How Project ECHO Is Changing Diabetes Care
The Project ECHO model began in New Mexico as a way to expand access to hepatitis C treatment. Today, the same philosophy of moving knowledge to primary care settings is transforming diabetes care.
There’s a basic math problem at the heart of diabetes care that is hard to solve. The number of people with diabetes is growing, the drug and technology options for care are expanding, yet there’s a shortage of specialists to care for them.
“About 90% of people with diabetes get their care in primary care,” said Dr. Nick Cuttriss, founding director of the ECHO Diabetes Action Network (EDAN). “There just aren’t enough endocrinologists, and you’ve got this lack of confidence of frontline providers managing complex diabetes.”
On top of that, there’s a shortage of primary care physicians, with some people waiting months to get an appointment.
That gap – between the needs of people living with diabetes and the resources available to care for them – is what Project ECHO was designed to close. It seeks to empower community clinicians around the globe with knowledge, mentorship, and a network of peers.
ECHO started almost 25 years ago to address hepatitis C in New Mexico by teaching primary care providers how to treat it.
“The idea was trying to move knowledge instead of patients, moving knowledge to the primary care setting and empowering them, upscaling them to manage hep C and make it easier for patients,” Cuttriss explained.
That simple idea of democratizing specialty knowledge has since become a global model applied to more than 100 diseases, from hepatitis C to mental health to diabetes.
How a New Mexico idea became a global model
At its core, Project ECHO uses a “hub-and-spoke” approach: An academic medical team connects regularly by video with community providers to share expertise and collaborate on real-world cases. The program seeks to expand diabetes care through shared knowledge.
Dr. Matt Bouchonville, associate director at ECHO and leader of New Mexico’s diabetes initiatives, has seen firsthand how the model transforms local practices after launching the diabetes ECHO program in the state.
“It was humbling to see the reality of diabetes care in rural communities, where resources – such as diabetes education, access to fresh food, or proximity to a pharmacy – can be scarce,” he said.
The core of ECHO’s strength is that it’s an “all teach, all learn” model of workforce development, Bouchonville said.
“At the same time that I provide mentorship on the ECHO network, I learn so much from primary care providers on the front lines about how clinical practice guidelines are actually implemented in resource-constrained settings,” he said.
The results from the hepatitis C program showed that people who stayed with their primary care provider for treatment had better outcomes.
“If you dig a little bit deeper, it was people who were on Medicaid and underinsured who actually had even better treatment outcomes,” Cuttriss added.
Those findings established the ECHO model as both effective and equitable, he said.
Applying ECHO to diabetes
ECHO’s structure proved to be an ideal fit for diabetes care.
“You’ve got treatment failure for diabetes, disparities in care, lack of specialists, and lack of confidence,” Cuttriss explained. “And so, diabetes was kind of a natural next step.”
The first diabetes-related ECHO program began in Nevada around 2010, followed by one in New Mexico funded by the Helmsley Charitable Trust. Over more than a decade, the New Mexico team has seen dramatic results. Among the patients in participating primary care practices, the average decrease in A1C has been more than 1 percentage point; for those with A1C over 9%, more than 40% have seen a decrease.
“That’s pretty phenomenal outcome data,” Cuttriss noted.
Despite its promise, diabetes remains underrepresented in the ECHO network. In 2014, Cuttriss found that although there were more than 1,100 ECHO programs in the U.S. supporting all kinds of medical topics, less than 1% were diabetes-related. In response, he created the ECHO Diabetes Action Network (EDAN) – a collaboration that supports and connects diabetes-focused ECHO programs nationwide.
“We’re trying to call attention to and support funding initiatives for other ECHO programs around the country to implement diabetes-related programs,” Cuttriss explained. The goal, he said, is to get more diabetes-related programming because the ECHO Institute and EDAN believe it’s a public health priority.
Recent EDAN-supported efforts include programs at Rutgers, the University of Colorado, and the University of Washington, which focus on diabetes, chronic kidney disease, and obesity.
Building confidence, capacity, and community
After participating in ECHO, many rural providers became more self-sufficient, Bouchonville said.
“They had the confidence and know-how to treat most of their patients on their own, with the ECHO network as their backup,” he said. “In fact, most indicated that they were becoming recognized by peers as experts themselves.”
One of the biggest challenges, Bouchonville added, is raising awareness that diabetes rates are skyrocketing around the globe and that early, aggressive care can prevent nearly every complication.
“Over the last decade, our international partners have developed a massive ECHO network, reaching virtually every corner of the world. But less than 1% of ECHO hubs are being used for diabetes,” he said. “I believe that activating this existing network for diabetes care is a tremendous opportunity that would have a major impact on global health for years to come.”
Looking ahead
From its beginnings in New Mexico to its global reach today, Project ECHO continues to embody the simple but transformative philosophy: Move knowledge, not patients.
Cuttriss said he sees momentum building. “The trend in terms of the uptick of diabetes-related programming is going in the right direction,” he said. “I think there’ll become a bigger community of us who are committed to leveraging the ECHO program to improve diabetes care.”
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