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, MD Core Director Center for Translational Neuroscience University of Arkansas for Medical Sciences Little Rock, AR

What we do now nationally Bench to bedside Bench to bedside –Meetings, lectures, abstracts, journal clubs, specialties with multiple areas of interest (Good) Bedside to curbside Bedside to curbside –Articles, communication with pharmaceutical reps, subspecialists (OK) Curbside to patient care (Poor) Curbside to patient care (Poor) NIH Initiatives to Implementation Research Duane Alexander, PAS 2007

Pediatric Problems to be addressed by the CoBRE 1) Neonatal outcomes are improved by regionalization of perinatal care 2) Follow-up of discharged neonates is complex –Subspecialty care –Available only at ACH –Frequently requires extensive travel

Background: Assessment of AR newborn care to date Assess current mortality, morbidity, and costs of academic vs. community care Assess current mortality, morbidity, and costs of academic vs. community care Assess increased dissemination of evidence based guidelines and research to community physicians through monthly neonatology conferences Assess increased dissemination of evidence based guidelines and research to community physicians through monthly neonatology conferences

USA 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 increasing Rate of preterm delivery increasing –Causes are multifactorial, social –No changes in preterm delivery rate or survival Changes needed will be in better organization of newborn care Pediatrics, 2005

Arkansas data Underserved and 43% rural Underserved and 43% rural Levels of care undesignated Levels of care undesignated UAMS: Sole hospital with perinatal coverage providing delivery service UAMS: Sole hospital with perinatal coverage providing delivery service ACH: Free standing Children’s Hospital ACH: Free standing Children’s Hospital Both supported by same neonatology service Both supported by same neonatology service

Arkansas Demographics Arkansas has 73 of 75 counties designated as medically underserved areas, with much of Arkansas facing a healthcare provider shortage. Arkansas has 73 of 75 counties designated as medically underserved areas, with much of Arkansas facing a healthcare provider shortage. © AR Dept. of Health and Human Services, 2006

Maternal Transport in AR: Maldistribution of Care Regionalization and maternal transport improve outcomes in smallest babies Regionalization and maternal transport improve outcomes in smallest babies Intensive newborn care provides money and prestige to hospitals, leading to deregionalization Intensive newborn care provides money and prestige to hospitals, leading to deregionalization Inappropriate referrals lead to overcrowding at referral center Inappropriate referrals lead to overcrowding at referral center Textbook of Neonatology by Fanaroff, 2004

Methods used in CoBRE to date Medicaid records Medicaid records –Matched birth records, death certificates with hospital records 91% match 91% match Outside data analysis Outside data analysis Cooperative Medicaid administration Cooperative Medicaid administration Analyzed mortality, morbidity, and costs Analyzed mortality, morbidity, and costs

Finding 1: Improved Survival for High-risk Infants Risk of Death within 60 days after Birth, by Delivery Hospital and Weight P<0.01P<0.05P>0.10

Comparison of grades 3 and 4 intraventricular hemorrhage for UAMS (inborn) vs ACH (outborn) neonates for P<0.01, UAMS vs. ACH at all weights Percent Finding 2: Better Neurodevelopmental Outcome for Inborn Delivery

Finding 3: Costs of IVH Total Medicaid costs over 4 years

Finding 4: Costs of Newborn Care Average cost per patient Average cost per patient Costs include Medicaid charges over 12 months Costs include Medicaid charges over 12 months –Inpatient hospital, outpatient hospital, homecare, prof services, drugs, other services $ per year per pt Average cost per year per pt over 2500 grams: $3723

Finding 5: Monthly neonatology conferences- Changes in Patterns of Delivery for LBW Infants in Rural Areas Regression-adjusted estimates controlling for maternal risks, insurance source, socioeconomic characteristics, and race/ethnicity. †p<0.05 † †

Problem 2: NICU Follow-up Increase in VLBW survival Increase in VLBW survival Medically fragile population Medically fragile population Increased hospital costs Increased hospital costs

Case Management Utilized in asthma, diabetes, psychiatry, and CHF in adults Utilized in asthma, diabetes, psychiatry, and CHF in adults Never utilized in ex-VLBW neonates Never utilized in ex-VLBW neonates Typically administered by vendor Typically administered by vendor –Emphasis on primary care –Decreased satisfaction –Primary motivator: financial savings

Background: Case Management and Medical Home In children with 2 or more chronic diseases In children with 2 or more chronic diseases –Decrease ER visits by 81% –Decrease hospitalizations by 50% –Decrease costs by 50% Palfrey, 2007

Problems with Follow-up Training Training –Pediatric residents receive 4 months intensive care over 3 years –No training in focused care Multiple subspecialists Multiple subspecialists Travel Travel Discharge difficulties Discharge difficulties

Complex Ex-preterm Children Medical Requirements BPD: Pulmonary BPD: Pulmonary Right Ventricular hypertrophy: Cardiology Right Ventricular hypertrophy: Cardiology Hyperalimentation: Gastroenterology Hyperalimentation: Gastroenterology Retinopathy: Ophthalmology Retinopathy: Ophthalmology Developmental: General Pediatrics Developmental: General Pediatrics G-Tubes: Surgery G-Tubes: Surgery

Finding: Medicaid Costs in AR 87 Medicaid recipients cost $7,955, Medicaid recipients cost $7,955,333 Outpatient costs: $18,330 compared to $1,447 Outpatient costs: $18,330 compared to $1,447 Higher mortality Higher mortality Increased hospital admissions Increased hospital admissions

Problem 1 Proposal: Telemedicine Unit in 5-7 Largest Nurseries Hospitals with NICU to participate in 8:15 conference Hospitals with NICU to participate in 8:15 conference –Currently used for census management at UAMS/ACH –Existing data –Improved communication –Eliminate “Town-gown” phenomenom

Other uses of Telemedicine Other uses besides census management Other uses besides census management –Resuscitation –Major medical decisions –X-ray interpretation (IT challenge) –24/7 connectivity with neonatology for consultation

Telemedicine sustainability ACH to keep referrals long term ACH to keep referrals long term Help wide swings in census Help wide swings in census Rural hospital will be able to keep more patients Rural hospital will be able to keep more patients Medicaid to save money on transports Medicaid to save money on transports It’s the right thing to do It’s the right thing to do

Problem 2: Case Management Proposal Apply case management to smaller hospitals Apply case management to smaller hospitals –Place telemedicine units in rural ERs –Place units in office setting –Historical and current controls Parent and executive board to evaluate Parent and executive board to evaluate

Potential pitfalls in Telemedicine Technological difficulties Technological difficulties –Maintenance at remote and central site Physician reluctance to change Physician reluctance to change –Monetary incentives for local champion Central reluctance to assess by telemedicine Central reluctance to assess by telemedicine –Currently done by phone

Potential pitfalls in Case Management Reluctance to use case manager Reluctance to use case manager –Excellent past experience Coordinate local physician time with subspecialist Coordinate local physician time with subspecialist Sustainability Sustainability –Remote hospitals to keep more patients –Medicaid reimbursement

Strengths available in AR to accomplish and evaluate goals T-1 lines capable of carrying 1.5 megs/sec (bioterrorism after 9/11) already in place to every hospital and ER in the state to allow live videoconferencing T-1 lines capable of carrying 1.5 megs/sec (bioterrorism after 9/11) already in place to every hospital and ER in the state to allow live videoconferencing Educational telemedicine already established with IT support available in remote sites Educational telemedicine already established with IT support available in remote sites Medical home at ACH and central 24/7 telephone triage system in place Medical home at ACH and central 24/7 telephone triage system in place Willingness of neonatal section to support remote sites Willingness of neonatal section to support remote sites Links with birth certificates and hospital discharge data for survival and cost analysis in place Links with birth certificates and hospital discharge data for survival and cost analysis in place

Thanks, RR Release time Release time Equipment Equipment Mentoring Mentoring “ ‘Tis better to curse the darkness than to light the wrong candle” Joe, Fireworks factory