Mohammed Ashraf

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22ranked-venue papers
0as first author
10since 2021 · last 2025
—ORCID · conflict

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Systems, architecture and hardware · 19 · 9 since 2021Security and privacy · 2 · 1 since 2021Software engineering, systems software and programming languages · 1 · 1 since 2021Applied, interdisciplinary, general and emerging computing · 1
YearPublicationVenuePosition
2025 DEFending Integrated Circuit Layouts
abstract
Modern integrated circuits (ICs) require a complex, outsourced supply-chain, involving computer-aided design (CAD) tools, expert knowledge, and advanced foundries. This complexity has led to various security threats, such as Trojans inserted by adversaries during outsourcing, but also run-time threats like physical probing. Our proposed design-time solution,DEFense, is an extensible CAD framework for holistic assessment and proactive mitigation of multiple prominent threats. The goal is to prioritize security concerns during the physical design of ICs, alongside traditional power, performance, and area (PPA) objectives.DEFenseutilizes an iterative and modular approach to assess and mitigate various known vulnerabilities in the IC layout, which are targeting on sensitive active devices and wires. It is a flexible and extensible scripting framework without the need for modifications to commercial CAD flows, yet with the same high level of design quality. We have conducted extensive case studies on representative modern IC designs to “DEFend” layouts against Trojan insertion, probing, and crosstalk attacks. We are providing the framework to the community.
Jitendra Bhandari, Jayanth Gopinath, Mohammed Ashraf, Johann Knechtel, Ozgur Sinanoglu, Ramesh Karri
IEEE Trans. Inf. Forensics Secur.3
2024 Silicon-Proven ASIC Design for the Polynomial Operations of Fully Homomorphic Encryption
abstract
In this work, we elaborate on our endeavors to design, implement, fabricate, and post-silicon validate CoFHEE 1, a co-processor for low-level polynomial operations targeting Fully Homomorphic Encryption execution. With a compact design area of 12mm2, CoFHEE features ASIC implementations of fundamental polynomial operations, including polynomial addition and subtraction, Hadamard product, and Number Theoretic Transform, which underlie most higher-level FHE primitives. CoFHEE is capable of natively supporting polynomial degrees of up to n = 214 with a coefficient size of 128 bits, and has been fabricated and silicon-verified using 55nm CMOS technology. To evaluate it, we conduct performance and power experiments on our chip, and compare it to state-of-the-art software implementations and other ASIC designs.
Mohammed Nabeel Thari Moopan, Homer Gamil, Deepraj Soni, Mohammed Ashraf, Mizan Abraha Gebremichael, Eduardo Chielle, Ramesh Karri, Mihai Sanduleanu, Michail Maniatakos
IEEE Trans. Comput. Aided Des. Integr. Circuits Syst.4
2023 CoFHEE: A Co-processor for Fully Homomorphic Encryption Execution
abstract
In this paper, we present the blueprint of a specialized co-processor for Fully Homomorphic Encryption, dubbed CoFHEE. With a small design area of$12mm^{2}$, CoFHEE incorporates ASIC implementations of fundamental polynomial operations, such as polynomial addition and subtraction, Hadamard product, and Number Theoretic Transform, which are underneath all higher-level FHE primitives. CoFHEE has native support of polynomial degrees of up to$n=2^{14}$with a coefficient size of 128 bits. We evaluate our chip with performance and power experiments and compare it against state-of-the-art software implementations and other ASIC designs. A more elaborate description of the CoFHEE design can be found in [1].
Mohammed Nabeel Thari Moopan, Deepraj Soni, Mohammed Ashraf, Mizan Abraha Gebremichael, Homer Gamil, Eduardo Chielle, Ramesh Karri, Mihai Sanduleanu, Michail Maniatakos
DATE3
2023 X-Volt: Joint Tuning of Driver Strengths and Supply Voltages Against Power Side-Channel Attacks
abstract
Power side-channel (PSC) attacks are well-known threats to sensitive hardware like advanced encryption standard (AES) crypto cores. Given the significant impact of supply voltages (VCCs) on power profiles, various countermeasures based on VCC tuning have been proposed, among other defense strategies. Driver strengths of cells, however, have been largely overlooked, despite having direct and significant impact on power profiles as well.
Saideep Sreekumar, Mohammed Ashraf, Mohammed Nabeel Thari Moopan, Ozgur Sinanoglu, Johann Knechtel
ISPD2
2022 Benchmarking Security Closure of Physical Layouts: ISPD 2022 Contest
abstract
Computer-aided design (CAD) tools mainly optimize for power, performance, and area (PPA). However, given a large number of serious hardware-security threats that are emerging, future CAD flows must also incorporate techniques for designing secure integrated circuits (ICs). In fact, the stakes are quite high for IC vendors and design companies, as security risks that are not addressed during design time will inevitably be exploited in the field, where vulnerabilities are almost impossible to fix. However, there is currently little to no experience related to designing secure ICs available within the CAD community. For the very first time, this contest seeks to actively engage with the community to close this gap. The theme of this contest is security closure of physical layouts, that is, hardening the physical layouts at design time against threats that are executed post-design time. More specifically, this contest is focused on selected and seminal threats that, once taken in, are relatively simple to approach and mitigate through means of physical design: Trojan insertion and probing as well as fault injection. Acting as security engineers, contest participants will iteratively and proactively evaluate and fix the vulnerabilities of provided benchmark layouts. Benchmarks and submissions are based on the generic DEF format and related files. Thus, participants are free to use any physical-design tools of their choice, helping us to open up the contest to the community at large.
Johann Knechtel, Jayanth Gopinath, Mohammed Ashraf, Jitendra Bhandari, Ozgur Sinanoglu, Ramesh Karri
ISPD3
2022 Design-time exploration of voltage switching against power analysis attacks in 14 nm FinFET technology
Johann Knechtel, Tarek Ashraf, Natascha Fernengel, Satwik Patnaik, Mohammed Nabeel Thari Moopan, Mohammed Ashraf, Ozgur Sinanoglu, Hussam Amrouch
Integr.6
2022 Concerted Wire Lifting: Enabling Secure and Cost-Effective Split Manufacturing
abstract
In this work, we advance the security promise of split manufacturing through judicious handling of interconnects. First, we study the cost-security tradeoffs underlying for split manufacturing, which are limiting its adoption. Next, aiming to resolve these concerns, we propose three effective and efficient strategies to dedicatedly lift nets to higher metal layers. Toward this end, we design custom “elevating cells” and devise procedures for routing blockages. All our techniques are employed in a commercial-grade computer-aided design (CAD) framework. For our security analysis, we leverage various state-of-the-art attacks (network flow-based attack, routing-congestion-aware attack, and deep learning-based attack), established metrics (correct connection rate, output error rate, and Hamming distance), and advanced metrics (percentage of netlist recovery and mutual information). Our extensive experiments show that our scheme provides superior protection. Simultaneously, we induce reasonably low and controllable overheads on power and performance, without any silicon area costs. Besides, we support higher split layers, which helps to alleviate concerns on the practicality of split manufacturing.
Satwik Patnaik, Mohammed Ashraf, Johann Knechtel, Ozgur Sinanoglu
IEEE Trans. Comput. Aided Des. Integr. Circuits Syst.2
2021 Security Closure of Physical Layouts ICCAD Special Session Paper
abstract
Computer-aided design (CAD) tools traditionally optimize for power, performance, and area (PPA). However, given a vast number of hardware security threats, we call for secure-by-design CAD flows, to adopt principles of secure hardware design and streamline security closure throughout the flow. The stakes are high for integrated circuit (IC) vendors and design companies, as security risks that are not addressed during design will inevitably be exploited in the field, where vulnerabilities are almost impossible to fix. This paper highlights the need for security closure of physical layouts because efforts taken toward securing ICs at higher abstraction layers may be futile without support for securing the tape-out ready layouts.
Johann Knechtel, Jayanth Gopinath, Jitendra Bhandari, Mohammed Ashraf, Hussam Amrouch, Shekhar Borkar, Sung Kyu Lim, Ozgur Sinanoglu, Ramesh Karri
ICCAD4
2021 Toward Security Closure in the Face of Reliability Effects ICCAD Special Session Paper
abstract
The reliable operation of ICs is subject to physical effects like electromigration, thermal and stress migration, negative bias temperature instability, hot-carrier injection, etc. While these effects have been studied thoroughly for IC design, threats of their subtle exploitation are not captured well yet. In this paper, we open up a path for security closure of physical layouts in the face of reliability effects. Toward that end, we first review migration effects in interconnects and aging effects in transistors, along with established and emerging means for handling these effects during IC design. Next, we study security threats arising from these effects; in particular, we cover migration effects-based, disruptive Trojans and aging-exacerbated side-channel leakage. Finally, we outline corresponding strategies for security closure of physical layouts, along with an outline for CAD frameworks.
Jens Lienig, Susann Rothe, Matthias Thiele, Nikhil Rangarajan, Mohammed Ashraf, Mohammed Nabeel Thari Moopan, Hussam Amrouch, Ozgur Sinanoglu, Johann Knechtel
ICCAD5
2021 Deep Learning Analysis for Split-Manufactured Layouts With Routing Perturbation
abstract
Split manufacturing of integrated circuits means to delegate the front-end-of-line (FEOL) and back-end-of-line (BEOL) parts to different foundries, in order to prevent overproduction, intellectual property (IP) piracy, or targeted insertion of hardware Trojans (i.e., threats arising from adversaries in the FEOL foundry). This article challenges the security promise of split manufacturing by formulating various layout-level placement and routing hints as vector-based and image-based features that enable a sophisticated deep neural network (DNN), which can infer the missing BEOL connections with high accuracy. Compared with the network-flow attack (Wanget al., 2018), we achieve on average$1.21 \times $and$1.12 \times $of their correct connection rate (CCR; the higher, the better) when splitting after M1 and M3, respectively, with less than 1% of their runtime (across the same set of ISCAS-85 and ITC-99 benchmarks). Compared with Zenget al.(2019), ours reduces the candidate list (the smaller, the better) by 47% with only 1% loss of accuracy, and we further achieve an average CCR of$2.2 \times $of that of Zenget al.(2019). Aside from these superior results, we propose a randomized, routing-blockage-centric defense strategy to escalate the resilience against our and other attacks. Our defense strategy, which can be integrated into any commercial design flow, leads on average to$22.78~pp$(percentage points) degradation in CCR when compared with unprotected layouts, while inducing only 3.3% and 3.2% overheads on power and timing, respectively, within the same die outlines (i.e., zero area cost). The source code of our heterogeneous feature extraction is available athttps://github.com/cuhk-eda/split-extract, and the source code of our DNN is available athttps://github.com/cuhk-eda/split-attack.
Satwik Patnaik, Mohammed Ashraf, Johann Knechtel, Bei Yu 0001, Ozgur Sinanoglu, Evangeline F. Y. Young
IEEE Trans. Comput. Aided Des. Integr. Circuits Syst.3
2020 2.5D Root of Trust: Secure System-Level Integration of Untrusted Chiplets
abstract
For the first time, we leverage the 2.5D interposer technology to establish system-level security in the face of hardware- and software-centric adversaries. More specifically, we integrate chiplets (i.e., third-party hard intellectual property of complex functionality, like microprocessors) using a security-enforcing interposer. Such hardware organization provides a robust 2.5D root of trust for trustworthy, yet powerful and flexible, computation systems. The security paradigms for our scheme, employed firmly by design and construction, are: 1) stringent physical separation of trusted from untrusted components and 2) runtime monitoring. The system-level activities of all untrusted commodity chiplets are checked continuously against security policiesvia physically separated security features. Aside from the security promises, the good economics of outsourced supply chains are still maintained; the system vendor is free to procure chiplets from the open market, while only producing the interposer and assembling the 2.5D system oneself. We showcase our scheme using the Cortex-M0 core and the AHB-Lite bus by ARM, building a secure 64-core system with shared memories. We evaluate our scheme through hardware simulation, considering different threat scenarios. Finally, we devise a physical-design flow for 2.5D systems, based on commercial-grade design tools, to demonstrate and evaluate our 2.5D root of trust.
Mohammed Nabeel Thari Moopan, Mohammed Ashraf, Satwik Patnaik, Vassos Soteriou, Ozgur Sinanoglu, Johann Knechtel
IEEE Trans. Computers2
2020 Obfuscating the Interconnects: Low-Cost and Resilient Full-Chip Layout Camouflaging
abstract
Layout camouflaging can protect the intellectual property of modern circuits. Most prior art, however, incurs excessive layout overheads and necessitates customization of active-device manufacturing processes, i.e., the front-end-of-line (FEOL). As a result, camouflaging has typically been applied selectively, which can ultimately undermine its resilience. Here, we propose a low-cost and generic scheme-full-chip camouflaging can be finally realized without reservations. Our scheme is based on obfuscating the interconnects, i.e., the back-end-of-line (BEOL), through design-time handling for real and dummy wires and vias. To that end, we implement custom, BEOL-centric obfuscation cells, and develop a CAD flow using industrial tools. Our scheme can be applied to any design and technology node without FEOL-level modifications. Considering its BEOL-centric nature, we advocate applying our scheme in conjunction with split manufacturing, to furthermore protect against untrusted fabs. We evaluate our scheme for various designs at the physical, DRC-clean layout level. Our scheme incurs a significantly lower cost than most of the prior art. Notably, for fully camouflaged layouts, we observe average power, performance, and area overheads of 24.96%, 19.06%, and 32.55%, respectively. We conduct a thorough security study addressing the threats (attacks) related to untrustworthy FEOL fabs (proximity attacks) and malicious end-users (SAT-based attacks). An empirical key finding is that only large-scale camouflaging schemes like ours are practically secure against powerful SAT-based attacks. Another key finding is that our scheme hinders both placement- and routing-centric proximity attacks; correct connections are reduced by 7.47x , and complexity is increased by 24.15x , respectively, for such attacks.
Satwik Patnaik, Mohammed Ashraf, Ozgur Sinanoglu, Johann Knechtel
IEEE Trans. Comput. Aided Des. Integr. Circuits Syst.2
2020 Truly Stripping Functionality for Logic Locking: A Fault-Based Perspective
abstract
Logic locking is a holistic solution to counter manufacturing threats, such as intellectual property (IP) piracy and overbuilding at the hardware level. However, years of research has exposed various flaws in locking, including a Boolean satisfiability (SAT)-based attack. Consequently, several SAT-resilient locking techniques, such as SARLock, Anti-SAT, and SFLL have been proposed, although certain instances of them have also been broken by a class of attacks, called removal attack. In this article, we approach logic locking by leveraging well-known principles from very large-scale integration (VLSI) testing and elicit logic locking properties that dictate the resilience of a locking technique against different attacks. We present a revised version of SFLL, namely SFLL-rem, that not only retains all security properties of SFLL, delivering resilience to all the state-of-the-art attacks SFLL can thwart, but also to the latest removal attacks that broke some SFLL instances. Further, we develop a security-aware CAD framework integrated with industry tools that incurs only -1.5%, 0%, and 4.13% overhead for power, performance, and area, respectively. We demonstrate a silicon implementation of SFLL-rem on ARM Cortex-M0 microprocessor in 65 nm. Moreover, we provide a framework for an SoC designer to customize logic locking based on the SoC blocks and their threat models; this is illustrated by locking a multimillion-gate SoC provided by DARPA, and taking the SoC all the way to GDSII layout.
Abhrajit Sengupta, Mohammed Nabeel Thari Moopan, Nimisha Limaye, Mohammed Ashraf, Ozgur Sinanoglu
IEEE Trans. Comput. Aided Des. Integr. Circuits Syst.4
2019 CAD-Base: An Attack Vector into the Electronics Supply Chain
abstract
Fabless semiconductor companies design system-on-chips (SoC) by using third-party intellectual property (IP) cores and fabricate them in offshore, potentially untrustworthy foundries. Owing to the globally distributed electronics supply chain, security has emerged as a serious concern. In this article, we explore electronics computer-aided design (CAD) software as a threat vector that can be exploited to introduce vulnerabilities into the SoC. We show that all electronics CAD tools—high-level synthesis, logic synthesis, physical design, verification, test, and post-silicon validation—are potential threat vectors to different degrees. We have demonstrated CAD-based attacks on several benchmarks, including the commercial ARM Cortex M0 processor [1].
Kanad Basu, Samah Mohamed Saeed, Christian Pilato, Mohammed Ashraf, Mohammed Nabeel Thari Moopan, Krishnendu Chakrabarty, Ramesh Karri
ACM Trans. Design Autom. Electr. Syst.4
2018 Concerted wire lifting: Enabling secure and cost-effective split manufacturing
abstract
Here we advance the protection of split manufacturing (SM)-based layouts through the judicious and well-controlled handling of interconnects. Initially, we explore the cost-security trade-offs of SM, which are limiting its adoption. Aiming to resolve this issue, we propose effective and efficient strategies to lift nets to the BEOL. Towards this end, we design custom “elevating cells” which we also provide to the community. Further, we define and promote a new metric, Percentage of Netlist Recovery (PNR), which can quantify the resilience against gate-level theft of intellectual property (IP) in a manner more meaningful than established metrics. Our extensive experiments show that we outperform the recent protection schemes regarding security. For example, we reduce the correct connection rate to 0% for commonly considered benchmarks, which is a first in the literature. Besides, we induce reasonably low and controllable overheads on power, performance, and area (PPA). At the same time, we also help to lower the commercial cost incurred by SM.
Satwik Patnaik, Johann Knechtel, Mohammed Ashraf, Ozgur Sinanoglu
ASP-DAC3
2018 Raise your game for split manufacturing: restoring the true functionality through BEOL
abstract
Split manufacturing (SM) seeks to protect against piracy of intellectual property (IP) in chip designs. Here we propose a scheme to manipulate both placement and routing in an intertwined manner, thereby increasing the resilience of SM layouts. Key stages of our scheme are to (partially) randomize a design, place and route the erroneous netlist, and restore the original design by re-routing the BEOL. Based on state-of-the-art proximity attacks, we demonstrate that our scheme notably excels over the prior art (i.e., 0% correct connection rates). Our scheme induces controllable PPA overheads and lowers commercial cost (the latter by splitting at higher layers).
Satwik Patnaik, Mohammed Ashraf, Johann Knechtel, Ozgur Sinanoglu
DAC2
2018 Best of both worlds: integration of split manufacturing and camouflaging into a security-driven CAD flow for 3D ICs
abstract
With the globalization of manufacturing and supply chains, ensuring the security and trustworthiness of ICs has become an urgent challenge. Split manufacturing (SM) and layout camouflaging (LC) are promising techniques to protect the intellectual property (IP) of ICs from malicious entities during and after manufacturing (i.e., from untrusted foundries and reverse-engineering by end-users). In this paper, we strive for “the best of both worlds,” that is of SM and LC. To do so, we extend both techniques towards 3D integration, an up-and-coming design and manufacturing paradigm based on stacking and interconnecting of multiple chips/dies/tiers. Initially, we review prior art and their limitations. We also put forward a novel, practical threat model of IP piracy which is in line with the business models of present-day design houses. Next, we discuss how 3D integration is a naturally strong match to combine SM and LC. We propose a security-driven CAD and manufacturing flow for face-to-face (F2F) 3D ICs, along with obfuscation of interconnects. Based on this CAD flow, we conduct comprehensive experiments on DRC-clean layouts. Strengthened by an extensive security analysis (also based on a novel attack to recover obfuscated F2F interconnects), we argue that entering the next, third dimension is eminent for effective and efficient IP protection.
Satwik Patnaik, Mohammed Ashraf, Ozgur Sinanoglu, Johann Knechtel
ICCAD2
2018 Customized locking of IP blocks on a multi-million-gate SoC
abstract
Reliance on off-site untrusted fabrication facilities has given rise to several threats such as intellectual property (IP) piracy, overbuilding and hardware Trojans. Logic locking is a promising defense technique against such malicious activities that is effected at the silicon layer. Over the past decade, several logic locking defenses and attacks have been presented, thereby, enhancing the state-of-the-art. Nevertheless, there has been little research aiming to demonstrate the applicability of logic locking with large-scale multi-million-gate industrial designs consisting of multiple IP blocks with different security requirements. In this work, we take on this challenge to successfully lock a multi-million-gate system-on-chip (SoC) provided by DARPA by taking it all the way to GDSII layout. We analyze how specific features, constraints, and security requirements of an IP block can be leveraged to lock its functionality in the most appropriate way. We show that the blocks of an SoC can be locked in a customized manner at 0.5%, 15.3%, and 1.5% chip-level overhead in power, performance, and area, respectively.
Abhrajit Sengupta, Mohammed Nabeel Thari Moopan, Mohammed Ashraf, Ozgur Sinanoglu
ICCAD3
2017 Provably-Secure Logic Locking: From Theory To Practice
abstract
Logic locking has been conceived as a promising proactive defense strategy against intellectual property (IP) piracy, counterfeiting, hardware Trojans, reverse engineering, and overbuilding attacks. Yet, various attacks that use a working chip as an oracle have been launched on logic locking to successfully retrieve its secret key, undermining the defense of all existing locking techniques. In this paper, we propose stripped-functionality logic locking (SFLL), which strips some of the functionality of the design and hides it in the form of a secret key(s), thereby rendering on-chip implementation functionally different from the original one. When loaded onto an on-chip memory, the secret keys restore the original functionality of the design. Through security-aware synthesis that creates a controllable mismatch between the reverse-engineered netlist and original design, SFLL provides a quantifiable and provable resilience trade-off between all known and anticipated attacks. We demonstrate the application of SFLL to large designs (>100K gates) using a computer-aided design (CAD) framework that ensures attaining the desired security level at minimal implementation cost, 8%, 5%, and 0.5% for area, power, and delay, respectively. In addition to theoretical proofs and simulation confirmation of SFLL's security, we also report results from the silicon implementation of SFLL on an ARM Cortex-M0 microprocessor in 65nm technology.
Muhammad Yasin, Abhrajit Sengupta, Mohammed Nabeel Thari Moopan, Mohammed Ashraf, Jeyavijayan Rajendran, Ozgur Sinanoglu
CCS4
2017 Obfuscating the interconnects: Low-cost and resilient full-chip layout camouflaging
abstract
Layout camouflaging (LC) is a promising technique to protect chip design intellectual property (IP) from reverse engineers. Most prior art, however, cannot leverage the full potential of LC due to excessive overheads and/or their limited scope on an FEOL-centric and accordingly customized manufacturing process. If at all, most existing techniques can be reasonably applied only to selected parts of a chip - we argue that such “small-scale or custom camouflaging” will eventually be circumvented, irrespective of the underlying technique. In this work, we propose a novel LC scheme which is low-cost and generic - full-chip LC can finally be realized without any reservation. Our scheme is based on obfuscating the interconnects (BEOL); it can be readily applied to any design without modifications in the device layer (FEOL). Applied with split manufacturing in conjunction, our approach is the first in the literature to cope with both the FEOL fab and the end-user being untrustworthy. We implement and evaluate our primitives at the (DRC-clean) layout level; our scheme incurs significantly lower cost than most of the previous works. When comparing fully camouflaged to original layouts (i.e., for 100% LC), we observe on average power, performance, and area overheads of 12%, 30%, and 48%, respectively. Here we also show empirically that most existing LC techniques (as well as ours) can only provide proper resilience against powerful SAT attacks once at least 50% of the layout is camouflaged - only large-scale LC is practically secure. As indicated, our approach can deliver even 100% LC at acceptable cost. Finally, we also make our flow publicly available, enabling the community to protect their sensitive designs.
Satwik Patnaik, Mohammed Ashraf, Johann Knechtel, Ozgur Sinanoglu
ICCAD2
2017 Rethinking split manufacturing: An information-theoretic approach with secure layout techniques
abstract
Split manufacturing is a promising technique to defend against fab-based malicious activities such as IP piracy, overbuilding, and insertion of hardware Trojans. However, a network flow-based proximity attack, proposed by Wang et al. (DAC'16) [1], has demonstrated that most prior art on split manufacturing is highly vulnerable. Here in this work, we present two practical layout techniques towards secure split manufacturing: (i) gate-level graph coloring and (ii) clustering of same-type gates. Our approach shows promising results against the advanced proximity attack, lowering its success rate by 5.27x, 3.19x, and 1.73x on average compared to the unprotected layouts when splitting at metal layers M1, M2, and M3, respectively. Also, it largely outperforms previous defense efforts; we observe on average 8x higher resilience when compared to representative prior art. At the same time, extensive simulations on ISCAS'85 and MCNC benchmarks reveal that our techniques incur an acceptable layout overhead. Apart from this empirical study, we provide-for the first time-a theoretical framework for quantifying the layout-level resilience against any proximity-induced information leakage. Towards this end, we leverage the notion of mutual information and provide extensive results to validate our model.
Abhrajit Sengupta, Satwik Patnaik, Johann Knechtel, Mohammed Ashraf, Siddharth Garg, Ozgur Sinanoglu
ICCAD4
2006 Research Paper: A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus
abstract
BACKGROUND: Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness. METHODS: The authors conducted a randomized, controlled trial comparing telemedicine case management to usual care, with blinding of those obtaining outcome data, in 1,665 Medicare recipients with diabetes, aged 55 years or greater, and living in federally designated medically underserved areas of New York State. The primary endpoints were HgbA1c, blood pressure, and low-density lipoprotein (LDL) cholesterol levels. RESULTS: In the intervention group (n = 844), mean HgbA1c improved over one year from 7.35% to 6.97% and from 8.35% to 7.42% in the subgroup with baseline HgbA1c > or =7% (n = 353). In the usual care group (n = 821) mean HgbA1c improved over one year from 7.42% to 7.17%. Adjusted net reductions (one-year minus baseline mean values in each group, compared between groups) favoring the intervention were as follows: HgbA1c, 0.18% (p = 0.006), systolic and diastolic blood pressure, 3.4 (p = 0.001) and 1.9 mm Hg (p < 0.001), and LDL cholesterol, 9.5 mg/dL (p < 0.001). In the subgroup with baseline HgbA1c > or =7%, net adjusted reduction in HgbA1c favoring the intervention group was 0.32% (p = 0.002). Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dL. The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York. CONCLUSION: Telemedicine case management improved glycemic control, blood pressure levels, and total and LDL cholesterol levels at one year of follow-up.
Steven Shea, Ruth S. Weinstock, Justin Starren, Jeanne A. Teresi, Walter Palmas, Lesley Field, Philip C. Morin, Robin Goland, Roberto E. Izquierdo, L. Thomas Wolff, Mohammed Ashraf, Charlyn Hilliman, Stephanie Silver, Suzanne Meyer, Douglas Holmes, Eva Petkova, Linnea Capps, Rafael A. Lantigua
J. Am. Medical Informatics Assoc.11