Teaching an old dog new tricks – telehealth, IT, and diabetes ...

428 views

Published on

Published in: Health & Medicine, Education
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
428
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
6
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Teaching an old dog new tricks – telehealth, IT, and diabetes ...

  1. 1. Teaching an old dog new tricks – telehealth, IT, and diabetes management in the Mississippi Delta Marshall Bouldin MD Director, Diabetes and Metabolism Program Associate Professor of Medicine University of Mississippi Medical Center
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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)
  7. 7. 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
  8. 8. 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)
  9. 9. 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
  10. 10. 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 HgA1c All n = 2,440
  11. 11. Mean LDL Cholesterol Over Time 90 100 110 120 130 Initial 6-12 Months 13-18 Months 19-24 Months 25-30 Months 31-36 Months 37-42 Months 43-48 Months 49-54 Months 55-60 Months 61-66 Months mg/dLLDLCholesterol
  12. 12. Percent of patients exceeding NCLB criteria for HgA1c 0 10 20 30 40 50 60 HgA1c > 9 (1) Percent Initial Year 1 Year 2 Year 3 Year 4 Year 5 n = 2,440
  13. 13. Percent of patients exceeding NCLB criteria for DBP 0 5 10 15 20 25 DBP > 90 (1) Percent Initial Year 1 Year 2 Year 3 Year 4 Year 5 n = 2,440
  14. 14. Percent of patients exceeding NCLB criteria for LDL Cholesterol of > 130 0 10 20 30 40 50 60 70 LDL > 130 Percent Initial Year 1 Year 2 Year 3 Year 4 Year 5 n = 2,440
  15. 15. Percent of patients meeting ADA criteria for HgA1c 0 5 10 15 20 25 30 35 40 HgA1c < 7 Percent Initial Year 1 Year 2 Year 3 Year 4 Year 5 n = 2,440
  16. 16. Percent of patients with LDL Cholesterol < 100 0 10 20 30 40 50 60 70 LDL < 100 Percent Initial Year 1 Year 2 Year 3 Year 4 Year 5 n = 2,440
  17. 17. Percent of patients meeting ADA criteria for DBP 0 10 20 30 40 50 60 70 80 90 DBP < 80 (1) Percent Initial Year 1 Year 2 Year 3 Year 4 Year 5 n = 2,440
  18. 18. 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
  19. 19. 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
  20. 20. 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%
  21. 21. Greenville Site Clinic Dynamics Month Visits 12/05 100 11/05 83 10/05 112 9/05 121 8/05 92 7/05 65 6/05 81 5/05 74 4/05 62 3/05 86 2/05 77 1/05 77 Total 1,030
  22. 22. 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%
  23. 23. 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 H bA 1c Eye Exa m s ** Lipids ** M is s * US A * G re e nv ille UM M C m o de l
  24. 24. 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 90 100 110 120 130 140 150 160 LDL Pre Post ADA goal
  25. 25. 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 90 100 110 120 130 140 150 160 LDL Pre Post ADA goal
  26. 26. 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 90 100 110 120 130 140 150 160 LDL Pre Post ADA goal
  27. 27. 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 – 2 Patient consultation sessions – 13 Quarterly quality improvement reports – 4 Provider education conference planning – 3 Telehealth/HER training sessions – 2 Delta Health Alliance meeting - 1
  28. 28. 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) $24,000 Travel costs savings $ 6,700 Total savings $30,700
  29. 29. 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.
  30. 30. 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.

×