Methods and initial findings from the Durham Diabetes Coalition: Integrating geospatial health technology and community interventions to reduce death and disability.

Journal Article (Journal Article)

OBJECTIVE: The Durham Diabetes Coalition (DDC) was established in response to escalating rates of disability and death related to type 2 diabetes mellitus, particularly among racial/ethnic minorities and persons of low socioeconomic status in Durham County, North Carolina. We describe a community-based demonstration project, informed by a geographic health information system (GHIS), that aims to improve health and healthcare delivery for Durham County residents with diabetes. MATERIALS AND METHODS: A prospective, population-based study is assessing a community intervention that leverages a GHIS to inform community-based diabetes care programs. The GHIS integrates clinical, social, and environmental data to identify, stratify by risk, and assist selection of interventions at the individual, neighborhood, and population levels. RESULTS: The DDC is using a multifaceted approach facilitated by GHIS to identify the specific risk profiles of patients and neighborhoods across Durham County. A total of 22,982 patients with diabetes in Durham County were identified using a computable phenotype. These patients tended to be older, female, African American, and not covered by private health insurance, compared with the 166,041 persons without diabetes. Predictive models inform decision-making to facilitate care and track outcomes. Interventions include: 1) neighborhood interventions to improve the context of care; 2) intensive team-based care for persons in the top decile of risk for death or hospitalization within the coming year; 3) low-intensity telephone coaching to improve adherence to evidence-based treatments; 4) county-wide communication strategies; and 5) systematic quality improvement in clinical care. CONCLUSIONS: To improve health outcomes and reduce costs associated with type 2 diabetes, the DDC is matching resources with the specific needs of individuals and communities based on their risk characteristics.

Full Text

Duke Authors

Cited Authors

  • Spratt, SE; Batch, BC; Davis, LP; Dunham, AA; Easterling, M; Feinglos, MN; Granger, BB; Harris, G; Lyn, MJ; Maxson, PJ; Shah, BR; Strauss, B; Thomas, T; Califf, RM; Miranda, ML

Published Date

  • March 2015

Published In

Volume / Issue

  • 2 / 1

Start / End Page

  • 26 - 36

PubMed ID

  • 29159106

Pubmed Central ID

  • PMC5684964

Electronic International Standard Serial Number (EISSN)

  • 2214-6237

Digital Object Identifier (DOI)

  • 10.1016/j.jcte.2014.10.006


  • eng

Conference Location

  • Netherlands