Democratizing type 1 diabetes specialty care in the primary care setting to reduce health disparities: project extension for community healthcare outcomes (ECHO) T1D

Abstract

IntroductionProject ECHO (Extension for Community Healthcare Outcomes) is a tele-education outreach model that seeks to democratize specialty knowledge to reduce disparities and improve health outcomes. Limited utilization of endocrinologists forces many primary care providers (PCPs) to care for patients with type 1 diabetes (T1D) without specialty support. Accordingly, an ECHO T1D program was developed and piloted in Florida and California. Our goal was to demonstrate the feasibility of an ECHO program focused on T1D and improve PCPs’ abilities to manage patients with T1D.Research design and methodsHealth centers (ie, spokes) were recruited into the ECHO T1D pilot through an innovative approach, focusing on Federally Qualified Health Centers and through identification of high-need catchment areas using the Neighborhood Deprivation Index and provider geocoding. Participating spokes received weekly tele-education provided by the University of Florida and Stanford University hub specialty team through virtual ECHO clinics, real-time support with complex T1D medical decision-making, access to a diabetes support coach, and access to an online repository of diabetes care resources. Participating PCPs completed pre/post-tests assessing diabetes knowledge and confidence and an exit survey gleaning feedback about overall ECHO T1D program experiences.ResultsIn Florida, 12 spoke sites enrolled with 67 clinics serving >1000 patients with T1D. In California, 11 spoke sites enrolled with 37 clinics serving >900 patients with T1D. During the 6-month intervention, 27 tele-education clinics were offered and n=70 PCPs (22 from Florida, 48 from California) from participating spoke sites completed pre/post-test surveys assessing diabetes care knowledge and confidence in diabetes care. There was statistically significant improvement in diabetes knowledge (p≤0.01) as well as in diabetes confidence (p≤0.01).ConclusionsThe ECHO T1D pilot demonstrated proof of concept for a T1D-specific ECHO program and represents a viable model to reach medically underserved communities which do not use specialists.

Glycemic outcomes among rural patients in the type 1 diabetes T1D Exchange registry, January 2016–March 2018: a cross-sectional cohort study

“…18 37 As these data were collected and analyzed prior to the COVID-19 pandemic, there is no way to know the impact of the pandemic's widespread adoption of virtual medical visits and telemedicine on the T1D Exchange participant sample we reported on here, especially those living in rural communities. Technology-based approaches to increase and democratize 38 diabetes care access among socioeconomically and geographically at-risk rural communities can be effective. Researchers and clinicians should work towards building flexible solutions that meet a wide diversity of needs for rural patient populations with type 1 diabetes.…”

Baseline Quality Improvement Capacity of 33 Endocrinology Centers Participating in the T1D Exchange Quality Improvement Collaborative

“…The initial recruitment of centers with greater QI capacity supported the development of a strong infrastructure, which has allowed for the subsequent addition of less experienced The results presented here invite future lines of inquiry regarding differences in centers' QI capacity by the demographics explored here. Endocrinology care is concentrated in urban areas, and there are many parts of the West and Midwest regions in which there is no access to an endocrinologist within a 20-or even 50-mile radius (32)(33)(34)(35). Furthermore, our data show that QI expertise is cloistered in certain geographical regions and that QI culture is better represented in pediatric versus adult type 1 diabetes care centers.…”

Challenges and Opportunities in Using Telehealth for Diabetes Care

“…Additionally, several developments within the diabetes world during this time period have enabled health care providers to more easily access and use PGHD for telehealth-based diabetes care. These developments include greater availability of Bluetoothenabled glucose meters (15); a dramatic increase in use of continuous glucose monitoring (CGM) technology (16); the creation of secure, internet-based platforms for diabetes data management (17,18); and the publication of standardized CGM-based metrics for evaluating glycemic control (19). Building on these advances, diabetes researchers have used telehealth in a variety of targeted programs throughout the past 20 years, both to replicate usual care at a distance and to explore new models of care that would not be feasible to deliver in person.…”

“…Some of these programs have also demonstrated an increase in the frequency of diabetes visits associated with telehealth use (20,22). At academic centers in the United States, telehealth outreach programs have connected primary care providers (PCPs) with diabetes specialists for remote consultations (18,24), demonstrating improved completion of consultations (17) and increased diabetes-specific knowledge among PCPs (18). In the past 15 years, researchers have also harnessed telehealth to explore novel care models designed to benefit specific subpopulations of people with type 1 diabetes.…”