Walker Ashby F, Haller Michael J, Addala Ananta, Filipp Stephanie L, Lal Rayhan A, Gurka Matthew J, Figg Lauren E, Hechavarria Melanie, Zaharieva Dessi P, Malden Keilecia G, Hood Korey K, Westen Sarah C, Wong Jessie J, Donahoo William T, Basina Marina, Bernier Angelina V, Maahs David M
University of Florida Diabetes Institute, Gainesville, FL.
Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL.
Diabetes Care. 2025 Feb 1;48(2):243-250. doi: 10.2337/dc24-2100.
The Project Extension for Community Healthcare Outcomes (ECHO) model is used in 180 countries to address chronic disease care through a provider empowerment, tele-education approach. Few studies have rigorously evaluated the impact of the program on patient outcomes using randomized designs.
Implementation of an ECHO Diabetes program was evaluated using a stepped-wedge design with recruitment of 20 federally qualified health centers (FQHCs) across California and Florida with randomized, phased-in intervention entry. Participating FQHCs (referred to as "spokes") provided aggregate data, including the Healthcare Effectiveness Data and Information Set (HEDIS) and diabetes technology use. Patients were recruited from spokes, and data collection involved historical and prospective HbA1c measures, HEDIS markers, and pre/post surveys. Linear mixed models were used to generate patient-level monthly HbA1c estimates and evaluate change over time; Poisson regression was used to model clinic-level technology use.
The spoke-level cohort included 32,796 people with type 1 diabetes (T1D; 3.4%) and type 2 diabetes (T2D; 96.6%), of whom 72.7% were publicly insured or uninsured. The patient-level cohort included 582 adults with diabetes (33.0% with T1D, 67.0% with T2D). Their mean age was 51.1 years, 80.7% were publicly insured or uninsured, 43.7% were non-Hispanic White, 31.6% were Hispanic, 7.9% were non-Hispanic Black, and 16.8% were in other race/ethnicity categories. At the spoke level, there were statistically significant reductions before and after the intervention in the proportion of people with HbA1c >9% (range 31.7% to 26.7%; P = 0.033). At the patient level, there were statistically significant increases in those using continuous glucose monitoring (range 25.1% to 36.8%; P < 0.0001) and pump use (range 15.3% to 18.3%; P < 0.001) before and after the intervention.
The ECHO model demonstrates promise for reducing health disparities in diabetes and contributes to our understanding of program benefits beyond the provider level.
社区医疗成果扩展项目（ECHO）模式在180个国家被用于通过增强医疗服务提供者能力的远程教学方法来解决慢性病护理问题。很少有研究使用随机设计严格评估该项目对患者结局的影响。
采用阶梯楔形设计对ECHO糖尿病项目的实施情况进行评估，在加利福尼亚州和佛罗里达州招募了20家联邦合格健康中心（FQHC），随机分阶段进行干预。参与的FQHC（称为“分支”）提供汇总数据，包括医疗保健有效性数据和信息集（HEDIS）以及糖尿病技术使用情况。患者从分支中招募，数据收集包括历史和前瞻性糖化血红蛋白（HbA1c）测量、HEDIS指标以及干预前后的调查。使用线性混合模型生成患者层面的每月HbA1c估计值并评估随时间的变化；使用泊松回归对诊所层面的技术使用情况进行建模。
分支层面的队列包括32796名1型糖尿病（T1D；3.4%）和2型糖尿病（T2D；96.6%）患者，其中72.7%为公共保险覆盖或未参保。患者层面的队列包括582名成年糖尿病患者（33.0%为T1D，67.0%为T2D）。他们的平均年龄为51.1岁，80.7%为公共保险覆盖或未参保，43.7%为非西班牙裔白人，31.6%为西班牙裔，7.9%为非西班牙裔黑人，16.8%属于其他种族/族裔类别。在分支层面，干预前后HbA1c>9%的人群比例有统计学意义的下降（范围从31.7%至26.7%；P = 0.033）。在患者层面，干预前后使用持续葡萄糖监测的患者比例有统计学意义的增加（范围从25.1%至36.8%；P < 0.0001），使用胰岛素泵的患者比例也有统计学意义的增加（范围从15.3%至18.3%；P < 0.001）。
ECHO模式在减少糖尿病健康差距方面显示出前景，并有助于我们理解该项目在医疗服务提供者层面之外的益处。
