Using "Big Data" to Provide Insights into Early Adopters of Continuing Professional Development: An Example from Project ECHO.

INTRODUCTION: Mental health care is often managed in primary care with limited specialist support, particularly in rural and remote communities. Continuing professional development programs (CPD) can offer a potential solution to further mental health training; however, engaging primary care organizations (PCOs) can be challenging. The use of "big data" to identify factors influencing engagement in CPD programs has not been well studied. Therefore, the aim of this project was to use administrative health data from Ontario, Canada to identify characteristics of PCOs associated with early engagement in a virtual CPD program, Project Extension for Community Healthcare Outcomes (ECHO) Ontario Mental Health (ECHO ONMH). METHODS: Ontario health administrative data for fiscal year 2014 was used to compare the characteristics of ECHO ONMH-adopting PCOs, and their patients, to nonadopter organizations (N = 280 vs. N = 273 physicians). RESULTS: ECHO-adopting PCOs did not differ with respect to physician age or years of practice, although PCOs with more female physicians were somewhat more likely to participate. ECHO ONMH adoption was more likely in regions with lower psychiatrist supply, among PCOs using partial salary payment models, and those with a greater interprofessional complement. Patients of ECHO-adopters did not differ on the basis of gender or health care utilization (physical or mental health); however, ECHO-adopting PCOs tended to have patients with less psychiatric comorbidity. CONCLUSION: Models such as Project ECHO, which deliver CPD to primary care, are advanced to address lack of access to specialist health care. These findings support the use of administrative health data to assess the implementation, spread, and impact of CPD.

Building Mental Health Capacity: Exploring the Role of Adaptive Expertise in the ECHO Virtual Learning Model.

INTRODUCTION: With the proliferation of virtual learning programs during the COVID-19 pandemic, there is increased need to understand learner experiences and impact on developing expertise. Project Extension for Community Healthcare Outcomes (Project ECHO®) is an established hub-and-spoke tele-education model aimed at building capacity and expertise in primary care providers. Our qualitative study explored how learning experiences within an ECHO mental health care program supported provider learning and ability to solve complex clinical problems. METHODS: We sampled ECHO sessions across a 34-week cycle and analyzed audio transcribed data. Two individuals coded participant interactions during 2-hour recorded sessions using an iterative, constant comparative methodology. RESULTS: The authors identified four key mechanisms of learning in ECHO: (1) fostering participants' productive struggle with cases, (2) development of an integrated understanding, (3) collaborative reformulation of cases, and (4) generation of conceptual solutions based on a new understanding. Throughout the ECHO sessions, learning was observed to be multidirectional from both the hub-to-spoke and between spoke sites. DISCUSSION: Despite the widespread implementation of Project ECHO and other virtual learning models, a paucity of research has focused on mechanisms of virtual learning within these models. Our study demonstrated a bidirectional exchange of knowledge between hub specialist teams and primary care provider spokes that aligned with the development of adaptive expertise through specific learning experiences in Project ECHO. Moreover, the ECHO structure may further support the development of adaptive expertise to better prepare participants to address patients' complex mental health needs.

The Impact of Project ECHO on Participant and Patient Outcomes: A Systematic Review.

PURPOSE: Project Extension for Community Healthcare Outcomes (ECHO) uses tele-education to bridge knowledge gaps between specialists at academic health centers and primary care providers from remote areas. It has been implemented to address multiple medical conditions. The authors examined evidence of the impact of all Project ECHO programs on participant and patient outcomes. METHOD: The authors searched PubMed, MEDLINE, EMBASE, PsycINFO, and ProQuest from January 2000 to August 2015 and the reference lists of identified reviews. Included studies were limited to those published in English, peer-reviewed articles or indexed abstracts, and those that primarily focused on Project ECHO. Editorials, commentaries, gray literature, and non-peer-reviewed articles were excluded. The authors used Moore's evaluation framework to organize study outcomes for quality assessment. RESULTS: The authors identified 39 studies describing Project ECHO's involvement in addressing 17 medical conditions. Evaluations of Project ECHO programs generally were limited to outcomes from Levels 1 (number of participants) to 4 (providers' competence) of Moore's framework (n = 22 studies, with some containing data from multiple levels). Studies also suggested that Project ECHO changed provider behavior (n = 1), changed patient outcomes (n = 6), and can be cost-effective (n = 2). CONCLUSIONS: Project ECHO is an effective and potentially cost-saving model that increases participant knowledge and patient access to health care in remote locations, but further research examining its efficacy is needed. Identifying and addressing potential barriers to Project ECHO's implementation will support the dissemination of this model as an education and practice improvement initiative.

Body contouring surgery after bariatric surgery: a study of cost as a barrier and impact on psychological well-being.

BACKGROUND: Body-contouring surgery can be a solution to excess skin folds following bariatric surgery. Many patients desire body-contouring surgery, but the cost of the procedure may be a limiting factor. This study aims to examine barriers to access and to compare socioeconomic variables and psychological variables between bariatric surgery patients who have undergone body contouring and those who have not. METHODS: In this cross-sectional study, a questionnaire packet was administered to (1) patients who underwent bariatric but not body-contouring surgery and (2) patients who underwent both. The questionnaire included perceived barriers to body-contouring surgery, socioeconomic barriers, measures of anxiety (Generalized Anxiety Disorder seven-item scale), depression (Patient Health Questionnaire nine-item scale), and quality of life (Short Form-36). RESULTS: Among the 58 study participants, 93.1 percent reported having excess skin folds. Of this sample, 95.4 percent desired body-contouring surgery, and the majority (87.8 percent) of this subsample identified cost as the major barrier to access. Mean scores on the Generalized Anxiety Disorder scale (6.08 ± 5.97 versus 3.50 ± 3.10; p = 0.030) and the Patient Health Questionnaire (6.40 ± 6.77 versus 2.40 ± 2.37; p = 0.002) were significantly higher for the bariatric surgery group versus bariatric surgery plus body contouring group. Patients in the latter group had significantly higher Short Form-36 physical health component scores (56.80 ± 4.88 versus 49.57 ± 8.25; p = 0.010). CONCLUSIONS: Bariatric surgery patients who desire body-contouring surgery perceive cost as a major barrier. Patients undergoing body-contouring surgery may experience improved physical quality of life but not mental quality of life; however, body-contouring surgery may improve aspects of depression and anxiety.

Understanding the neuropsychiatric consequences associated with significant traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) can give rise to a variety of neuropsychiatric syndromes. The objective of this review is to describe the neurobiological mechanisms that have been proposed to underlie many of these post-TBI syndromes, explore the utility of various investigative modalities and review the mechanisms of treatment available for them. METHODS: Six authors reviewed PubMed and Ovid literature that addressed TBI in the context of the neuropsychiatric sequelae, evaluation and management. RESULTS: Depressed mood, anxiety, impulsive/aggressive behaviour, impaired memory and sleep disturbances are among the most prevalent sequelae of severe TBI. Delirium, while less common, can also result from TBI, predisposing individuals to other psychiatric conditions, while psychosis, usually presenting with atypical features, is relatively rare. The evaluation of the brain following TBI has often relied on traditional structural imaging which, according to recent studies, is less sensitive than chemical and functional neuroimaging. A variety of pharmacologic and non-pharmacologic treatments have been investigated with varying degrees of success in managing the spectrum of post-TBI psychiatric illnesses. CONCLUSIONS: Neuropsychiatric sequelae are common following TBI. Several of these syndromes are amenable to treatment. Further investigations are required, however, to better understand the mechanistic aetiology of these conditions and the effectiveness of various therapeutic modalities.