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

Links Diabetes-Disparities

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)
Other Studies and Important Outcomes

J Clin Outcomes Manage
2008 Oct;15(10):494-501
Evaluation of a diabetes case management intervention in an underserved population: a retrospective cohort study at a heatlh disparities collaborative site
Sekhobo JP, Wang C, Ferrari P

Abstract Objective: To evaluate the impact of case management on glycemic control in a predominantly low-income, minority patient population receiving care at a multisite community health center. Methods: The case management intervention was implemented at a Health Disparities Collaborative site in 2002. A control clinic that that did not have case management but belonged to the same network as the intervention clinic was used for comparison. Type 2 diabetes patients who had 4 or more documented glycosylated hemoglobin (HbA1c) test results from 1 January 2003 through 31 December 2005 comprised the study sample (n = 132). Baseline predictor variables included sociodemographic characteristics, weight status, insurance coverage, hypertension status, medication status, and case management. Results: Regardless of site, participants with poor glycemic control at baseline (HbA1c ? 9.0%) tended to experience the greatest reductions in HbA1c, with the mean HbA1c declining from 11. 0% during the baseline visit to 9.1% during the fourth visit. In repeated-measures multivariate analysis of variance, statistically significant differences were detected between overall mean HbA1c values in the categories of case management status (F = 42.15, p ? 0.001), baseline glycemic control (F = 6.07, p = 0.0157), treatment status (F = 5.87, P = 0.0011), and race/ethnicity (F = 3.77, p = 0.0134). Tests for within-subject effects did not produce a statistically significant effect of visit (F3,86 = 0.92, p = 0.4547). Conclusion: These results provide preliminary evidence of the effectiveness of a collaborative case management intervention in a predominantly low-income, minority study population. These findings should be confirmed in larger studies of pooled community health center data.

Medicare spending on heart failure issues underscores need for coordinated care
December 3, 2008
By Bruce Jancin
NEW ORLEANS (EGMN) – Medicare beneficiaries with heart failure see 16-23 physicians annually, depending on the severity of their heart failure. This finding, based on extrapolation from fiscal year 2005 data on a representative sample of more than 1.7 million Medicare beneficiaries, underscores the need to develop systems and processes of coordinated care for the nation’s more than 5 million heart failure patients, three-quarters of whom are aged 65 years or older, Robert L. Page II, Pharm.D., asserted at the annual scientific sessions of the American Heart Association.
Better-coordinated care is the key to avoiding duplication of services, Close to half of all outpatient care for Medicare beneficiaries with heart failure was provided by internists and family physicians. Beneficiaries – regardless of their heart failure severity – saw an internist at 26% of all outpatient visits and a family physician at 20%. Cardiologists handled 16%-20% of all outpatient visits, with the proportion climbing as severity of heart failure increased.
As severity of heart failure increased, so did total costs of care and the proportion of those costs devoted to inpatient or emergency department care. There were significant differences in spending by race and gender. For example, total 2005 costs of care in black men with mild, moderate, and severe heart failure averaged $35,106, $43,536, and $55,457, respectively. The same costs for white men averaged $26,433, $30,536, and $44,433. Costs for black women with heart failure were lower than for black men but higher than costs for white men. Costs for white women were lowest of all.
In patients with mild heart failure, 58% of total health care costs went for care provided in the emergency department or on an inpatient basis, while this proportion climbed to 66% in patients with severe heart failure. In black beneficiaries with mild or moderate heart failure, 67% of total health care spending covered emergency department or inpatient services; in whites with mild or moderate heart failure, this figure was 56%.

Am J Manag Care.
Effective Diabetes Care by a Registered Nurse Following Treatment Algorithms in a Minority Population
Mayer B. Davidson, MD; Maria Castellanos, RN; Petra Duran, BS; and Vicki Karlan, MPH

A total of 367 patients completed a full year in the DMCP. Data from the prior year were available for 331 patients. Among a subset of Latino patients, 95% earned less than $25 000 and 73% had an education of 6th grade or less. Process measures recommended by the American Diabetes Association (ADA) were met 98% of the time during the DMCP year compared with 54% of the time during the prior year (P < .001). Mean glycosylated hemoglobin (A1C) levels fell from 9.3% to 8.7% in the year before entry into the DMCP and to 7.0% by the end of the first DMCP year (P < .001). At DMCP entry, 28% met the ADA A1C goal of less than7%; 60% did so at the end of the year. Fifty-one percent met the ADA low-density lipoprotein cholesterol goal at entry into the DMCP compared with 82% at the end of the year.
Conclusion: A nurse making clinical decisions based on detailed treatment algorithms did a better job of achieving ADArecommended process and outcome measures than physicians providing usual care.

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