RAND Corporation, Boston, MA, USA.
Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
J Gen Intern Med. 2019 Dec;34(12):2842-2857. doi: 10.1007/s11606-019-05291-1. Epub 2019 Sep 4.
Extension for Community Healthcare Outcomes (ECHO) and related models of medical tele-education are rapidly expanding; however, their effectiveness remains unclear. This systematic review examines the effectiveness of ECHO and ECHO-like medical tele-education models of healthcare delivery in terms of improved provider- and patient-related outcomes.
We searched English-language studies in PubMed, Embase, and PsycINFO databases from 1 January 2007 to 1 December 2018 as well as bibliography review. Two reviewers independently screened citations for peer-reviewed publications reporting provider- and/or patient-related outcomes of technology-enabled collaborative learning models that satisfied six criteria of the ECHO framework. Reviewers then independently abstracted data, assessed study quality, and rated strength of evidence (SOE) based on Cochrane GRADE criteria.
Data from 52 peer-reviewed articles were included. Forty-three reported provider-related outcomes; 15 reported patient-related outcomes. Studies on provider-related outcomes suggested favorable results across three domains: satisfaction, increased knowledge, and increased clinical confidence. However, SOE was low, relying primarily on self-reports and surveys with low response rates. One randomized trial has been conducted. For patient-related outcomes, 11 of 15 studies incorporated a comparison group; none involved randomization. Four studies reported care outcomes, while 11 reported changes in care processes. Evidence suggested effectiveness at improving outcomes for patients with hepatitis C, chronic pain, dementia, and type 2 diabetes. Evidence is generally low-quality, retrospective, non-experimental, and subject to social desirability bias and low survey response rates.
The number of studies examining ECHO and ECHO-like models of medical tele-education has been modest compared with the scope and scale of implementation throughout the USA and internationally. Given the potential of ECHO to broaden access to healthcare in rural, remote, and underserved communities, more studies are needed to evaluate effectiveness. This need for evidence follows similar patterns to other service delivery models in the literature.
扩展社区医疗成果（ECHO）和相关的医学远程教育模式正在迅速扩展；然而，其效果仍不清楚。本系统评价考察了 ECHO 及类似的医疗远程教育模式在改善提供者和患者相关结果方面的有效性。
我们在 PubMed、Embase 和 PsycINFO 数据库中搜索了 2007 年 1 月 1 日至 2018 年 12 月 1 日发表的英文文献，并进行了文献回顾。两名审查员独立筛选出满足 ECHO 框架六个标准的报告技术支持的协作学习模型对提供者和/或患者相关结果的同行评议出版物的参考文献。审查员随后独立提取数据、评估研究质量，并根据 Cochrane GRADE 标准评估证据强度（SOE）。
纳入了 52 篇同行评议文章的数据。其中 43 篇报告了提供者相关的结果；15 篇报告了患者相关的结果。关于提供者相关结果的研究表明，在三个领域存在有利的结果：满意度、知识增加和临床信心增加。然而，SOE 较低，主要依赖于低应答率的自我报告和调查。一项随机试验已经进行。关于患者相关的结果，15 项研究中有 11 项纳入了对照组；没有一项涉及随机分组。四项研究报告了护理结果，11 项研究报告了护理过程的改变。证据表明，对于丙型肝炎、慢性疼痛、痴呆和 2 型糖尿病患者的结果改善有效。证据质量普遍较低，为回顾性、非实验性的，且易受社会期望偏差和低调查应答率的影响。
与美国和国际上 ECHO 和类似的医学远程教育模式的实施范围和规模相比，研究 ECHO 和类似的医学远程教育模式的研究数量还不够多。考虑到 ECHO 在扩大农村、偏远和服务不足社区获得医疗保健方面的潜力，需要更多的研究来评估其效果。这种对证据的需求与文献中其他服务提供模式的需求相似。
