Effectiveness of the Extension for Community Health Outcomes Model as Applied to Primary Care for Autism: A Partial Stepped-Wedge Randomized Clinical Trial

Abstract

Importance: The Extension for Community Health Outcomes (ECHO) model is a widely adopted technology-based model for training primary care physicians and practitioners (PCPs) to care for patients with complex conditions. Despite its popularity, to our knowledge, direct effects of ECHO on clinical practice have not been tested in a large-scale study.

Objective: To test the effectiveness of the ECHO model as applied to primary care for autism and whether it resulted in improved clinical practice, knowledge, and self-efficacy regarding autism screening and comorbidity management.

Design, setting, and participants: Primary care physicians and practitioners were recruited to participate in a 6-month ECHO Autism program delivered by 1 of 10 academic medical center sites. A sequential, staggered rollout of ECHO Autism was delivered to 5 cohorts of participants (15 per site; 2 sites per cohort). Sites were randomized after recruitment to cohort/start time. Cohorts launched every 3 months. The ECHO Autism program used videoconferencing technology to connect community-based PCPs with interdisciplinary expert teams at academic medical centers. There were 148 participants (PCPs [family practice physicians, pediatricians, nurse practitioners, and physician assistants] providing outpatient services to underserved children) studied between December 2016 and November 2018.

Interventions: The 6-month ECHO Autism program included twelve 2-hour sessions connecting PCP participants with an interdisciplinary expert team. Sessions included didactics, case-based learning, guided practice, and discussion.

Main outcomes and measures: Coprimary outcomes were autism screening practices and comorbidity management (assessed by medical record review). Secondary outcomes were knowledge (assessed by direct testing) and self-efficacy (assessed by self-report survey). Assessments were conducted at baseline, mid-ECHO, post-ECHO, and follow-up (3 months after ECHO).

Results: Ten sites were randomized to 1 of 5 cohorts. Participants were 82% female (n = 108), 76% white (n = 100), and 6% Hispanic or Latino (n = 8); the median age was 46 years (interquartile range, 37-55 years). Significant changes in autism screening and treatment of comorbidities in children with autism were not observed. Participants demonstrated significant improvements in knowledge (9%; 95% CI, 4-13; P < .001) and self-efficacy (29%; 95% CI, 25-32; P < .001).

Conclusions and relevance: The ECHO model was developed to increase access to high-quality health care for underserved patients with complex conditions. Study results provide support for the model in improving clinician knowledge and confidence but little support for achieving practice change.

Trial registration: ClinicalTrials.gov Identifier: NCT03677089.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Mazurek reported grants from Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services during the conduct of the study. Dr Parker reported other support from HRSA and grants from Autism Speaks during the conduct of the study. Since completing the study, Dr Parker has become a consultant to the ECHO Institute, University of New Mexico. Dr Kuhlthau reported grants from Autism Intervention Research Network on Physical Health grant from MCHB HRSA and funding from the Autism Speaks Foundation during the conduct of the study. Dr Sohl reported other support from Quadrant Biosciences, Autism Navigator, the National Institutdes of Health/National Institute of Neurological Disorders and Stroke; and Cognoa and personal fees from university-based grand rounds; in addition, Dr Sohl had a patent to Autism Ready Communities pending. No other disclosures were reported.

Figures

Figure 1.. CONSORT Flow Diagram

PCP indicates primary care physician or practitioner; ECHO, Extension for Community Health Outcomes; WCV, well-child visit.

Figure 2.. Planned Data Collection Times Across Cohorts

ECHO indicates Extension for Community Health Outcomes; T, time.