Reducing major amputations for rural patients with diabetic foot ulcers: the who’s and how’s of integrated care.

项目摘要 每年有近200万美国人患糖尿病足溃疡。布纳恩博士的研究小组和其他人 在溃疡形成的5年内，记录了>50%的死亡率和5%的大截肢率。接下来他们 确定与溃疡相关的发病率和死亡率给农村患者带来不成比例的负担， 与城市患者相比，大截肢率高出50%，死亡率高出40%。布纳恩博士的 长期目标是通过改善糖尿病患者质量的干预措施消除这种农村差异。 足部溃疡护理农村患者在门诊环境中接受。 在过去的十年里，许多城市三级护理中心已经发展出一种对病人进行综合护理的模式 糖尿病足溃疡综合护理模式涉及多名专家并肩工作， 遵循护理算法，以协调的方式解决4个诱发性生理因素：血糖不良 控制、血管疾病、机械并发症和继发感染。布纳恩博士的系统回顾 发现97%的城市综合护理诊所减少了大截肢，相对风险降低 从11%到90%。然而，这种城市模式很难在农村实施， 供应商稀少，地理位置分散。 博士布伦南的目标是成为一个学术临床研究人员在传染病领导一个独立的 研究计划，以改善农村地区糖尿病足溃疡的护理和结果。她提出了一个三年 K08期间，在临床试验、利益相关者参与、系统工程和实施方面进行培训 科学和先进的定量技能。在KL2的支持下，Brennan博士已经做好了充分的准备， 成功的K08奖励期。她的重点培训，专家指导和研究计划将催化她 过渡到独立。这一提议预示着她从界定护理差距到缩小差距的进步。 该提案的主要目标是建立和试行一个适合农村地区的综合护理算法， 设置.拟议的目标是：1）确定哪些专家与增加无截肢率有关 生存，以及他们参与的最佳时机2）共同设计一个综合护理算法及其 实施计划与农村医疗保健系统，和3）试点算法在农村设置，以最大限度地提高 通过和执行。在完成拟议的研究和培训后，布伦南博士将 最好准备提交一份竞争性的AHRQ R01，以测试新出现的干预措施为中心， 实施效果研究。她目前和未来的研究目标将推进AHRQ的使命， 重点关注高优先级人群（农村患者）、问题（大截肢）和关注领域 （门诊护理）。

PROJECT SUMMARY ABSTRACT Nearly 2 million Americans develop a diabetic foot ulcer each year. Dr. Brennan's research team and others documented a >50% mortality and 5% major amputation rate within 5-years of ulceration. Next, they determined that morbidity and mortality associated with ulcers disproportionately burdens rural patients, who have 50% higher odds of major amputation and 40% higher odds of death than urban patients. Dr. Brennan's long-term objective is to eliminate this rural disparity through interventions that improve the quality of diabetic foot ulcer care rural patients receive in the ambulatory setting. Over the past decade, many urban tertiary care centers have developed a model of integrated care for patients with diabetic foot ulcers. The integrated care model involves multiple specialists working side-by-side and following a care algorithm to address 4 precipitating physiologic factors in a coordinated manner: poor glycemic control, vascular disease, mechanical complications, and secondary infection. Dr. Brennan's systematic review found that 97% of these urban integrated care clinics reduced major amputation, with relative risk reductions ranging from 11 to 90%. However, this urban model is difficult to implement in the rural setting, where providers are scarce and geographically dispersed. Dr. Brennan's goal is to become an academic clinician-researcher in infectious disease leading an independent research program to improve care and outcomes of diabetic foot ulcers in rural settings. She proposes a 3-year K08 period with training in clinical trials, stakeholder engagement, systems engineering, implementation science, and advanced quantitative skills. Following her KL2 support, Dr. Brennan is well prepared for a successful K08 award period. Her focused training, expert mentorship, and research plan will catalyze her transition to independence. This proposal heralds her advancement from defining gaps in care to closing them. The primary objective of this proposal is to build and pilot an integrated care algorithm adapted to the rural setting. The proposed aims are to: 1) identify which specialists are associated with increased amputation-free survival, and the optimal timing of their involvement 2) co-design an integrated care algorithm and its implementation plan with rural healthcare systems, and 3) pilot the algorithm in the rural setting to maximize adoption and implementation. Upon completion of the proposed research and training, Dr. Brennan will be ideally poised to submit a competitive AHRQ R01 centered on testing the emerging intervention with an effectiveness-implementation study. Her current and future research aims will advance AHRQ's mission by focusing on a high-priority population (rural patients), problem (major amputation), and area of interest (ambulatory care).