National Center for Research Resources Workshop

“Fostering Collaborative Community-Based Clinical and Translation Research” May 15, 2007 Bethesda, MD

Community Based Research and Education (CoBRE) Core Facility

R. Whit Hall, MDCore Director

Center for Translational NeuroscienceUniversity of Arkansas

for Medical SciencesLittle Rock, AR

What we do now What we do now nationallynationally

Bench to bedsideBench to bedside– Meetings, lectures, abstracts, journal Meetings, lectures, abstracts, journal

clubs, specialties with multiple areas of clubs, specialties with multiple areas of interest (Good)interest (Good)

Bedside to curbsideBedside to curbside– Articles, communication with Articles, communication with

pharmaceutical reps, subspecialists pharmaceutical reps, subspecialists (OK)(OK)

Curbside to patient care (Poor)Curbside to patient care (Poor)NIH Initiatives to Implementation Research

Duane Alexander, PAS 2007

Pediatric Problems to be Pediatric Problems to be addressed by the CoBREaddressed by the CoBRE

1) Neonatal outcomes are improved 1) Neonatal outcomes are improved by regionalization of perinatal careby regionalization of perinatal care

2) Follow-up of discharged neonates is 2) Follow-up of discharged neonates is complexcomplex

– Subspecialty careSubspecialty care– Available only at ACHAvailable only at ACH– Frequently requires extensive travelFrequently requires extensive travel

Background: Background: Assessment of AR newborn Assessment of AR newborn care to datecare to date Assess current mortality, morbidity, Assess current mortality, morbidity,

and costs of academic vs. community and costs of academic vs. community carecare

Assess increased dissemination of Assess increased dissemination of evidence based guidelines and evidence based guidelines and research to community physicians research to community physicians through monthly neonatology through monthly neonatology conferencesconferences

USA dataUSA data

60,000 babies <1500 grams (VLBW)60,000 babies <1500 grams (VLBW) 20,000 babies <1000 grams (ELBW)20,000 babies <1000 grams (ELBW) Rate of preterm delivery increasingRate of preterm delivery increasing

– Causes are multifactorial, social Causes are multifactorial, social – No changes in preterm delivery rate or No changes in preterm delivery rate or

survival survival

Changes needed will be in better Changes needed will be in better organization of newborn careorganization of newborn care

Pediatrics, 2005

Arkansas dataArkansas data

Underserved and 43% ruralUnderserved and 43% rural Levels of care undesignatedLevels of care undesignated UAMS: Sole hospital with perinatal UAMS: Sole hospital with perinatal

coverage providing delivery servicecoverage providing delivery service ACH: Free standing Children’s ACH: Free standing Children’s

HospitalHospital Both supported by same Both supported by same

neonatology serviceneonatology service

Arkansas DemographicsArkansas Demographics

Arkansas has 73 of Arkansas has 73 of 75 counties 75 counties designated as designated as medically medically underserved areas, underserved areas, with much of with much of Arkansas facing a Arkansas facing a healthcare healthcare provider shortage.provider shortage.

© AR Dept. of Health and Human Services, 2006

Maternal Transport in Maternal Transport in AR:AR:Maldistribution of CareMaldistribution of Care RegionalizationRegionalization and maternal and maternal

transport improve outcomes in transport improve outcomes in smallest babies smallest babies

Intensive newborn care provides Intensive newborn care provides money and prestige to hospitals, money and prestige to hospitals, leading to leading to deregionalizationderegionalization

Inappropriate referrals lead to Inappropriate referrals lead to overcrowding at referral centerovercrowding at referral center

Textbook of Neonatology by Fanaroff, 2004

Methods used in CoBRE to Methods used in CoBRE to datedate

Medicaid recordsMedicaid records– Matched birth records, death Matched birth records, death

certificates with hospital recordscertificates with hospital records 91% match91% match Outside data analysisOutside data analysis Cooperative Medicaid administrationCooperative Medicaid administration

Analyzed mortality, morbidity, Analyzed mortality, morbidity, and costsand costs

Finding 1: Improved Survival for Finding 1: Improved Survival for High-risk InfantsHigh-risk Infants

0%

5%

10%

15%

20%

25%

30%

35%

40%

500-999 grams 1000-1499 grams 1500-2499 grams

UAMSOther hospitals with NICUHospitals without NICU

Risk of Death within 60 days after Birth, by Delivery Hospital and WeightRisk of Death within 60 days after Birth, by Delivery Hospital and Weight

P<0.01 P<0.05 P>0.10

0

5

10

15

20

25

30

500-750g 751-1000g 1001-1500g All

UAMS

ACH

Comparison of grades 3 and 4 intraventricular hemorrhage for UAMS (inborn) vs ACH (outborn) neonates for 2001-2004

P<0.01, UAMS vs. ACH at all weights Percent

Finding 2: Better Finding 2: Better Neurodevelopmental Neurodevelopmental Outcome for Inborn DeliveryOutcome for Inborn Delivery

Finding 3: Costs of IVHFinding 3: Costs of IVH

0

100000

200000

300000

400000

500000

600000

500-750 750-1000100-1250 1250-1500

IVHNo IVH

Total Medicaid costs over 4 years

Finding 4: Costs of Finding 4: Costs of Newborn CareNewborn Care Average cost per Average cost per

patientpatient Costs include Costs include

Medicaid charges Medicaid charges over 12 monthsover 12 months– Inpatient hospital, Inpatient hospital,

outpatient outpatient hospital, hospital, homecare, prof homecare, prof services, drugs, services, drugs, other servicesother services

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

<1000 grams 1000-1500grams

UAMSHosp NIHosp w/ o NI

$ per year per pt

Average cost per year per pt over 2500 grams: $3723

Finding 5: Monthly neonatology Finding 5: Monthly neonatology conferences-conferences-Changes in Patterns of Delivery Changes in Patterns of Delivery for LBW Infants in Rural Areasfor LBW Infants in Rural Areas

0%

5%

10%

15%

20%

25%

30%

35%

40%

2001 2002 2003 2004

<1000 grams 1000-1499 grams1500-1999 grams 2000-2499 grams

Regression-adjusted estimates controlling for maternal risks, insurance source, socioeconomic characteristics, and race/ethnicity. †p<0.05

†

†

Problem 2: NICU Follow-Problem 2: NICU Follow-upup

Increase in VLBW survivalIncrease in VLBW survival Medically fragile populationMedically fragile population Increased hospital costsIncreased hospital costs

Case Management Case Management

Utilized in asthma, diabetes, Utilized in asthma, diabetes, psychiatry, and CHF in adultspsychiatry, and CHF in adults

Never utilized in ex-VLBW Never utilized in ex-VLBW neonatesneonates

Typically administered by vendorTypically administered by vendor– Emphasis on primary careEmphasis on primary care– Decreased satisfactionDecreased satisfaction– Primary motivator: financial savings Primary motivator: financial savings

Background: Case Background: Case Management and Medical Management and Medical HomeHome In children with 2 or more chronic In children with 2 or more chronic

diseasesdiseases– Decrease ER visits by 81%Decrease ER visits by 81%– Decrease hospitalizations by 50%Decrease hospitalizations by 50%– Decrease costs by 50%Decrease costs by 50%

Palfrey, 2007

Problems with Follow-Problems with Follow-upup TrainingTraining

– Pediatric residents receive 4 months Pediatric residents receive 4 months intensive care over 3 yearsintensive care over 3 years

– No training in focused careNo training in focused care Multiple subspecialistsMultiple subspecialists TravelTravel Discharge difficulties Discharge difficulties

Complex Ex-preterm Complex Ex-preterm ChildrenChildrenMedical RequirementsMedical Requirements BPD: PulmonaryBPD: Pulmonary Right Ventricular hypertrophy: Right Ventricular hypertrophy:

CardiologyCardiology Hyperalimentation: Hyperalimentation:

GastroenterologyGastroenterology Retinopathy: OphthalmologyRetinopathy: Ophthalmology Developmental: General PediatricsDevelopmental: General Pediatrics G-Tubes: SurgeryG-Tubes: Surgery

Finding: Medicaid Costs in Finding: Medicaid Costs in ARAR

87 Medicaid recipients cost 87 Medicaid recipients cost $7,955,333$7,955,333

Outpatient costs: $18,330 Outpatient costs: $18,330 compared to $1,447compared to $1,447

Higher mortalityHigher mortality Increased hospital admissionsIncreased hospital admissions

Problem 1 Proposal: Problem 1 Proposal: Telemedicine Unit in 5-7 Telemedicine Unit in 5-7 Largest NurseriesLargest Nurseries Hospitals with NICU to participate Hospitals with NICU to participate

in 8:15 conferencein 8:15 conference– Currently used for census Currently used for census

management at UAMS/ACHmanagement at UAMS/ACH– Existing dataExisting data– Improved communicationImproved communication– Eliminate “Town-gown” Eliminate “Town-gown”

phenomenom phenomenom

Other uses of Other uses of TelemedicineTelemedicine

Other uses besides census Other uses besides census managementmanagement

– ResuscitationResuscitation– Major medical decisionsMajor medical decisions– X-ray interpretation (IT challenge)X-ray interpretation (IT challenge)– 24/7 connectivity with neonatology 24/7 connectivity with neonatology

for consultation for consultation

Telemedicine sustainabilityTelemedicine sustainability

ACH to keep referrals long term ACH to keep referrals long term Help wide swings in censusHelp wide swings in census Rural hospital will be able to keep Rural hospital will be able to keep

more patientsmore patients Medicaid to save money on Medicaid to save money on

transportstransports It’s the right thing to do It’s the right thing to do

Problem 2: Case Problem 2: Case Management ProposalManagement Proposal

Apply case management to Apply case management to smaller hospitalssmaller hospitals– Place telemedicine units in rural ERsPlace telemedicine units in rural ERs– Place units in office settingPlace units in office setting– Historical and current controlsHistorical and current controls

Parent and executive board to Parent and executive board to evaluate evaluate

Potential pitfalls in Potential pitfalls in TelemedicineTelemedicine

Technological difficultiesTechnological difficulties– Maintenance at remote and central siteMaintenance at remote and central site

Physician reluctance to changePhysician reluctance to change– Monetary incentives for local championMonetary incentives for local champion

Central reluctance to assess by Central reluctance to assess by telemedicinetelemedicine– Currently done by phoneCurrently done by phone

Potential pitfalls in Case Potential pitfalls in Case ManagementManagement

Reluctance to use case managerReluctance to use case manager– Excellent past experienceExcellent past experience

Coordinate local physician time Coordinate local physician time with subspecialistwith subspecialist

SustainabilitySustainability– Remote hospitals to keep more Remote hospitals to keep more

patientspatients– Medicaid reimbursementMedicaid reimbursement

Strengths available in AR to Strengths available in AR to accomplish and evaluate accomplish and evaluate goalsgoals T-1 lines capable of carrying 1.5 megs/sec T-1 lines capable of carrying 1.5 megs/sec

(bioterrorism after 9/11) already in place to (bioterrorism after 9/11) already in place to every hospital and ER in the state to allow every hospital and ER in the state to allow live videoconferencinglive videoconferencing

Educational telemedicine already established Educational telemedicine already established with IT support available in remote siteswith IT support available in remote sites

Medical home at ACH and central 24/7 Medical home at ACH and central 24/7 telephone triage system in placetelephone triage system in place

Willingness of neonatal section to support Willingness of neonatal section to support remote sitesremote sites

Links with birth certificates and hospital Links with birth certificates and hospital discharge data for survival and cost analysis discharge data for survival and cost analysis in place in place

Thanks, RR020146Thanks, RR020146

Release timeRelease time EquipmentEquipment MentoringMentoring

“ ‘“ ‘Tis better to curse the darkness Tis better to curse the darkness than to light the wrong candle”than to light the wrong candle”

Joe, Fireworks factoryJoe, Fireworks factory