Affiliated with East Carolina University, Brody School of Medicine, Department of Family Medicine
Redesigning Diabetes Care in Rural Fee-for-Service Practices

Supported by Finding Answers: Disparities Research for Change, a National Program of the Robert Wood Johnson Foundation with direction and technical assistance provided by the University of Chicago

Project Funded May 1, 2008- Two Years Funding

Goal Statement and Specific Aims

Funded Institutions
Bertie Memorial Hospital-University Health Systems and
East Carolina University
(a.k.a., East Carolina Health / Bertie All-County Health Services, Windsor, North Carolina)
Principal Investigators
Paul Bray, MA, LMFT, PI
Assistant Research Professor, Dept. of Family Medicine
East Carolina University Project Coordinator-ECARE
Coordinator Group Diabetes Program
University Health Systems-Bertie Memorial Hospital

Doyle M. "Skip" Cummings, Pharm.D., FCP, FCCP, Co-PI
Berbecker Distinguished Professor of Rural Medicine
Professor of Family Medicine and Pediatrics, ECU
Director, Research Division, Family Medicine, ECU
Brody School of Medicine at East Carolina University

Goal Statement
The proposed study will evaluate the clinical effectiveness and feasibility of an innovative model of redesigned diabetes care for African American patients with historically disparate outcomes in rural, fee-for-service primary care practices. While studied in urban managed care sites, these redesign elements have not been systematically evaluated in fee-for-service rural communities where the incentives for care of underserved minority citizens are markedly different. The proposed study will specifically address this important need. The specific aims are to evaluate the effect of the redesigned model on glycemic control (HbA1c) and other diabetes-specific outcome measures, to explore the effects of the model on transitions in care from inpatient to outpatient settings, and to assess the cost-benefit and cost-effectiveness of the intervention.

The redesign components are based on the Chronic Care Model described by Wagner et al. The intervention is already funded by two regional foundations. The study is designed as a cohort study in which six rural fee-for-service practices (three intervention practices already begun and three control practices yet to be selected) will be pair matched based on practice size and patient demographics. A total of 510 patients will be randomly selected from these six practices and will reflect the effects of the intervention or control conditions in each practice. The primary outcome of interest will be the change in HbA1c from baseline to 6 and 12 months after initiation of the intervention or usual care, along with other diabetes specific clinical and cost analysis measures. The proposed study has tremendous potential to inform disparities improvement through the evaluation of an innovative model that can bring state of the art diabetes care to minority patients in underserved and vulnerable rural communities at a cost that is reasonable and acceptable.

Specific Research Aims
1. To determine the effectiveness of implementing a redesigned model of interdisciplinary care delivery in a series of rural, fee-for-service, primary care practices on glycemic control (and secondarily on other diabetes-specific and cardiovascular risk outcomes), in a representative cohort of African American adult patients with Type 2 diabetes mellitus and previously disparate outcomes, at six months and one year following implementation compared to that from similar control practices.

Hypothesis: redesigned interdisciplinary care will result in improved glycemic control (decrease in HbA1c) among adult African American patients with Type 2 diabetes mellitus relative to that observed in control practices.

2. For African American patients with diabetes mellitus who are hospitalized, to assess the impact of redesigned interdisciplinary care on short-term care outcomes during the transition from inpatient (hospitalist) to outpatient (outpatient provider) settings.

Hypothesis: redesigned interdisciplinary care will result in improved delivery of diabetes self-management education and improved glycemic control post-hospitalization.

3. To determine the cost-benefit and cost-effectiveness of this redesigned model of interdisciplinary care delivery among African American patients with diabetes mellitus.

Hypothesis: redesigned interdisciplinary care will result in fewer emergency room visits and shorter length of stay hospitalizations compared to usual care and will constitute a sustainable model of care.

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