The Promotora Telemedicine Project: A Summary
Combining Technology and Cultural Sensitivity to Improve Diabetes Care in a Medically Underserved Community
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The Promotora Telemedicine Project utilizes a telemedicine network to link diabetic patients in underserved areas with teams of physicians and Certified Diabetes Educators who deliver state-of-the-art health care services. Care is assisted by a support network of Spanish-speaking facilitators who serve as a cultural interface between Latino patients and diabetes care providers. This project is designed to test the hypothesis that new technology can be combined with culturally sensitive programs to improve access to high-quality care and to reduce the cost of diabetes care in Santa Clara County, California.
Background
In Santa Clara County, California, 24% of the population is of Latino descent (U.S. Census Bureau, 2003). Of these,
Mexican-Americans in the U.S. who have diabetes:
In addition to its high prevalence and higher likelihood of complications in Mexican-Americans, diabetes presents a special challenge because it’s such a rapidly changing field in terms of both technology and treatment methods. This makes it very difficult for primary care physicians to remain current in knowledge and skills.
For the patient with diabetes, treatment regimens are much more complicated than those for most other chronic diseases, and require more patient effort. Compliance is further complicated by poverty, as well as by language, educational and cultural barriers. Lack of health insurance is a major barrier to accessing health care services. A survey of residents of Santa Clara County (all ethnicities) showed that 42.7% of those who were uninsured and needed to see a doctor during the previous year had not done so because of the cost, compared to 4% of those who had employer-based insurance (SCCPHD, 1997, p. 41). Unfortunately, many of those who defer medical attention for minor problems or for chronic conditions will develop complications that require hospitalization or surgery. In Santa Clara County, diabetes is the third leading cause of hospitalization and the sixth leading cause of death among all older adults. Among Hispanics, the mortality rate for diabetes.
Health care costs for diabetics in Santa Clara County are estimated to total $1.5 billion, or 29% of all health care dollars spent in the county (CHPSCC, 2003).
National statistics are similarly alarming. A recent study by the American Diabetes Association estimated total costs for diabetes in the US in 2002 to be nearly $132 billion, including $91.8 billion for direct medical expenditures and $39.8 billion for indirect costs. Considering only direct medical expenditures, people with diabetes accounted for costs of $13,243 per year, compared to $2,560 for people without diabetes (ADA, 2003).
This 5:1 cost ratio would be even higher if the figure included indirect costs such as lost productivity due to disability and early mortality as well as expenses for over-the-counter medications and supplies. Also, since approximately one-third of all people with diabetes are undiagnosed, they are categorized with the non-diabetic population, resulting in further underestimation of the true costs of diabetes and of the differential between costs for those with and without diabetes.
Applying current diabetes prevalence rates to Census Bureau population projections, the national cost of diabetes could grow to $192 billion by 2020. However, if the prevalence of diabetes continues to increase as a result of the growing problem of obesity in the U.S., the actual future cost of diabetes will be substantially higher yet.
Conclusion
Diabetes imposes a substantial cost burden to society and, in particular, to those individuals with diabetes and their families. Eliminating or reducing the health problems caused by diabetes through factors such as better access to preventive care, more widespread diagnosis, more intensive disease management, and the advent of new medical technologies could significantly improve the quality of life for people with diabetes and their families while at the same time potentially reducing national expenditures for health care services and increasing productivity in the U.S. economy (ADA, April 2003).
Earlier projects by the Pacific Medical Research Foundation (PMRF) and the Endocrine Metabolic Medical Center (EMMC) have demonstrated the usefulness of telephone and email communication in improving quality of care and lowering its cost (unpublished data). The current project is designed to determine whether those benefits can be further enhanced by the addition of telemedicine technology, defined as the use of two-way video and audio systems that allow physicians and other health professionals to treat patients at remote locations. The Pacific Medical Research Foundation (PMRF) is dedicated to exploring new modalities for the treatment of diabetes and to educating physicians, health care professionals and people with diabetes to manage and successfully live with the disease. Founded in 1986 as a 501(c)(3) nonprofit organization, PMRF has conducted several previous studies involving new technologies and innovative methods of treatment for diabetes.
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