Improving Outcomes for Patients with Multiple Chronic Conditions Using ECHO

Diabetes mellitus is a chronic condition that affects the body’s ability to process sugar effectively, which over time can increase the risk of heart disease, high blood pressure and kidney damage. Other chronic conditions include high cholesterol, obesity and depression. Persons with diabetes mellitus and multiple chronic conditions (DMMC) face higher risks of losing physical or mental function, experiencing other chronic conditions and death. Most of the residents of New Mexico belong to groups at risk for developing DMMC. Finding quality health care is a key factor, as New Mexico also ranks among the largest, poorest, and most rural states. Primary care providers (PCPs) in New Mexico–including doctors, nurse practitioners, physician assistants–most often treat DMMC patients, but they can lack confidence in managing these complex patients and struggle to keep up with recommended guidelines. There is an urgent need to increase PCP knowledge and confidence in providing guidelines-based care for DMMC patients. 

This ECHO for Diabetes and Multiple Chronic Conditions (E4DMMC) study asks whether the Project ECHO model (ECHO), a telehealth intervention for PCPs, can lead to lower blood sugar levels in DMMC patients being treated at New Mexico primary care clinics. Project ECHO is a “telementoring” program that trains PCPs to provide specialized medical care at their local clinics. This is done by connecting PCPs with specialist mentors at academic medical centers on a regular basis through videoconferencing sessions. During ECHO sessions, groups of PCPs hear lectures on key topics in DMMC care from experts, and then give presentations of anonymous patient case by a PCP for discussion and to receive recommendations. After attending ECHO sessions for a period, providers gain expertise in providing specialized care for DMMC patients. Thus, the ECHO model expands access to best practice specialty healthcare by increasing PCP ability to care for those with DMMC, saving patients the time and expense of seeing a specialist. 

To answer the study question, the research team plans to conduct a cluster randomized controlled trial in partnership with Presbyterian Medical Services (PMS), which has the largest network of primary care clinics in New Mexico. The “clusters” are PMS clinics, which will be randomly assigned to two conditions. First, 10 PMS clinics will be assigned to participate in an ECHO program for 18 months (intervention arm), while the research team collects data on a variety of measures of DMMC patient health. Second, for the same 18 months, another 10 PMS clinics will proceed with care for DMMC as usual, while the research team collects data on the same measures (control arm). After 30 months of follow up, for the primary outcome, the study team hopes to see lower blood sugar levels on average (>0.5% reduction in HbA1c) in the intervention arm relative to the control arm, and for these improvements to last at least 12 months. The study team also hopes to see improvements in key secondary measures for other chronic conditions including lower blood pressure and cholesterol levels, less prevalence of depressive symptoms and higher levels of patient engagement in their care (i.e., patient activation). 

The patient population is the approximately 7,000 DMMC patients getting care at the 20 PMS clinics. Using PMS’ electronic health record (EHR) system, the study team will passively collect data for the study without asking for additional effort from providers or patients. They will also regularly get input from a variety of stakeholders with a stake in DMMC patient care, including DMMC patients, diabetes educators and patient advocates, primary care providers, diabetes advocacy organizations like the American Diabetes Association and representatives from the New Mexico Department of Health and Indian Health Services. 

The results of this study will be useful for policy makers hoping to expand access to health care for patients with chronic conditions in areas with under-resourced healthcare systems.