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

项目总结摘要 每年有近200万美国人患上糖尿病足溃疡。布伦南博士的研究团队和其他人 记录了溃疡5年内50%的死亡率和5%的主要截肢率。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了不成比例的负担， 比城市病人大截肢的几率高50%，死亡的几率高40%。布伦南博士的 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距 农村患者在门诊环境中接受足部溃疡护理。 在过去的十年里，许多城市三级护理中心发展了一种为患者提供综合护理的模式 患有糖尿病足部溃疡。综合护理模式涉及多名专家并肩工作， 遵循CARE算法，以协调的方式解决4个诱发生理因素：血糖低 控制、血管疾病、机械并发症和继发感染。布伦南博士的系统评价 发现97%的城市综合护理诊所减少了主要截肢，相对风险降低 从11%到90%不等。然而，这种城市模式很难在农村环境中实施，在那里 供应商稀缺且地理位置分散。 Brennan博士的目标是成为传染病方面的学术临床医生和研究员，领导一个独立的 改善农村地区糖尿病足部溃疡的护理和预后的研究计划。她提议用3年的时间 K08期间，在临床试验、利益相关者参与、系统工程、实施方面进行培训 科学和高级量化技能。在KL2的支持下，Brennan博士已经为 成功的K08奖励期。她专注的培训、专家指导和研究计划将催化她 向独立过渡。这项提议预示着她的进步，从界定护理差距到弥合这些差距。 这项提案的主要目标是建立和试点适用于农村地区的综合护理算法 布景。提议的目标是：1)确定哪些专家与增加免截肢有关 生存，以及他们参与的最佳时机2)共同设计了一个集成的护理算法和它的 农村医疗保健系统的实施计划，以及3)在农村环境中试行算法，以最大限度地 通过和实施。在完成拟议的研究和培训后，布伦南博士将 最好准备好提交一份具有竞争力的AHRQ R01，以测试新兴干预措施为中心 有效性--执行研究。她目前和未来的研究目标将推动AHRQ的使命 重点关注高优先级人群(农村患者)、问题(重大截肢)和感兴趣的领域 (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).