University of Mississippi Medical Center takes diabetes care from bad to best

Jackson 11 May 2006Mississippi has traditionally been the worst state in the United States for patients with diabetes. The incidence of diabetes is higher here, the complications more numerous, and until now, the quality of care was at rock bottom. The complications from diabetes - kidney failure, amputation, blindness and heart disease - are both life-threatening and severely debilitating. A new system of diabetes care, however, is changing all that. In several clinics around the state - three in the Mississippi Delta where diabetes numbers soar - patients have reduced their risk for complications by 70 percent in just six visits.

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The scourge of the state has met its enemy - Dr. Marshall Bouldin, associate professor of medicine at the University of Mississippi Medical Center, where he started the first clinic in 1999. The growth of the system wasn't unplanned. Dr. Dan Jones, vice chancellor for health affairs at the Medical Center, urged Dr. Bouldin to create a system that could be replicated in other parts of the state to bring diabetes care up to the national standard and help prevent some of the tragic complications of the disease.

Now, with six years of data and experience in several locations, Dr. Bouldin has shown that patients in the clinics, even those who were formerly considered "difficult", average a two-point drop in their long-term levels of blood sugar, and for every point that level decreases, the patient reduces his or her risk for complications by 35 percent. Even more encouraging, there is no disparity of outcomes between African-Americans and Caucasians.

Dr. Bouldin noted that the prevalence of diabetes among adults in Mississippi increased from 7,3 percent to 11 percent from 1999-2001. In some subsets of the Mississippi population, the prevalence is even higher. Among African-American women between 55-64, for example, 34,7 percent have diabetes. And diabetes definitely hits hardest among the poor. Mississippi is the poorest state in the nation, and counties that make up the Mississippi Delta are the poorest of the poor. Still, in this population, Dr. Bouldin's system has produced outcomes equal to or better than those in affluent white communities in the Northeast.

"Diabetes control ultimately hinges on the patient's ability to manage his or her own diabetes, and everyone responds to interventions that allow them to do that", Dr. Bouldin stated.

Pete Johnson, the federal co-chairman for the Delta Regional Authority, stated that his group was looking for models of health care delivery when it became obvious that health was a key driver of the economy. "You cannot turn an economy around if you don't have a competitive work force, and you can't have a competitive work force if they're not healthy." The authority, created by Congressional act in 2000 under the administration of President Bill Clinton, works to improve conditions in 240 counties and parishes in eight states.

"We're right at the beginning of taking this region-wide", Pete Johnson stated. "We were looking for an efficient model of health care delivery, and it was right under our noses." Pete Johnson, it turns out, is friends with Dr. Bouldin's father, the famous portrait artist from Clarksdale. "He sits two rows in front of me in church, and one Sunday, when Marshall was home for the weekend, he told me about his project and how he thought it could work in the Delta. We looked at his data and analysed his results and decided it was a programme we should embrace and replicate."

Funding for the Delta clinics comes from the Delta Health Alliance, under the direction of Dr. Cass Pennington. One thing that appeals to both agencies is the cost-effectiveness of the clinics. "It costs about $250.000 to start up a clinic, but reimbursement from Medicaid and Medicare make it self-sustaining", Pete Johnson stated.

Dr. Pennington said his agency is impressed with the strong patient education component of the diabetes project and the impact it has had on the health of the Delta. "Employers in the Delta cite frequent employee absences because of sickness as a major problem. And they identify diabetes as the major cause of those absences. This programme is a Godsend, and it will have a tremendous impact on the Delta counties." Dr. Pennington also credited Dr. Bouldin for his perseverance in seeing the clinics implemented. "I think his car could find its way to the Delta without a driver."

But Dr. Bouldin knows that he can't be in all locations all the times he's needed, so he's developed another collaboration with the University of Tennessee to use its telemedicine capabilities. "This way, I can meet with the staff of the clinics in the Delta once a week and go over patient records with them or discuss any problems they may have encountered." Dr. Bouldin also trains local physicians to use the system he's devised for diabetes care, so it can be done in his absence. But the system uses physicians very sparingly, and that's one of the reasons it can be replicated in regions where physicians are scarce. "We don't do anything that's revolutionary. We use all the tried-and-true methods of diabetes management."

What is perhaps revolutionary is the absence of the traditional hierarchy of care starting with the physician at the top and the patient educators and dieticians at the bottom. "In this model, every professional role is critical", Dr. Bouldin stated. Nurse practitioners, RNs, diabetic educators, pharmacists and dietitians all work as a team to teach and care for patients. Nurse practitioners and pharmacists manage diabetes care much as a physician specialist would. Dr. Bouldin, the physician, manages medical problems beyond the scope of the other professionals and supervises quality assurance.

"As far as we know, this is the first time pharmacists have ever been used in this specific role of diabetes management", he stated, "and our studies have shown that they're particularly effective in reducing blood sugar levels." The risk for complications, Dr. Bouldin explained, correlates with the concentration of sugar in the blood. The insulin in individuals who don't have diabetes allows glucose (sugar) to enter cells and be converted to energy, to synthesize proteins and store fat. In patients with diabetes, sugar and fat stay in the bloodstream and damage vessels and nerves that can eventually lead to kidney disease, blindness, amputation and heart disease.

No system in Mississippi - and few in the country - has reported outcomes as good as Dr. Bouldin's, and especially not in the high-risk populations the clinics serve. "Our outcomes have been consistent over six years, and we were surprised that results could be seen so quickly. Our patients average a two-point drop in their blood sugar levels in just six months", he stated.

The clinical outcomes of Dr. Bouldin's system have not escaped notice on a national level. In the last three years, Dr. Bouldin has succeeded in obtaining $3,5 million in external funding with more funding anticipated. In May 2005, Dr. Bouldin presented results from the various clinics to the Bipartisan Committee on Health Information Technology on Capitol Hill and made a special presentation to Medicare staff in Baltimore, Maryland, at the request of the Medicare director. "I think the general feeling is that if we can do this in Mississippi, it can work anywhere", Dr. Bouldin stated.

To Dr. Bouldin, one of the key components of success is the degree of collaboration between agencies, institutions, the local community and the federal government. In addition to the Delta Regional Authority, the Delta Health Alliance and the University of Tennessee, other active partners are the Joslin Diabetes Center, Mississippi Valley State University, Delta State University, Mississippi State University, and the Centers for Disease Control (CDC).

The CDC will put a field station in the Delta to work with the Delta Health Alliance and the diabetes project. "We had always planned that the diabetes programme we first established at the Medical Center in 1999 would really be a test case for the management of chronic disease. If you've done diabetes well, you have essentially already done high blood pressure, dyslipidemia and cardiovascular mortality. The partnership with CDC will enable the coalition to develop regional programmes along these lines."


Leslie Versweyveld

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