Mazurek Micah O, Parker Robert A, Chan James, Kuhlthau Karen, Sohl Kristin
Curry School of Education and Human Development, Department of Human Services, University of Virginia, Charlottesville.
Biostatistics Center, Department of Medicine, Massachusetts General Hospital, Boston.
JAMA Pediatr. 2020 May 1;174(5):e196306. doi: 10.1001/jamapediatrics.2019.6306. Epub 2020 May 4.
The Extension for Community Health Outcomes (ECHO) model is a widely adopted technology-based model for training primary care physicians and practitioners (PCPs) to care for patients with complex conditions. Despite its popularity, to our knowledge, direct effects of ECHO on clinical practice have not been tested in a large-scale study.
To test the effectiveness of the ECHO model as applied to primary care for autism and whether it resulted in improved clinical practice, knowledge, and self-efficacy regarding autism screening and comorbidity management.
DESIGN, SETTING, AND PARTICIPANTS: Primary care physicians and practitioners were recruited to participate in a 6-month ECHO Autism program delivered by 1 of 10 academic medical center sites. A sequential, staggered rollout of ECHO Autism was delivered to 5 cohorts of participants (15 per site; 2 sites per cohort). Sites were randomized after recruitment to cohort/start time. Cohorts launched every 3 months. The ECHO Autism program used videoconferencing technology to connect community-based PCPs with interdisciplinary expert teams at academic medical centers. There were 148 participants (PCPs [family practice physicians, pediatricians, nurse practitioners, and physician assistants] providing outpatient services to underserved children) studied between December 2016 and November 2018.
The 6-month ECHO Autism program included twelve 2-hour sessions connecting PCP participants with an interdisciplinary expert team. Sessions included didactics, case-based learning, guided practice, and discussion.
Coprimary outcomes were autism screening practices and comorbidity management (assessed by medical record review). Secondary outcomes were knowledge (assessed by direct testing) and self-efficacy (assessed by self-report survey). Assessments were conducted at baseline, mid-ECHO, post-ECHO, and follow-up (3 months after ECHO).
Ten sites were randomized to 1 of 5 cohorts. Participants were 82% female (n = 108), 76% white (n = 100), and 6% Hispanic or Latino (n = 8); the median age was 46 years (interquartile range, 37-55 years). Significant changes in autism screening and treatment of comorbidities in children with autism were not observed. Participants demonstrated significant improvements in knowledge (9%; 95% CI, 4-13; P < .001) and self-efficacy (29%; 95% CI, 25-32; P < .001).
The ECHO model was developed to increase access to high-quality health care for underserved patients with complex conditions. Study results provide support for the model in improving clinician knowledge and confidence but little support for achieving practice change.
ClinicalTrials.gov Identifier: NCT03677089.
社区健康成果扩展（ECHO）模式是一种广泛采用的基于技术的模式，用于培训初级保健医生和从业者（PCP），以照顾患有复杂疾病的患者。尽管其很受欢迎，但据我们所知，ECHO对临床实践的直接影响尚未在大规模研究中得到检验。
测试ECHO模式应用于自闭症初级保健的有效性，以及它是否能改善关于自闭症筛查和合并症管理的临床实践、知识和自我效能。
设计、设置和参与者：招募初级保健医生和从业者参加由10个学术医疗中心之一提供的为期6个月的ECHO自闭症项目。ECHO自闭症项目按顺序、交错地向5个参与者队列（每个站点15人；每个队列2个站点）推出。招募后，各站点被随机分配到队列/开始时间。队列每3个月启动一次。ECHO自闭症项目使用视频会议技术，将社区初级保健医生与学术医疗中心的跨学科专家团队联系起来。在2016年12月至2018年11月期间，对148名参与者（为服务不足的儿童提供门诊服务的初级保健医生[家庭医生、儿科医生、执业护士和医师助理]）进行了研究。
为期6个月的ECHO自闭症项目包括12次每次2小时的数据连接会议，将初级保健医生参与者与跨学科专家团队联系起来。会议包括教学、基于案例的学习、指导实践和讨论。
共同主要结果是自闭症筛查实践和合并症管理（通过病历审查评估）。次要结果是知识（通过直接测试评估）和自我效能（通过自我报告调查评估）。在基线、ECHO中期、ECHO后期和随访（ECHO后3个月）进行评估。
10个站点被随机分配到5个队列中的1个。参与者中82%为女性（n = 108），76%为白人（n = 100），6%为西班牙裔或拉丁裔（n = 8）；年龄中位数为46岁（四分位间距，37 - 55岁）。未观察到自闭症儿童的自闭症筛查和合并症治疗有显著变化。参与者在知识（9%；95% CI，4 - 13；P <.001）和自我效能（29%；95% CI，25 - 32；P <.001）方面有显著改善。
ECHO模式的开发是为了增加服务不足的复杂疾病患者获得高质量医疗保健的机会。研究结果为该模式在提高临床医生知识和信心方面提供了支持，但在实现实践改变方面支持甚少。
ClinicalTrials.gov标识符：NCT03677089。
