STRENGTHS AND LIMITATIONS OF THIS STUDY

The study relies on a relatively large number of study participants that include both those participating in the programme Extension for Community Healthcare Outcomes (ECHO) as learners (spokes) and those participating as experts (hub members), thus providing multiple perspectives on the programme implementation.

Study participants were interviewed only once, during or after their participation in one ECHO programme.

A longitudinal design would have been interesting to adopt in order to contrast their expectations prior to joining the programme with their experiences on follow-up.

The study is conducted in a single centre, thereby limiting the differences in organisational components that could have contrasted participants’ experiences.

Our study is cross-sectional and interviews were not conducted before study implementation, making it impossible to examine how expectations influenced this process.

Introduction

One in five individuals live with at least one common chronic disease, while four out of five Canadians present at least one modifiable risk factor for developing such chronic condition.1 Chronic diseases can have major negative impacts on those affected, including decreased quality of life and sometimes early death. The chronic disease burden also results in important economic consequences for individuals and society. In 2015, the financial losses due to chronic diseases and early death in Canada were projected at Intl$1.5 billion.2

Primary healthcare providers are at the forefront of the prevention and management of chronic diseases, yet they are often inadequately equipped to do so and have minimal access to specialists.3 4 For instance, although patient self-management is one of the key components in the care of patients with chronic diseases,5 it still needs to be sufficiently integrated into the primary care curriculum.4 Various modalities have been developed to enhance primary healthcare chronic disease management, such as the Project Extension for Community Healthcare Outcomes (Project ECHO).

Initially launched in New Mexico, Project ECHO is a knowledge-sharing model which brings together primary healthcare professionals and specialists from multiple focus areas. As raised in the RAND report,6 ECHO programme’s goals are multiple ranging from facilitating access to care to improving the quality of care. The benefits of the ECHO model on the knowledge7 and care delivery8 of primary healthcare providers are well established. Numerous studies have demonstrated the model’s effectiveness in improving attendees’ confidence, self-efficacy and knowledge and gaining new skills.9–13 Many qualitative inquiries have reported on participants’ motivations and barriers participating in Project ECHO.14–17 To the best of our knowledge, only one qualitative inquiry explored the experiences of participants simultaneously across multiple ECHO programmes. However, the specificities and characteristics of each condition studied (cancer prevention/survivorship, integrated pain management, hepatitis C (HepC), HIV and lesbian, gay, bisexual, transgender, queer and plus healthcare), which are characteristics of the programme, were not considered as part of the analysis of programmes’ successes or limitations in this single study.14 This is surprising, given that implementation of a programme can vary according to its very characteristics, such as its complexity,18 appropriateness and acceptability.19 University Health Networks, with their academic mission, are particularly well positioned to implement continuous education programmes targeting primary care providers. In publicly funded healthcare systems such as in Quebec, Canada, ECHO programmes can help facilitate access to care within various patients’ communities. It can also potentially reduce the waitlist for specialised care. Hence, three ECHO programmes were launched during the same period at the Centre Hospitalier de l’Université de Montréal (Hospital Center of the University of Montréal (CHUM)), targeting the following conditions: HepC, chronic pain (CP) and concurrent mental health and substance use disorders (CMSD), which refers to the presence of both a substance use and a mental health disorder simultaneously.

While published studies support the use of the ECHO model for these three conditions individually,9 11 13 16 20–30 including also opioid use disorder,31–33 little is known about how particularities of each of these diseases (eg, level of desirable interdisciplinary care, presence of objective disease markers, complexity of treatment algorithm) may impact the implementation and success of an ECHO programme. Peculiarities related to the condition studied should be investigated, as they may influence the participants’ experience in the first years of implementation, as well as the impact of the programme (eg, the impact may be different for ECHO HepC than for ECHO CP, since there is a treatment for HepC). Thus, similarities and differences related to a curable (HepC) or non-curable (CP, CMSD) chronic condition can affect the experiences of participants. Considering that the programme is not homogeneous across conditions, it is important to study the factors related to the pathologies themselves, which may provide more precise information about the implementation of the ECHO programme. The objective of this study was to compare and contrast the experiences of both attendees (spokes) and experts (hub members) from three ECHO programmes (HepC, CP and CMSD), in order to highlight the similarities and differences between ECHO programmes in terms of the conditions studied. The results of this study could help teams who wish to replicate the ECHO model in tailoring their future programme to the targeted condition.

MethodsDescription of the ECHO CHUM programmes

In April 2017, the ECHO CHUM HepC was launched as a pilot project to enable healthcare professionals to increase the rate of HepC screening, assessment and treatment in Quebec. Each team of ECHO CHUM comprises hub members which are experts from different specialised care services and spokes which are predominantly primary healthcare providers. The ECHO CHUM HepC hub members consist of a hepatologist, an addiction specialist, an infectiologist, a pharmacist and a nurse. Shortly thereafter, the ECHO CHUM Douleur Chronique programme (CP) was launched in September 2017. Its goal is to foster knowledge regarding best practices in CP management and pain evaluation, and enable collaboration between healthcare professionals of different degrees of specialisation. Most experts in this hub work in the same care pain clinic and have the same expertise level. They form a multidisciplinary team composed of acupuncturists, anaesthesiologists, nurses, family physicians, neurologists, pharmacists, physiotherapists, psychiatrists, psychologists and social workers. Finally, a third programme ECHO CHUM Troubles Concomitants programme (CMSD) began in September 2018. This programme aims to help healthcare professionals from different backgrounds gain knowledge in assessing, treating and referring patients with concurrent disorders. The hub team is made up of clinicians and professionals from various disciplines (addiction psychiatry, addiction medicine, nursing, occupational therapy, social work, pharmacy and information sciences)).

The structure of the ECHO Tele-Clinics is similar across the three ECHO CHUM programmes. The first part of the session is dedicated to discussing clinical cases presented by the spokes ending with shared decision-making between spokes and hub members. The facilitator then summarises the proposed treatment plan. Following the Tele-clinic, written recommendations are emailed to the participant who presented the case. A brief didactic presentation on a specific topic by a hub member or an invited expert concludes the session. Characteristics of each ECHO CHUM programme are presented in table 1.

Table 1

Characteristics of the three Project ECHO CHUM programmes

Study design

This study relied on a qualitative approach where 30 one-on-one interviews with spokes and 4 focus groups with hub members from the three ECHO CHUM programmes were conducted between April 2020 and December 2020. Focus groups were chosen as the method of data collection since it allows different opinions to emerge and potentially brings out the contrasts and similarities between each of the three ECHO programmes. Individual interviews, on the other hand, were chosen as a means of gathering individual experiences. The focus group size was between three and five participants. Each focus group involved at least one hub member from the three ECHO CHUM programmes to stimulate conversation around the similarities and differences between programmes and the three chronic health conditions.

Three research team members were involved in the analyses. The first analyst is a sociologist and the second a psychologist. They are both trained and experienced in qualitative methods and have experience in implementation research. The third analyst is a physician and clinical director of an ECHO CHUM programme. We used a constructionist paradigm that argues that one’s representations of reality are socially and historically situated and therefore that researchers necessarily play a role in recognising and interpreting participants’ experiences. We followed the Standards for Reporting Qualitative Research.34

Participants and recruitment

Spokes and hub members were informed of the study during Tele-Clinics by each programme coordinator. Eligible individuals were active or past participants of ECHO CHUM, were 18 years of age or older, had attended at least one Tele-Clinic in one of the programmes (ECHO CHUM HepC (cycle 1, 2 or 3 between 2017 and 2020), ECHO CHUM CP (cycle 1, 2 or 3 between 2017 and 2020) or ECHO CHUM CMSD (cycle 1 or 2 between 2018 and 2020) at the time of contact. The research coordinator then emailed individuals who met those criteria to confirm their willingness to participate. A maximum variation sampling was used to recruit participants with different levels of exposure to the Tele-Clinics (number of clinics attended <5 sessions and >20 sessions) and from diverse professional backgrounds. Recruitment was also diversified in terms of professional backgrounds of participants, degree of engagement in ECHO, practice setting and years of practice. No experts (hub members) were involved in more than one ECHO programme.

Procedure

Interested individuals completed an online consent form along with a sociodemographic questionnaire hosted on LimeSurvey. Individual semi-structured interviews with participating spokes and semi-structured focus groups with participating hub members were conducted remotely using a secured video-conferencing platform (Zoom Web Conferencing software Zoom Video Communications, USA) by one (individual interviews) or two (focus groups) research team members trained and experienced in qualitative methods. Interviews were recorded with the participants’ consent. Semi-structured interview guides were built with open-ended questions aimed to explore topics such as therapeutic challenges encountered, benefits derived from participating in the programme, overall experience with the programme, relevance of session content and contributions of ECHO to their knowledge and clinical practice (see online supplemental file 1 for the interview guides). One-on-one interviews lasted between 16 and 48 min (mean=32 min and median=30 min) and focus groups lasted between 55 and 61 min (mean and median=58 min). All interviews were audio-recorded and transcribed verbatim with de-identification of all names, places and dates. Interviews were carried out in French and the selected quotes were translated into English using a forward-backward translation process.

A total of 30 spokes and 14 hub members participated in the study between July 2020 and April 2021. The final number of participants was determined when sufficient diversity and quality of data were collected, as well as adequate information power.35 The final decision to stop recruitment was made by two researchers.

Data analysis

We used a reflexive thematic analysis as defined by Braun et al and Clarke nd Braun.36 37 This inductive method of analysis was particularly suitable to answer our research question. Six steps were executed as part of the analysis process: familiarisation with the data by active listening and reading transcripts several times, generating initial codes by going through all of the data, generating themes by interpreting and aggregating units of meaning, reviewing potential themes by examining relationships among coded data, codes and their subthemes and reviewing themes in relation to the dataset, defining and naming themes by providing a detailed analysis of the framework of the themes and generating the final report of the data analysis. Memos were written throughout the analysis process to enhance the researchers’ reflexivity in interpreting the data. Several meetings during the analysis process allowed analysts to validate the codebook and evolve it into our final themes and subthemes. Dedoose software38 was used for analysing data based on platform access and preferences of analysts.

Characteristics of participants

Participants’ sociodemographic and professional characteristics are shown in table 2. Spokes were predominantly from family medicine and nursing (60% of hub members and 90% of spokes) in ECHO CHUM HepC, whereas there was a large variety of professional backgrounds for ECHO CP and ECHO CMSD, including social work/psychology/psychoeducation, pharmacy and rehabilitation. Number of years of practice varied across participants for all three programmes and most spokes interviewed were in their first year of participating in the programme.

Table 2

Participant’s sociodemographic and professional characteristics

Results

Three overarching themes were identified from the data analysis: (1) perceived impacts of an interprofessional educational setting; (2) nature of disease and interprofessional interactions as determinants of clinical practice changes in diagnoses and treatments and (3) providers’ perceptions of patient engagement and care pathways. Themes and subthemes are presented in box 1.

Box 1 Summary of themes and subthemes

Theme 1: perceived impacts of an interprofessional educational setting

Facilitating shared learning and responsibilities.

Biopsychosocial complexity impacting active participation.

Feeling supported by normalising complexity and trials and errors.

Theme 2: nature of disease and interprofessional interactions as determinants of clinical practice changes in diagnoses and treatments

Sharing realities to overcome lack of resources.

Collective ability to overcome uncertainty in the absence of objective markers.

Application of recommendations limited by some systemic issues.

Theme 3: providers’ perceptions of patient engagement and care pathways

Empowerment through evidence-based educational programmes to increase patient engagement in care.

Saving time and limiting disruption to the care pathway.

Perceived impacts of an interprofessional educational setting

We identified three impacts that the interprofessional educational setting provided by the ECHO programmes had on participants’ experiences and engagement. First, the Project ECHO that was highly interprofessional in terms of types of professionals present were providing a unique learning opportunity particularly for those practising in primary care with generally less access to other professions. Second, the necessity to adopt a biopsychosocial understanding of complex cases impacted participants’ abilities to comprehensively present cases and implement the recommendations. Finally, the degree of interdisciplinarity provided a safe environment, whereby participants felt supported through trials and errors. These impacts varied across the three programmes, as the degree of interdisciplinarity was different. While the majority of ECHO HepC spokes and hub members came from the fields of medicine, nursing and pharmacy, the composition of ECHO CP and ECHO CMSD attendees was more interdisciplinary and included members from the disciplines of psychology, social work, rehabilitation/physiotherapy and occupational therapy. Nonetheless, spokes from all three ECHO programmes perceived benefits from such an environment but tended to vary according to the degree of interdisciplinarity.

Facilitating shared learning and responsibilities

CP and CMSD can rarely be treated exclusively using a pharmacological approach; the implication of professionals from different disciplines is usually necessary. Yet, in primary care settings, this expertise is not always accessible. ECHO CP and ECHO CMSD programmes provided an opportunity for spokes to learn in a multidisciplinary and interprofessional setting, having their own expertise valued and receiving support from hub members to evaluate and manage patients from an interdisciplinary lens.

But of course, I love this part of the work where we each have a different view of the patient, but which, combined together, will really help us to help the patient. Because that’s the point anyway. But it’s true that it’s interesting to get others’ perspectives on a case. And sometimes, when it’s complex patients, it seems easier, when it doesn’t just fall on… [a person’s shoulders]. (Spoke 407, ECHO CP)

Nurses are at the forefront of the care of patients living with HepC, especially in countries where specialised nurse practitioners can prescribe direct-acting antivirals (DAA) therapy such as in Quebec. In this particular ECHO CHUM programme, the more homogeneous disciplinary background of participants (60% were from family medicine or nursing) allowed for spokes to develop an expertise leading to increased independence in treating their patients. This was gratifying for hub members who could see the tangible impact of the knowledge they shared with spokes.

What made me most proud was a nurse who didn’t have a prescribing physician for Hep C. But the fact that she participated in ECHO, well, that allowed her to treat patients in her sector. She alone made a big difference and became an expert nurse herself. It’s to see the ramifications of ECHO with our clientele. And for us, what we want, is that our patients, well you know, I’m talking about hepatitis C here, to be treated. (Expert FG1, ECHO HepC)

This was also reported by spokes, who have noticed a significant impact of the programme on their practice, resulting in optimised patient care. This was particularly true of those working in the penitentiary system where abilities to initiate new treatments are limited.

Because we had no one to guide us. So it was really enriching to participate in ECHO. We have evolved a bit, because we just managed to get our first Hep C treatment approved, in part due to ECHO, because we presented a case, and the doctor followed the recommendations we had received from ECHO and signed the prescription. We don’t have doctors trained in Hep C treatment, so they were not willing to prescribe. But now, by guiding the doctors by showing them the didactic slides…on the different medications, side effects and all, and the hub recommendations, we have made it possible for that doctor to prescribe that medication. (Spoke 100, ECHO HepC)

Biopsychosocial complexity impacting active participation

Complexity of considering biological, psychological and social aspects. CP and CMSD are diseases understood from a biopsychosocial model. This requires healthcare providers to consider various biological, psychological and social components in evaluating and treating a condition, often requiring interprofessional consultations. Preparing a case presentation may be challenging and discouraging for spokes who must provide information outside their scope of expertise. Due to the scarcity of allied health services in primary care, gathering all relevant information may also be difficult and burdensome for many spokes who do not have access to these professionals. Presenting cases can become discouraging and leave one feeling ill-equipped to do so.

The case presentations, if I have anything to point out, it’s that I found that sometimes, it was one time in particular, that I noticed that the person’s case was rather poorly prepared. In the sense that people in physio, or those from the CHUM, asked questions about complementary exams, about elements to clarify, and in fact the physician was not necessarily very aware of those information to complete the case. (Spoke 321, ECHO CP)

From hub members’ perspectives, complex conditions that require combined pharmacological, physical and psychological approaches lack straightforward treatment algorithms and guidelines evolve quickly. Providing recommendations requires frequently going back to the literature to keep up with the latest changes in clinical practice guidelines or innovations.

In hepatitis C, I would say the guidelines are relatively simple, because it’s a lot of biochemical data, imaging data, hard data. Whereas in pain, in concurrent disorders, in addiction in general, the literature is so heterogeneous that it’s much more difficult. So I think that’s one of the issues in ECHO topics that are not based on hard biological data. […] I think that for ECHO, it poses particular challenges, because we should be making our recommendations based on evidence obviously. But when the evidence doesn’t tell us a categorical answer, like in hepatitis C, I think we have to be particularly careful or at least the way we state it is going to be challenging compared to other areas. (Expert FG2, ECHO HepC)

Time pressure. The extent to which the condition needed to be addressed from a biopsychosocial perspective was also discussed as a potential determinant of how long it would take to prepare a case or make recommendations. For some participants, if Project ECHO is not part of their protected clinical work time, it further undermines their motivation to present a case and participate in the programme. This, combined with the time necessary to draft the recommendations, was considered a significant challenge for a hub’s clinical lead who reported that this task often required several extra hours of work per week.

I would say that speaking for myself, in my clinical time, it can quickly become a challenge, because it’s also me and my colleague who write the recommendations, which are sometimes quite exhaustive. So you know, when you add everything together… (Expert FG1, ECHO CMSD)

In contrast, the availability of well-tolerated, all-oral and pan-genotypic DAA has considerably simplified the treatment of individuals living with HepC leading to now relatively straightforward HepC guidelines. This was identified as reducing the time pressure required to participate in the programme. The didactic presentation also did not required extensive revision across cycles.

In hepatitis C, we went three years ago from injected chemical therapy with terrible side effects, to now one pill a day for two or three months. So all this required a total revision of the content of course. But that didn’t happen this year. So I don’t count it in my involvement this year, it’s more in the last few years when we really had to completely modify the capsules, especially for [name of medical lead] and pharmacists, who had to take into account the evolution of practices. (Expert FG2, ECHO HepC)

However, the lack of an allotted budget for protected clinical time for their participation in the programme negatively affects their long-term motivation.

Well, in fact, the collaboration we’ve had to date remains. So it’s not more difficult. But it’s like we still walk a little bit on eggshells… You feel like you could easily be told, ‘Well, this week we can’t’, but so far, we’re doing fine, we’re surviving just fine. I think that people have been convinced of the interest of ECHO. Among other things, everyone is convinced when we make presentations at conferences or when we present how ECHO works and the impacts that ECHO has. But when you have to put your hand in the wallet or in the budget of time allocated, that’s when it could get tough. (Expert FG2, ECHO HepC)

Feeling supported by normalising complexity and trials and errors

Complexity can take many forms, such as the complexity of the condition, of the treatment or the environment. Participating in a continuous education programme appeared to be beneficial to support participants in navigating all of these complexities.

Managing of CP and CMSD can lead to treatment impasses due to the complexity and chronicity of those conditions. Having a safe space to discuss these cases, failed treatment attempts and strategising subsequent treatment plans is a source of hope for participants. This decreases their feelings of letting the patient down or of failure.

It’s really really appreciated to have moments when we can discuss these cases, because those clients… who linger in the network, who had many experiences… Cases I was hearing about, those are patients who are complex, who are not easy to help either. There are many things that have been done, that were not successful, so it brings on feelings of powerlessness. (Spoke 204, ECHO CMSD)

The work environment for primary healthcare professionals managing patients with HepC can at times be complex and challenging due to the psychosocial difficulties faced by the clientele or the demanding conditions of the environment, such as those found in correctional facilities. The opportunity for peer gathering provided by Project ECHO CHUM allows them to support each other, learn from their experiences and regain hope.

I work in correctional facilities and there were also nurses from correctional facilities who were logged. We used to talk about our trial and error, our positive points, so it was really interesting, from that perspective. (Spoke 116, ECHO HepC)

Knowledge gained also helps feeling valued by other professionals in their community.

I work in prisons, and it goes well when they are in prison, actually they like to come and see me. After, well I’m not there, you know they get transferred and they fall through [the cracks]. At some point, I had called their family doctor, because he was getting out, …, and I transferred him all of the information that we got through ECHO, and he was very happy. So at least for him, he didn’t fall between two chairs. (Spoke 112, ECHO HepC)

Nature of disease and interprofessional context as determinants of clinical practice changes in diagnoses and treatments

In this theme, we discuss how the nature of the disease addressed by a Project ECHO influences the changes that can be implemented in clinical practice, as well as the resources and levels of interprofessional interactions required to achieve these changes. Finally, we discuss how the structure of the provincial public healthcare system and the programme ECHO model both influence the spokes and hub experts’ experiences and perceived benefits.

Sharing realities to overcome lack of resources

Being part of a group sharing similar interests was beneficial both in terms of networking, but also in terms of adapting techniques and tools based on availability of resources.

As mentioned earlier, CP and CMSD require healthcare providers to interact with other disciplines to implement biopsychosocial management approaches. Spokes working in remote settings do not always have access to such allied healthcare providers. Having access to a large panel of hub members and spokes is a unique networking opportunity for them to learn about each other’s roles and thus develop needed collaborations for referring patients.

It gives us input from everyone. What an anesthesiologist can bring to us, yes, will be targeted to chronic pain. But the point of view that a pharmacist might have on the problem, you know… we also have a lot of health care professionals… Professor [name], who is a chiropractor, has also been part of the program for a long time. He’s already presented several cases. And just to see what he had already done with the case… it was eye opening, you know? ‘Ah, that’s true’, when I have a case like that, yes, I could send him/her to such and such a professional to suggest working in such and such a way. (Spoke 345, ECHO CP)

Once an individual has been diagnosed with HepC, determination of the liver fibrosis stage is essential. A non-invasive evaluation using measurement of the hepatic elastometry and/or fibrosis tests is recommended by local guidelines. However, this evaluation requires technological tools that many remote services do not all have access to. Sharing the realities of spokes with similarly limited resources allows them to familiarise themselves with other methods of assessing liver fibrosis that are available and easy to use.

For example, in large healthcare centers, we can order complementary exams, like ultrasounds, all that, very easily. In smaller regional centers, well, it’s not the same. So we have to learn other ways of evaluating patients. And precisely with the ECHO program, it allowed us to learn about other means of evaluation than the technological ones. So, we understand better biological tests which can compensate for the lack of availability of technological tests. (Spoke 120, ECHO HepC)

Collective ability to overcome uncertainty in the absence of objective markers

A lack of definite objective markers for a disease can make diagnosing or evaluating treatment outcomes difficult. Having a large and diverse group of spokes and hub members in ECHO CMSD and CP enables rich discussions necessary to reconsider or select the most likely diagnoses, and identify optimal treatment solutions. The composition of the ECHO CP hub with experts from different disciplines such as physiotherapy and chiropractic care is important since it offers the possibility to reconsider diagnoses based on the expertise of each. These reconsiderations may not be possible outside the context of ECHO.

In terms of pain diagnosis, sometimes it’s interesting to have a different perspective. Because there is a chiropractor who regularly participates in ECHO CP, you know, since we don't often have contacts with chiropractors in the field of pain, and it’s really interesting to have a different perspective, to see the problems from a more anatomical level. And the physios can also bring us certain dimensions at the diagnostic level: did we make a mistake in the initial diagnosis? What could we look at to confirm a diagnosis? (Expert FG3, ECHO CP)

For ECHO CMSD, access to more physician-experts was identified as a unique opportunity to complement the psychosocial perspective more often encountered in the work setting of spokes.

I think what’s interesting is that it was a more varied panel, where there were even more professionals. It’s not necessarily training courses where it’s only psychosocial, there were a lot of doctors, pharmacists, or nurses, in any case. There were several backgrounds, perhaps more medical in fact than what I'm used to. At the same time, I think that’s really appreciated, because it’s not a view that you have all the time. (Spoke 201, ECHO CMSD)

In contrast, the diagnosis of HepC defined by a positive HepC viraemia on a simple blood test is quite straightforward. There is also a clear treatment guideline. Having a large group of participating spokes is not necessarily perceived as advantageous for ECHO HepC programme. This could even be detrimental to the group dynamics and speed of learning for some spokes.

But if we, as physicians, had read before, [the facilitator] would have just mentioned a word, and we would have said: ‘Well, yeah’ you know, and not go back see the explanation. I don’t know if it could work for the nurses. And since it’s a mixed course, it’s complex. How far you have to go with the nurses? How far you have to go with the doctors? It has to be the same, it’s not easy. (Spoke 102, ECHO HepC)

Additionally, multiple recommendations from the hub members bring a level of complexity that can sometimes appear contradictory.

But I, sometimes I could say maybe not to have too much contradictory information. You know, let’s say, someone says something, and another person can give another opinion, so people can be a bit mixed up. So, it’s really about saying: ‘well, there’s such and such a school of thought’, you know, there are two ways. Then sometimes, I find that it can be confusing for the participants when there is too much information, like schools of thought that are a bit contradictory. (Expert FG1, ECHO HepC)

Application of recommendations limited by some systemic issues

The long waiting lists to access a CP specialist or the costs associated with such consultations, institutional barriers authorising HepC treatments and the lack of collaboration from colleagues to treat patients with substance use disorders, are all systemic challenges difficult to act on. These obstacles encountered by the spokes may prevent them from applying the recommendations issued at the Tele-Clinic, no matter which ECHO they were participating in.

Although the majority of the participating spokes emphasised that they felt ready to initiate the new HepC treatment, some of them working in provincial detention centres were not able to do so. This arose from the fact they did not have the authorisation of their supervisors, or because of the lack of budget of their institution, thus limiting the initiation of antiviral treatments.

We don’t know how far we can go, because, well, the [local healthcare network] doesn’t want us to promote the treatment right now. So, I think it’s largely related to costs, because it’s the [local healthcare network] that has to pay for it, and it’s expensive for them. So for now, there doesn’t seem to be a dedicated program, nothing is clear, there are no guidelines like: ‘We’ll provide the treatment in such a case, and we’ll accompany the persons for whom we can’t provide the treatment’. There is nothing in place, there are no programs at all related to this. (Spoke 100, ECHO HepC)

For individuals working in the field of CP, access to the resources recommended in the group discussions (for instance, consulting a psychiatrist or undergoing psychotherapy) can be limited by the lack of accessibility. This forces patients to travel to urban areas, where the waiting lists for access to a psychologist or pain clinic are very long. Another limitation is the cost of certain consultations that are not refunded. These difficulties do not always allow spokes to see their patients progress towards treatment solutions suggested by hub members.

One of the things that I find a bit unfortunate is how accessible are some of the recommendations given. I was given several pieces of advice for the clinical case that I presented in [date]. One of them was to send my patient to a chronic pain rehabilitation program. That request was made last year, once the written recommendations were received. But my patient still hasn’t had his appointment. So, I would say that this is one of the more negative aspects. (Spoke 345, ECHO CP)

Some of the treatment challenges in concurrent disorders lie in the difficulty of integrating mental disorders and substance use disorders services for person-centred care; these two services often work in silos in many participating spokes settings. Thus, even when professionals are available, obtaining their collaboration is not always successful in CMSD, which limits the implementation of the hub members’ recommendations.

There’s the aspect of concurrent disorders where there’s, somewhat, at the level of psychiatrists, there’s the old school and there’s the young people who are a little more ‘willing’ to meet with people who have substance abuse problems. So when the participants come up against difficulties in obtaining psychiatric services because the psychiatrists who work in these territories are not open to seeing this type of patient, well that reflects a little bit… I think it was [expert’s name] who was talking about the fact that not all regions are equipped with all the professionals… And sometimes, even when we have professionals on site, well, sometimes they are not very ‘collaborative’ in offering services or being open to doing something different. So that can cause some frustration on the part of participants. (Expert FG3, ECHO CMSD)

Providers’ perceptions of patient engagement and care pathways

From the providers’ perspectives, several beneficial impacts of the ECHO programmes were noticeable at the patient level. The ECHO HepC and CMSD programmes have provided clinicians with tools adapted to some of the common characteristics of their patients. Second, only healthcare providers in the ECHO HepC programme reported any impact on their patient’s trajectory as a result of the programme.

Empowerment through evidence-based educational programmes to increase patient engagement in care

Seeking care and adhering to treatment plans might pose particular challenges to individuals living with stigmatised illnesses, such as those living with CMSD or with HepC. These persons are often far from the healthcare system. They are poorly perceived as drug addicts and may not be aware of new, less severe treatment options. Programme ECHO’s evidence-based data provide spokes with up-to-date tools to understand these diseases and their global impact better. These tools enable spokes to be convincing, thereby promoting patient engagement in healthcare without the need to refer them to a specialist in a tertiary centre.

First of all, there is a lot of prejudice in the population that I treat for viral hepatitis. Then when you have hepatitis, first of all there’s a lot of judgment… it’s bad. Hepatitis C’s only for people who have a promiscuous life, something like that, and so drug addicts, all that. There’s a lot of education to do, so that people accept to be screened and to be treated. Otherwise they are stigmatized for having this disease. They don’t want to talk about it, they don’t want to be treated. I understand them better. So when I offer my expertise, it’s easier for them to accept the treatment than if they are referred to a specialist in a hospital setting. (Spoke 120, ECHO HepC)

Saving time and limiting disruption to the care pathway

The frequent transfer of patients from one institution to other figures among the multiple barriers to treating HepC in detention settings (eg, change of correctional facility). The complete and concise report completed for an inmate patient’s case presentation facilitates the transmission and application of the medical care plan when the patient is transferred, thus saving valuable time in the patient care pathway.

What happens now is that when they go to federal [prisons], I have a complete report, and I use the template we created in HepC. There’s a sheet that was made, that’s used for case presentations, when there’s the Hepatitis C ECHO meetings, and [name of the clinical lead] allowed me to use their sheet. So now when I refer, the assessment is really complete and they don’t waste time and they can start treatment. (Spoke 106, ECHO HepC)

Discussion

To the best of our knowledge, this study is the first to contrast ECHO spokes and hub members’ experiences based on similarities and differences across various chronic conditions. We found that beyond recognised impacts inherent to the continuous education Project ECHO model, the perceived benefits and limitations of participating in an ECHO programme vary according to the targeted chronic health condition. This relation with the nature of the disease addressed should be kept in mind when adapting and implementing ECHO programmes.

Our results suggest that ECHO CP and ECHO CMSD experiences present similarities in terms of impacts of the interprofessional setting of ECHO. Both programmes are characterised by the presence of spokes from multidisciplinary backgrounds and case discussions requiring a biopsychosocial approach. The interprofessional environment of these ECHOs is much appreciated by spokes who do not often have a chance to participate in continuous education modalities offering direct opportunities to interact with and learn from various health disciplines experts. On the other hand, the biopsychosocial dimension of CP and CMSD represents a challenge when preparing a case, as spokes need to search for information across several domains that they might be less familiar with or less equipped to evaluate. Case-based recommendations can be time consuming for the clinical lead in the context of rapidly evolving guidelines. In a study about an ECHO CP programme, case presentations which included comprehensive biopsychosocial patient dimensions were perceived as ‘ cumbersome’ by some audience spokes. The difficulty arose from the assimilation in the case presentation of aspects other than pharmacological treatments.39 The authors did not mention whether this impacted the spokes participation. However, one could assume that the workload associated with both the preparation of a multidisciplinary case then its presentation may affect the long-term spokes’ motivation to participate in ECHO.

In contrast, for HepC, a condition for which clear objective markers are available (such as a detectable or an undetectable HepC viraemia) and which can be managed in <3 months from screening to cure, a multidisciplinary collaboration does not appear as essential to optimise treatment pathways. DAA treatments can be initiated and managed solely by nurse practitioners, without involving other professionals. ECHO’s interprofessional context where each healthcare professional is recognised for their expertise and importance in the treatment helps them feeling valued. The confidence gained enables them to take a lead role in treatment initiation when they return to their own setting. The literature supports the importance of delivering interprofessional care for patients with chronic diseases, but multidisciplinary work environments can sometimes be organised hierarchically thus preventing some providers to play a more prominent role in the patient’s care.40 When ECHO programmes can foster egalitarian dynamics across professionals, they offer an excellent opportunity to learn about interprofessional care.14 39

The ECHO’s interprofessional context additionally provided spokes an opportunity to network and learn about the clinical realities of other spokes, promoting changes in their clinical practice. Many remote services do not have access to allied healthcare to implement biopsychosocial management approaches or to sophisticated instruments that could aid in diagnosis. Gathering with a large panel of hub members and spokes enables networking opportunies crucial to learning about each other’s role, developing collaborations for referring patients and/or adapting their knowledge and skills based on resources and instrument availability. Thus, the interactions occurring during the Tele-Clinics help the spokes overcome a lack of resources and better understand the healthcare ecosystem in which they work. This networking opportunity inherent to the ECHO model has previously been reported in the literature.12 14 15 39 41 42

Our results showed that participants in all three programmes perceived important benefits of participating in the programme, however these benefits varied across the chronic health conditions targeted. For providers treating individuals with CP and CMSD, therapeutic impasses can be frequent, making the peer support provided at ECHO valuable. For HepC, the need for peer support appears to stem from challenging treatment environments, such as treating inmates in prisons and having to adapt treatment modalities to the logistics and regulatory characteristics of those environments. Our team also reported similar results in another study of ECHO CHUM CP16: the feeling of belonging to a group sharing similar difficulties and similar emotional reactions helped them regain hope.

Additional benefits of ECHO CP and CMSD related to treatment and diagnosis were associated with the large group of spokes and hubs at each session. This strength in numbers allows to consider multiple perspectives and reflections when considering and reconsidering adequate diagnoses and treatment plans. The literature on both ECHO CP or ECHO CMSD reports similar results; the multiple interacting perspectives of interprofessional spokes and hubs are seen as an opportunity to learn in an interprofessional context,13 16 39 and various recommendations are helpful given the complexity of the cases.43 In a study that evaluated a telementoring programme similar to ECHO, called the TeleLink Mental Health Programme, Volpe et al also found many participants stimulate as much as pose some challenge to group discussions. Yet, disagreements among participants were seen as a successful factor in moving the discussion forward.44 Surprisingly, our results showed that a large and heterogeneous group could be perceived as detrimental to the spokes’ experience from ECHO HepC, as it would impede the group dynamic and slow down the speed of learning. Another study focusing on ECHO COVID-19 also found that a large group of participants may be challenging during Tele-Clinics as it brings communication issues.45 Larger number of hub members and spokes could also lead to multiple recommendations, unnecessarily raising the treatment complexity level. Interestingly, Sockalingam et al29 noted that one way to benefit from multiple recommendations is to synthesise the final recommendations, based on several iterative rounds of clarifying issues during the case presentation and rephrasing the pivot, ultimately leading to a better understanding of the patient’s situation.

Importantly, we found that changes in clinical practice resulting from the interprofessional context provided by ECHO programmes were limited by systemic barriers to implementing the hubs’ recommendations, as previously reported in the ECHO model literature.25 46 47

While evidence-based knowledge gains seem inherent to the ECHO model according to the literature, our results suggest that knowledge gains about experiences of stigmatised patients are particularly helpful to clinicians working with patients with HepC and CMSD. Indeed, clinicians felt they had a better understanding of their patients, and could answer to their questions, which increases the likelihood that patients will engage and adhere to treatments. Two studies about ECHO HepC supported similar findings of improved knowledge about the realities of stigmatised patients through participation in ECHO.48 49

Similarly, we also found that the concise ECHO report would save time in the patient trajectory when transferring from one prison facility to another. This facilitated transmission is significant for treatments initiated in correctional settings as it improves linkage to care and is a key priority for improving HepC care in incarcerated individuals. It may not be as crucial in the broader context of HepC treatment. ECHO HepC has been promoted by Akiyama et al as a solution to be considered given the challenges with the trajectory of patients with HepC in a prison setting, which may be limited due to the movement of patients between institutions or on release.50 For CP and CMSD, patient trajectories are impacted by healthcare access. Therefore, for ECHO to influence the trajectory of these patients, the programme would have had impacted the waiting time to access clinicians.51–53

Study limitations

The limitations of this study include first the fact that participants were interviewed only once, during or after their participation in one ECHO programme. A longitudinal design would have been interesting to adopt in order to interview individuals before and after their participation, and contrast their expectations prior to joining the programme with their experiences on follow-up. Another limitation remains in having analysed experiences of participants in programmes developed in a single centre, thereby limiting the differences in organisational components that could have contrasted participants’ experiences.

Conclusions

The specificities and characteristics of each chronic condition (curable or not, importance of the biopsychosocial component, disease markers) influence the benefits and limitations that spokes and hubs can draw from their experience at the three ECHOs.

The biopsychosocial component of CP and CSMD means that ECHO’s multidisciplinary context, peer support and wide range of participants are beneficial to their ECHO experience and their clinical practice. On the other hand, the biopsychosocial component hinders the participation of spokes and hub members in formulating recommendations and presenting cases.

In addition, our results showed that the curability of HepC, the straightforward guidelines and the issues associated with the care of this disease in the spokes’ work setting, means that spokes and hubs can benefit from their experience at ECHO HepC. This includes the fact that ECHO HepC promotes the role of nurses in treatment, and provides peer support in similar working conditions (prison setting). On the other hand, the presence of objective markers for HepC limits the benefits that spokes could derive from a multidisciplinary environment such as ECHO.

The benefits gained from networking, and the systemic limitations encountered by the spokes, do not appear to be related to the characteristics of the pathologies targeted by ECHO. Our results showed that ECHO contributed to patient engagement by raising spokes’ awareness to the realities of the disease and saved them time in their care pathway. These points raised by our study are essential in understanding the successes and limitations of implementing an ECHO programme. They are important as they provide key information for tailoring Project ECHO to the chronic disease it addresses.

Data availability statement

Data are available on reasonable request. The datasets generated and analysed during this study are not publicly available due to privacy concerns given the qualitative nature of the data. They can be made available from the corresponding authors on reasonable request and pending ethics approval for data sharing.

Ethics statementsPatient consent for publication

Consent obtained directly from patient(s).

Ethics approval

The study was approved by the Research Ethics Committee of the Centre hospitalier de l’Université de Montréal (19.281) and written informed consent was obtained from participants.

Acknowledgments

GP is a Junior 2 research scholar from the Fonds de recherche du Québec en santé. We thank all study participants for their willingness to share their experience. We also wish to thank Clémence Provost-Gervais and the entire team of clinicians, managers and stakeholders involved in the Projects ECHO CHUM without whom these programmes could not be offered.