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Democratizing type 1 diabetes specialty care in the primary care setting to reduce health disparities: project extension for community healthcare outcomes (ECHO) T1D
  1. Ashby F Walker1,2,
  2. Nicolas Cuttriss3,
  3. Michael J Haller1,4,
  4. Korey K Hood3,5,
  5. Matthew J Gurka6,
  6. Stephanie L Filipp6,
  7. Claudia Anez-Zabala4,
  8. Katarina Yabut3,
  9. Xanadu Roque4,
  10. Jessie J Wong3,
  11. Linda Baer3,
  12. Lauren Figg3,
  13. Angelina Bernier4,
  14. Sarah Westen7,
  15. Eugene Lewit8,
  16. Eleni Sheehan4,
  17. Marina Basina3,9,
  18. Rayhan Lal3,9,
  19. Jennifer Maizel10,
  20. David M Maahs3
  1. 1University of Florida Diabetes Institute, Gainesville, FL, USA
  2. 2Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA
  3. 3Department of Pediatrics and Division of Pediatric Endocrinology and Diabetes, Stanford University, Palo Alto, California, USA
  4. 4Department of Pediatrics, University of Florida, Gainesville, Florida, USA
  5. 5Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
  6. 6Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
  7. 7Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
  8. 8Department of Health Research and Policy, Stanford, Palo Alto, California, USA
  9. 9Department of Medicine, Division of Endocrinology, Gerontology & Metabolism, Stanford University, Palo Alto, California, USA
  10. 10College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
  1. Correspondence to Dr Ashby F Walker; afwalker{at}


Introduction Project ECHO (Extension for Community Healthcare Outcomes) is a tele-education outreach model that seeks to democratize specialty knowledge to reduce disparities and improve health outcomes. Limited utilization of endocrinologists forces many primary care providers (PCPs) to care for patients with type 1 diabetes (T1D) without specialty support. Accordingly, an ECHO T1D program was developed and piloted in Florida and California. Our goal was to demonstrate the feasibility of an ECHO program focused on T1D and improve PCPs’ abilities to manage patients with T1D.

Research design and methods Health centers (ie, spokes) were recruited into the ECHO T1D pilot through an innovative approach, focusing on Federally Qualified Health Centers and through identification of high-need catchment areas using the Neighborhood Deprivation Index and provider geocoding. Participating spokes received weekly tele-education provided by the University of Florida and Stanford University hub specialty team through virtual ECHO clinics, real-time support with complex T1D medical decision-making, access to a diabetes support coach, and access to an online repository of diabetes care resources. Participating PCPs completed pre/post-tests assessing diabetes knowledge and confidence and an exit survey gleaning feedback about overall ECHO T1D program experiences.

Results In Florida, 12 spoke sites enrolled with 67 clinics serving >1000 patients with T1D. In California, 11 spoke sites enrolled with 37 clinics serving >900 patients with T1D. During the 6-month intervention, 27 tele-education clinics were offered and n=70 PCPs (22 from Florida, 48 from California) from participating spoke sites completed pre/post-test surveys assessing diabetes care knowledge and confidence in diabetes care. There was statistically significant improvement in diabetes knowledge (p≤0.01) as well as in diabetes confidence (p≤0.01).

Conclusions The ECHO T1D pilot demonstrated proof of concept for a T1D-specific ECHO program and represents a viable model to reach medically underserved communities which do not use specialists.

  • diabetes mellitus
  • type 1
  • healthcare disparities
  • public health
  • poverty

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Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors AFW helped design the study, oversaw study operations and wrote the manuscript. DMM, MJH, and NC helped design the study and oversaw all study operations. MJG and SLF aided in study design, had access to data, and conducted data analysis. KKH, SW, LB, JJW, EL, CA-Z, XR, ES, MB, RL, JM, AB, and LF contributed input to the study design, reviewed findings, and provided critical revisions to the manuscript. All authors have reviewed and approved this version of the manuscript. AFW and DMM are the guarantors of this work and, as such, had full access to all the data and take full responsibility for the integrity of the data and the accuracy of the analysis.

  • Funding Funding for this study was provided by the Leona M and Harry B Helmsley Charitable Trust (2019 PG-T1D052).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.