections. CONCLUSION: The interaction between ritonavir and oral corticosteroids, resulting in ICS, has been established. This case adds to the literature as one of the few cases illustrating that interaction can also occur between ritonavir and intrabursal administration of corticosteroids. This case further supports concerns regarding use of corticosteroids in HIV-infected patients who are treated with ritonavir-containing antiretroviral regimens.