On 5 p.m. on the day before Thanksgiving, Dr. Alan Caroe, a general practitioner in Las Cruces, N.M., had to decide whether to prescribe an opiate medication to "a very smooth individual from out of town who had a story that was just barely plausible."
Dr. Caroe felt he had insufficient expertise in opioid management, an area that’s complex and difficult and fraught with risk but also an opportunity to help patients in chronic pain, he said in an interview. He needed a quick consultation, but who would answer the phone on that day, at that hour?
Experts at the chronic pain and headache clinic at Project ECHO (Extension for Community Healthcare Outcomes), that’s who. They walked him through the complex issues in the case, which led him to retract an opiate prescription that he initially had phoned into a pharmacy for this patient.
Real-time consultations are only a part of Project ECHO, an
award-winning program based at the University of New Mexico in Albuquerque. In
addition, the program provides weekly videoconferences, not only to discuss
cases but also to educate and mentor community physicians to take on frontline
management of chronic diseases in their geographic areas.
The aim is to act as a multiplier, and to expand the health
system’s capacity to manage common, chronic, but complex diseases, Dr. Sanjeev
Arora explained in a presentation at the annual meeting of the American Academy
of Pain Medicine. New Mexico’s 1.8 million people are spread across 121,000
square miles, and 32 of the state’s 33 counties are listed as medically
underserved areas.
Project ECHO began with a focus on improving the care of
patients with hepatitis C, and its success has spawned Project ECHO programs for
asthma, rheumatology, HIV infection, cardiac risk reduction, chronic pain
management, geriatrics, palliative care, substance abuse, prevention of teenage
suicide, high-risk pregnancy, childhood obesity, child psychiatry,
psychotherapy, antibiotic stewardship, and ethics consultation. More than 400
clinical sites can now connect with Project ECHO.
The Project ECHO model has been cloned by the University of
Washington in Seattle, the U.S. Veterans Health Administration, the U.S.
Department of Defense, and the country of India, among other entities. The focus
is not just on helping rural areas; the University of Chicago’s project works
with urban physicians in the community to improve the care of black patients
with difficult-to-treat hypertension, whose numbers would overwhelm the limited
number of specialists.
When the project’s director, Dr. Arora, a gastroenterologist
and hepatologist, founded Project ECHO in 2002, an estimated 28,000 people in
the state had hepatitis C, and patients faced an 8-month waiting list to be seen
at Dr. Arora’s specialty clinic, which often required traveling long distances.
The project has conducted more than 500 "telehealth clinics" on hepatitis C, and
has helped get more than 5,000 patients into hepatitis C treatment who
previously had no access to care, said Dr. Arora, a professor of medicine at the
University of New Mexico.
"We want to transform the nature of what primary care looks
like in the United States," he said.
The quality of care these patients are getting in the
community rivals the quality at the university, and minorities’ access to care
is expanding, a prospective study of 407 patients found. A sustained viral
response to treatment for hepatitis C was achieved in 58% of patients managed at
the university and by 58% of patients managed by primary care physicians at
rural and prison sites who participated in Project ECHO (N. Engl.
J. Med. 2011;364:2199-2207). Response rates to different subtypes of
hepatitis C also did not differ significantly between the two groups.
Patients who received care at the Project ECHO community sites, however, were
significantly more likely to be racial/ethnic minorities (68%), compared with
the university’s patients (49%), he said. The cure rate at community sites was
significantly higher than cure rates reported in previous community-based
studies of hepatitis C treatment, which hovered around 20%, he added. This may
be a result of Project ECHO’s emphasis on best-practices protocols and other
attributes.
"Project ECHO has brought so much balance. We’ve reduced
variation in prescribing" practices for pain medications, for example, Dr.
Joanna G. Katzman said in a separate presentation at the meeting. "The degree to
which people have evolved blows my mind."
Dr. Katzman, director of Project ECHO’s chronic pain and headache clinic and a neurologist at the University of New Mexico, said that her weekly videoconference typically starts at noon so that primary care physicians can join in during their lunch break. Participants get free CME credits.
The project’s interdisciplinary team of experts and remote participants spend the first half-hour reviewing and discussing three or four cases that have been faxed in by remote participants, followed by 25-30 minutes of didactic presentations. A second hour covers more cases, for those who can stay on. Once a month, the videoconference includes a skills demonstration, such as a trigger point examination or a procedure. Community physicians who miss the live videoconference can watch a video of it later.
"It’s the best use of lunchtime that you can consider," said Dr. Caroe, the generalist in Las Cruces.
Since starting in 2009, Project ECHO’s chronic pain and headache clinic sessions have attracted 474 participants in 168 locations in multiple states, averaging more than six sessions per attendee. In all, 42% are physicians, 23% are nurses or physician assistants, and 35% are others including pharmacists and chiropractors.
Physician assistant Debra Newman worked for several years as a community health extension agent at a rural clinic in Espanola, N.M., with part of her salary paid by the clinic and part by Project ECHO. She managed hundreds of patients who were referred to her for everything from simple low back pain to fibromyalgia, rheumatoid arthritis, and failed back surgery syndrome.
"After sitting in on Project ECHO for years, I could manage many of these patients on my own," said Ms. Newman, now of Christus St. Vincent Regional Medical Center in Santa Fe, N.M. As a P.A., she could practice independently if a supervising physician was within 100 miles – but, she said, she still took complex cases to the teleconference for consultations.
Project ECHO is funded by grants from state and federal government sources and the Robert Wood Johnson Foundation. Large health care systems are cloning the model because they see that it’s a cost-effective way to provide specialty services to more patients without transferring them to specialty care, Dr. Arora said.
"It isn’t expensive if you think that you’re training someone
out there to replace you," Dr. Rollin M. Gallagher said in a separate
presentation at the meeting. Project ECHO inspired the creation of the
similarly-modeled Veterans Affairs SCAN (Specialty Care Access Network), said Dr. Gallagher, deputy
national program director for pain management in the Veterans Health
Administration and director for pain policy and primary care research at Penn
Pain Medicine at the University of Pennsylvania, Philadelphia.
Dr. Ilene R. Robeck runs what she calls a "poor man’s Project
ECHO" that provides pain management education, mentoring, and consultations
primarily to physicians at three Veterans Affairs medical centers in Florida.
"As much as I thought [Project ECHO] was a fantastic program, the resources
needed were really higher than the resources I had," she said in an interview.
Funded by a federal grant through September 2013, her project
offers a weekly telephone audioconference and immediate access to expert
consultations by phone – initiatives that stress the education of participants
as much as individual case consultations.
"The results have been overwhelmingly positive," with close to
100 health care providers now calling in from VA facilities around the country
each week, said Dr. Robeck of Bay Pines (Fla.) Veterans Affairs Healthcare
System.
When Dr. Caroe first heard about Project ECHO, he listened to
the weekly conferences by phone because the Internet connection for
videoconferencing was too slow where he was practicing in Chaparral, N.M. He now
videoconferences each week on a faster connection at his current practice in Las
Cruces.
The nearest pain specialists are in Albuquerque (about 260
miles away and too far for many patients to travel for routine visits) or in El
Paso, Tex. Crossing state lines for care can create problems with insurance.
He has no doubt that the skills he has gained through Project
ECHO have benefited his patients. One 49-year-old female engineer had suffered
nearly a lifetime of terrible migraine headaches. Prior to Project ECHO’s
didactic and clinical presentations, Dr. Caroe had never heard of premenstrual
migraine, and the patient had never noticed that her headaches regularly got
worse 2 days before the start of her menstrual period.
"She went from monthly hell" to treatment with a low-dose,
short-term estrogen patch to get her through her 4-day period of risk, he said.
When she came in for a follow-up visit recently, she told him, "You changed my
life."
Dr. Arora has received research funding from Genentech,
Gilead, Pharmasset, Tibotec, Vertex, and ZymoGenetics. The other people
interviewed for this story reported having no financial disclosures.
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