Impact of Project ECHO Models of Medical Tele-Education: a Systematic Review.

BACKGROUND: Extension for Community Healthcare Outcomes (ECHO) and related models of medical tele-education are rapidly expanding; however, their effectiveness remains unclear. This systematic review examines the effectiveness of ECHO and ECHO-like medical tele-education models of healthcare delivery in terms of improved provider- and patient-related outcomes. METHODS: We searched English-language studies in PubMed, Embase, and PsycINFO databases from 1 January 2007 to 1 December 2018 as well as bibliography review. Two reviewers independently screened citations for peer-reviewed publications reporting provider- and/or patient-related outcomes of technology-enabled collaborative learning models that satisfied six criteria of the ECHO framework. Reviewers then independently abstracted data, assessed study quality, and rated strength of evidence (SOE) based on Cochrane GRADE criteria. RESULTS: Data from 52 peer-reviewed articles were included. Forty-three reported provider-related outcomes; 15 reported patient-related outcomes. Studies on provider-related outcomes suggested favorable results across three domains: satisfaction, increased knowledge, and increased clinical confidence. However, SOE was low, relying primarily on self-reports and surveys with low response rates. One randomized trial has been conducted. For patient-related outcomes, 11 of 15 studies incorporated a comparison group; none involved randomization. Four studies reported care outcomes, while 11 reported changes in care processes. Evidence suggested effectiveness at improving outcomes for patients with hepatitis C, chronic pain, dementia, and type 2 diabetes. Evidence is generally low-quality, retrospective, non-experimental, and subject to social desirability bias and low survey response rates. DISCUSSION: The number of studies examining ECHO and ECHO-like models of medical tele-education has been modest compared with the scope and scale of implementation throughout the USA and internationally. Given the potential of ECHO to broaden access to healthcare in rural, remote, and underserved communities, more studies are needed to evaluate effectiveness. This need for evidence follows similar patterns to other service delivery models in the literature.