Duke, CHA Curbing Diabetes through a New Model of Patient Care

Duke, CHA Curbing Diabetes through a New Model of Patient Care

October 14, 2013

Diabetes is near the top of the list of 21st century public health epidemics. Duke University and Cabarrus Health Alliance (CHA), both North Carolina Research Campus (NCRC) partners, are taking a bold step to curb the effects of the disease by developing a new model of care for patients with type 2 diabetes, especially those at the highest risk for complications.

Considering that diabetes is an underlying cause of heart disease, stroke, high blood pressure, blindness, kidney disease, amputation and neurological damage, the ramifications of leaving the disease unchecked are a marked decline in longevity, quality of life and productivity for millions of children and adults worldwide.

The Urgent Need to Address Diabetes

Diabetes is actually a group of diseases where insulin is not produced or used correctly causing high blood glucose levels. The American Diabetes Association (ADA) reported that 8.3 percent or 25.8 million children and adults in the United States have the disease. The incidence is on the rise. In the United States, the Centers for Disease Control and Prevention (CDC) released statistics in May 2013 that revealed that the percentage of adults with diabetes increased by 45 percent over the last 20 years.

The number of Americans with diabetes is just a drop in the insulin bucket compared to the global crisis. Findings from a study in the Journal of the American Medical Association published in September 2013, showed China is now the country with the largest diabetes epidemic. Of all Chinese adults, 11.6 percent or about 139.9 million have diabetes, and 50.1 percent or another 493.4 million Chinese are pre-diabetic. In 1980, the prevalence of diabetes in China was less than one percent. The International Diabetes Federation (IDF) reports that at least 366 million people worldwide already have diabetes and that by 2030 the number will exceed 552 million.

The economic impact is dizzying too. The ADA released in March 2013 that the cost of diabetes totals $176 billion in direct medical costs and $69 billion in reduced productivity. That is a total of $245 billion annually. On a personal level, the ADA found that the “average medical expenditures among people with diagnosed diabetes were 2.3 times higher than what expenditures would be in the absence of diabetes.”

“We want to prevent diabetes, but if you have already been diagnosed there are ways to control it with medication, behavior change and titration of your insulin that can really reduce your risk and serious complications associated with poorly controlled diabetes,” said Ashley Dunham, MSPH, PhD, project leader for the MURDOCK Study and the newly funded Southeastern Diabetes Initiative.

The MURDOCK Study is a multi-tiered, long-term, community-based study at the NC Research Campus (NCRC) in Kannapolis that is collecting and storing biological samples to find biomarkers and genomic linkages within and across diseases and disorders.

Dr. William “Phred” Pilkington, chief executive officer and director of Public Health for the Cabarrus Health Alliance, located adjacent to the NCRC, added. “Managing diabetes can be easy for some, more complex for others. At a basic level, people have to change their diets, exercise, continually check their blood sugar to make sure it stays in the correct range and follow their physician’s advice. The problem is that generally, people don’t.”

Launching a New Model of Diabetes Care

Building on a program started by the Bristol-Myers Squibb Foundation and aimed at Durham County, North Carolina, Robert Califf, MD, director of the Duke Translational Medical Institute and a principal investigator of the MURDOCK Study, set out to meld strategies in diabetes care like using data mining and geospatial mapping to identify patients and neighborhoods at highest risk, intense clinical interventions for the highest risk patients and community mobilization around improving outcomes. By doing that, he is spearheading the creation of a comprehensive program designed to hone in on the factors that will motivate people to make the lifestyle changes necessary to manage diabetes, specifically type 2, and to identify new ways to assess and identify diabetes risk at a population level.

The program, now called the Southeastern Diabetes Initiative, is funded by a $9.7 million Centers for Medicare and Medicaid (CMS) Health Care Innovation Awards grant. The grant is led by Califf and Duke University in partnership with the University of Michigan National Center for Geospatial Medicine and four southeastern counties – Cabarrus County, NC, Durham County, NC, Mingo County, West Virginia and Quitman County, Mississippi.

The southeastern United States is targeted because, Dunham said, it is a region “in trouble from a chronic health outcomes perspective. When you look at a map we are in the worst shape (in terms of) cardiovascular disease, stroke and diabetes.”

A 2011 CDC report dubbed the southeast the “diabetes belt” where over 11 percent of the population has diabetes verses an average of 8.5 percent outside the belt. The most common form of diabetes is type 2. Although some forms of diabetes like juvenile diabetes are dependent on genetics, type 2 diabetes primarily results from lifestyle decisions like smoking, poor dietary choices and the lack of physical activity. It also has the best chance of being prevented and managed, reducing the lifestyle and economic consequences.

Progress So Far

The four counties are in the process of recruiting type 2 diabetes patients who are more likely to have complications within the next year to take part in an intensive clinical intervention delivered by a multidisciplinary clinical team. Pilkington has overseen the hiring of nine new CHA staff members who have established connections with local physicians, Federally-qualified health centers and the Community Free Clinic located in Cabarrus County. To allow for the highest level of individualized care and support, each patient starts with one-on-one visits with the team’s case manager, nurse, nurse practitioner and registered dietitian.

The team works with each patient collaboratively to develop a specific and personal action plan. Patients are also connected with the teams’ health educator and community health workers for enrollment in diabetes self-management and cooking classes, support groups, physical activity programs and other resources based on the individual needs of the patients. The Case Manager and Community Health Workers are also available to help patients solve challenges like finding a grocery store with a selection of healthy foods, locating an exercise class, finding medication assistance, accessing the Internet or getting a bus pass.

Duke’s role is the development of a geospatially-enabled informatics platform entitled the Southeastern Diabetes Initiative DataMart. The platform is one of the first to combine data from electronic health records such as hospitalizations and emergency visits with social data.

“So you can imagine if you have patients and you have access to their electronic health data you can access their risk and the costs, but another huge component of why people utilize the healthcare system and don’t utilize it effectively . . . is social in nature.” Dunham clarified. “Poverty, lack of insurance, lack of social support, mental illness- these social factors also contribute to risks later in life. So not only are we looking at clinical risk, we are looking at social risk and pinpointing it to communities and neighborhoods.”

Knowing on a population level where the highest risk patients are, in turn, facilitates more targeted and effective recruitment of patients into the educational and support groups at the community level. “This type of approach,” Dunham emphasized, “gets us out of the mindset that all care has to be delivered by a physician and allows a team of people who are much lower in cost to address diabetes. You would think that delivering home-based care by a team of providers would be expensive. But if it keeps people stable and out of the emergency rooms and hospitals, you are actually saving the healthcare system a lot of money.”

Pilkington projects that as the program progresses, the results will change the course of how diabetes is managed. “I think we can demonstrate that these types of intensive, individualized interventions that reach outside of the clinical setting will show outcomes that far exceed what you see when patients don’t have the proper support and knowledge to self-manage their diabetes.”

For more information, contact the Cabarrus Health Alliance at www.cabarrushealth.org or The Murdock Study at www.murdock-study.com.

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