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.