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Teaching an old dog new tricks –
telehealth, IT, and diabetes
management in the Mississippi
DeltaMarshall Bouldin MD
Director, Diabetes and Metabolism Program
Associate Professor of Medicine
University of Mississippi Medical Center
Background: Mississippi
• Highest prevalence of diabetes and obesity in U.S.• 52nd in quality of care in diabetes in U.S.• Very high in all diabetes complications• Worst socioeconomic status in U.S.• Very large at-risk population• Very high in health disparities and poor access to
care• Half the average number of providers per capita
The Delta Diabetes Project
CBPR intervention which is implementing a regional DM management network for MS Delta
No access to multi-disciplinary support services
Rural
70-100% African-American
If the Delta were removed from Mississippi, most MS health statistics would become normative
DHA/UMMC Delta Diabetes Project Model
Multidisciplinary, chronic disease model; CBPR Non-traditional features Role changes – resource sparing Two arms: education and management – patient
self-management is the key 4500+ patients, 800+ visits/mo Data and outcomes driven; novel applications of
teleinformatics Excellent quality of care, outcome, and patient
satisfaction results Successfully reproduced in community settings
Delta Diabetes Project Regional system of diabetes care improvement for Mississippi Delta Community-based participatory research collaboration;
sustainability 6 sites Single data-driven model of care and database; integral
telemedicine and teleinformatics Integral provider education Duplicating or exceeding UMMC results in all outcomes Diabetes is only a test case chronic disease – CHF, CV mortality,
HTN, asthma, etc. Foothold for regional prevention programs in diabetes, obesity, and
CV mortality
DDP Outcomes Average patient has had diabetes for 10 years; 36% no-pay; 70%
African-American Mean A1c on presentation = ~10.0%; mean decrease in A1c –1.92% Significant improvements in blood pressure, lipids Outcomes are durable The model and its outcomes are easily reproducible in community
practice Outcomes independent of race and gender High quality of care measures: ~90+% High patient satisfaction measures: 97+% Resource utilization: 4 management and 2 education visits (year 1)
DDP Sites
UMMC Model Greenville (Delta Regional Medical Center) Cleveland (Boliver Medical Center)* UMMC Pavilion DMC Clarksdale (NW Ms Regional Med Cntr) Clarksdale (Aaron E. Henry Community Health
Center) 2nd tier – smaller towns, local MD offices 3rd tier – lay education/prevention initiative
Delta Health Alliance Delta State University Mississippi Valley State University Mississippi State University Delta Council University of Mississippi Medical Center Mississippi State Medical Association Mississippi Hospital Association Community Health Centers Area Health Education Centers (AHEC)
DDP External Collaborators
HRSA, Office of Rural Health Policy Delta Regional Authority Centers for Disease Control (CDC) Mississippi State Department of Health Joslin Diabetes Center University of Tennessee Health Sciences
Center Georgetown University
HgA1c Changes over time
6.5
7.0
7.5
8.0
8.5
9.0
9.5
10.0
Initial Year 1 Year 2 Year 3 Year 4 Year 5
Hg
A1c
All
n = 2,440
Mean LDL Cholesterol Over Time
90
100
110
120
130
Initial 6-12Months
13-18Months
19-24Months
25-30Months
31-36Months
37-42Months
43-48Months
49-54Months
55-60Months
61-66Months
mg
/dL
LD
L C
ho
lest
ero
l
Percent of patients exceeding NCLB criteria for HgA1c
0
10
20
30
40
50
60
HgA1c > 9 (1)
Per
cen
t
Initial
Year 1
Year 2
Year 3
Year 4
Year 5
n = 2,440
Percent of patients exceeding NCLB criteria for DBP
0
5
10
15
20
25
DBP > 90 (1)
Per
cen
t
Initial
Year 1
Year 2
Year 3
Year 4
Year 5
n = 2,440
Percent of patients exceeding NCLB criteria for LDL Cholesterol of > 130
0
10
20
30
40
50
60
70
LDL > 130
Per
cen
t
Initial
Year 1
Year 2
Year 3
Year 4
Year 5
n = 2,440
Percent of patients meeting ADA criteria for HgA1c
0
5
10
15
20
25
30
35
40
HgA1c < 7
Per
cen
t
Initial
Year 1
Year 2
Year 3
Year 4
Year 5
n = 2,440
Percent of patients with LDL Cholesterol < 100
0
10
20
30
40
50
60
70
LDL < 100
Perc
en
t
Initial
Year 1
Year 2
Year 3
Year 4
Year 5
n = 2,440
Percent of patients meeting ADA criteria for DBP
0
10
20
30
40
50
60
70
80
90
DBP < 80 (1)
Per
cen
t
Initial
Year 1
Year 2
Year 3
Year 4
Year 5
n = 2,440
Racial parity in metabolic outcomes
• n=284, pre-post, 12 months• 67.2% AA, 30.7% EA; 63.4% female, 36.2% male• 34% no insurance, 26% medicaid• Initial A1c > in AA: 10.23 v 9.24 (p=0.0006)• A1c, SBP, DBP, LDL improved significantly in
both groups• No statistical difference between outcomes for
both groups in terms of A1c, SBP, DBP, LDL
Educational Outreach Programs
Large scale patient education and outreach programs
Provider education programs >600 providers, >4,200 hours continuing
education delivered per year 3 annual clinical CME conferences Annual Southeast regional health policy
conference
Greenville Site Demographics
• Race: AA 76.7%, Cauc 20.8%, Other 2.5%• Gender: M 28%, F 72%• Age: <19 1.5%, 19-44 28.4%, 45-67 47.6%, >65
22.5%• Payor source:
Medicare 24.3%
Medicaid 21.2%Medicaid/Medicare 17%Private 25.8%Self 11.7%
Greenville Site Clinic DynamicsMonth Visits12/05 10011/05 8310/05 1129/05 1218/05 927/05 656/05 815/05 744/05 623/05 862/05 771/05 77Total 1,030
Greenville Site Quality of Care Measures
• A1c each quarter 100%• Microalbuminuria, on ACEi or ARB Rx
100%• Age > 30 on aspirin therapy 87%• LDL screening annually 87%• BP check each visit 98%• Optho exam annually 82%• Foot exam annually 93%
Sample Quality Indicator Results
* Mississippi and US data derived from Jencks SF, Cuerdon T, Burwen DR. Quality of medical care delivered to medicare beneficiaries: a profile at state and national levels. JAMA 2000;284:1670-76.
**DMC period = 12 mos, US and Mississippi data period = 24 mos
0
20
40
60
80
100
HbA1c EyeExams**
Lipids**
Miss*
USA*
Greenville
UMMC model
Greenville Site Metabolic Outcomes
6.0
7.0
8.0
9.0
10.0
A1c
Pre
Post
ADA goal
100
110
120
130
140
150
160
170
180
SBP
Pre
Post
ADA goal
60
70
80
90
DBP
Pre
Post
ADA goal
n = 61, matched pre/post, consecutive patients with more than one A1c; Interval: 6-18 months
70
80
90
100
110
120
130
140150
160
LDL
Pre
Post
ADA goal
Cleveland Site Metabolic Outcomes
6.0
7.0
8.0
9.0
10.0
A1c
Pre
Post
ADA goal
100
110
120
130
140
150
160
170
180
SBP
Pre
Post
ADA goal
60
70
80
90
DBP
Pre
Post
ADA goal
n = 205, matched pre/post, consecutive patients with more than one A1c; Interval: 6-12 months
70
80
90
100
110
120
130
140150
160
LDL
Pre
Post
ADA goal
UMMC Model Site Metabolic 1 Year Outcomes
6.0
7.0
8.0
9.0
10.0
A1c
Pre
Post
ADA goal
100
110
120
130
140
150
160
170
180
SBP
Pre
Post
ADA goal
60
70
80
90
DBP
Pre
Post
ADA goal
n = 2,440, unmatched, all patients; Interval: 12 months
Engagement rate: % active patients/all patients ever seen (2440/3710 x 100%) = 65.8%
70
80
90
100
110
120
130
140150
160
LDL
Pre
Post
ADA goal
Greenville Telehealth Pilot Site Equipment Utilization Report
• Time in use: 9 mos• Formal sessions: 23• Average session length: 35 min• Session content breakdowns:
Weekly comprehensive training conference – 21
Patient educational programs – 2Patient consultation sessions – 13Quarterly quality improvement reports – 4Provider education conference planning – 3Telehealth/HER training sessions – 2Delta Health Alliance meeting - 1
Economic Utility of Telehealth Pilot
• 40% UMMC FTE x 260 mile roundtrip: 20% FTE available for teaching
• Telehealth was able to eliminate 20% FTE (one day/wk)• Reduced travel costs (260 mile round trip x1/wk)• Anticipate savings of up to 30% FTE MD per site, plus
travel costs• Current savings/yr:
Faculty time savings (20% FTE MD) $24,000Travel costs savings $ 6,700Total savings $30,700
Projected Outcome Translation in Terms of Mean Glycemic Improvement
Reduction in hemodialysis : 58% Reduction in blindness : 48% Reduction in limb amputation : 45% Reduction in DM neuropathy : 45%
Eastman RC, et al. Model of complications of NIDDM. Diabetes Care, May 1997, 20(5), 735-44.
UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 38). BMJ 1998;317:703-13.
UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulfonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53.
Significance
The benefits of metabolic control under this chronic disease management system are easily achievable and seem to be realistically sustainable over very long periods of time in a disadvantaged population
Racial and gender based disparities in metabolic parameters can be overcome by this intervention
If this can be done in the Mississippi Delta it can probably be done anywhere in the U.S.