Project ECHO Diabetes: T1D Pilot Study Findings

In 2018, Stanford Medicine and the University of Florida Diabetes Institute partnered to launch the first ECHO Type 1 Diabetes (T1D) program in the United States. The ECHO T1D program offered weekly tele-education clinics and continuing medical education (CME) credits for primary care providers, real-time support with complex diabetes-related medical decision-making, and access to diabetes support coaches for patients. The ECHO T1D program addressed urgent geographic, racial, and socioeconomic disparities to promote health equity and improve health outcomes within highly vulnerable populations with T1D in Florida and California.

Stanford Medicine enrolled 11 spoke sites representing 37 clinics serving roughly 1,000 adult and pediatric patients with T1D. To target spoke sites, the Project ECHO T1D team identified areas with low endocrinology provider density (>30-minute drive) and high health risk/poverty, according to the Neighborhood Deprivation Index (NDI). In California, 30 areas were targeted for ECHO T1D spoke recruitment.

Major findings include:

  • A pre-pilot study questionnaire and provider focus groups found a low level of confidence among PCPs in providing T1D care, especially related to diabetes technologies. Despite low confidence, PCPs reported regularly filling insulin prescriptions.
  • A post-pilot study questionnaire and provider focus groups found a high level of satisfaction among spoke providers with improved competencies in T1D and changes in care practices for T1D patients. Participants reported a significant increase in confidence, especially with diabetes technologies, and demonstrated a significant increase in knowledge.
  • Focus groups of 86 T1D high-need, high-cost adults found barriers to care, including long wait times for endocrinologist appointments, difficulty affording insulin and supplies, poor access to technology and equipment, a lack of well-rounded care, and a lack of social support for T1D.
  • Provider participation demonstrated statistically significant change and improvement in knowledge and confidence in managing T1D.

“I call but it takes two weeks to get the medication; now it’s been the two weeks and now I’ve got nobody, no medication. Then we are back again at the ER. It’s grasping at straws all the time. It’s a constant worry in my head.”—Focus group member

“I had an excellent insurance—the pump was never mentioned to me in any way, shape, or form.”—Focus group member

“Moving up here, I couldn’t even get a doctor, and I didn’t have a doctor for a good eight months. ... They don’t have appointment times. There’s nothing, and it took months, and it was just ridiculous.”—Focus group member

Reactions from PCP Spoke Members

ECHO T1D provider participants reported an appreciation for the expertise of the hub teams, especially voicing enthusiasm for the weekly learning didactic and case presentations. Major takeaways among PCP participants included an increase in knowledge and an increase in their comfort level to care for individuals with T1D. Providers voiced a commitment to improve many different facets of their care delivery, including the following: put patients on continuous glucose monitors (CGMs), address psychological issues, improve insulin regimens, educate on diet, strengthen motivational interviewing skills, and address hypoglycemia.

The pilot study made clear the need, and the potential impact, of implementing ECHO Diabetes on an ongoing basis at Stanford Medicine. The pilot study was made possible by a partnership with the University of Florida and a $1.6 million supporting grant from The Leona M. and Harry B. Helmsley Charitable Trust.

“I appreciated having that avenue to talk with a specialist about some of our more complex patients. I think that when cases get complicated because there’s multiple factors, just having an open discussion was more. … Made me feel more involved than just reading the endocrine note, so I appreciated that.”—Spoke group member

“We had a huge increase in continuous glucose monitors systemwide, and I’m starting to see hospitalists start to suggest that and talk about it with patients. And these are providers who definitely did not participate in ECHO, so a big increase in knowledge about technology and utilization. ... I think specifically people that haven’t participated have more access to the diabetes technology now, whereas before they might not have been as familiar and might not have had as much access within our clinics. It’s made it much more accessible, which has been great.”—Spoke group member

“It has increased my confidence in my ability to care for folks with T1D in ways I wasn’t sure were possible in this remote geographic locale. It has also made me feel more secure in my care, in that I know you guys are available as resources.”—Spoke group member

“I think the ECHO program is definitely supporting us as primary care providers, both in the didactic portion, the cases, and just help with resources in general. It’s been a great tool to be able to follow up every week with experts and learn new things, and get new ideas on how to manage complex patients. It’s great.”—Spoke group member

“Speaking for myself, it just makes me feel more secure knowing that we have the team to speak with almost on a weekly basis; also we can contact by email.”—Spoke group member