Small trial links weekly ECHO training to better Long COVID care

A three-year randomized trial found that primary care clinicians who attended weekly, case-based virtual ECHO sessions for Long COVID and related fatiguing illnesses reported greater knowledge and confidence than colleagues who received only monthly webinars and quarterly short courses. Clinicians in the intervention group also made fewer specialist referrals per patient, although the between-group difference in self-reported changes to practice was not statistically significant. The trial enrolled 20 clinicians from the federally qualified health center network of Family Health Centers of San Diego and followed 590 adult patients with Long COVID, myalgic encephalomyelitis/chronic fatigue syndrome, or other infection-associated chronic conditions.

The study, published in Frontiers in Health Services on October 21, 2026, evaluated the Long COVID and Fatiguing Illnesses Recovery Program as a two-arm, single-blind, professional cluster randomized controlled trial registered as NCT05167227. Clinicians were individually assigned at a 1:1 ratio. The intervention group received weekly ECHO sessions in addition to the educational opportunities available to both groups, while the control group received monthly interactive webinars and quarterly online short courses. One clinician from each arm withdrew after baseline data collection, leaving 18 participants and 92 repeated clinician observations for the primary survey analysis.

Each weekly ECHO meeting combined a presentation on emerging clinical topics and recommended practices with an interactive discussion and a case presented by a participating clinician. Subject-matter experts included specialists in pulmonology, physical medicine and rehabilitation, cardiology, neurology, nutrition, and ME/CFS, many based at academic medical centers. People with lived experience took part in every session, adding perspectives on symptom trajectories, stigma, and patient priorities. Across the study, which ran from December 2021 through October 2024, investigators conducted 89 weekly ECHO sessions, 34 monthly webinars, and nine quarterly courses. The monthly webinars averaged about 300 participants and reached audiences in the United States and more than 62 countries.

Clinicians reported their knowledge, confidence or self-efficacy, and changes to practice through quarterly surveys. The researchers constructed standardized composite scores for each outcome and used generalized linear models to account for repeated observations within clinicians. The preferred adjusted model controlled for time since baseline, clinician sex, years of experience, possession of a medical degree, and baseline confidence. In this model, the intervention was associated with a 0.77-standard-deviation increase in knowledge, with a 95% confidence interval from 0.20 to 1.33, and a 0.48-standard-deviation increase in confidence, with a 95% confidence interval from 0.09 to 0.88. The corresponding estimate for self-reported practice change was 0.52, but its interval ranged from -0.08 to 1.12 and included no effect.

The absence of a statistically significant between-group difference in self-reported practice change was important because clinicians in both arms improved. The investigators said it may reflect the design of the program, which deliberately converted lessons from the small weekly ECHO sessions into monthly webinars and short courses so that control clinicians received many of the same recommendations. Contamination was also possible because clinicians could not be blinded to their assignments and sometimes worked in the same clinics. Administrators reported that intervention clinicians shared information in staff meetings, training sessions, and informal consultations. Such exchanges would tend to improve control-group performance and reduce the measured difference between arms rather than exaggerate it, although the study did not directly quantify how much contamination occurred.

Objective electronic health record data nevertheless supported a change in behavior. Intervention clinicians made significantly fewer specialist referrals for each patient assigned to them with Long COVID or a related condition: the adjusted estimate was -0.44 referrals per patient, with a 95% confidence interval from -0.62 to -0.26. They also made fewer referrals when assigned and unassigned patients were combined, with an estimate of -0.33 and a 95% confidence interval from -0.50 to -0.15. The reduction for unassigned patients alone did not reach statistical significance. There was no significant difference in the number of patients seen each month or in average visit duration. Among 806 clinical recommendations made by multidisciplinary experts during weekly ECHO sessions, 178 were subsequently applied by intervention clinicians to patient care.

Participation appeared related to the size of the clinician outcomes. Across the pooled sample, each additional learning session was associated with an improvement of about 0.013 standard deviations on each of the three main outcome scales, and the corresponding standardized regression coefficients ranged from 0.34 to 0.37. Intervention clinicians attended an average of 51.3 learning sessions, compared with 16.6 among controls, accumulating about 27 more hours of educational exposure. An exploratory, unregistered analysis estimated that marginal gains began to plateau at approximately 65 sessions for knowledge and 74 sessions for confidence and practice change. The researchers cautioned that these thresholds should not be treated as definitive because the analysis was exploratory, the maximum observed attendance was 97 sessions, and the intervention-only estimate for knowledge was not statistically significant.

The ECHO approach uses a hub-and-spoke structure in which specialist teams interact with frontline clinicians through case-based learning. Its goal is to strengthen primary care capacity for conditions in which patients may otherwise wait months for specialty appointments or travel long distances. The program pairs access to multidisciplinary expertise with structured discussion of real cases and lived-experience input. In this clinician-outcomes report, the measured referral result is consistent with intervention clinicians managing more aspects of these cases themselves. The broader recovery program included separate analyses of patient outcomes; this paper reports the clinician results and does not by itself establish that reduced referral use improved symptoms, quality of life, or other patient health outcomes.

The evidence remains constrained by the trial’s scale and setting. It included only 20 clinicians from one health system, had approximately 66% power to detect a standardized mean effect of 0.5, and had limited external validity for clinicians, specialties, and communities operating in different systems. Most clinician outcomes were self-reported and therefore vulnerable to response bias, while knowledge improvement and practice change could only be measured after baseline because they were defined as changes from baseline. The control group received active education rather than no intervention, and knowledge sharing between colleagues was inherent to the pragmatic clinical setting. The results therefore support weekly ECHO sessions as a promising means of improving clinician knowledge and confidence and reducing specialist referral for complex chronic conditions, but they do not show that every health system will obtain the same effects.

Subject of Research: Randomized trial of weekly virtual ECHO clinician education for Long COVID and other infection-associated chronic conditions

Article Title: Effectiveness of an Extension for Community Health Outcomes case-based virtual community of practice model on clinician outcomes for the management of long COVID and fatiguing illnesses: a randomized control trial

Article References: Zuber, A., Rothwell, J. T., Samaniego, J. C., Sharp, S. P., Taren, D., Unger, E. R., Bertolli, J., Lin, J.-M. S., Regan, J. J., Armistad, A. J., Scott, J. D., Struminger, B. B., Godino, J. G., & Ramers, C. B. (2026). Effectiveness of an Extension for Community Health Outcomes case-based virtual community of practice model on clinician outcomes for the management of long COVID and fatiguing illnesses: a randomized control trial. Frontiers in Health Services, 6, Article 1912262. https://doi.org/10.3389/frhs.2026.1912262

Image Credits: AI Generated

DOI: 10.3389/frhs.2026.1912262

Keywords: Long COVID, ME/CFS, ECHO model, randomized controlled trial, primary care, clinician education, specialist referrals, telehealth, community health centers, infection-associated chronic conditions, Effectiveness, Extension