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IMPACTO DO MODELO ECHO® NO ACOMPANHAMENTO DE PESSOAS COM DIAGNÓSTICO DE DIABETES MELLITUS: REVISÃO DE ESCOPO
THE IMPACT OF THE ECHO® MODEL ON MONITORING PEOPLE DIAGNOSED WITH DIABETES MELLITUS: A SCOPING REVIEW

Isla Evellen Santos Souza1
Marcela Santos da Silva2
Cindy Kemille Andrade de Araújo3
Beatriz Carvalho Ferreira4
Alice Cardoso5
Glebson Moura Silva6
Liudmila Miyar Otero7

1 Graduate Program in Nursing, Federal University of Sergipe, São Cristóvão, Sergipe, Brazil. E-mail: ievellenss@gmail.com. Orcid: https://orcid.org/0000-0002-0703-7493.
2 Federal University of Sergipe, São Cristóvão, Sergipe, Brazil. E-mail: marcelasdas@hotmail.com. Orcid: https://orcid.org/0009-0006-8412-5979.
3 Federal University of Sergipe, São Cristóvão, Sergipe, Brazil. E-mail: cindyykemille@hotmail.com. Orcid: https://orcid.org/0009-0002-8921-1973.
4 Graduate Program in Nursing, Federal University of Sergipe, São Cristóvão, Sergipe, Brazil. E-mail: beatrizcarv.ferreira@gmail.com. Orcid: https://orcid.org/0000-0002-5202-283X.
5 Federal University of Sergipe, São Cristóvão, Sergipe, Brazil. E-mail: ali_ce_cardoso@hotmail.com. Orcid: https://orcid.org/0000-0001-7835-3306.
6 Nursing Department, Federal University of Sergipe, Lagarto, Sergipe, Brazil. E-mail: glebson@academico.ufs.br. Orcid: https://orcid.org/0000-0002-4977-2787.
7 Nursing Department, Federal University of Sergipe, Aracaju, Sergipe, Brazil. E-mail: liudmilamiyar@gmail.com. Orcid: https://orcid.org/0000-0002-4436-2877.

RESUMO
A presente revisão teve como objetivo identificar o impacto do Modelo ECHO® no acompanhamento de pessoas com diagnóstico de diabetes mellitus. O trabalho foi desenvolvido de acordo com as recomendações do Joanna Briggs Institute e do Checklist PRISMA-ScR, cujas buscas foram realizadas nas bases de dados Cochrane Library, Embase, Biblioteca Virtual em Saúde, PubMed/MEDLINE, Scopus e Web of Science, através de estratégias compostas pelos descritores “Diabetes mellitus”, "Diabete Melito”, “Diabetes”, "Diabetes Melito", “model ECHO", "Project ECHO" e "Extension for Community Healthcare Outcomes”. A seleção dos estudos contou com dois revisores trabalhando de forma independente através do software de gestão Rayyan-Intelligent Systematic Review. Dos 151 trabalhos identificados, nove foram selecionados. Um estudo foi identificado através da literatura cinzenta. Os dez estudos incluídos foram publicados em inglês, entre os anos de 2012 a 2022. Observou-se melhorias no conhecimento e na autoconfiança dos profissionais, além de diminuição da hemoglobina glicada, redução de hospitalizações e de gastos com internações das pessoas com diabetes. Conclui-se que este trabalho expôs um impacto positivo do Modelo ECHO® no acompanhamento de pessoas com diabetes mellitus, principalmente em comunidades de maior vulnerabilidade.
Palavras-chave: Diabetes Mellitus; Educação; Conhecimento.

ABSTRACT
This review aimed to identify the impact of the ECHO® Model on monitoring people diagnosed with diabetes mellitus. It followed the Joanna Briggs Institute and the PRISMA-ScR Checklist. The search was conducted in the Cochrane Library, Embase, Virtual Health Library, PubMed/MEDLINE, Scopus, and Web of Science databases. The strategy included the descriptors “Diabetes mellitus,” “Diabetes Melito,” “Diabetes,” “Diabetes Melito,” “Model ECHO,” “Project ECHO,” and “Extension for Community Healthcare Outcomes.” Two independent reviewers selected the studies using the Rayyan-Intelligent Systematic Review management software. Nine of the 151 studies initially identified were selected, and one study was identified through gray literature. The ten studies were published in English between 2012 and 2022. Improvements were found in the professionals’ knowledge and self-confidence, besides decreased glycated hemoglobin levels, hospital admissions, and hospitalization costs among people with diabetes. The conclusion is that the ECHO® Model positively impacted the monitoring of people with diabetes mellitus, especially in vulnerable communities.
Keywords: Diabetes Mellitus; Education; Knowledge.

INTRODUCTION
Diabetes mellitus (DM) is considered one of the health emergencies of the 21st century, as the number of people living with this condition exceeds half a billion worldwide. Additionally, projections indicate a rapid and concerning increase in the coming years¹. Diabetes mellitus is a chronic condition characterized by high blood sugar levels resulting from absolute or relative deficiency of insulin, which is the glucose-synthesizing hormone². Late diagnosis and a lack of adequate treatment may lead to micro or macrovascular complications, which harm one’s health and quality of life, not to mention billions in economic costs for health systems³.
Data from Brazil show that approximately 16.8 million inhabitants live with DM, being the third leading cause of death in the country¹. Additionally, Brazil ranks third among the countries spending the most on DM worldwide, with 42.9 billion dollars in 2021¹. Metabolic control is the primary objective of DM treatment, and its pillars include drug adherence and changes in habits and healthy lifestyle, which require multidisciplinary health professionals to monitor patients continuously³. The DM therapeutic process is supposed to be predominantly performed within Primary Health Care (PHC), a care model focused on prevention, to decrease complications and mortality². Data indicate that patients with type 2 DM cared for in the PHC network experience more than 50% less risk of cardiovascular disease and 66.1% less mortality risk.
The main obstacles to DM treatment are the PHC workers’ lack of specific clinical training and knowledge on managing complex cases³. Hence, many professionals and managers seek educational alternatives, such as Project ECHO: Extension for Community Healthcare Outcomes, to overcome obstacles and improve the quality of healthcare services.
Project ECHO is considered an innovative educational model that uses videoconferencing technology to connect health professionals with mentors and specialists. The project began in 2003 in New Mexico, USA, through the initiative of a specialist in liver diseases. The objective was to qualify PHC professionals in treating people with hepatitis C by discussing actual cases with specialists in the field4.
Because Project ECHO® enables the exchange of knowledge and the provision of best practices through creating a community of practice (CoP), it has been replicated at other healthcare levels and sectors, such as business, climate change, and violence. In healthcare, it allows participants to acquire new skills to provide faster, more effective, and dynamic care5. The telementoring enabled through Project ECHO does not incur costs to its participants, enabling healthcare professionals to obtain the specific knowledge to act rapidly and with little financial resources despite their location.
Hence, this study aimed to conduct a scoping review to identify Project ECHO®’s impact on monitoring people diagnosed with diabetes mellitus.

METHOD
A scoping review is primarily conducted to gather scientific evidence on complex and seldom-studied topics6. This study followed the recommendations of the Joanna Briggs Institute (JBI)7 and the Preferred Reporting Items for Systematic reviews, in addition to the Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist8 for writing the final report.

Study’s registration
This review’s protocol is registered on the Open Science Framework (OSF) platform under DOI 10.17605/OSF.IO/2VPY8, available at https://doi.org/10.17605/OSF.IO/2VPY8.

Identification of the Research Question
According to JBI7 guidelines, the mnemonic PCC (Participants, Concept, and Context), widely recommended for this type of review, was used to establish the research question. The participants are people with diabetes mellitus, the concept is the impact of Project ECHO®, and the context concerns the monitoring of people diagnosed with diabetes mellitus cared for at all levels of the healthcare system. In this context, the following guiding question was established: “What is the impact of Project ECHO on the monitoring of people diagnosed with diabetes mellitus?”

Identification of Relevant Studies
The inclusion criteria were studies addressing the results of the ECHO® Model applied to the context of DM, regardless of the participants. Studies not reporting the ECHO® Model applied to DM, whose full texts were not available, or presented the application of the ECHO® Model together with another educational intervention, were excluded.

Study selection and data mapping
The keywords and descriptors extracted from EMTREE and Medical Subject Headings (MESH) were used together with the Boolean operators “AND” and “OR” in the search strategy. The search was performed between March and April 2023 in the following bibliographic databases: Cochrane Library, Embase (Elsevier), Virtual Health Library (VHL), PubMed/MEDLINE, Scopus (Elsevier), Web of Science (Clarivate Analytics). Gray literature was obtained by manually consulting the references of the studies identified in the screening process, the Google Scholar, and the CAPES thesis database. No timeframe or language restrictions were imposed. Table 1 presents the search strategies and respective databases, which were organized with the support of a librarian.
The screening process was performed using systematic review management software, the Rayyan-Intelligent Systematic Review9. Two independent reviewers selected the studies, and a third was consulted to resolve disagreements.
Table 1

The categories of analysis were year of publication, degree of recommendation, evidence level, study scope, journal’s impact factor, objective, methodology, and primary results.

RESULTS
The flowchart in Figure 1 presents the study selection performed according to the PRISMA Checklist8. A total of 151 studies were identified, and the full texts of 31 of these were selected. Three more studies were identified in the gray literature, but only one was included.
Figure 1

The ten studies were published between 2012 and 2022 (Table 2). There were cohort studies and non-randomized intervention studies of the before-and-after type; hence, they were categorized with a degree of recommendation B and C and level of evidence 3 and 4 according to the classification by the Oxford Centre for Evidence-Based Medicine for the Degree of Recommendation and Level of Evidence10. Regarding the periodicals, 60% of the studies were published in journals under A classification according to the CAPES Classification of Journals for the 2017-2020 Quadrennial. Only two journals were not included in the previous list: Medical Care, which has an impact factor of 3.0, and The Diabetes Educator, which ceased its activities in 2020.
Table 2

Table 3 details the studies’ objectives, methods, and results. Six are intervention studies, five of which included pre- and post-tests, three are retrospective cohort studies, and one is a pilot study. Regarding the population, seven studies addressed healthcare providers qualified by the ECHO® Model, while three verified the results of patients.
Most studies report significant improvements in management and professional conduct after the ECHO® Model was introduced. Regarding the studies whose objectives were to evaluate the impact of ECHO on the participants’ results, two showed decreased glycated hemoglobin (HbA1c) levels, and one found a qualitative improvement in access to care provided by PHC workers. Furthermore, one of the studies showed a decrease in the financial burden generated by DM expenses for those patients treated by PHC workers trained via the ECHO model.
Table 3

All the studies included in this review were conducted in the United States of America and published in English. The studies’ limitations include the fact that positive assessments of response rates and willing and well-evaluated care providers may not represent all primary care providers. Additionally, studies developed in a single ECHO® Model center that had been recently implemented may limit generalizations to other contexts or centers. Finally, there were difficulties connecting to videoconference sessions, while patients’ self-reported data may be subject to social-desirability bias. Methodological details and respective results are available in SciELO Data at https://doi.org/10.48331/scielodata.SDPKQ0.

DISCUSSION
The ten primary studies in this scooping review discuss the impact of the ECHO® Model on monitoring people diagnosed with DM. The findings indicate that there is incipient research on the topic. Additionally, it mainly focuses on the results of the ECHO Project applied to the PHC workers’ DM knowledge and management rather than on improving the quality of life of people with DM and screening potential diagnoses11. Such focus is explained by the essential role of PHC professionals in managing chronic diseases; hence, these professionals must have clinical skills to prescribe pharmacological dosages, provide guidance, and implement preventive practices, besides managing complications that lead to high morbidity and mortality12.
The PHC service is the main entry door of the health network, and PHC professionals are the leading healthcare providers. These professionals deal with the most varied and non-specific cases, requiring comprehensive and quality knowledge, especially concerning chronic diseases. Countries with well-organized and highly scored PHC services present a better balance between chronic disease control rates, such as the glycemic control of DM, which has increased by 54.8% in countries such as Portugal13.
The ECHO telementoring project presents promising results of the services provided by participating professionals, as it provides specific knowledge and skills in a health-disease context, such as DM, the condition addressed here. For example, the results of a study conducted with people infected with the Hepatitis C virus report a comparison between patients treated by PHC providers instructed through the ECHO® Model and patients treated by specialists. It shows that approximately 58.2% of the patients monitored by ECHO and 57.5% of those assisted by specialists presented a sustained viral load, with no statistically significant difference between them14.
The ECHO intervention model has brought positive results in the general perception of DM, such as improved knowledge about its parameters, specific complications, and the most appropriate intervention, besides professionals’ improved self-confidence regarding the pharmacological treatment and the management of more complex cases within PHC services. These results show a decreased need to refer patients to secondary or tertiary care levels, consequently decreasing costs and improving patient quality of life, which are the objectives of the ECHO Project15,16.
The analysis of these studies indicates that the ECHO Project promotes decreased hospital admissions and related costs; a 44.3% drop in admissions was found among the groups covered by the ECHO model. The cost per patient decreased by $327 compared to those who did not receive care within the PHC service17. Most people with DM are hospitalized due to foot ulcers. Diabetic foot is related to high morbidity and mortality rates and may lead to lower limb amputation, which accounts for a large portion of expenses in the health system. Therefore, foot and leg assessments should be included in these peoples’ physical examination as a preventive measure and early diagnosis of ulcers and neuropathies18.
Furthermore, the ECHO Model also promoted a 1.2% decrease in HbA1c levels among people with complex DM who underwent educational interventions mediated by ECHO; complex conditions concerned patients taking insulin and with low glycemic control19. HbA1c is a fraction of hemoglobin (Hb) produced when free sugar is in the blood, which is one of the main parameters for diagnosing and treating DM20. HbA1c enables identifying high glucose levels in the last 90 days; hence, the higher the glucose level, the higher the HbA1c. Such changes confirm that the ECHO Project promotes better treatment adherence and necessary monitoring, considering that most patients usually never see a specialist or have not been to a health service for at least a year21.
Some studies indicate that, despite the positive impacts on PHC professionals’ self-confidence, clinical skills, and ability to use technologies, the ECHO Project has shown low effectiveness regarding mental processes developed due to a DM diagnosis. Other studies did not take this aspect into consideration15. The psychological disorders triggered by the DM diagnosis-treatment-rehabilitation process are highly relevant, as they directly impact the efficiency of an individual’s treatment and self-care. Neglecting the psychological aspects of DM favors one’s inattention and lack of interest in his/her health, a factor essential for treatment adherence and willingness to be treated, the lack of which increases the likelihood of more severe complications and even premature death.
Currently, the treatment of diseases and health promotion are represented in comprehensive care, one of the objectives of healthcare delivery, which must consider the individuals’ biological, psychological, and social processes. Comprehensive care, focused on health promotion, protection, and disease prevention, is a principle of the Brazilian Unified Health System (SUS)22. Pursuing these objectives involves decreasing disparities in providing services and heeding the individuals’ needs. For this reason, focusing on psychosocial aspects is vital23. Therefore, the psychological context of patients with DM must also be considered in future applications of the ECHO Project to qualify workers to promote comprehensive and increasingly humanized health care.

FINAL CONSIDERATIONS
This study’s findings show the positive impact of the ECHO® Model on the monitoring of people with DM. The positive results concerning the professionals’ knowledge and self-confidence directly reflect on the findings involving people living with this comorbidity, such as decreased HbA1c levels. Such a scenario reaffirms the potential of the ECHO® Model in training frontline professionals, especially for the monitoring of complex diseases such as DM.
Additionally, few studies address this topic. The lack of evidence on the impact of the ECHO® Model on this population requires further research, primarily focusing on the results of people monitored by professionals trained within this model. Future studies and, whenever possible, systematic reviews are suggested.

FUNDING
This study was financially supported by the Coordination for the Improvement of Higher Education Personnel – Brazil (CAPES) - Financing Code 001.

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