Crossing the divide: piloting an integrated care model to bridge rural-urban healthcare systems and reduce major amputations among rural patients with diabetic foot ulcers

PROJECT SUMMARY ABSTRACT
While other diabetes complications decreased, amputations (combined major and minor) due to foot ulcers
increased 63%, reaching a 20-year peak. More than two million Americans develop a foot ulcer annually,
placing them at risk of limb loss. Even worse, rural patients face a 37% greater risk of above-ankle, major
amputation compared to urban counterparts, a health disparity identified by our group and others. We urgently
need interventions to address this grave rural disparity and escalating amputation rate.
Our systematic review of 33 studies spanning four continents reported that urban integrated care models
reduce major amputation by approximately 40%. Urban integrated care models work by co-locating multiple
specialists in the same clinic and using algorithms to address four physiologic factors: 1) poor glycemic control,
2) vascular disease, 3) mechanical complications, and 4) secondary infection. However, the urban integrated
care model has never been adapted to rural, primary care settings.
We engineered the first integrated care model for rural patients with diabetic foot ulcers, which is innovative in
supporting both rural primary care and care that bridges rural and urban settings. To do so, we partnered with
a HRSA-awarded Cooperative of 43 rural healthcare systems with a nationally recognized focus on improving
rural diabetes care. Together, we identified the #1 health system barrier to rural, integrated care: poor
collaboration across the rural-urban health system divide. Without co-location, rural providers and urban
specialists struggle to manage the highest risk patients―those with ischemia and infection. Next, we co-
designed an integrated care model to promote cross-setting collaboration without co-location. Our model
includes two tools: 1) a care algorithm and 2) a referral checklist. The care algorithm supports rural primary
care in providing high quality, local care to most patients. It also addresses obstacles to collaborating with
urban specialists by providing a priori agreed upon referral criteria including timeframes, clinical indications,
and pre-consultation diagnostics for severe disease. The referral checklist will support rural clinic schedulers,
who place referrals to urban specialty clinics, by providing schedulers with a list of documents that should be
included, reducing barriers of time-consuming triage and disjointed electronic health records.
This early-stage-investigator proposal answers NIDDK’s call for small R01 pilot/feasibility trials in preparation
for a statewide trial. We aim to: 1) build recruitment and retention strategies that work across diverse, rural
clinics, and 2) evaluate the potential of our integrated care model to reduce major amputations by examining its
impact on guideline-concordant care processes, including urban specialty referral. These aims 1) address the
top reasons clinical trials fail―poor recruitment and retention, and 2) generate preliminary evidence of efficacy
for the statewide trial. Our pilot is the next step towards the first intervention to reduce rural health disparities in
major amputations, addressing amputation as a NIDDK priority outcome in a priority, rural population.

Grant Number: 5R01DK132569-03
NIH Institute/Center: NIH
Principal Investigator: Meghan Brennan