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

项目总结摘要 在其他糖尿病并发症减少的同时，由于足部溃疡而进行的截肢(包括大的和小的) 上涨了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， 使他们面临失去肢体的风险。更糟糕的是，农村患者脚踝以上的风险要高出37%。 截肢与城市同行相比，这是我们小组和其他人确定的健康差距。我们急切地 需要干预措施来解决这一严重的农村差距和不断攀升的截肢率。 我们对横跨四大洲的33项研究的系统回顾报告称，城市综合护理模式 减少约40%的主要截肢。城市综合护理模式通过将多个 并使用算法来解决四个生理因素：1)血糖控制不佳， 2)血管疾病，3)机械并发症，4)继发感染。然而，城市一体化 保健模式从未适应过农村初级保健环境。 我们为农村糖尿病足部溃疡患者设计了第一个一体化护理模式，这在 支持农村初级保健和连接农村和城市环境的保健。为了做到这一点，我们与 HRSA授予的43个农村医疗保健系统合作社，全国公认的重点是改善 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：贫困 城乡卫生系统之间的协作存在鸿沟。如果没有主机代管，农村供应商和城市供应商 专家们正在努力处理最高风险的患者--那些患有缺血和感染的患者。接下来，我们共同-- 设计了一种集成的护理模式，以促进跨环境协作，而无需共同定位。我们的模特 包括两个工具：1)护理算法和2)转诊核对表。CARE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 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、 以及对严重疾病的会诊前诊断。转诊清单将支持乡村诊所调度员， 世卫组织通过向调度员提供一份应该符合以下条件的文件清单，将转诊到城市专科诊所 包括减少耗时的分类和相互脱节的电子健康记录的障碍。 这一早期阶段的调查员提案响应了NIDDK的呼吁，即准备进行小规模的R01试点/可行性试验 进行全州范围的审判。我们的目标是：1)建立适用于不同农村地区的招聘和留住战略 诊所，以及2)评估我们的综合护理模式减少重大截肢的潜力，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)解决了 临床试验失败的主要原因--招募和保留不佳，以及2)产生了初步的疗效证据 全州范围内的审判。我们的试点是朝着减少#年农村健康差距的第一次干预迈出的下一步 重大截肢，将截肢作为NIDDK在优先农村人口中的优先结果。

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.