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: 10597125
• 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/10597125
• 关键词: Address; Agreement; 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; Dedications; 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; 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 Care; Process; Provider; Reporting; Research; Research Personnel; Risk; Risk Reduction; Rural; Rural Health; Rural Population; Side; Specialist; Telefacsimile; Testing; Time; Triage; United States Health Resources and Services Administration; Universities; Urban Health; Vascular Diseases; Wisconsin; Work; clinically significant; cohort; cost; design; efficacy trial; feasibility trial; follow-up; glycemic control; health disparity; high risk; improved; innovation; integrated care; limb loss; medical specialties; multi-site trial; primary care setting; programs; recruit; retention rate; rural disparities; rural health clinic; 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.

项目摘要摘要 虽然其他糖尿病并发症减少，但由于足溃疡而导致的截肢（重量和小型） 增加了63％，达到20年的高峰。每年有超过200万美国人出现脚步溃疡， 使他们面临肢体损失的风险。更糟糕的是，粗糙的患者面临上层，主要的风险大37％ 与城市同行相比，截肢是我们小组和其他人确定的健康差异。我们紧急 需要干预措施来解决这种严重的粗糙差异和截肢率的升级。 我们对33项研究的系统评价涵盖了四个连续性，报告了城市综合护理模型 将主要截肢降低约40％。城市综合护理模型通过共同销售多个 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。但是，城市融合了 护理模型从未适应过粗糙的初级保健环境。 我们为糖尿病足溃疡的粗糙患者设计了第一个综合护理模型，这在 支持桥接农村和城市环境的粗糙初级保健和护理。为此，我们与 43个农村医疗保健系统的HRSA授予合作社，全国认可的重点是改善 农村糖尿病护理。我们一起确定了农村综合护理的＃1卫生系统障碍：糟糕 跨越农村卫生系统的合作鸿沟。没有共同位置，农村提供商和城市 专家努力管理最高风险的患者 - 缺血和感染。接下来，我们共同 设计了一个集成的护理模型，以促进交叉设定的协作而无需共同设置。我们的模型 包括两个工具：1）护理算法和2）转介清单。护理算法支持农村小学 为大多数患者提供高质量，当地护理的护理。它还解决了与之合作的障碍 城市专家通过提供先验同意的推荐标准，包括时间表，临床指示， 以及严重疾病的临时诊断。推荐清单将支持粗糙的诊所调度程序， 谁推荐给城市专业诊所，通过向调度程序提供应该是的文件列表 包括，减少了耗时的分类障碍和脱节的电子健康记录。 此早期评估者提案回答了NIDDK进行小型R01飞行员/可行性试验的呼吁 进行全州审判。我们的目标是：1）建立在潜水员，粗糙的潜水 诊所，以及2）评估我们综合护理模型的潜力，以减少主要截肢 对指南协调过程的影响，包括城市专业推荐。这些目的1）解决 临床试验失败招募和保留率的主要原因，以及2）产生效率的初步证据 对于全州审判。我们的飞行员是迈向首次干预措施的下一步 主要的截肢，将截肢作为NIDDK的优先结果，重点是粗糙的人口。