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.