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Evaluation of a mobile diabetes care telemedicine clinic serving Aboriginal communities in Northern British Columbia, Canada.

Introduction. In British Columbia, Aboriginal diabetes prevalence, hospitalization and mortality rates are all more than twice as high as in the rest of the population. We describe and evaluate a program to improve access to diabetes care for Aboriginal people in northern communities. Study design. Cost-effectiveness evaluation. Methods. A diabetes nurse educator and an ophthalmic technician travel to Aboriginal reserves, offering people with diabetes services recommended in current clinical practice guidelines: retinopathy screening by digital retinal fundus photography, glaucoma screening by tonometry, point-of-care urine and blood testing to detect microalbuminuria and dyslipidemia and to measure glycated hemoglobin, foot examinations and foot care advice, blood pressure and height and weight measurement and diabetes care advice. Via electronic communication, an ophthalmologist and an endocrinologist in Vancouver review the findings and supervise the mobile clinic staff. Results. During the first year, 25 clinics were held at 22 sites, examining 339 clients with diabetes. Exit surveys showed high levels of client satisfaction. Mean cost per client (Cdn$1,231) was less than for the alternative, transporting clients to care in the nearest cities (Cdn$1,437). Conclusions. The mobile clinic is cost-ef-fective and improves access to the recommended standard of diabetes care.


INTRODUCTION
In the province of British Columbia, Canada, diabetes mellitus is three times more prevalent among Aboriginal people than in the general population (1), and deaths (2) and hospitalizations (3) from diabetes are twice as frequent among Aboriginal people. The long-term complications of diabetes (blindness, kidney failure, heart attack, stroke, limb amputation) are preventable with good selfmanagement and appropriate health care (4). However, due to geographic remoteness and socioeconomic disadvantage, Aboriginal people have difficulty accessing diabetes care services.
The British Columbia First Nations Mobile Di-abetes Telemedicine Clinic serves Aboriginal people living in reserve communities in the northern part of the province. This area contains reserves belonging to 59 registered Aboriginal bands. The population of these reserves is 22,689 people (5). We estimate the prevalence of diabetes to be 3.6% (6)  Blood and urine specimens are analyzed at the clinic site with portable, point-of-care laboratory equipment, providing immediate feedback to the client. The point-of-care testing is monitored by a program of daily internal quality control at each clinic site and periodic external quality assessment at a reference laboratory (D. Seccombe). The client record is transmitted by e-mail to a medical specialist in diabetes (K. G. Dawson) who verifies the appropriateness of the nurse's advice. The retinal photographs are recorded in digital electronic format and transmitted to a retinal specialist ophthalmologist (D. Maberley) for interpretation. If any serious eye disease is detected, the clinic facilitates referral to the nearest ophthalmologist. A summary report of the entire clinic examination is sent to the client's personal physician.
The program objectives for first year that we sought to evaluate were: • to implement the clinic service for First Nations reserve communities in northern BC, • to monitor and report the delivery of program services, • to compile a descriptive profile of diabetes in the target population, • to assess client satisfaction, and • to assess the program's cost-effectiveness.

METHODS
We monitored clinic activity (number and location of clinic sites, numbers of clinic-days of operation, numbers of clients examined) and resource consumption (capital purchases and operating expenses) from the clinic inception in March 2002 until the end of the first complete fiscal year (March 31, 2003). Client satisfaction was assessed by anonymous, self-administered survey questionnaires completed by clients as they exited the clinic. Descriptive information about the client's diabetic condition was extracted from the clinical records.
We assessed the mean cost per client examined by the mobile clinic program as the total operating expenses plus one-fifth of the capital expenditures (we assumed that the major equipment items, the motor vehicle and the retinal camera, would have a useful life expectancy of 5 years), divided by the number of diabetic clients examined.
As the alternative service model, we assumed that the mobile clinic's clients would otherwise have obtained equivalent services by travelling to the nearest primary care physician, clinical laboratory, diabetes education centre, ophthalmologist and medical diabetes specialist. For each site visited by the mobile clinic team, we determined the location of the nearest providers of these services, the cost of the services that would have been paid by the Medical Services Plan of British Columbia (the provincial health care insurance system) and the cost of a person travelling to these services that would have been reimbursed by the Non-Insured Health Benefits program (Health Canada's supplemental health care insurance program for registered Aboriginal persons with Indian Status). If more than one service was located in the same location, we assumed that a person would obtain all the services in one excursion. We ascertained the usual routes and modes of transportation to the services by interviewing local community health workers at each clinic site. We ascertained fares for transportation by commercial carriers from quotes obtained in August 2003. Use of a personal motor vehicle was assessed at Cdn$0.20 per kilometre driven. Overnight accommodation we assessed at Cdn$100.00 per night. Meals while travelling we assessed at Cdn$31.00 per day. If, for reasons of age, infirmity, illness or disability, a client would have required an escort person to accompany him or her during travel, then we multiplied the client's assumed travel expenses by a factor of two. We assessed the mean alternative cost per client as the total Medical Services Plan costs plus the total Non-Insured Health Benefits program costs divided by the number of clients examined.

RESULTS
An office base was established in the northern city of Prince George, British Columbia. Personnel consist of a project coordinator (full time), an eye care technician (half-time), and a diabetes nurseeducator (full time). Capital purchases consisted of a motor vehicle (a 2002 GMC Suburban sportutility vehicle), a digital retinal photography system, a Tonopen tonometer, miscellaneous other eye and medical examination equipment, and point-of-care blood and urine testing equipment (Ames/Bayer DCA 2000 and Cholestech LDX systems, two of each). Total capital expenditure was Cdn$160,260.
Clinic activity: The mobile clinic began examining clients in March 2002, offering eye examination, blood pressure, height and weight measurements and group diabetes education. Beginning in January 2003, foot examination and foot care advice, blood and urine testing, and personal diabetes care advice by the diabetes nurse educator were added. As of March 31, 2003, 25 clinics (operating 62 days) had been held at 22 sites. Three sites had been visited twice. The clinic examined 402 people, 339 had previously been diagnosed as diabetic by a health care professional. As for the other 63 persons who were examined, it was not clear if they were diabetic, glucose intolerant or merely at risk of diabetes. Of the 339 diabetic persons examined, 148 (44%) would have required an escort person for medical travel outside of their home communities. The number of diabetic persons examined at each clinic was highly variable, the fewest was one, the most was 41, at six clinics five or fewer diabetic persons attended, at five clinics 22 or more attended. had a history of high cholesterol, • 10% had a previous heart attack, 34% had angina, 12% had a previous stroke, • 11% had symptoms of neuropathy, • 12% said they had protein in their urine, • 18% smoked cigarettes daily, 11% smoked occasionally, • 46% had had diabetes for five years or longer, • 19% took insulin (with or without oral medication), 53% took oral hypoglycaemic medication alone, 28% took no medication for diabetes, • 30% were due for a retinal examination (last dilated eye examination was 1 to 2 years ago), 23% were overdue (last dilated eye examination was more than 2 years ago, or never had such an examination), • among those who had ever had a dilated eye examination, only 55% (160 of 289) had been examined by an ophthalmologist.

DISCUSSION
Our cost-effectiveness method evaluated cost per unit service delivered, for the mobile diabetes clinic and for the alternative of having clients travel to the nearest service providers. We did not evaluate cost per unit health outcome because we do not yet have an empiric method to predict, in the absence of the mobile diabetes clinic, either the likelihood of clients accessing services from alternate sources, or the health impacts of the alternate services. However, even if we assumed a "worst case" scenario, that in the absence of the mobile diabetes clinic all of the clients would have obtained equivalent services elsewhere, and that their health outcomes would have been just as good, we still have evidence that the mobile clinic is worthwhile, because it delivers equivalent services at less cost than the alternative.
Regardless of who provides the services, the relevance and the effectiveness of the specific screening and education procedures provided by the mobile diabetes clinic have already been established by previous researchers. This is reflected by the inclusion of these procedures in current, evidence-based clinical practice guidelines (4).
The mobile diabetes clinic continues to operate, making an annual circuit of its northern reserve community sites. In the second year, the Chiefs' Health Committee will intensify efforts to promote the mobile clinic and increase diabetes awareness in the target population. It is anticipated that this will improve attendance at the clinics and further improve the mobile clinic's cost-effectiveness. The mobile clinic also intends to develop a system to transmit the retinal photographs directly from the clinic sites using Internet communication, thus reducing the time clients have to wait before obtaining interpretive advice from the consulting retinal specialist ophthalmologist. Funding from First Nations and Inuit Health Branch, Health Canada continues during the second year; afterwards, the source is uncertain.
We conclude that the mobile diabetes clinic program was needed, that it provides relevant services, known to be effective and beneficial, that it delivers the services at less cost than the existing alternative, and that the clients were very satisfied with the convenience and accessibility of the mobile clinic. The program is worth continuing.