Abstract
Background:
Cardiovascular diseases (CVD) are the leading cause of mortality in Arkansas, West Virginia, and Oklahoma, underscoring the need for approaches to build primary care capacity to address CVD in these states.
Methods:
The “ECHO+” model integrates a CVD-focused tele-education course with quality improvement (QI) training and coaching to empower rural primary care providers (PCPs) in diagnosing and managing CVD effectively.
Results:
41 clinicians participated in the program. 100% reported high satisfaction and intention to apply learnings in practice. CVD knowledge and confidence increased among participants immediately post-course, with sustained improvements at a 6-month follow-up. QI teams achieved measurable improvements in clinical metrics and evidence-based CVD care practices through Plan-Do-Study-Act (PDSA) cycles, including an increase in optimized statin therapy rates from 72% to 86%. The clinical course also increased statin prescribing, with participating providers prescribing significantly more statins in the 6 months following the course than the 6 months before. Patients of participating clinicians experienced improved health outcomes, as evidenced by reductions in systolic blood pressure.
Conclusion:
These findings illustrate the potential of academic medical centers collaborating with rural primary care clinics to address health disparities through the ECHO+ model, which combines tele-education and QI to enhance clinician capacity and improve population health outcomes.
Keywords: primary care, cardiovascular disease, rural health, tele-mentoring
Introduction
Cardiovascular diseases (CVD) are the leading cause of death in the United States, representing a major burden on healthcare systems, specifically in primary care. 1 This burden may be more significant in medically underserved areas where lifestyle and demographic factors such as increased sedentary lifestyle and obesity, limited access to specialized care, higher rates of poverty, and lower educational attainment 2 contribute to disparities in CVD prevalence and outcomes. 3 In 2022, heart disease was the leading cause of death in Oklahoma (257.1 deaths/100 000 people), Arkansas (224.1 deaths/100 000 people), and West Virginia (209.5 deaths/100 000 people). 4 High mortality rates in these states highlight the pressing need for targeted interventions to support and strengthen primary care’s ability to deliver high quality CVD care. Primary care providers (PCPs) play a critical role in CVD screening, diagnosis, treatment, and management. Supporting rural PCPs in identifying and managing CVD is a targeted strategy to address the significant health burden caused by CVD on individual and population health outcomes.
Technology-enabled collaborative learning is a promising intervention to address the challenges of CVD management in rural primary care settings by disseminating up-to-date clinical information and building clinical care capacity. One well-known model of technology-enabled collaborative learning, Project Extension for Community Healthcare Outcomes (Project ECHO), has demonstrated high levels of clinician engagement, and increased confidence, self-efficacy, and acquisition of subject area knowledge, as well as improved patient and community health outcomes, such as reduced HbA1c, improved treatment of Hepatitis C infection, reduced mortality, and improved quality of life.5,6
Building on the ECHO Model, our team has developed the “ECHO+” (ECHO Plus) model.7-9 As with the traditional ECHO model, this includes live case-based discussions led by clinical specialists. In addition, ECHO+ includes brief specialty-specific courses provided via asynchronous pre-recorded lectures and a quality improvement (QI) learning collaborative designed to adapt evidence-based course learning objectives into rural primary care site workflows to improve quality of care and patient outcomes. 10 This builds on other ECHO models with QI initiatives, which have demonstrated improvements in structural, process, and outcome measures. 7
The team collaborated with PCPs at 3 rural spoke sites in 3 states: Arkansas (ARcare), Oklahoma (the Chickasaw Nation), and West Virginia (Minnie Hamilton Health System). ARcare is the largest FQHC in Arkansas. The Chickasaw Nation is a federally recognized tribe headquartered in Ada, Oklahoma. Minnie Hamilton Health System (MHHS) is an FQHC that includes a rural access hospital in West Virginia.
This paper describes how ECHO+ improved CVD management capacity and patient health across rural primary care clinics in OK, AR, and WV via an asynchronous course, synchronous case-based discussions, and a QI learning collaborative. Results include clinic and clinician characteristics, short-term and long-term course impact on clinician-reported knowledge, confidence, and practices, and patient CVD-related health outcomes.
Methods
The ECHO+ Model involves an urban medical school as the hub site and the 3 rural primary care systems as spoke sites. These sites were selected based on HRSA definitions for rural and medically underserved areas, including (1) non-metropolitan counties, (2) outlying metropolitan counties with no population from an urban area of 50 000 or more people, (3) census tracts with RUCA codes 4-10 in metropolitan counties, (4) census tracts of at least 400 square miles in an area with population density of 35 or fewer people per square mile with RUCA codes 2-3 in metropolitan counties, and (5) census tracts with RRS 5 and RUCA codes 2-3 that are at least 20 miles in area in metropolitan counties. All 3 sites were eligible rural areas due to their locations in non-metropolitan counties.
To determine the CVD burden of each site, we examined state-specific morbidity and mortality data from the US CDC and we obtained site-specific EHR data regarding the total number of CVD-related visits and number of unique visits (see Table 1). Based on this data, primary care and cardiology faculty collaborated with partner sites to develop and implement the CVD ECHO+ course. The course was designed to provide rural PCPs with knowledge on high-burden cardiovascular diseases, including presentation, diagnosis, and management approaches. The course incorporated the most up-to-date research and clinical practice data, and provided PCPs a forum to share their experiences and ask questions. The course included 7 asynchronous modules and 5 live case-based sessions, along with supportive resources and tools (see Box 1 for course topics). The course was accredited by The Massachusetts Medical Society for AMA PRA Category 1 CreditsTM and participants received a Certificate of Completion. Participants, including physicians, nurses, physician assistants, and pharmacists, were recruited via a course registration flier (Figure 1) and through encouragement from site leadership.
Table 1.
Cross-Site Disease Burden in 2022.
| ICD-10 code | Disease | Site #1 | Site #2 | Site # 3 | |||
|---|---|---|---|---|---|---|---|
| # unique patients | # total visits | # unique patients | # total visits | # unique patients | # total visits | ||
| I20-I25.9, Z82.3-Z82.49 | Chronic ischemic heart diseases, family of history stroke, ischemic heart disease, sudden cardiac arrest | 323 | 754 | 664 | 947 | 196 | 307 |
| I10-I16 | Hypertensive diseases | 2500 | 6012 | 16803 | 35410 | 0 | 0 |
| I50-I50.9 | Heart failure | 104 | 253 | 454 | 731 | 450 | 1253 |
| I60-I69 | Cerebrovascular disease | 0 | 0 | 177 | 215 | 0 | 0 |
| I48-I48.92, I49.9, | Atrial fibrillation and flutter, cardiac arrhythmia, unspecified | 186 | 514 | 137 | 198 | 625 | 1875 |
| I73.9 | Peripheral vascular disease, unspecified | 42 | 118 | 99 | 138 | 242 | 562 |
| Z73-Z73.9, Z72.0-Z72.4 | Problems related to life management difficulty and lifestyle (tobacco, lack of physical exercise, inappropriate diet, and eating habits) | 288 | 439 | 86 | 111 | 40 | 86 |
Figure 1.
CVD course registration flyer.
| Module | Title |
|---|---|
| Module 1 | Cardiovascular Pharmacological Agents |
| Module 2 | Atrial Fibrillation |
| Module 3 | ASCVD Risk Reduction |
| Module 4 | Chronic Heart Failure |
| Module 5 | Chronic Ischemic Heart Diseases |
| Module 6 | Hypertensive Disorders |
| Module 7 | Peripheral Arterial Diseases |
Asynchronous modules were released monthly on Canvas, a learning management web portal. Each module was developed by faculty to synthesize the most up-to-date knowledge of the CVD topic being covered. In addition, PCPs participated in monthly live clinical case-based discussions. During these discussions, participants created and led the sessions using real-life examples drawn from their own practices. A template for the case presentation was provided beforehand for participants presenting their case. Cases were presented from each site with topics relating to the most recent asynchronous module released. These cases were created with mentorship from faculty, who helped facilitate the discussion and provided teaching points on the case.
The QI component launched 3 months following the CVD course. This component supports long-term QI capacity building and integration of CVD course knowledge into health center care practices. Over the course of the QI component, QI experts supported each site to develop and sustain QI skills and infrastructure and worked with each site to redesign clinical workflows to improve patient outcomes using evidence-based practices. Site QI teams met weekly for 4 months, identified CVD quality indicators (i.e., use of high-intensity statin) to improve using a QI approach, and submitted monthly QI data to QI experts, followed by coaching sessions to review and provide team feedback.
Several methods were utilized to assess learning and build engagement over the course. Knowledge checks consisting of 1-3 questions were embedded in the asynchronous recordings requiring participants to answer a multiple-choice or true/false question regarding the knowledge most recently provided in the video. Post-module quizzes followed completion of the video with 3 questions reviewing the material discussed. Starting in module two, 1 randomly selected question from the previous modules was also included in the post-module quizzes as a knowledge retention question.
Evaluation of course impact on clinician-reported knowledge, confidence, and intentions to integrate learning into care practices was assessed via change in pre-, post-, and 6-month post-course surveys. This was done via a 4-point Likert scale for the pre- and post-course surveys. Post-course and 6-month post-course surveys also asked participants if they intended to make changes to care practices as a result of course learnings (yes, maybe, no), and to describe those changes (open response item). In addition, to measure patient outcomes, for each PCP who completed the course, we asked sites to provide CVD patient blood pressure data from the EHR for the 6 months prior to the initiation of the course, as well as the 6 months following the completion of the course (Pre: 9/10/22-3/10/23; Post: 7/28/23-1/28/24). Data included patients with cardiovascular diseases on high-intensity statin therapy and average blood pressures.
Results
The CVD morbidity burden across 3 sites, as reported by the number of unique patients and number of unique visits related to relevant ICD-10 cardiovascular disease codes, showed that the top 3 cardiovascular conditions seen are hypertensive diseases, heart failure, and chronic ischemic heart diseases (Table 1).
Across the 3 sites, 66 clinicians enrolled in the course and 41 participants completed the course (62%). A participant was considered to have completed the course if they completed at least 80% of required activities. Course participants were predominantly female and identified as white. There was a wide variety in the types of professionals who participated in the course with Advanced Practice Registered Nurses (APRN’s) making up over half (57%) of the registrants. Participants’ clinical experiences ranged from 1-10 years (57%) to 30+ years (3.6%) (Table 2).
Table 2.
Course Participant Demographics.
| Participant demographics | Site #1 (%) | Site #2 (%) | Site #3 (%) |
|---|---|---|---|
| Sex | |||
| Female | 12 (80) | 22 (79) | 10 (36) |
| Race | |||
| White | 13 (87) | 26 (93) | 21 (75) |
| Other | 2 (13) | 2 (7) | 4 (25) |
| Ethnicity | |||
| Hispanic or Latino/a/x | 0 (0) | 0 (0) | 2 (8) |
| Not Hispanic or Latino/a/x | 15 (100) | 28 (100) | 29 (84) |
| Chose not to reply | 0 (0) | 0 (0) | 3 (12) |
| Profession | |||
| Administrative personnel | 0 (0) | 1 (4) | 0 (0) |
| Direct patient care | |||
| MD/DO | 3 (20) | 1 (4) | 19 (76) |
| RN/NP | 9 (60) | 25 (89) | 5 (20) |
| PA | 3 (20) | 0 (0) | 1 (4) |
| Other | 0 (0) | 1 (4) | 0 (0) |
| Years in practice | |||
| Between 1 and 10 years | 7 (47) | 20 (71) | 12 (48) |
| Between 10 and 20 years | 6 (40) | 5 (18) | 6 (24) |
| Between 20 and 30 years | 2 (13) | 3 (11) | 5 (20) |
| 30 years or more | 0 (0) | 0 (0) | 1 (4) |
| Chose not to reply | 0 (0) | 0 (0) | 1 (4) |
The majority of participants reported improved knowledge and confidence for all CVD subject areas immediately post-course and 6 months later (Table 3). Prior to the course, clinicians reported the lowest knowledge in Basic Pharmacology, Chronic Diastolic Heart Failure, and Chronic Ischemic Heart Diseases. After course completion, 100% of clinicians reported significantly increased or increased knowledge and confidence in these areas. For the same topics, 6-month retention of knowledge was high with most patients reporting a maintained increase in knowledge (97%, 91%, and 91%). Participants scored an average of 88% on knowledge checks embedded within each module, 72% on post-module quizzes, and 79% on knowledge retention questions, which assessed knowledge of the previous module (Figure 2).
Table 3.
Change in Reported Cardiovascular Disease Knowledge and Confidence from Pre- to Post-Course and 6-Month Post-Course.
| Since completing the TEECH cardiovascular disease course, to what degree has your level of knowledge and confidence changed with. . . | Knowledge | Confidence | ||
|---|---|---|---|---|
| Immediately post-course, N (%) | At 6 months, N (%) | Immediately post-course, N (%) | At 6 months, N (%) | |
| Basic and novel pharmacology | ||||
| Increased | 41 (100) | 28 (97) | 41 (100) | 27 (93) |
| Remains unchanged | 0 (0) | 1 (3) | 0 (0) | 2 (7) |
| Atrial fibrillation | ||||
| Increased | 41 (100) | 27 (93) | 41 (100) | 27 (93) |
| Remains unchanged | 0 (0) | 2 (7) | 0 (0) | 2 (7) |
| Chronic diastolic heart failure | ||||
| Increased | 41 (100) | 28 (97) | 41 (100) | 28 (97) |
| Remains unchanged | 0 (0) | 1 (3) | 0 (0) | 1 (3) |
| Chronic ischemic heart diseases | ||||
| Increased | 41 (100) | 27 (93) | 41 (100) | 25 (86) |
| Remains unchanged | 0 (0) | 2 (7) | 0 (0) | 4 (14) |
| Hypertensive disorders | ||||
| Increased | 40 (98) | 28 (97) | 40 (98) | 26 (90) |
| Remains unchanged | 1 (2) | 1 (3) | 1 (2) | 3 (10) |
| Peripheral arterial diseases | ||||
| Increased | 40 (98) | 26 (90) | 40 (98) | 27 (93) |
| Remains unchanged | 1 (2) | 3 (10) | 1 (2) | 2 (7) |
Figure 2.
Demonstrated cardiovascular disease knowledge.
The majority of clinicians who completed the course reported making changes in their practice as a result of course learnings, both immediately post-course and 6 months later (Table 4). Examples of practice changes shared by clinicians include starting patients on moderate-to-high intensity statin more often and using cardiovascular risk score more frequently in clinical care. 100% of participants also reported satisfaction with the course curriculum and affirmed that the activity promoted improvement in health care.
Table 4.
Impact on Practice Change.
| Do you expect to make changes in your practice as a result of participating in this activity? | Since completing the Cardiovascular Disease course, have you made any changes in your practice? | |
|---|---|---|
| Participant response | Post (%) | 6 months (%) |
| Yes | 37 (90) | 19 (66) |
| Maybe | 4 (10) | 8 (28) |
| No | 0 (0) | 2 (7) |
After the competition of the CVD certificate course, 3 interdisciplinary QI teams at the 3 respective sites (including 21 course participants) worked to integrate course learnings into site workflows in order to improve quality of care. Each team identified CVD quality goals, with 2 sites focusing on improving blood pressure control and 1 site focusing on statin therapy optimization (Table 5). Site #1 demonstrated best practices of blood pressure management (94% of patients with a reduced BP at reassessment) through manual data collection. At Site #2, the number of patients that were screened for tobacco use and received cessation education if identified as a user increased by 14% after 6 months. Site #3 demonstrated a 14% increase in patients optimized on statin therapy for secondary prevention over 15 months after the CVD course completion.
Table 5.
QI Metrics by Site.
| Site | Smart aim | Baseline | Goal |
|---|---|---|---|
| Site #1 | Increase the % of patients with a diagnosis of hypertension with controlled blood pressures (140/90 or less). | 55% | 65% |
| Site #2 | Reduce the systolic and diastolic blood pressure of chronic care management (CCM), remote patient monitoring (RPM), and CCM/RPM patients. | 147/86 | 140/90 |
| Site #3 | Increase the % of ABLE—statin therapy for patients with a diagnosis of Atherosclerotic Cardiovascular Disease (ASCVD). | 72% | 88% |
Across all sites, the impact of CVD course participation on provider statin prescribing was evaluated. For providers who completed the course, high-intensity statin prescribing increased significantly for patients with cardiovascular disease from the 6-month period prior to the course to the 6-month period following course completion (P = .011).
The impact of ECHO+ CVD course participation on CVD patient outcomes was evaluated by assessing systolic and diastolic BP metrics for CVD patients of providers who participated in the course. An average BP rating for each patient was determined for the 6-month time period before the course and was compared to the 6-month time period after the course was completed. Change in systolic and diastolic BP was variable but trending towards a significant decrease across the 3 sites (see Table 6). When patients were pooled and weighted across the sites, change from pre- to post-course in systolic BP showed a statistically significant decrease (Pre: 139.13 [n = 14 950]; Post: 138.64 [n=15 545]; P = .008) and a trending decrease in diastolic BP (Pre: 82.79 [n = 14 950), Post: 82.43 [n = 15 545]).
Table 6.
Independent T-test of Means for Impact of Course Participation on Patient Blood Pressure.
| Site | Systolic BP pre-course, mmHg (n) | Systolic BP post-course, mmHg (n) | P-value | Diastolic BP pre-course, mmHg (n) | Diastolic BP post-course, mmHg (n) | P-value |
|---|---|---|---|---|---|---|
| Site #1 | 143.07 (2908) | 141.96 (3147) | .052 | 82.95 (2908) | 82.48 (3147) | .138 |
| Site #2 | 138.13 (11467) | 137.84 (11929) | .238 | 82.88 (11467) | 82.53 (11929) | .018* |
| Site #3 | 139.10 (575) | 136.75 (469) | .013* | 80.14 (575) | 79.50 (469) | .401 |
| Adjusted aggregate | 139.13 (14950) | 138.64 (15545) | .008** | 82.79 (14950) | 82.43 (15546) | .056 |
P < .05.
P < .01.
Discussion
The ECHO+ model demonstrates a promising approach to increasing cardiovascular care capacity in rural primary care settings. Through its innovative combination of tele-education and quality improvement (QI) initiatives, ECHO+ effectively builds clinician knowledge, confidence, and the ability to integrate evidence-based practices into clinical workflows. Evaluation of this approach addresses gaps in the literature regarding the long-term impact of ECHO models on clinician knowledge and patient outcomes. 5 Findings have implications for improving rural healthcare delivery and reducing CVD burden in underserved areas.
The integration of asynchronous specialty-focused modules, live case-based discussions, and QI initiatives proved effective in engaging a diverse group of healthcare providers. Participants reported improvements in knowledge and confidence in managing high-burden CVD conditions, which persisted at 6 months post-course. A drop from 90% of participants expecting to make practice changes after the course to 66% reporting changes at 6 months is unsurprising, reflecting initial enthusiasm versus long-term follow-through. Still, 66% is a strong outcome and underscores the sustainability of our educational model. Importantly, the model’s focus on active learning, through interactive quizzes and case discussions, supported high levels of knowledge retention. 11 This finding underscores the value of continuous engagement and assessment in continuing medical education programs for sustainable learning outcomes.
The inclusion of QI projects was pivotal in translating knowledge gains into measurable improvements in clinical practice. Teams successfully implemented evidence-based interventions, such as optimizing statin therapy and improving blood pressure measurement strategies, leading to demonstrable improvements in patient outcomes. For instance, EHR data from sites reported increased rates of statin therapy optimization and reductions in patients’ blood pressure metrics. These results highlight the importance of coupling education with actionable strategies that enable clinicians to apply their learning in practice.
While ECHO-like models have been widely used to increase rural primary care capacity, the evidence has been limited regarding the impact of these models on patient outcomes. 5 Evidence from ECHO+ demonstrates that patients of providers who participated in the ECHO+ course demonstrated a significant improvement on BP metrics from pre- to post-course.
Several factors contributed to the success of the ECHO+ model. The model relied on relatively accessible technology and associated support, requiring internet and basic technology skills from rural site staff. The interprofessional nature of the program allowed clinicians across disciplines to collaboratively address complex clinical issues. Support from rural health system leadership, including protected time for participation in the CVD course and QI activities, was essential. Additionally, the tailored design of the course—developed in collaboration with partner sites—ensured relevance to the unique challenges of rural practice. Despite these successes, the program faced barriers typical of rural healthcare settings, such as time constraints, high staff turnover, and limited resources. The program’s completion rate of 62% highlights the need for ongoing strategies to enhance engagement. Offering continuing medical education (CME) credits and maintaining a flexible, asynchronous course structure were mitigating solutions to some of these barriers.
The findings from ECHO+ reinforce the potential of technology-enabled collaborative learning to strengthen rural healthcare systems. By equipping primary care providers with the skills and confidence to manage CVD more effectively, the model addresses critical gaps in specialist availability and may reduce reliance on referrals to specialists. Moreover, the integration of QI methods fosters a culture of continuous improvement, empowering rural health systems to adapt and sustain best practices.
To build on the successes of the ECHO+ model, future programs should explore ways to enhance long-term engagement and address systemic barriers to participation. This includes leveraging remote patient monitoring technologies to expand the capacity to monitor and manage CVD metrics, such as BP. Further research should evaluate the scalability of the ECHO+ approach and its impact on broader population health metrics over time.
Conclusion
The ECHO+ model demonstrates how academic medical centers can collaborate with rural health systems to address disparities in healthcare delivery. By combining innovative educational strategies with practical implementation support, this approach has the potential to transform rural primary care capacity and improve health outcomes for underserved populations.
Acknowledgments
We would like to thank the Chickasaw Nation, Minnie Hamilton Health System, and ARcare for their ongoing partnership and contributions.
Footnotes
ORCID iD: Dru Ricci 
https://orcid.org/0000-0001-9123-597X
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by HRSA 5 U3IRH43510-04-00
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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