ENDO ECHO IMPROVES PRIMARY CARE PROVIDER AND COMMUNITY HEALTH WORKER SELF-EFFICACY IN COMPLEX DIABETES MANAGEMENT IN MEDICALLY UNDERSERVED COMMUNITIES.

OBJECTIVE: To determine whether participation in a multidisciplinary telementorship model of healthcare delivery improves primary care provider (PCP) and community health worker (CHW) confidence in managing patients with complex diabetes in medically underserved regions. METHODS: We applied a well-established healthcare delivery model, Project ECHO (Extension for Community Healthcare Outcomes), to the management of complex diabetes (Endo ECHO) in medically underserved communities. A multidisciplinary team at Project ECHO connected with PCPs and CHWs at 10 health centers across New Mexico for weekly videoconferencing virtual clinics. Participating PCPs and CHWs presented de-identified patients and received best practice guidance and mentor-ship from Project ECHO specialists and network peers. A robust curriculum was developed around clinical practice guidelines and presented by weekly didactics over the ECHO network. After 2 years of participation in Endo ECHO, PCPs and CHWs completed self-efficacy surveys comparing confidence in complex diabetes management to baseline. RESULTS: PCPs and CHWs in rural New Mexico reported significant improvement in self-efficacy in all measures of complex diabetes management, including PCP ability to serve as a local resource for other healthcare providers seeking assistance in diabetes care. Overall self-efficacy improved by 130% in CHWs ( P<.0001) and by 60% in PCPs ( P<.0001), with an overall large Cohen's effect size. CONCLUSION: Among PCPs and CHWS in rural, medically underserved communities, participation in Endo ECHO for 2 years significantly improved confidence in complex diabetes management. Application of the ECHO model to complex diabetes care may be useful in resource-poor communities with limited access to diabetes specialist services. ABBREVIATIONS: CHW = community health worker; CME = Continuing Medical Education; ECHO = Extension for Community Healthcare Outcomes; FQHC = federally qualified health center; PCP = primary care provider.

Electric field distribution predicts efficacy of accelerated intermittent theta burst stimulation for late-life depression.

Introduction: Repetitive transcranial magnetic stimulation (rTMS) is a promising intervention for late-life depression (LLD) but may have lower rates of response and remission owing to age-related brain changes. In particular, rTMS induced electric field strength may be attenuated by cortical atrophy in the prefrontal cortex. To identify clinical characteristics and treatment parameters associated with response, we undertook a pilot study of accelerated fMRI-guided intermittent theta burst stimulation (iTBS) to the right dorsolateral prefrontal cortex in 25 adults aged 50 or greater diagnosed with LLD and qualifying to receive clinical rTMS. Methods: Participants underwent baseline behavioral assessment, cognitive testing, and structural and functional MRI to generate individualized targets and perform electric field modeling. Forty-five sessions of iTBS were delivered over 9 days (1800 pulses per session, 50-min inter-session interval). Assessments and testing were repeated after 15 sessions (Visit 2) and 45 sessions (Visit 3). Primary outcome measure was the change in depressive symptoms on the Inventory of Depressive Symptomatology-30-Clinician (IDS-C-30) from Visit 1 to Visit 3. Results: Overall there was a significant improvement in IDS score with the treatment (Visit 1: 38.6; Visit 2: 31.0; Visit 3: 21.3; mean improvement 45.5%) with 13/25 (52%) achieving response and 5/25 (20%) achieving remission (IDS-C-30 < 12). Electric field strength and antidepressant effect were positively correlated in a subregion of the ventrolateral prefrontal cortex (VLPFC) (Brodmann area 47) and negatively correlated in the posterior dorsolateral prefrontal cortex (DLPFC). Conclusion: Response and remission rates were lower than in recently published trials of accelerated fMRI-guided iTBS to the left DLPFC. These results suggest that sufficient electric field strength in VLPFC may be a contributor to effective rTMS, and that modeling to optimize electric field strength in this area may improve response and remission rates. Further studies are needed to clarify the relationship of induced electric field strength with antidepressant effects of rTMS for LLD.

A Telementoring Intervention Leads to Improvements in Self-Reported Measures of Health Care Access and Quality among Patients with Complex Diabetes.

Individuals living with complex diabetes experience limited access to endocrine care due to a nationwide shortage of endocrinologists. Project ECHO (Extension for Community Healthcare Outcomes) is an innovative, scalable model of health care that extends specialty care to medically underserved areas through ongoing telementorship of community primary care providers. We evaluated the effects of an endocrine-focused ECHO program (Endo ECHO) on patients with type 1 and complex type 2 diabetes, and report here on changes in patient-reported measures of health care access and quality from baseline to one year aft er program enrollment. Patients were eligible for Endo ECHO if they were 18 years or older with complex diabetes. Aft er participating in Endo ECHO, access to health care and diabetes-related quality of care improved dramatically. Our results suggest that Endo ECHO may be a suitable intervention for extending best practices in diabetes care to medically underserved patients.

The use of "overall accuracy" to evaluate the validity of screening or diagnostic tests.

OBJECTIVE: Evaluations of screening or diagnostic tests sometimes incorporate measures of overall accuracy, diagnostic accuracy, or test efficiency. These terms refer to a single summary measurement calculated from 2 x 2 contingency tables that is the overall probability that a patient will be correctly classified by a screening or diagnostic test. We assessed the value of overall accuracy in studies of test validity, a topic that has not received adequate emphasis in the clinical literature. DESIGN: Guided by previous reports, we summarize the issues concerning the use of overall accuracy. To document its use in contemporary studies, a search was performed for test evaluation studies published in the clinical literature from 2000 to 2002 in which overall accuracy derived from a 2 x 2 contingency table was reported. MEASUREMENTS AND MAIN RESULTS: Overall accuracy is the weighted average of a test's sensitivity and specificity, where sensitivity is weighted by prevalence and specificity is weighted by the complement of prevalence. Overall accuracy becomes particularly problematic as a measure of validity as 1) the difference between sensitivity and specificity increases and/or 2) the prevalence deviates away from 50%. Both situations lead to an increasing deviation between overall accuracy and either sensitivity or specificity. A summary of results from published studies (N = 25) illustrated that the prevalence-dependent nature of overall accuracy has potentially negative consequences that can lead to a distorted impression of the validity of a screening or diagnostic test. CONCLUSIONS: Despite the intuitive appeal of overall accuracy as a single measure of test validity, its dependence on prevalence renders it inferior to the careful and balanced consideration of sensitivity and specificity.