Telemedicine: an increasing role in diabetes care
The COVID-19 pandemic forced diabetes clinics to go online at short notice. The benefits and challenges involved in the continuing use of telemedicine in diabetes care were in the spotlight at the recent Advanced Technologies & Therapies for Diabetes (ATTD) conference. Dr Susan Aldridge reports.
In recent years, there was a slow and steady increase in the use of telemedicine around the world until the pandemic in 2020 when its growth necessarily became exponential, according to Dr Paul Wadwa, Director of the Telemedicine Program at the Barbara Davis Center, University of Colorado. He defines three categories of telemedicine: asynchronous, where data is stored and forwarded; synchronous, which involves videoconferencing, and remote monitoring.
Telemedicine has been used at his centre since 2012. “In the early days, our challenges included reimbursement, buy in, inconsistent data uploads, privacy and security,” he said. “With each clinic, we had to establish a new workflow. It was almost like starting a new clinic from scratch with scheduling, obtaining data, labs, prescriptions and instructions to patients.”
An example of one of their initiatives is in Wyoming and West Colorado, where young people with type 1 diabetes in rural locations visit a local clinic to link via videoconference with the diabetes team at the Barbara Davis Center. Previously, they were not getting access to care as often as they should. Now, with telemedicine, the number of visits per year has increased, patient satisfaction is high and time off work and school has decreased, so there is a corresponding increase in productivity.
“During the pandemic, telemedicine expanded and many clinics adapted very rapidly, with videoconferencing from home replacing in-person outpatient care,” said Dr Wadwa. “Several clinics were still able to maintain good glycaemic control and this set the stage for long-term use of videoconference visits as part of diabetes care on a larger scale. The silver lining has been the opportunity to refine our telemedicine processes and improve our literacy in data sharing.”
Home telemedicine challenges
Dr Wadwa went on to consider the challenges faced in pivoting to home telemedicine during the pandemic. Rapid training of large numbers of providers and staff was required, along with the development of new material to train families how to upload data from continuous glucose monitoring (CGM) and pumps. Scheduling, insurance, troubleshooting, consent, uploads and post-visit virtual paperwork also had to be taken into account.
Initial feedback was positive, but videoconferencing ‘burnout’ has increased over time. “There is currently a need to develop more sustainable models of in-home telemedicine, including infrastructure, workflow and staffing,” he said. “Staff are otherwise stretched between in-person and telemedicine clinics. The model we originally used is not sustainable because we had extra help from research staff in 2020.”
At the Barbara Davis Center, telemedicine for paediatric type 1 diabetes accounted for over 4,000 visits in 2020, which was 12 times the number of visits in the previous most productive year. From 2021 to the present, telemedicine accounts for 10 to 20% of all visits, versus 3% in 2019. This approach will continue because it decreases time out of school and work, overcomes travel and distance barriers and increases family and patient satisfaction. Frequency can change depending on patient need, but disparities in access and utilisation must be tackled, as must language barriers and the needs of those with government insurance.
Then there are the diabetes-specific challenges involved in telemedicine. These include the logistics of obtaining CGM data, measurement of HbA1c, lipids and other markers, and the lack of physical examination to check blood pressure, weight, eyes, feet, injection and insertion sites, paediatric growth and pubertal development. Other team members, such as the diabetes educator, dietitian, social worker and psychologist, also need to be integrated into the telemedicine care plan.
More general challenges include hardware and software, adequate internet access and the person with diabetes having access to a private and quiet setting for the consultation. Finally, the US Public Health Emergency for COVID-19, is due to expire in May this year, so payment and reimbursement issues for telemedicine will need to be considered.
Telehealth in type 2 diabetes
The application of telehealth goes beyond replacing in-person appointments with a phone call or Zoom session, which is episodic care. Robert Ratner, Professor of Medicine at Georgetown University School of Medicine, who has been working with people who have prediabetes and type 2 diabetes said: “We’ve promoted continuous remote care, requiring a two-way exchange of patient data and patient instruction in therapeutics – it’s asynchronous communication, which means you don’t have to have the patient and the provider together at the same time and it can all be done with a smartphone.”
This approach is being used for nutritional therapy, consisting of a very-low-calorie diet, which reduces blood sugar and dependence on medication, and is the primary intervention modality used by Professor Ratner and his team. “We define this as a Mediterranean diet without the pasta and the bread,” he said. “Lots of nuts, olive oil, high-quality protein and leafy vegetables. This therapy is being delivered with advanced telehealth to ensure engagement, safety and sustainability, with the advantage that we don’t have to have anyone do calorie counts or food diaries.”
The telemedicine system is set up so that data such as HbA1c, blood pressure and weight is continually coming in to the healthcare provider, who can then evaluate who needs immediate attention and then refer them on. The intervention involves, on average, four interactions per day per patient and it’s carried out through messaging.
In 2017, Professor Ratner and his team carried out a two-year, open-label, non-randomised trial with participants who were on lots of medication – one-third of them on insulin – and also living with obesity. Outcomes were HbA1c and reduction in medication. “This study was a success,” said Professor Ratner. “HbA1c dropped by 0.9%. What’s particularly interesting is that this was achieved by deprescribing medications, particularly those that have potential to cause hypoglycaemia. Sulphonylureas were almost eliminated, while insulin was reduced by half. So you can get control with good nutritional intervention, if people follow it. The one-year retention in our study was 83% and 74% at two years, so it was clearly acceptable.”
Other outcomes at two years included weight reduction and improvements in blood pressure, insulin resistance, inflammatory markers and liver fat. Around 25% of participants had remission of their type 2 diabetes and the majority met the American Diabetes Association target of 7% (53 mmol/mol) HbA1c. An option to continue the trial for another three years was offered and 87% of participants accepted. At five years, mean weight loss was almost 9 kg, HbA1c continued to go down and the number of medications needed to achieve this was significantly reduced. All this was delivered virtually.
A similar trial has been carried out with participants who had impaired fasting glucose, with significant weight loss and improved insulin sensitivity and HbA1c at five years. In another study, Professor Ratner’s team worked with a group of US Veterans Administration participants – a population where adherence to treatment may be problematic and social determinants of health are a very important factor. The 200 participants had obesity and were on one or more medications other than metformin. One year retention was 73% and it was 53% at three years. “People can follow this diet and they stay in the trial because they can see immediate beneficial effects,” said Professor Ratner.
Two years into the trial, glycaemic control had improved, while medications with a risk of hypoglycaemia, such as sulphonylureas, were reduced. And nutritional therapy is cost-effective too, compared with surgery or the new weight-loss medications such as semaglutide and tirzepatide. “Obesity and diabetes are ideal conditions for the application of telehealth in the real world,” Professor Ratner concluded. “Nutritional therapy with asynchronous communications promotes adherence, durability and sustainability.”
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Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.
