Spotlight on virtual and digital diabetes care
The pandemic has provided healthcare professionals with a unique opportunity to make the most of a digital approach to diabetes care.
The last year has seen dramatic changes in the way diabetes teams deliver care – with COVID-19 dictating a switch from traditional face-to-face appointments to remote care, backed up by the use of digital diabetes technology. This is something every diabetes healthcare professional has had to address. Therefore, when introducing a discussion on virtual and digital diabetes care at Advanced Technologies & Treatment for Diabetes, Satish Garg of the Barbara Davis Center, Colorado, argued that this was one of the most important sessions the online meeting had to offer. He’s been publishing widely on diabetes telehealth and keeping a close eye on the data. As is well known, glucose control among people with diabetes has got worse in the USA over the past five years, as shown by data from the Type 1 Diabetes Exchange, possibly because more people with type 1 have overweight and obesity.
Maybe telemedicine, driven by the pandemic, offers an opportunity to address this?
Satish noted that all diabetes care at the UNC Diabetes Care Centre had to be transitioned to a virtual setting from March/April 2020 and this had been achieved within two weeks. “Data shows this can be managed with no adverse effects on time in range or rates of hypoglycaemia. Emergency use of continuous glucose monitoring (CGM) was authorised, which facilitated the transition.” At the Barbara Davis Diabetes Centre, CGM use is now up to 80% and he noted that time in range during the pandemic actually improved. “However, the improvement was directly related to socioeconomic status, which is unfortunate, but it was still seen in all groups.”
Newer CGM systems, like the Dexcom G7, and smart solutions like the InPen insulin pen- like pump are beginning to make an important contribution and Satish is working to standardise downloads from these systems and multiple daily injection (MDI) with connected pens. “I think CGM and MDI, with connected pens, might be the best way to manage diabetes globally – though in the USA and Europe, maybe insulin pumps are preferred – with data being shared through iCloud and apps. I do think that COVID-19 might have shown us that remote care through telehealth might be the way to reduce costs in diabetes care. Of course, I don’t know what the future is, but I hope diabetes telehealth is here to stay, as it will remove many barriers and patients can receive more equal care. We may even be able to use the digital and virtual approach to go beyond HbA1c and find new ways of managing diabetes.”
Telemedicine certainly seems to offer much in terms of paediatric type 1 diabetes care delivery, which can be taken into the post-pandemic world, according to Lori Laffel, of the Joslin Diabetes Centre. The gold standard would be to spend up to an hour with patient and family in an attempt to combat that suboptimal glucose control, which reaches its peak in adolescent years. Previous research has shown that more frequent follow-up visits may help in this respect. “Research at Joslin shows paediatric patients were offered six visits over two years on average, but 15% of these were ‘Did Not Attend’ or were cancelled – maybe because the face-to-face visit is inconvenient. But those who missed two visits did have worse HbA1c.” In this analysis, they looked at who attended the visit with the patient, and found lower HbA1c among those who had fathers in attendance. “Virtual care may encourage more contact and presence of one or more parents,” Lori said. “So telehealth is a potential way to improve care and outcomes.”
Telehealth can increase the pool of healthcare professionals involved in paediatric diabetes care and there is data from CGM and from insulin pumps – which converted very quickly, at the start of the pandemic, to remote data acquisition. With all this, there is now data showing that telehealth can increase frequency of care and this, in itself, may improve outcomes. “Virtual care itself isn’t new, because the intensive group in the Diabetes Control and Complications Trial had telephone calls. I think we need to look at the hybrid approach going forward, combining face-to-face with virtual or remote care.” Hybrid rather than 100% remote, because in paediatric diabetes care the remote approach has gaps. Personal interaction is needed to assess growth, inspect injection sites and carry out eye and foot examinations.
These limitations notwithstanding, the stats around remote care are impressive, with a big increase in mental health, educator and dietitian appointments. “We’ve done a study of over 600 patients before and after the pandemic and there was an increase from 2.7 to 3 visits per person per year. We saw an improvement in glycaemic control, with a doubling of those reaching target. Therefore, by potentially changing process of care through telehealth, we are able to change the outcomes.”
What are the hopes for post-pandemic paediatric care? “This increased frequency of visits works, so we are looking for a hybrid model with face-to-face visits twice a year, and remote [appointments] four times [a year]. But we will need to show non-inferiority and cost-effectiveness,” Lori concluded.
For more on the pandemic and diabetes care, see our series of short tutorials ‘Diabetes and COVID-19’.
The views expressed in this article are those of the author, Dr Eleanor D Kennedy.