National Center for Research Resources Workshop “Fostering Collaborative Community-Based Clinical and Trans

1. 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

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

3. 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

4. Background: Assessment of AR newborn care to date • 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

5. USA data • 60,000 babies <1500 grams (VLBW) • 20,000 babies <1000 grams (ELBW) • 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

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

7. Arkansas Demographics 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

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

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

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

11. Finding 2: Better Neurodevelopmental Outcome for Inborn Delivery P<0.01, UAMS vs. ACH at all weights Percent Comparison of grades 3 and 4 intraventricular hemorrhage for UAMS (inborn) vs ACH (outborn) neonates for 2001-2004

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

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

14. 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

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

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

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

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

19. Complex Ex-preterm ChildrenMedical Requirements • BPD: Pulmonary • Right Ventricular hypertrophy: Cardiology • Hyperalimentation: Gastroenterology • Retinopathy: Ophthalmology • Developmental: General Pediatrics • G-Tubes: Surgery

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

21. Problem 1 Proposal: Telemedicine Unit in 5-7 Largest Nurseries • 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

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

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

24. Problem 2: Case Management Proposal • 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

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

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

27. 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 • Educational telemedicine already established with IT support available in remote sites • Medical home at ACH and central 24/7 telephone triage system in place • Willingness of neonatal section to support remote sites • Links with birth certificates and hospital discharge data for survival and cost analysis in place

28. Thanks, RR020146 • Release time • Equipment • Mentoring “ ‘Tis better to curse the darkness than to light the wrong candle” Joe, Fireworks factory