Community Strategies to Reduce Health Disparities What Must We Do? (A Tale of Two Neighbors)

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1 Community Strategies to Reduce Health Disparities What Must We Do? (A Tale of Two Neighbors) James R. Gavin III, MD, PhD CEO & Chief Medical Officer Healing Our Village, Inc. Clinical Professor of Medicine Emory University School of Medicine Atlanta, Georgia

2 Trends in Diabetes Burden A Major Threat for CVD Note that Central & South America have high single-digit rates of diabetes prevalence---and GROWING, especially in Mexico!

3 So Why Does Diabetes Continue to Command Our Attention? Because EVERY 24 HOURS there are, in the USA alone approximately: 4,100 new cases of diabetes, 810 deaths due to diabetes, 230 amputations, 120 kidney failures, and 55 new cases of blindness Source: NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.

4 Diabetes Complications 2 in 3 people with diabetes die of heart disease or stroke Diabetes is the #1 cause of adult blindness Diabetes is the #1 cause of kidney failure Diabetes causes more than 60% of nontraumatic lower-limb amputations each year NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.

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6 Classifications of Diabetic Retinopathy Normal Healthy Eye

7 Screening and Diagnosis for Diabetic Retinopathy History/physical exam Refer once per year to an ophthalmologist for a dilated eye exam In-office screening can be conducted with a Fundus camera and photos read by a central office (EyeTel, Inoveon, Nidek) Proper diagnosis can be followed with treatment that can reduce or halt this problem Fong DS, et al. Diabetes Care. 2003;26(suppl 1):S99-S102. Gibbins RL, et al. Diabetologia. 1998;41: Images: Ahttp:// B C

8 Diabetes-related eye disease is a clear disparity. This is preventable and treatable disease. What must we do to reduce the impact of this problem? What might we learn from the experiences of our neighbors?

9 PROGRAM HISTORY 2002 Exploration Vision for All proposes screening program to Health Ministry-Guanajuato, because of high rates of T2DM * Several local doctors wanted to make a difference! Needs Assessment/Service Ophthalmoscopic screening-community health clinics Laser treatment-dif Hospital Guanajuato 2006 Telemedicine Solution Proposed Health Ministry purchases Topcon digital retinal camera Vision for All/EyePACS trains primary care physicians August 2006-March 2008 Roll Out 7012 patients imaged

10 FINDINGS No retinopathy screening program for public health patients Many patients had never seen an eye doctor (limited face-to-face encounters) High prevalence of untreated vision-threatening retinopathy

11 WHY DID GUANAJUATO NOT HAVE A RETINOPATHY SCREENING PROGRAM? Limited resources Too few ophthalmologists Screening not covered by seguro popular Geographic barriers Rural clinics widely dispersed Travel to urban centers difficult/expensive Knowledge barriers Limited patient understanding of vision threat from diabetes

12 HOW DOES TELEMEDICINE SOLVE THESE PROBLEMS? Digital retinal camera comes to the patient in health clinics Retinal evaluation same time as general medical evaluation Non-specialists obtain retinal data Specialists evaluate digital images remotely

13 Digital Retinal Photography 13

14 EyePACS Workflow 14

15 EyePACS in Guanajuato, Mexico 19 sites: Community Health Clinics Total Cases: over 7000 in 18 months Sight threatening retinopathy: 14% 15

16 FIRST YEAR RESULTS GTO PERCENT OF DIABETIC PATIENTS SCREENED AUGUST 2006 TO AUGUST /8 Jurisdicciónes Sanitarias Total diabetic population under care Number of patients screened 4,998 % patients screened (first year) 22, %

17 PREVALENCE OF RETINOPATHY IN GUANAJUATO RESULTS OF YEAR-ONE SCREENING 4998 patients Gradeable images 3758 (81%) Repeat images in one year (1st step in prevention!) No retinopathy 65% Mild to moderate NPDR 26% Refer to ophthalmology (Pathway to halting progression!) Severe NPDR 4% PDR 3% Macular edema 7% Ungradeable images 887 (19%)

18 What Made the Guanajuato Project a Success in Community Action? The entire community embraced and supported the project ( activated volunteerism ) The entire region knew about the program Health professionals, media, community organizations all championed the effort There was only one setting for the majority of persons to obtain health care Since most were uninsured, there was a single payer ( patient-friendly system ) There was significant leveraging of technology to capture efficiency & economy

19 Why is the Guanajuato Program Relevant as a Tale of 2 Neighbors? A similar program using the same technology and approach was only able to screen 210 people (vs. ~7100 in Mexico) in a year The diabetes-related eye probems were as great or greater than in the Mexico community There was very little buzz created in the community and no media mention Patients had no central location or pathway to the screening Health professionals did not champion the effort No volunteer advocacy undertaken

20 Is Such a Tale Replicable in the USA--What Must we do? There must first be commitment to making a difference by key health professionals There must be more effective partnerships to promote and implement such a program The public communication must be adequate Is it possible for us to have a central anything regarding healthcare delivery? Do we have the tools or capability to make such an effort the thing that one must do?

21 NDEP Diabetes Prevention Materials

22 Diabetes Control: Patient Materials

23 TRAINING

24 Diabetes Control: Health Care Professionals

25 Expert Panel of NMQF Recommendations to Improve Outcomes in Minority Patients Consider the earlier use of combination medications given synergies in mechanisms of action. The panel emphasized that earlier use of insulin a flexible and underutilized treatment tool should be considered as a tool for more effectively reaching goals Engage the Centers for Medicare and Medicaid Services (CMS) to highlight the need for some risk stratification and sensitivity to the clinical benchmarks according to the demographics of the patient population, perhaps including a point or scoring system based on movement toward rather than actually reaching the specified goal Engage minority communities to promote diabetes support and education, particularly as it relates to aggressive management of diabetes ( create buzz, generate excitement, promote hope) Implies more effective use of partnerships, including activated volunteerism

26 International Diabetes Federation

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