Paul Dupenloup

All Publications

• Assessing the Financial Sustainability of a Virtual Clinic Providing Comprehensive Diabetes Care. Journal of diabetes science and technology Dupenloup, P., Guan, G., Aleppo, G., Bergenstal, R. M., Hood, K., Kruger, D., McArthur, T., Olson, B., Oser, S., Oser, T., Weinstock, R. S., Gal, R. L., Kollman, C., Scheinker, D. 2025: 19322968251340664

  Abstract

  The Virtual Diabetes Specialty Clinic (VDiSC) study demonstrated the feasibility of providing comprehensive diabetes care entirely virtually by combining virtual visits with continuous glucose monitoring support and remote patient monitoring (RPM). However, the financial sustainability of this model remains uncertain.We developed a financial model to estimate the variable costs and revenues of virtual diabetes care, using visit data from the 234 VDiSC participants with type 1 or type 2 diabetes. Data included virtual visits with certified diabetes care and education specialists (CDCES), endocrinologists, and behavioral health services (BHS). The model estimated care utilization, variable costs, reimbursement revenue, gross profit, and gross profit margin per member, per month (PMPM) for privately insured, publicly insured, and overall clinic populations (75% privately insured). We performed two-way sensitivity analyses on key parameters.Gross profit and gross profit margin PMPM (95% confidence interval) were estimated at $-4 ($-14.00 to $5.68) and -4% (-3% to -6%) for publicly insured patients; $267.26 ($256.59-$277.93) and 73% (58%-88%) for privately insured patients; and $199.41 ($58.43-$340.39) and 67% (32%-102%) for the overall clinic. Profits were primarily driven by CDCES visits and RPM. Results were sensitive to insurance mix, cost-to-charge ratio, and commercial-to-Medicare price ratio.Virtual diabetes care can be financially viable, although profitability relies on privately insured patients. The analysis excluded fixed costs of clinic infrastructure, and securing reimbursement may be challenging in practice. The financial model is adaptable to various care settings and can serve as a planning tool for virtual diabetes clinics.

  View details for DOI 10.1177/19322968251340664

  View details for PubMedID 40357670

• Therapeutic Drug Monitoring in Patients with Ulcerative Colitis on Infliximab: A Cost-Effectiveness Analysis. Digestive diseases and sciences Dupenloup, P., Zhou, M., Dizon, M. P., Shah, A. P., Goldhaber-Fiebert, J. D., Owens, D. K., Streett, S. E., Brandeau, M. L., Barber, G. E. 2024

  Abstract

  Ulcerative colitis (UC) can be treated with infliximab (IFX). Therapeutic drug monitoring (TDM) can yield superior outcomes, but its cost-effectiveness is unknown.We used a decision analytic Markov model to conduct a cost-effectiveness analysis comparing proactive TDM, reactive TDM, no TDM, and combinations of proactive and reactive TDM in 25-year-old patients with UC started on IFX. Under proactive TDM, IFX concentration and anti-drug antibodies were measured every 6 months and during a flare; under reactive TDM, these were only measured during a flare. Patients with flares experienced decreased quality of life (QoL) and risked further complications. We evaluated lifetime costs (2021 U.S. dollars), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios, all discounted at 3% annually, from a healthcare sector perspective. We performed probabilistic sensitivity analysis (PSA) and deterministic sensitivity analyses. We used a willingness-to-pay threshold of $100,000 per QALY gained.All TDM strategies increased QALYs and healthcare costs. Compared to no TDM, reactive TDM increased costs from $496,700 to $497,500 ($3,200 per QALY gained). 1 year of proactive TDM followed by reactive TDM increased costs to $508,600 ($63,800 per QALY gained relative to reactive TDM). In 46% of PSA samples, 1 year of proactive TDM followed by reactive TDM was most likely to be the optimal strategy. This strategy was less likely to be cost-effective when remission QoL was lower and when post-surgical QoL was higher.1 year of proactive TDM followed by reactive TDM is cost-effective in patients with UC on IFX.

  View details for DOI 10.1007/s10620-024-08802-1

  View details for PubMedID 39724469

  View details for PubMedCentralID 1856849

• A quantitative model to ensure capacity sufficient for timely access to care in a remote patient monitoring program. Endocrinology, diabetes & metabolism Chang, A., Gao, M. Z., Ferstad, J. O., Dupenloup, P., Zaharieva, D. P., Maahs, D. M., Prahalad, P., Johari, R., Scheinker, D. 2023: e435

  Abstract

  Algorithm-enabled remote patient monitoring (RPM) programs pose novel operational challenges. For clinics developing and deploying such programs, no standardized model is available to ensure capacity sufficient for timely access to care. We developed a flexible model and interactive dashboard of capacity planning for whole-population RPM-based care for T1D.Data were gathered from a weekly RPM program for 277 paediatric patients with T1D at a paediatric academic medical centre. Through the analysis of 2 years of observational operational data and iterative interviews with the care team, we identified the primary operational, population, and workforce metrics that drive demand for care providers. Based on these metrics, an interactive model was designed to facilitate capacity planning and deployed as a dashboard.The primary population-level drivers of demand are the number of patients in the program, the rate at which patients enrol and graduate from the program, and the average frequency at which patients require a review of their data. The primary modifiable clinic-level drivers of capacity are the number of care providers, the time required to review patient data and contact a patient, and the number of hours each provider allocates to the program each week. At the institution studied, the model identified a variety of practical operational approaches to better match the demand for patient care.We designed a generalizable, systematic model for capacity planning for a paediatric endocrinology clinic providing RPM for T1D. We deployed this model as an interactive dashboard and used it to facilitate expansion of a novel care program (4 T Study) for newly diagnosed patients with T1D. This model may facilitate the systematic design of RPM-based care programs.

  View details for DOI 10.1002/edm2.435

  View details for PubMedID 37345227

• Disparities in Hemoglobin A1c Levels in the First Year After Diagnosis Among Youths With Type 1 Diabetes Offered Continuous Glucose Monitoring. JAMA network open Addala, A., Ding, V., Zaharieva, D. P., Bishop, F. K., Adams, A. S., King, A. C., Johari, R., Scheinker, D., Hood, K. K., Desai, M., Maahs, D. M., Prahalad, P. 2023; 6 (4): e238881

  Abstract

  Continuous glucose monitoring (CGM) is associated with improvements in hemoglobin A1c (HbA1c) in youths with type 1 diabetes (T1D); however, youths from minoritized racial and ethnic groups and those with public insurance face greater barriers to CGM access. Early initiation of and access to CGM may reduce disparities in CGM uptake and improve diabetes outcomes.To determine whether HbA1c decreases differed by ethnicity and insurance status among a cohort of youths newly diagnosed with T1D and provided CGM.This cohort study used data from the Teamwork, Targets, Technology, and Tight Control (4T) study, a clinical research program that aims to initiate CGM within 1 month of T1D diagnosis. All youths with new-onset T1D diagnosed between July 25, 2018, and June 15, 2020, at Stanford Children's Hospital, a single-site, freestanding children's hospital in California, were approached to enroll in the Pilot-4T study and were followed for 12 months. Data analysis was performed and completed on June 3, 2022.All eligible participants were offered CGM within 1 month of diabetes diagnosis.To assess HbA1c change over the study period, analyses were stratified by ethnicity (Hispanic vs non-Hispanic) or insurance status (public vs private) to compare the Pilot-4T cohort with a historical cohort of 272 youths diagnosed with T1D between June 1, 2014, and December 28, 2016.The Pilot-4T cohort comprised 135 youths, with a median age of 9.7 years (IQR, 6.8-12.7 years) at diagnosis. There were 71 boys (52.6%) and 64 girls (47.4%). Based on self-report, participants' race was categorized as Asian or Pacific Islander (19 [14.1%]), White (62 [45.9%]), or other race (39 [28.9%]); race was missing or not reported for 15 participants (11.1%). Participants also self-reported their ethnicity as Hispanic (29 [21.5%]) or non-Hispanic (92 [68.1%]). A total of 104 participants (77.0%) had private insurance and 31 (23.0%) had public insurance. Compared with the historical cohort, similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were observed for Hispanic individuals (estimated difference, -0.26% [95% CI, -1.05% to 0.43%], -0.60% [-1.46% to 0.21%], and -0.15% [-1.48% to 0.80%]) and non-Hispanic individuals (estimated difference, -0.27% [95% CI, -0.62% to 0.10%], -0.50% [-0.81% to -0.11%], and -0.47% [-0.91% to 0.06%]) in the Pilot-4T cohort. Similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were also observed for publicly insured individuals (estimated difference, -0.52% [95% CI, -1.22% to 0.15%], -0.38% [-1.26% to 0.33%], and -0.57% [-2.08% to 0.74%]) and privately insured individuals (estimated difference, -0.34% [95% CI, -0.67% to 0.03%], -0.57% [-0.85% to -0.26%], and -0.43% [-0.85% to 0.01%]) in the Pilot-4T cohort. Hispanic youths in the Pilot-4T cohort had higher HbA1c at 6, 9, and 12 months postdiagnosis than non-Hispanic youths (estimated difference, 0.28% [95% CI, -0.46% to 0.86%], 0.63% [0.02% to 1.20%], and 1.39% [0.37% to 1.96%]), as did publicly insured youths compared with privately insured youths (estimated difference, 0.39% [95% CI, -0.23% to 0.99%], 0.95% [0.28% to 1.45%], and 1.16% [-0.09% to 2.13%]).The findings of this cohort study suggest that CGM initiation soon after diagnosis is associated with similar improvements in HbA1c for Hispanic and non-Hispanic youths as well as for publicly and privately insured youths. These results further suggest that equitable access to CGM soon after T1D diagnosis may be a first step to improve HbA1c for all youths but is unlikely to eliminate disparities entirely.ClinicalTrials.gov Identifier: NCT04336969.

  View details for DOI 10.1001/jamanetworkopen.2023.8881

  View details for PubMedID 37074715

  View details for PubMedCentralID PMC10116368

• A model to design financially sustainable algorithm-enabled remote patient monitoring for pediatric type 1 diabetes care. Frontiers in endocrinology Dupenloup, P., Pei, R. L., Chang, A., Gao, M. Z., Prahalad, P., Johari, R., Schulman, K., Addala, A., Zaharieva, D. P., Maahs, D. M., Scheinker, D. 2022; 13: 1021982

  Abstract

  Population-level algorithm-enabled remote patient monitoring (RPM) based on continuous glucose monitor (CGM) data review has been shown to improve clinical outcomes in diabetes patients, especially children. However, existing reimbursement models are geared towards the direct provision of clinic care, not population health management. We developed a financial model to assist pediatric type 1 diabetes (T1D) clinics design financially sustainable RPM programs based on algorithm-enabled review of CGM data.Data were gathered from a weekly RPM program for 302 pediatric patients with T1D at Lucile Packard Children's Hospital. We created a customizable financial model to calculate the yearly marginal costs and revenues of providing diabetes education. We consider a baseline or status quo scenario and compare it to two different care delivery scenarios, in which routine appointments are supplemented with algorithm-enabled, flexible, message-based contacts delivered according to patient need. We use the model to estimate the minimum reimbursement rate needed for telemedicine contacts to maintain revenue-neutrality and not suffer an adverse impact to the bottom line.The financial model estimates that in both scenarios, an average reimbursement rate of roughly $10.00 USD per telehealth interaction would be sufficient to maintain revenue-neutrality. Algorithm-enabled RPM could potentially be billed for using existing RPM CPT codes and lead to margin expansion.We designed a model which evaluates the financial impact of adopting algorithm-enabled RPM in a pediatric endocrinology clinic serving T1D patients. This model establishes a clear threshold reimbursement value for maintaining revenue-neutrality, as well as an estimate of potential RPM reimbursement revenue which could be billed for. It may serve as a useful financial-planning tool for a pediatric T1D clinic seeking to leverage algorithm-enabled RPM to provide flexible, more timely interventions to its patients.

  View details for DOI 10.3389/fendo.2022.1021982

  View details for PubMedID 36440201

  View details for PubMedCentralID PMC9691757