ECHO-Chicago program improves self-efficacy across 11 clinical areas

The ECHO-Chicago program — the first urban-centered ECHO program — improved self-efficacy across multiple clinical topics, ranging from behavioral health to hypertension, according to researchers.

“There is a lack of specialty care available to much of the U.S., with an estimated shortfall between 33,700 and 86,700 specialists by 2033,” Sandra J. Tilmon, MPH, MS, a health care data scientist and epidemiologist at the University of Chicago, and colleagues wrote in the American Journal of Preventive Medicine. “The burden of this dearth of specialists will continue to fall on the least served U.S. populations.”

Project ECHO — which stands for the Extension for Community Health Outcomes — works to allay the lack of specialty health care by training community-based primary care providers to better manage, treat and prevent the progression of common health conditions, the researchers wrote.

Daniel Johnson, MD, the founder of ECHO-Chicago, and Karen Lee, MS, executive director of ECHO-Chicago, told Healio that disparities in health care access “remains a vexing problem for our society.”

“An effective way to address this problem is to use the Project ECHO model, which uses an asset-based approach that leverages existing providers (academic and community based) in an urban (or rural) setting, resulting in expansion of services available for a community of patients,” they said. “ECHO expands the available patient care services, allowing patients and providers to offer the right services, at the right time, in the right location, without the need to significantly increase the cost of care due to efficiencies of scale by adding skills and focusing the use of limited resources.”

In 2010, ECHO-Chicago became the first urban-centered ECHO program, training more than 5,175 clinicians in 34 subject areas and focusing on safety-net clinicians.

“Although definitions vary, safety net organizations commonly deliver health care to persons unable to pay,” Tilmon and colleagues wrote. “Safety-net clinicians experience more difficulty when seeking specialist appointments for their patients who are uninsured or on public insurance than those with private insurance.”

To better understand self-efficacy in ECHO-Chicago participants, the researchers collected survey data from more than 950 clinicians from 2014 to 2019. Among the individual participants, 99% were urban and 79% were from safety-net health organizations. The question themes included changing health care systems, clinical skills, collaboration, educating others and more.

They focused on 11 clinical topics, referred to as series:

• behavioral health;
• childhood obesity and comorbidities;
• complex pediatric asthma;
• geriatrics for primary care;
• geriatrics for skilled nursing facilities;
• hepatitis C;
• opioid use disorder;
• pediatric attention deficit and hyperactivity disorder;
• resistant hypertension;
• serious mental illness; and
• women’s health.

The researchers assessed changes in self-efficacy by participants’ prescription privilege status, adult or pediatric focus, individual series and across series by qualitative question theme, with the following metrics: total change, meeting the clinical competency threshold of 5, any improvement and meeting a common quality improvement goal of 10% — a 0.7 change in the seven-point Likert scale, which also brings participants to the next level of competence.

Self-efficacy scores

Tilmon and colleagues found that all clinical series saw statistically significant improvements in self-efficacy and most had a large effect size.

More specifically, 52% met the competency threshold of 5 in the post-survey, 65% met the 10% target of 0.7 points and 88% had any improvement.

“The results of this inquiry ... provide support for the ECHO model increasing clinicians’ confidence and self-assessed competency in providing diagnosis, management, and treatment of complex chronic conditions in their community-based primary care locations,” Tilmon and colleagues wrote.

They further noted that participants rated themselves at baseline as most competent in the clinical themes of diagnosis and sensitive communication and least competent in screening and engaging caregivers. Medication and education staff represented the largest increases, and diagnosis and engaging caregivers had the smallest increases.

Compared with non-prescribers, prescribers had significantly greater increases in their self-efficacy scores. Additionally, adult series’ participants saw higher changes in self-efficacy compared with pediatric series (1.21 vs. 0.96 points).

“Because ECHO series tend to focus on clinicians with prescribing privileges, the greater self-efficacy increase for prescribers makes sense,” the researchers wrote. “For reasons not entirely clear, there was a difference in increase in self-efficacy when comparing adult and pediatric series. A further qualitative investigation would be welcome for differences between adult and pediatric ECHO series.”

Question themes

When it came to question themes, all 18 met the 10% improvement threshold, 88% met statistical significance and 22% met the post-survey competency threshold: changing health care systems, clinical-sensitive communication, clinical-diagnosis and miscellaneous.

The researchers also noted that several of the themes represented soft skills, including “engaging caregivers and sensitive communication.” They wrote that soft skills can be defined in different ways, “from feeling empathy for others to communication skills in motivating others.”

“Within ECHO evaluations, although other thematic work has occurred and recent qualitative efforts have shown the effectiveness of Project ECHO, the mechanisms of ECHO’s effectiveness would benefit from further inquiry,” the researchers wrote. “Therefore, further in-depth qualitative research into different realms of soft skills development in the ECHO model is recommended, including an investigation into the roles of empathy, communication skills, and mentorship or modeling.”

One of the question themes — educating others — reflects an important factor to improving the quality of care, the researchers wrote: diffusion of received education.

“This project documented improvement in this area,” they wrote. “ECHO participants reported increased self-efficacy in their ability to more effectively communicate information to their patients as well as educate other clinicians around them; these improvements further increase the impact of the series on quality of care at participating sites.”

Clinical Implications

Tilmon and colleagues concluded that the ECHO-Chicago program was able to successfully increase participants’ self-efficacy and that their study adds multiple series, years of data, an urban focus and a novel qualitative theme component “to enable comparisons across rather than solely within the ECHO series.”

“The implication of this work, still to be tested further, is that an asset-based model leveraging existing clinicians who are knowledgeable about their own communities could lead to an expansion of health services to underserved populations,” they wrote. “ECHO-Chicago is successful at building hard and soft skills, thereby increasing participants’ self-efficacy in providing expanded care in safety-net, urban, and primary care environments.”

The researchers also wrote that their findings hold implications for the training of future primary care clinicians.

“Clinical training does not end at the conclusion of residency and fellowship; clinicians need to continue to build the skill sets needed in response to the demands of their practice,” they wrote. “The data presented in this paper support the importance of active, case-based learning and practical training for the postgraduate education of clinicians, especially as more is being asked of PCCs. The ECHO model provides a proven platform for this continuation of training.”

Johnson and Lee said that Project ECHO “works as a time efficient, effective method for expanding the abilities of community-based primary care providers to take care of a larger number of more complex patients in need of care across a varied set of services: adult and pediatric, medical and behavioral.”

“Due to Project ECHO-related training and the commitment of primary care providers and their organizations, patients can receive state-of-the-art primary care close to home, delivered by providers they know, in community-based settings that more often than not offer more culturally appropriate care for the patient,” they said. “And the added value for subspecialists and the patients in need of their services is that subspecialist time is freed up so they can direct their efforts to more complex patients in need of care.”