Abstract
Introduction
Healthcare uses extensive resources (manpower and money) across the globe and especially in the United States and Western Europe. Many developed economies spend trillions of US dollars to provide healthcare and may spend from 10% to 17% of their Gross Domestic Product (GDP). Despite higher costs, several ethnic minorities are not provided the same access to healthcare. This is specifically relevant to chronic health conditions like Type 1 Diabetes (T1D) and Type 2 Diabetes (T2D). In part, this may be due to rising prevalence of diabetes globally whereby the year 2045, it is expected that more than 737 million people will be affected with the disease, primarily T2D. Many countries do not have enough providers to deliver good quality care to patients with diabetes. It has been well known that suboptimal glucose control is likely to result in many long term micro- and macrovascular complications of diabetes.
The COVID pandemic lockdowns in 2020 taught us all how to provide effective diabetes care virtually through tele-health. This in part was facilitated by the development of many digital tools like Continuous Glucose Monitoring (CGM), insulin pumps, memory pens, and Hybrid Closed-Loop Systems (HCL) for insulin-requiring patients with T1D or T2D. Providing healthcare remotely became mandatory during the lockdown and has been successfully used in patients with diabetes since then. The availability of remote care allowed patients to visit their Health Care Providers (HCPs) without having to travel to the clinics, resulting in convenience and cost savings both for patients and HCPs.
For the past 4 years, we have written this chapter, and the interest in providing virtual care is only increasing globally. It also allows to remove barriers in providing care to ethnic minorities and reach out to wider populations living remotely and globally. It has been shown to be cost effective and most patients like it, as their data can be viewed remotely by the HCPs during the tele-visits. We hope that various healthcare insurance companies (where applicable) will continue to reimburse at the same level as for in-person visits. In the past 4 years, this chapter has been one of the most downloaded chapters from the ATTD yearbook. We reviewed more than 700 abstracts published from July 1, 2023, to June 30, 2024, and chose the following 15 abstracts for this chapter.
VIRTUAL CLINICS: TYPE 1 DIABETES
Virtual Clinic for Young People with Type 1 Diabetes: A Randomized Wait-List Controlled Study
Leksell J1, Toft E3,4, Rosman J1, Eriksson JW1, Fischier J5, Lindholm-Olinder A1,6, Rosenblad A1,7,8, Nerpin E2,9,10
1Department of Medical Sciences, Clinical Diabetology and Metabolism, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden; 2School of Education, Health and Social Studies, Dalarna University, Falun, Sweden; 3Department of Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden; 4Diabetes Unit, Ersta Hospital, Stockholm, Sweden; 5Diabetes Unit, Karolinska University Hospital, Stockholm, Sweden; 6Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; 7Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden; 8Department of Statistics, Uppsala University, Uppsala, Sweden; 9Department of Medical Sciences, Respiratory Medicine, Allergy and Sleep, Uppsala University, Uppsala, Sweden; 10Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden
BMC Endocr Disord 2023; 23: 255
The transition from pediatric to adult care for young adults with type 1 diabetes poses unique challenges. Virtual diabetes clinics using smartphone applications offer a promising approach to support self-management and enhance communication with healthcare providers. The primary objective of this study was to evaluate the effects of a virtual diabetes clinic on glycemic control, treatment satisfaction, and quality of life among young adults diagnosed with type 1.
A total of 79 participants with type 1 diabetes aged 18–25 years were included in a prospective, single-center, randomized, wait-list controlled trial. Participants were randomly assigned to either the intervention group or the wait-list control group. The intervention group received instant access to a virtual care platform called Vista Dialog, which facilitated real-time communication between patients and healthcare providers. Glycosylated hemoglobin (HbA1c) levels, time in range (TIR), time below range (TBR), diabetes treatment satisfaction, and quality of life were assessed at baseline and after 6 months.
Baseline characteristics were similar between the intervention and control groups, except for education level, where there was a skewed distribution between the groups (the intervention group had a lower education level). At the 6-month follow-up, there were no significant differences in HbA1c levels, TIR, TBR, or diabetes treatment satisfaction between the two groups. However, the intervention group demonstrated a significant decrease in the burden on physical health compared with the control group, indicating an improved quality of life.
The implementation of a virtual diabetes clinic using the Vista Dialog platform did not result in significant improvements in glycemic control or treatment satisfaction compared with usual care. However, it did show potential benefits in terms of reducing the burden on physical health and improving quality of life in young adults with type 1 diabetes. Further research is needed to explore the long-term effects and optimal use of virtual clinics in diabetes management.
Institutional Barriers to the Successful Implementation of Telemedicine for Type 1 Diabetes Care
Lee JM1, Ospelt E2, Noor E2, Mungmode A2, Ebekozien O2,3, Gupta M4, Malik FS4, Fogel NR5, Accacha S6, Hsieh S7, Wilkes M8, Neyman A9, Vendrame F10; on behalf of the T1D Exchange Quality Improvement Collaborative
1Susan B. Meister Child Health Evaluation and Research Center, C.S. Mott Children’s Hospital, Ann Arbor, MI; 2T1D Exchange, Boston, MA; 3University of Mississippi School of Population Health, Jackson, MS; 4Seattle Children’s Hospital, University of Washington, Seattle, WA; 5Ann & Robert Lurie Children’s Hospital, Chicago, IL; 6School of Medicine NYU Long Island, Mineola, NY; 7Cook Children’s Hospital, Fort Worth, TX; 8Icahn School of Medicine at Mt. Sinai, New York, NY; 9Indiana University School of Medicine, Riley Children’s Hospital, Indianapolis, IN; 10University of Miami Miller School of Medicine, Miami, FL
Clin Diabetes 2024; 42: 34–39
The aim of this study was to describe rates of telemedicine use 18 months after the start of the coronavirus disease 2019 pandemic and to assess the institutional barriers to its implementation for type 1 diabetes care across centers of the T1D Exchange Quality Improvement Collaborative.
Observational electronic health record data capturing telemedicine rates from 15 U.S. centers between September 2020 and September 2021 and a survey of 33 centers capturing telemedicine rates and key components of telemedicine were analyzed. A capacity score was developed and summed to a total capacity score and compared with overall telemedicine rates across centers.
Telemedicine visits decreased by 17.4% from September 2020 to September 2021. Generally, it was observed that the lower the average telemedicine capacity score, the lower the rate of telemedicine visits.
Despite a decline in the utilization of telemedicine 18 months after the start of the pandemic, visit rates were still 20% higher than in the prepandemic period. However, there is a need to improve structural components to ensure telemedicine capacity and robust telemedicine utilization.
Understanding whether and How a Digital Health Intervention Improves Transition Care for Emerging Adults Living with Type 1 Diabetes: Protocol for a Mixed Methods Realist Evaluation
Wang R1, Rouleau G2,3,4, Booth GL5,6,7, Brazeau AS8, El-Dassouki N9, Taylor M9, Cafazzo JA7,9,10,11, Greenberg M12,13, Nakhla M14,15, Shulman R7,16,17,18, Desveaux L1,7
1Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada; 2Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, ON, Canada; 3Département des Sciences Infirmières, Université du Québec en Outaouais, St-Jérôme, QC, Canada; 4Faculté des sciences infirmières, l'Université de Montréal, Montreal, QC, Canada; 5MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada; 6Department of Medicine, University of Toronto, Toronto, ON, Canada; 7Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; 8School of Human Nutrition, McGill University, Montréal, QC, Canada; 9Centre for Digital Therapeutics, Toronto General Hospital, University Health Network, Toronto, ON, Canada; 10Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada; 11Department of Computer Science, University of Toronto, Toronto, ON, Canada; 12Department of Philosophy, Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada; 13Diabetes Action Canada, Toronto, ON, Canada; 14Division of Endocrinology, Montreal Children’s Hospital, McGill University, Montréal, QC, Canada; 15Research Institute of the McGill University Health Centre, Montréal, QC, Canada; 16Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; 17Division of Endocrinology, The Hospital for Sick Children, Toronto, ON, Canada; 18Department of Pediatrics, University of Toronto, Toronto, ON, Canada
JMIR Res Protoc 2023; 12: e46115
Emerging adults living with type 1 diabetes (T1D) face a series of challenges with self-management and decreased health system engagement, leading to an increased risk of acute complications and hospital admissions. Effective and scalable strategies are needed to support this population to transfer seamlessly from pediatric to adult care with sufficient self-management capability. Although digital health interventions for T1D self-management are a promising strategy, it remains unclear which elements work, how, and for which groups of individuals.
This study aims to evaluate the design and implementation of a multicomponent SMS text message–based digital health intervention to support emerging adults living with T1D in real-world settings. The objectives are to identify the intervention components and associated mechanisms that support user engagement and T1D health care transition experiences and determine the individual characteristics that influence the implementation process.
We used a realist evaluation embedded alongside a randomized controlled trial, which uses a sequential mixed-method design to analyze data from multiple sources, including intervention usage data, patient-reported outcomes, and realist interviews. In Step 1, we conducted a document analysis to develop a program theory that outlines the hypothesized relationships among “individual-level contextual factors, intervention components and features, mechanisms, and outcomes,” with special attention paid to user engagement. Among them, intervention components and features depict 10 core characteristics such as transition support information, problem-solving information, and real-time interactivity. The proximal outcomes of interest include user engagement, self-efficacy, and negative emotions, whereas the distal outcomes of interest include transition readiness, self-blood glucose monitoring behaviors, and blood glucose. In Step 2, we plan to conduct semistructured realist interviews with the randomized controlled trial’s intervention-arm participants to test the hypothesized “context-intervention-mechanism-outcome” configurations. In Step 3, we plan to triangulate all sources of data using a coincidence analysis to identify the necessary combinations of factors that determine whether and how the desired outcomes are achieved and use these insights to consolidate the program theory.
For Step 1 analysis, we have developed the initial program theory and the corresponding data collection plan. For Step 2 analysis, participant enrollment for the randomized controlled trial started in January 2023. Participant enrollment for this realist evaluation was anticipated to start in July 2023 and continue until we reached thematic saturation or achieved informational power.
Beyond contributing to knowledge on the multiple pathways that lead to successful engagement with a digital health intervention as well as target outcomes in T1D care transitions, embedding the realist evaluation alongside the trial may inform real-time intervention refinement to improve user engagement and transition experiences. The knowledge gained from this study may inform the design, implementation, and evaluation of future digital health interventions that aim to improve transition experiences.
Virtual Insulin Pump Initiation is Safe Effective in Children Adolescents with Type 1 Diabetes
Nwosu BU1,2, Pellizzari M1, Pavlovic MN2, Ciron J1, Talib R1, Sohail R3
1Division of Endocrinology, Department of Pediatrics, Cohen Children’s Medical Center, Hempstead, NY; 2Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Queens, NY; 3Biostatistics Unit, Office of Academic Affairs, Northwell Health, NY
Front Clin Diabetes Healthc 2024; 5: 136262
There is no head-to-head comparison of the safety and efficacy of virtual versus in-office insulin pump initiation for youth with type 1 diabetes in the United States. The study’s aim was to determine the safety and efficacy of virtual versus in-office pump initiation in pediatric type 1 diabetes.
A longitudinal retrospective study of 112 subjects: 65% (n = 73), ages 11.2 ± 3.8 years(y), received in-office training; and 35% (n = 39), ages 12.0 ± 4.0 y, received virtual training. The number of White subjects was 40 (55%) in the in-office group and 25 (66%) in the remote group, while Black subjects were 11 (15%) in the in-office group and 4 (10%) in the virtual group. Data were collected at pump initiation, 3, and 6 months.
There were no significant differences in sex, race, height, weight, BMI, and the duration of diabetes between the groups at baseline. There was no significant difference in A1c between the groups at 0, 3, and 6 months. A1c correlated significantly with the glucose management indicator at 0, 3, and 6 months: baseline: r = 0.49, P < 0.0001; 3 months: r = 0.77, P < 0.0001; and 6 months: r = 0.71, P < 0.0001. There was no relationship between A1c or TIR and pubertal status, BMI, sex, or race. A1c was significantly elevated in the non-White individuals at 6 months only: 57.9 mmol/mol (50.8–69.4) versus 51.9 mmol/mol (46.5–59.6), P = 0.007.
Virtual insulin pump initiation is safe and effective in children with type 1 diabetes. This approach could accelerate the adoption of the use of diabetes technology in minority populations in the United States.
The first section includes four abstracts regarding virtual clinics in patients with T1D. Leksell et al. report a randomized wait-list controlled study on 79 participants with T1D ages 18–25 years. The baseline characteristics were similar in the two groups. After 6 months there was no difference in HbA1c, time-in-range (TIR), time-below-range (TBR), or diabetes treatment satisfaction. However, the intervention telehealth group did show a significant decrease on the burden of physical health when compared with the control group.
The second abstract reports on the rates of telemedicine use 18 months after the start of the COVID-19 pandemic. This study was done in collaboration with T1D Exchange Quality Improvement Group across 15 centers in the United States from September 2020 to September 2021. The authors reported a significant decline in the utilization of telemedicine 18 months after the start of the COVID pandemic. The visit rates were still 20% higher than the prepandemic period. Interestingly, the third abstract reports improvement in transition care for emerging adults living with T1D using digital health.
The fourth abstract highlights the safety and efficacy of pump initiation in children and adolescents with T1D. The study included 112 subjects of which 15% were from ethnic minorities. Baseline characteristics were similar. In addition, HbA1c and TIR were significantly improved in white participants. However, African Americans and other nonwhite groups had elevated HbA1c levels at six months. This study highlights using diabetes technology can reach minorities more effectively and reach similar glucose control.
VIRTUAL CLINICS: TYPE 2 DIABETES
Experiences and Perceptions of Telehealth Visits in Diabetes Care During and After the COVID-19 Pandemic Among Adults with Type 2 Diabetes and their Providers: Qualitative Study
Sun C1, Shenk Z1, Renda S1, Maruthur N1,2,3, Zheng S4, Perrin N1, Levin S5,6, Han H1,7
1Johns Hopkins School of Nursing, Baltimore, MD; 2Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD; 3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; 4Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; 5Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD; 6Center for Data Science in Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD; 7Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
JMIR Diabetes. 2023: 8: e44283
Since the COVID-19 pandemic, telehealth has been widely adopted in outpatient settings in the United States. Although telehealth visits are publicly accepted in different settings, little is known about the situation after the wide adoption of telehealth from the perspectives of adults with type 2 diabetes mellitus (T2D) and their providers.
This study aims to identify barriers and facilitators of maintaining continuity of care using telehealth for patients with T2D in a diabetes specialty clinic.
As the second phase of a multimethod study to understand missed appointments among adults with T2D, we conducted semistructured, individual, in-depth phone or Zoom interviews with 23 adults with T2D (14/23, 61% women; mean age 55.1, SD 14.4, range 35–77 years) and 10 providers from diabetes clinics in a tertiary academic medical center in Maryland. Interviews were audio-recorded, transcribed, and analyzed using thematic content analysis by the research team.
Adults with T2D and their providers generally reported positive experiences with telehealth visits for diabetes care with some technical challenges resulting in the need for in-person visits. We identified the following three themes: (1) “perceived benefits of telehealth visits,” such as convenience, time and financial efficiencies, and independence from caregivers, benefits shared by both patients and providers; (2) “perceived technological challenges of telehealth visits,” such as disparities in digital health literacy, frustration caused by unstable internet connection, and difficulty sharing glucose data, challenges shared by both patients and providers; and (3) “impact of telehealth visits on the quality of diabetes care,” including lack of diabetes quality measures and needs and preferences for in-person visits, shared mainly from providers’ perspectives with some patient input.
Telehealth is generally received positively in diabetes care with some persistent challenges that might compromise the quality of diabetes care. Telehealth technology and glucose data platforms must incorporate user experience and user-centered design to optimize telehealth use in diabetes care. Clinical practices need to consider new workflows for telehealth visits to facilitate easier follow-up scheduling and lab completion. Future research to investigate the ideal balance between in-person and telehealth visits in diabetes care is warranted to enhance the quality of diabetes care and to optimize diabetes outcomes. Policy flexibilities should also be considered to broaden access to diabetes care for all patients with T2D.
A Hybrid Model of In-Person and Telemedicine Diabetes Education and Care for Management of Patients with Uncontrolled Type 2 Diabetes Mellitus: Findings and Implications from a Multicenter Prospective Study
Tourkmani AM1, Alharbi TJ1, Rsheed AMB1, Alotaibi AF1, Aleissa MS1, Alotaibi S1, Almutairi AS1, Thomson J1, Alshahrani AS1, Alroyli HS1, Almutairi HM1, Aladwani MA1, Alsheheri ER1, Sati HS1, Aljuaid B1, Algarzai AS2, Alabood A1, Bushnag RA1, Ghabban W1, Albaik M1, Aldahan S1, Redda D1, Almalki A1, Almousa N1, Aljehani M2, Alrasheedy AA3
1Family and Community Medicine Department, Chronic Illness Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; 2Health Services, Ministry of Defense, Riyadh, Saudi Arabia; 3Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Saudi Arabia
Telemed Rep 2024; 5: 46–57
Patients with uncontrolled type 2 diabetes mellitus (T2DM) require close follow-up, support, and education to achieve glycemic control, especially during the initiation or intensification of insulin therapy and self-care management. This study aimed to describe and evaluate the impact of implementing a hybrid model of in-person and telemedicine care and education on glycemic control for patients with uncontrolled T2DM (hemoglobin A1c [HbA1c] ≥9%) during the coronavirus disease pandemic.
This prospective multicenter-cohort pre-/postintervention study was conducted on patients with uncontrolled T2DM. This study included three chronic illness centers affiliated with the Family and Community Medicine Department at Prince Sultan Military Medical City in Riyadh, Saudi Arabia. A hybrid model of in-person (onsite) and telemedicine care and education was developed. This involved implementing initial in-person care at the physicians' clinic and initial in-person education at the diabetes education clinic, followed by telemedicine services of tele-follow-ups, support, and education for an average 4-month follow-up period.
Of the enrolled 181 patients, more than half of the participants were women (n = 103, 56.9%). The mean age of participants (standard deviation) was 58.64 ± 11.23 years and the mean duration of diabetes mellitus was 13.80 ± 8.55 years. The majority of the patients (n = 144; 79.6%) were on insulin therapy. Overall, in all three centers, the hybrid model had significantly reduced HbA1c from 10.47 ± 1.23% to 7.87 ± 1.59% (mean difference of reduction 2.59% [95% confidence interval (CI) = 2.34–2.85%], P < 0.001). At the level of each center, HbA1c was reduced significantly with mean differences of 3.17% (95% CI = 2.81–3.53%), 2.49% (95% CI = 1.92–3.06%), and 2.16% (95% CI = 1.76–2.57%) at centers A, B, and C, respectively (all P < 0.001).
The findings showed that the hybrid model of in-person and telemedicine care and education effectively managed uncontrolled T2DM. Consequently, the role of telemedicine in diabetes management could be further expanded as part of routine diabetes care in primary settings to achieve better glycemic control and minimize nonessential in-person visits when appropriate.
Effect of Virtual Versus in Person Interpreting on Diabetes Outcomes in Non-English Language Preference Patients: A Pilot Study
So M1, Jadoo H2, Stong J1, Klemenhagen KC1, Philbrick AM3, Freeman K1
1University of Minnesota Medical School, Minneapolis, MN; 2University of Minnesota College of Pharmacy, Minneapolis, MN; 3University of Minnesota College of Pharmacy and University of Minnesota Medical School, Minneapolis, MN
J Prim Care Community Health 2024: 15: 21501319241240347
The objective of this pilot study was to explore the impact of interpreter format (virtual vs in person) on clinical outcomes in patients with non-English language preference (NELP) and type 2 diabetes mellitus (T2DM) in a primary care setting. We hypothesized that NELP patients utilizing in person interpreters would have improved HbA1c values, better follow-up rate, and more complex care plans compared to patients utilizing virtual interpreters.
We completed a retrospective chart review of 137 NELP patients with T2DM who required a medical interpreter (February to June 2021). We calculated univariate and bivariate statistics to characterize the sample and assess the extent to which measures of continuity (follow-up visit rate and time to follow-up visit), quality (change in HbA1c), and complexity (medication intervention complexity) were associated with interpreter type.
There was no statistically significant difference in follow-up rate or average days to follow-up visit for NELP patients with in person as opposed to virtual interpreters. Patients with virtual interpreters demonstrated a nonstatistically significant decrease in HbA1c compared to those with in person interpreters. Finally, there was no statistically significant association between interpreter format and intervention complexity.
Quality medical interpretation contributes to optimal health outcomes in NELP patients with diabetes. Our study suggests that both in person and virtual interpreters can be effective in providing care for NELP patients, especially for chronic disease management in the context of a primary care relationship. It also highlights the importance of pursuing additional qualitative and mixed method studies to better understand the benefits of various interpreter formats across different visit types.
Patterns of Telemedicine use and Glycemic Outcomes of Endocrinology Care for Patients with Type 2 Diabetes
Zupa MF1, Vimalananda VG2,7, Rothenberger SD3, Lin JY3, Ng JM1, McCoY JG4,5, Rosland A3,6
1Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, PA; 2Center for Health Outcomes Research, Veterans Affairs Bedford Healthcare System, Bedford, MA; 3Division of General Internal Medicine, University of Pittsburgh School of Medicine, PA; 4Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD; 5University of Maryland Institute for Health Computing, Bethesda, MD; 6Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, PA; 7Department of Medicine, Boston University School of Medicine, MA
JAMA Netw Open 2023; 6: e2346305
Telemedicine can increase access to endocrinology care for people with type 2 diabetes (T2D), but patterns of use and outcomes of telemedicine specialty care for adults with T2D beyond initial uptake in 2020 are not known.
The objective of this study was to evaluate patterns of telemedicine use and their association with glycemic control among adults with varying clinical complexity receiving endocrinology care for T2D.
This was a retrospective cohort study in a single large integrated US health system. Participants were adults who had a telemedicine endocrinology visit for T2D from May to October 2020. Data were analyzed from June 2022 to October 2023.
Patients were followed up through May 2022 and assigned to telemedicine-only, in-person, or mixed care (both telemedicine and in-person) cohorts according to visit modality.
Multivariable regression models were used to estimate hemoglobin A1c (HbA1c) change at 12 months within each cohort and the association of factors indicating clinical complexity (insulin regimen and cardiovascular and psychological comorbidities) with HbA1c change across cohorts. Subgroup analysis was performed for patients with baseline HbA1c of 8% or higher.
Of 11,498 potentially eligible patients, 3778 were included in the final cohort (81 Asian participants [2%], 300 Black participants [8%], and 3332 White participants [88%]); 1182 used telemedicine only (mean [SD] age 57.4 [12.9] years; 743 female participants [63%]), 1,049 used in-person care (mean [SD] age 63.0 [12.2] years; 577 female participants [55%]), and 1547 used mixed care (mean [SD] age 60.7 [12.5] years; 881 female participants [57%]). Among telemedicine-only patients, there was no significant change in adjusted HbA1c at 12 months (−0.06%; 95% CI, −0.26% to 0.14%; P = .55) while in-person and mixed cohorts had improvements of 0.37% (95% CI, 0.15% to 0.59%; P < .001) and 0.22% (95% CI, 0.07% to 0.38%; P = .004), respectively. Patients with a baseline HbA1c of 8% or higher had a similar pattern of glycemic outcomes. For patients prescribed multiple daily injections vs no insulin, the 12-month estimated change in HbA1c was 0.25% higher (95% CI, 0.02% to 0.47%; P = .03) for telemedicine vs in-person care. Comorbidities were not associated with HbA1c change in any cohort.
In this cohort study of adults with T2D receiving endocrinology care, patients using telemedicine alone had inferior glycemic outcomes compared with patients who used in-person or mixed care. Additional strategies may be needed to support adults with T2D who rely on telemedicine alone to access endocrinology care, especially for those with complex treatment or elevated HbA1c.
We chose four abstracts highlighting the efficacy and perceptions of virtual clinics for patients with T2D. Even though the first study included only 23 adults and 10 providers from diabetes clinics in a tertiary academic medical center in the United States, interviews were audio and video recorded and analyzed using thematic content analysis. They concluded that telehealth was generally received positively in the diabetes community that included both HCPs and the patients with T2D. It is important that healthcare insurance companies need to consider broadening the access to diabetes care through telehealth for patients with T2D.
The next two abstracts highlight a hybrid model of in person and telemedicine diabetes education and care models. Their findings show a hybrid model effectively managed glycemia in uncontrolled patients with T2D. They recommended wider use of telemedicine in the primary care settings. In addition, non-English speaking patients with T2D using virtual interpreters were effective in chronic disease management.
The last abstract published in JAMA in large number of patients with T2D showed inferior glycemic outcomes in patients who used telemedicine only. Additional strategies for complex patients like hybrid models may be required to optimize the outcomes.
VIRTUAL CLINICS: PREGNANCY AND DIABETES
Successful Implementation of Virtual Care to Overcome the Challenges of Managing Gestational Diabetes during the COVID-19 Pandemic: A Quality Improvement Project
Khurana R1,2, Tong J1, Burrows J3,4, Stafford S1,2, Singh A5,6, Jain A1,2, Severin N1,2, Kissock J1,2, Pisani S1,2, Eng J7
1Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada; 2Medicine, Fraser Health, Surrey, British Columbia, Canada; 3Maternal-Fetal Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada; 4Maternal-Fetal Medicine, Fraser Health, Surrey, British Columbia, Canada; 5Pediatrics, Surrey Memorial Hospital, Surrey, British Columbia, Canada; 6Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada; 7Quality Improvement, Fraser Health, Surrey, British Columbia, Canada
BMJ Open Qual 2023; 12: e002235
At the start of the COVID-19 pandemic, the Jim Pattison Diabetes and Pregnancy (JP DAP) clinic quickly switched from in-person to virtual care for patients with gestational diabetes (GDM) to reduce the risk of viral transmission.
Poor glycemic control in pregnancies increases the risk of maternal–fetal complications and thus women with GDM require education, frequent follow-up, and treatment to reduce these risks. Delays in care could potentially result in increased maternal–fetal complications. We conducted a prospective, single-center quality improvement (QI) study of women with GDM who attended the JP DAP clinic and delivered between September 1, 2019, and March 31, 2021. 2,123 singleton pregnancies between September 1, 2019, and March 31, 2021, with GDM were analyzed for this study.
The time of referral to see the endocrinologist was lower than baseline in the first wave but rose significantly in the second wave. No-shows for appointments increased in the first wave but were lower than baseline after the implementation of time slots. There was no special cause variation for maternal–fetal complications pre pandemic, first wave, or during the second wave. A patient satisfaction survey reported that 93% of respondents strongly agreed or agreed with the statement “I was satisfied with the care provided to me over the telephone appointments.” The GDM education package, online educational videos in Hindi and English, and the glucometer smartphone application helped to maintain the time of referral to first endocrinologist appointment in the first wave and therefore were considered an effective substitute for in-person education.
Despite the delays in care seen in the second wave, there was no increase in maternal–fetal complications. Our clinic plans to continue using virtual tools for the foreseeable future.
Telehealth and Technology for Diabetes in Pregnancy Clinics: Staff Perspectives from South Auckland, New Zealand
Singhal M1, Oyston C1,2
1Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; 2Department of Obstetrics and Gynaecology, Middlemore Hospital, Te Whatu Ora Counties Manukau Health, South Auckland, New Zealand
Int J Telemed Appl 2024; 2024: 6429519
Providing care for patients with diabetes in pregnancy (DiP) provides unique challenges beyond those faced in standard antenatal care or diabetes outside of pregnancy. Teleclinics (use of telephone, email, or other technologies) as an alternative to in-person clinic appointments have become more widely used for care since the start of the COVID-19 pandemic. To understand how teleclinics might be improved for ongoing use, it is important to understand the experiences and perceptions of the clinicians involved in DiP care.
This study aims to understand staff experiences of DiP teleclinics and gain their perspectives on if and how teleclinics and other technologies might be best used in the future.
A qualitative study using semistructured interviews of healthcare providers in a large DiP service. Twenty staff members (midwifery, obstetrics, physician, dietician, and administration) were approached to participate. Fifteen staff across five specialties consented to be interviewed. Template analysis of interview transcripts was performed, with a focus on three themes: collaboration and working together are important for providing care for DiP, a need for flexibility in scheduling and the ability to individualize the way care is provided, and challenges to adapting to new technology.
Potential benefits of teleclinics were acknowledged, but respondents also viewed teleclinics as not suitable for all DiP patients due to different needs and risks. Challenges to using teleclinics include establishing good rapport and the current limited infrastructure and patient resources.
Healthcare providers viewed teleclinics as a way of supporting rather than replacing current care. Maintaining flexibility in clinic scheduling to allow incorporation of teleclinics into patient's current schedule of visits ad hoc and providing extra technical and administrative support are important considerations for developing a teleclinic service.
It is well known that poor glycemic outcome in patients with gestational diabetes (GDM) may result in adverse maternal and fetal outcomes. The study was conducted from September 2019 to March 2021. The study included 2,123 singleton pregnancies in subjects with GDM. The virtual care was provided for managing gestational diabetes during the COVID-19 pandemic. 93% of the participants strongly supported the virtual care and appreciated the online educational programs. Despite the delays in care seen in the second wave, there was no increase in maternal and fetal complications. The virtual care supports the ongoing care for glycemia in patients with GDM, especially where frequency of visits may be increased.
The second abstract is from New Zealand that highlights the use of telehealth for diabetes care in pregnancy clinics, especially providing staff perspectives. The HCPs viewed teleclinics as a way of supporting rather than replacing the in-person care. They highlighted the need for continued administrative support for ongoing teleclinics.
VIRTUAL CLINICS: BENEFITS AND BARRIERS OF DIGITAL TECHNOLOGY IN DIABETES MANAGEMENT
Patient Perspectives on the Benefits and Challenges of Diabetes and Digital Technology
Edelman S1,2, Cheatham WW3, Norton A4, Close KL5
1University of California San Diego, Veterans Affairs Medical Center, San Diego, CA; 2Taking Control of Your Diabetes, Solana Beach, CA; 3Metabolic Services, Laurel, MD; 4National Minority Quality Forum, Washington, DC; 5Close Concerns, Inc., and the diaTribe Foundation, San Francisco, CA
Clin Diabetes 2024; 42: 243–256
Diabetes technology continues to evolve, advancing with our understanding of human biology and improving our ability to treat people with diabetes.
Diabetes devices are broadly classified into the following categories: glucose sensors, insulin delivery devices, and digital health care technology (i.e., software and mobile applications). When supported by education and individually tailored, technology can play a key role in optimizing outcomes.
Digital devices assist in diabetes management by tracking meals, exercise, sleep, and glycemic measurements in real time, all of which can guide physicians and other clinicians in their decision-making.
Here, as people with diabetes and patient advocates, as well as diabetes specialists, primary care providers, and diabetes care and education specialists, we present our perspectives on the advances, benefits, and challenges of diabetes technology in primary care practices.
Comprehensive Telehealth Model to Support Diabetes Self-Management
Aleppo G1, Gal JL2, Raghinaru D2, Kruger D3, Beck RW2, Bergenstal RM4, Cushman T3, Hood KK5, Johnson ML4, McArthur T6, Bradshaw A6, Olson BA7, Oser SM8, Oser TK8, Kollman C2, Weinstock RS9
1Northwestern University Feinberg School of Medicine, Chicago, IL; 2Jaeb Center for Health and Research, Tampa, FL; 3Henry Ford Health System, Detroit, MI; 4International Diabetes Center, Minneapolis, MN; 5Stanford University School of Medicine, Stanford, CA; 6Cecelia Health, New York, NY; 7Lagoon Health, Minneapolis, MN; 8University of Colorado School of Medicine, Aurora, CO; 9SUNY Upstate Medical University, Syracuse, NY
JAMA Netw Open 2023; 6: e2336876
This manuscript is also discussed in Chapter 10, page 315
As the number of patients with diabetes continues to increase in the United States, novel approaches to clinical care access should be considered to meet the care needs for this population, including support for diabetes-related technology.
The objective of this study is to evaluate a virtual clinic to facilitate comprehensive diabetes care, support continuous glucose monitoring (CGM) integration into diabetes self-management, and provide behavioral health support for diabetes-related issues.
This cohort study was a prospective, single-arm, remote study involving adult participants with type 1 or type 2 diabetes who were referred through community resources. The study was conducted virtually from August 24, 2020, to May 26, 2022; analysis was conducted at the clinical coordinating center.
Training and education was led by a Certified Diabetes Care and Education Specialist for CGM use through a virtual endocrinology clinic structure, which included endocrinologists and behavioral health team members.
Main outcomes included CGM-measured mean glucose level, coefficient of variation, and time in range (TIR) of 70 to 180 mg/dL, time with values greater than 180 mg/dL or 250 mg/dL, and time with values less than 70 mg/dL or 54 mg/dL. Hemoglobin A1c was measured at baseline and at 12 and 24 weeks.
Among the 234 participants, 160 had type 1 diabetes and 74 had type 2 diabetes. The mean (SD) age was 47 (14) years, 123 (53%) were female, and median diabetes duration was 20 years. Median (IQR) CGM use over 6 months was 96% (91%–98%) for participants with type 1 diabetes and 94% (85%–97%) for those with type 2 diabetes. Mean (SD) hemoglobin A1c (HbA1c) in those with type 1 diabetes decreased from 7.8% (1.6%) at baseline to 7.1% (1.0%) at 3 months and 7.1% (1.0%) at 6 months (mean change from baseline to 6 months, −0.6%, 95% CI, −0.8% to −0.5%; P < .001), with an 11% mean TIR increase over 6 months (95% CI, 9% to 14%; P < .001). Mean HbA1c in participants with type 2 diabetes decreased from 8.1% (1.7%) at baseline to 7.1% (1.0%) at 3 months and 7.1% (0.9%) at 6 months (mean change from baseline to 6 months, −1.0%; 95% CI, −1.4% to −0.7%; P < .001), with an 18% TIR increase over 6 months (95% CI, 13% to 24%; P < .001). In participants with type 1 diabetes, mean percentage of time with values less than 70 mg/dL and less than 54 mg/dL decreased over 6 months by 0.8% (95% CI, −1.2% to −0.4%; P = .001) and by 0.3% (95% CI, −0.5% to −0.2%, P < .001), respectively. In the type 2 diabetes group, hypoglycemia was rare (mean [SD] percentage of time <70 mg/dL, 0.5% [0.6%]; and <54 mg/dL, 0.07% [0.14%], over 6 months).
Results from this cohort study demonstrated clinical benefits associated with implementation of a comprehensive care model that included diabetes education. This model of care has potential to reach a large portion of patients with diabetes, facilitate diabetes technology adoption, and improve glucose control.
Technology and Health Inequities in Diabetes Care: How do we Widen Access to Underserved Populations and Utilize Technology to Improve Outcomes for All?
Ebekozien O1,2, Fantasia K3, Farrokhi F4, Sabharwal A5, Kerr D6
1T1D Exchange, Boston, MA; 2Department of Population Health, University of Mississippi, Jackson, MS; 3Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; 4Alta Bates Summit Medical Centre, Sutter East Bay Medical Foundation, Oakland, CA; 5Department of Electrical and Computer Engineering, Rice University, Houston, TX; 6Centre for Health System Research, Sutter Health, Santa Barbara, CA
Diabetes Obes Metab 2024; 26 (Suppl 1): 3–13
This manuscript was discussed also in Chapter 6, page 182
Digital health technologies are being utilized increasingly in the modern management of diabetes.
These include tools such as continuous glucose monitoring systems, connected blood glucose monitoring devices, hybrid closed-loop systems, smart insulin pens, telehealth, and smartphone applications (apps).
Although many of these technologies have a solid evidence base, from the perspective of a person living with diabetes, there remain multiple barriers preventing their optimal use, creating a digital divide.
In this article, we describe many of the origins of these barriers and offer recommendations on widening access to digital health technologies for underserved populations living with diabetes to improve their health outcomes.
Exploring the Challenges and Opportunities of Adopting and using Telemedicine for Diabetes Care and Management: Qualitative Semistructured Interview Study among Health Care Providers and Patients with Diabetes
Altabtabaei R1, Alhuwail D1,2
1Information Science Department, Kuwait University, Kuwait City, Kuwait; 2Health Informatics Unit, Dasman Diabetes Institute, Kuwait City, Kuwait
JMIR Hum Factors 2023; 10: e46324
Around the world, over half of the global population experiences noncommunicable diseases, resulting in premature death. Health care providers (HCPs) can deliver medical treatment from a distance by using digital advancements such as telemedicine. However, there is a limited understanding of the difficulties and opportunities of implementing telemedicine solutions in different socioeconomic and cultural environments, including Kuwait.
The purpose of this study is to (1) examine the obstacles and benefits of telemedicine in the context of diabetes treatment and management, as perceived by both HCPs and patients with diabetes; (2) investigate the nonfunctional requirements for telemedicine applications used in diabetes care and management; and (3) provide suggestions to enhance the integration and adoption of telemedicine in Kuwait’s health care system for diabetes care and management.
The research used a qualitative and exploratory design, with semistructured interviews as the main data collection method. Participants were recruited on the internet through social media platforms due to the COVID-19 pandemic. The results were analyzed using thematic analysis and the Framework Method. The “diffusion of innovation” model was used as a perspective to interpret the findings.
A total of 20 participants were included in this study—10 HCPs and 10 patients with diabetes—all of whom supported telemedicine. The HCPs reported that many diabetes cases could be managed through telemedicine, with only a few requiring in-person visits. Patients with diabetes noted the convenience and time-saving aspect of telemedicine. Both groups recommended the creation of a secure and user-friendly telemedicine system similar to popular social media platforms. Additionally, participants emphasized the importance of telemedicine during the pandemic as a way to prioritize patient safety.
The results of this study provide valuable insights into the needs and preferences of both HCPs and patients with diabetes in a resource-rich country like Kuwait to embrace telemedicine. The COVID-19 pandemic has changed the way medical care is provided and has pushed both groups to consider digital solutions for ongoing diabetes management and treatment.
Advancing Virtual At-Home Care for Community Health Center Patients using Patient Self-Care Tools, Technology, and Education
Modica C1, Lewis JH2, Bay RC3
1National Association of Community Health Centers, Bethesda, MD; 2Department of Medicine and Public Health, A.T. Still University, School of Osteopathic Medicine, Mesa, AZ; 3Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ
J Multidiscip Healthc 2024: 17: 521–531
Health centers are community-based, patient-directed primary care providers that offer accessible, high-quality primary care within medically underserved communities. Screening for cancer and managing complex chronic conditions such as diabetes, hypertension, obesity, and depression are vital services for the vulnerable populations seen by community health centers. Delivering care for complex chronic conditions and preventive services using virtual models that integrate self-care tools and technology is an important approach to increasing access for hard-to-reach patients served by health centers.
This study aimed to explore the use of a virtual care model, applied using a systems approach and patient-driven tools and technology, on the performance of clinical and patient experience measures.
A virtual care model, applied using a systems approach offered by the Value Transformation Framework (VTF), was combined with self-care tools and technology in 20 health centers across 17 states to drive improvement efforts. Changes in clinical measures and patient experience were compared.
A total of 385 patients were enrolled and 270 (70.1%) completed a baseline visit and at least four virtual visits during the six-month intervention period. Statistically significant improvements were seen in measures for HbA1c, systolic and diastolic blood pressure, and bodyweight. Among the 270 who completed the baseline and at least four virtual visits, the percentage up-to-date for colorectal cancer screening increased from 113/270 (41.9%) to 169/270 (62.6%) after six months, P < 0.001, a 20.7% increase. Patients completing the baseline visit and at least four virtual visits reported a 10.7% decrease in depression and increased satisfaction with virtual care visits compared to in-person visits (P < 0.001).
Health centers applying the Value Transformation Framework’s organizing framework to the use of virtual care models together with patient self-care tools, technology, and education, had improvements in measures for chronic and preventive conditions and patient experience.
The last four abstracts included in this chapter documents the benefits and barriers of digital technology in diabetes management. The second abstract reported a study in 234 subjects with diabetes in JAMA (online). They included 160 patients with T1D and 74 had T2D. The investigators conducted a prospective, single arm remote study in adults with diabetes. Since the study included the COVID pandemic time period between 2020 to 2022, their goal was to evaluate the role of comprehensive telehealth to support diabetes self-management. The results show improvement in glycemia at 3 and 6 months in both groups of patients with T1D and T2D, with no significant increase in TBR. A structured certified diabetes care and educational program incorporating CGM can facilitate better glycemic outcomes in a virtual care setting.
The last study included 385 patients across 20 health centers from 17 states in the United States. In all, 270 patients completed the baseline visit and at least four virtual visits during the six months of intervention period. Significant improvements in glycemic control, systolic and diastolic blood pressures, and body weight were reported at the end of six months. The patients completing four virtual visits also reported about 11% drop in depression and increased satisfaction from virtual visits compared to in-person visits.
Conclusion
Since the COVID-19 pandemic, virtual clinics, telehealth, and tele-visits have been widely adopted for patients with diabetes. Several studies in the past four years have shown similar or improved healthcare outcomes in patients with T1D, T2D, GDM, and pregnancy-associated diabetes. Both HCPs and patients have liked the virtual clinics. This digital approach can reach a wider population across the states and even different countries. The structured programs for virtual clinics have the advantage of including different family members for patient care. Undoubtedly, it is less expensive, and patients do not need to travel long distances to see their providers.
Only time will tell if different countries adopt telehealth for chronic illnesses like diabetes. Implementing this may be challenging if HCPs do not have a medical license that covers the whole country or allows them to practice across the states, which is the case in the USA. Patients with GDM and pregnancy-associated diabetes benefit much more because the frequency of visits for optimal maternal and fetal outcomes are sometimes as frequent as every 7 to 14 days, which might be impossible for in-person visits due to insufficient providers available across the globe. We hope that you have enjoyed reading our chapter and are looking forward to wider adoption of virtual care for patients with diabetes.
Authors Disclosure Statement
S.K.G. has grant support from Dexcom, Dario, Eli Lilly, Medtronic and Diasome. He receives honoraria fees from Abbott, Roche, Novo-Nordisk and Medtronic DR and AR report no competing financial interests.