Crossing the divide: piloting an integrated care model to bridge rural-urban healthcare systems and reduce major amputations among rural patients with diabetic foot ulcers

跨越鸿沟：试点综合护理模式，以架起城乡医疗保健系统的桥梁，减少农村糖尿病足溃疡患者的大截肢

• 批准号: 10417888
• 负责人: Meghan Brennan
• 金额: $ 31.1万
• 依托单位: UNIVERSITY OF WISCONSIN-MADISON
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-07-01 至 2025-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10417888
• 关键词: Address; Algorithms; American; Amputation; Ankle; Automobile Driving; Award; Blood Vessels; Caring; Cessation of life; Clinic; Clinical; Clinical Trials; Collaborations; Communicable Diseases; Complications of Diabetes Mellitus; Consultations; Consumption; Data; Diabetes Mellitus; Diabetic Foot Ulcer; Diagnostic; Disease; Electronic Health Record; Engineering; Face; Feedback; Foot Ulcer; Goals; Guidelines; Health; Health Personnel; Health system; Healthcare Systems; Infection; Intervention; Ischemia; Location; Measures; Mechanics; Minor; Modeling; National Institute of Diabetes and Digestive and Kidney Diseases; Operative Surgical Procedures; Outcome; Participant; Patients; Phase; Physiological; Pilot Projects; Population; Preparation; Primary Health Care; Process; Provider; Reporting; Research; Research Personnel; Risk; Rural; Rural Health; Rural Population; Schedule; Side; Specialist; Testing; Time; Triage; United States Health Resources and Services Administration; Universities; Urban Health; Vascular Diseases; Wisconsin; Work; base; clinically significant; cohort; cost; design; efficacy trial; feasibility trial; follow-up; glycemic control; health disparity; high risk; improved; innovation; limb loss; medical specialties; multi-site trial; primary care setting; programs; recruit; retention rate; rural disparities; rural health disparities; rural healthcare; rural patients; rural setting; secondary infection; success; systematic review; tertiary care; tool; urban setting; wound care

PROJECT SUMMARY ABSTRACT While other diabetes complications decreased, amputations (combined major and minor) due to foot ulcers increased 63%, reaching a 20-year peak. More than two million Americans develop a foot ulcer annually, placing them at risk of limb loss. Even worse, rural patients face a 37% greater risk of above-ankle, major amputation compared to urban counterparts, a health disparity identified by our group and others. We urgently need interventions to address this grave rural disparity and escalating amputation rate. Our systematic review of 33 studies spanning four continents reported that urban integrated care models reduce major amputation by approximately 40%. Urban integrated care models work by co-locating multiple specialists in the same clinic and using algorithms to address four physiologic factors: 1) poor glycemic control, 2) vascular disease, 3) mechanical complications, and 4) secondary infection. However, the urban integrated care model has never been adapted to rural, primary care settings. We engineered the first integrated care model for rural patients with diabetic foot ulcers, which is innovative in supporting both rural primary care and care that bridges rural and urban settings. To do so, we partnered with a HRSA-awarded Cooperative of 43 rural healthcare systems with a nationally recognized focus on improving rural diabetes care. Together, we identified the #1 health system barrier to rural, integrated care: poor collaboration across the rural-urban health system divide. Without co-location, rural providers and urban specialists struggle to manage the highest risk patients―those with ischemia and infection. Next, we co- designed an integrated care model to promote cross-setting collaboration without co-location. Our model includes two tools: 1) a care algorithm and 2) a referral checklist. The care algorithm supports rural primary care in providing high quality, local care to most patients. It also addresses obstacles to collaborating with urban specialists by providing a priori agreed upon referral criteria including timeframes, clinical indications, and pre-consultation diagnostics for severe disease. The referral checklist will support rural clinic schedulers, who place referrals to urban specialty clinics, by providing schedulers with a list of documents that should be included, reducing barriers of time-consuming triage and disjointed electronic health records. This early-stage-investigator proposal answers NIDDK’s call for small R01 pilot/feasibility trials in preparation for a statewide trial. We aim to: 1) build recruitment and retention strategies that work across diverse, rural clinics, and 2) evaluate the potential of our integrated care model to reduce major amputations by examining its impact on guideline-concordant care processes, including urban specialty referral. These aims 1) address the top reasons clinical trials fail―poor recruitment and retention, and 2) generate preliminary evidence of efficacy for the statewide trial. Our pilot is the next step towards the first intervention to reduce rural health disparities in major amputations, addressing amputation as a NIDDK priority outcome in a priority, rural population.

项目摘要 虽然其他糖尿病并发症减少，但由于足部溃疡导致的截肢（合并大小） 增长了63%，达到了20年来的最高点。每年有200多万美国人患上足部溃疡， 使他们面临截肢的危险。更糟糕的是，农村患者面临踝关节以上，主要 截肢相比，城市同行，我们的小组和其他人确定的健康差距。我们迫切 需要采取干预措施，解决这一严重的农村差距和不断上升的截肢率。 我们对跨越四大洲的33项研究进行了系统回顾，报告称，城市综合护理模式 减少大约40%的截肢手术。城市综合护理模式的运作方式是将多个 同一诊所的专家并使用算法来解决四个生理因素：1）血糖控制不良， 2)血管疾病，3）机械并发症，和4）继发感染。然而，城市综合 保健模式从未适应农村的初级保健环境。 我们为农村糖尿病足溃疡患者设计了第一个综合护理模式， 支持农村初级保健和连接农村和城市环境的保健。为此，我们与 一个由43个农村医疗保健系统组成的合作组织，国家认可的重点是改善 农村糖尿病护理我们共同确定了农村综合保健的头号卫生系统障碍：贫穷 跨越城乡卫生系统鸿沟的合作。如果不合用同一地点，农村提供者和城市 专家们努力管理最高风险的患者-那些患有缺血和感染的患者。接下来，我们共同- 设计了一个综合护理模式，以促进跨环境协作，而无需合用同一地点。我们的模型 包括两个工具：1）护理算法和2）转诊清单。护理算法支持农村小学 为大多数患者提供高质量的本地护理。它还解决了与合作的障碍， 城市专家通过提供事先商定的转诊标准，包括时间范围，临床适应症， 和严重疾病的咨询前诊断。转诊清单将支持农村诊所医生， 谁把转诊到城市专科诊所，通过提供一个文件清单，应 包括，减少耗时的分类和脱节的电子健康记录的障碍。 这份早期研究者提案响应了NIDDK对准备中的小型R 01中试/可行性试验的呼吁 进行全州范围的审判我们的目标是：1）建立招聘和保留战略， 诊所，2）评估我们的综合护理模式的潜力，以减少重大截肢，通过检查其 对符合指南的护理流程的影响，包括城市专科转诊。这些目标（1）针对 临床试验失败的主要原因-招募和保留不足，2）产生疗效的初步证据 全州范围的审判我们的试点是第一个干预措施的下一步，以减少农村健康差距， 重大截肢，将截肢作为国家残疾人发展基金的一项优先成果，优先针对农村人口。