The authors describe an innovative academic health center (AHC)-led program of health care delivery and clinical education for the management of complex, common, and chronic diseases in underserved areas, using hepatitis C virus (HCV) as a model. The program, based at the University of New Mexico School of Medicine, represents a paradigm shift in thinking and funding for the threefold mission of AHCs, moving from traditional fee-for-service models to public health funding of knowledge networks. This program, Project Extension for Community Health care Outcomes (ECHO), involves a partnership of academic medicine, public health offices, corrections departments, and rural community clinics dedicated to providing best practices and protocol-driven health care in rural areas. Telemedicine and Internet connections enable specialists in the program to comanage patients with complex diseases, using case-based knowledge networks and learning loops. Project ECHO partners (nurse practitioners, primary care physicians, physician assistants, and pharmacists) present HCV-positive patients during weekly two-hour telemedicine clinics using a standardized, case-based format that includes discussion of history, physical examination, test results, treatment complications, and psychiatric, medical, and substance abuse issues. In these case-based learning clinics, partners rapidly gain deep domain expertise in HCV as they collaborate with university specialists in hepatology, infectious disease, psychiatry, and substance abuse in comanaging their patients. Systematic monitoring of treatment outcomes is an integral aspect of the project. The authors believe this methodology will be generalizable to other complex and chronic conditions in a wide variety of underserved areas to improve disease outcomes, and it offers an opportunity for AHCs to enhance and expand their traditional mission of teaching, patient care, and research.

BACKGROUND/OBJECTIVES: Post-gastrostomy complications range from 8 to 30%. These complications often occur following discharge into the community and may result in hospital readmission. Our unit previously reported a readmission rate of 23% in 6 months. There is a paucity of data evaluating community gastrostomy management. We therefore aimed to evaluate the benefits of a dedicated dietetic home enteral feed (HEF) team. SUBJECTS/METHODS: Demographic data, gastrostomy complications, readmission rates and HEF team input was prospectively collected from a cohort of discharged gastrostomy patients over a 1-year period and comparisons made with a similar historical cohort. RESULTS: A total of 371 complications were encountered in 313 gastrostomy patients during this period, with the commonest complication being over-granulated stoma sites (27%). Of these, 227 hospital admissions were avoided because of direct actions taken by the HEF team. Fifty-nine gastrostomy patients were admitted to the hospital, of which only seven (12%) were specifically for gastrostomy-related problems. Introduction of the HEF team significantly reduced gastrostomy-related hospital readmissions from 23 to 2% (P ¼ 0.0001). CONCLUSION: Although patients with gastrostomies may need attention to a variety of complex medical problems, many encounter problems specifically related to their gastrostomy after discharge. This is the largest prospective study demonstrating how dietitians trained in gastrostomy aftercare may optimize the management of gastrostomy complications and reduce unnecessary hospital readmissions.

Anecdotal evidence suggests the use of bolus tube feeding is increasing in the long-term home enteral tube feed (HETF) patients. A crosssectional survey to assess the prevalence of bolus tube feeding and to characterise these patients was undertaken. Dietitians from ten centres across the UK collected data on all adult HETF patients on the dietetic caseload receiving bolus tube feeding (n 604, 60 % male, age 58 years). Demographic data, reasons for tube and bolus feeding, tube and equipment types, feeding method and patients' complete tube feeding regimens were recorded. Over a third of patients receiving HETF used bolus feeding (37 %). Patients were long-term tube fed (4·1 years tube feeding, 3·5 years bolus tube feeding), living at home (71 %) and sedentary (70 %). The majority were head and neck cancer patients (22 %) who were significantly more active (79 %) and lived at home (97 %), while those with cerebral palsy (12 %) were typically younger (age 31 years) but sedentary (94 %). Most patients used bolus feeding as their sole feeding method (46 %), because it was quick and easy to use, as a top-up to oral diet or to mimic mealtimes. Importantly, oral nutritional supplements (ONS) were used for bolus feeding in 85 % of patients, with 51 % of these being compact-style ONS (2·4 kcal (10·0 kJ)/ml, 125 ml). This survey shows that bolus tube feeding is common among UK HETF patients, is used by a wide variety of patient groups and can be adapted to meet the needs of a variety of patients, clinical conditions, nutritional requirements and lifestyles.

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Having shown that PEG-related complications are a common cause of hospital readmission (1) , two home-enteral-feed (HEF) dietitians were appointed to provide patient support in the community by regular dietetic monitoring and having the ability to respond to gastrostomy-related problems efficiently to prevent hospital re-admission. They also provide training to patients, carers and other health care professionals on how to deal with tube complications including displacement. All patients were discharged with an aftercare protocol including advice and contact numbers in the event of problems. Data for the year ending February 2007 were collected prospectively using the Infoflex PEG database. The caseload at the year end was 180 patients. Over this period, a total of 245 individual patients were home-enterally-fed at some point. Seventy-nine of these were new patients of whom 91 % were seen within 5 working days (mean 2.9 d) of hospital discharge. There were 1514 follow-up contacts (home, n 825; nursing or residential home, n 392; telephone, n 303; outpatients , n 3 and hospital inpatients, n 2). A total of 545 PEG-related complications were dealt with (over-granulated stoma, n 98; broken Y adaptor, n 88; broken clamp, n 50; leaking stoma, n 47; fixation device too tight, n 23; damaged tube, n 15 and other, n 123). A total of 101 patients required new balloon retained gastrostomies (seventy-one balloon gastrostomies and thirty low profile gastrostomies), fifty-eight as emergency procedures (following PEG displacement, tube damage or blockage) and forty-three planned, with no complications. Although sixty-nine patients were admitted during this year, only fifteen (21 %) were for PEG problems and all occurred at times of non-availability of staff at weekends or holidays or failure of carers to adhere to the written aftercare protocol. Hospital admissions were avoided in all fifty-eight instances (thirty patients, 12 % of the total cohort of 245 patients) of PEG displacement, damage or blockage by emergency replacement by the HEF dietitians. However, it is likely that the early diagnosis and treatment of less urgent complications, and the training of patients, carers and other health care professionals will have avoided many further admissions.