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In perhaps one of the most significant changes to occur in health care as a result of the coronavirus disease 2019 (COVID-19) pandemic, telemedicine has suddenly reached the widespread adoption many proponents have championed for years. Recognizing the necessity of telemedicine in light of the current crisis — both to address increased treatment needs and to prevent unnecessary in-person contact — some payors and state legislators have loosened certain restrictions regarding its use across clinical specialties.
Although considerable variation and lack of clarity regarding such changes have been reported, the changes include alterations to rules requiring that patients reside in rural areas with limited access to health care, now allowing for the remote care of patients in all areas.1,2
This unexpected development represents a major boon to diabetes care, which has long been viewed as optimally suited to delivery via telemedicine. A sizable body of research supports its value in the management of adult and pediatric diabetes, with several types of technology used by various providers including endocrinologists and registered dietitians.3-6
In a 2019 meta-analysis published in the journal Telemedicine and e-Health, researchers from several university hospitals in France analyzed 42 randomized controlled trials investigating the use of telemedicine (8 studies used teleconsultation and 34 used device-based telemonitoring) vs usual care in diabetes management.5 They examined data from a total of 6170 patients (mean ages, 13.3-71.0 years) from 12 studies focused on type 1 diabetes, 21 focused on type 2 diabetes, and 9 that included both patients with type 1 and type 2 diabetes.
The results demonstrated a significantly greater mean reduction in hemoglobin A1c (HbA1c) in the telemedicine groups compared with usual care (P <.001), especially in trials lasting >6 months and in patients with type 2 diabetes compared with type 1 diabetes (P <.0001). In addition, greater benefits were observed in older patients (aged 41-50 years or >50 years) compared with younger patients.5
These observations align with findings from a 2018 meta-analysis of 19 studies that included data from a total of 6294 individuals, which showed better glycemic control with telehealth vs usual care (weighted mean difference in glycemic index, -0.22%; 95% CI, -0.28 to -0.15; P < .001).6
Other findings suggest that multiple types of technology can be used to provide these remote care services. A 2018 review found no clear link between technology type (such as telephones, mobile devices, and computers) and patient outcomes in remote diabetes management.7 Even text-only alerts have been found to improve diabetes care: in a 2019 meta-analysis of 11 randomized controlled trials that together included 1710 individuals, interventions involving lifestyle-focused text messaging via mobile phone were associated with an overall HbA1c reduction of 0.38% (95% CI, -0.53 to -0.23; P <.001).8
Tchero et al, whose 2019 review focused on overall clinical effectiveness of telemedicine in diabetes care,5 concluded that “[i]mplementing rigorous and continued training of the intervention team, securing funding to lower the cost of telemedicine care, and development of uniform telemedicine systems can hasten the universal application of telemedicine in diabetes care.”
We checked in with the following experts for additional discussion on the topic: Mark H. Schutta, MD, medical director of the Penn Rodebaugh Diabetes Center and G. Clayton Kyle associate professor of diabetes at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia; and Kellie Antinori-Lent, MSN, RN, ACNS-BC, BC-ADM, CDCES, FADCES, a diabetes clinical nurse specialist at the University of Pittsburgh Medical Center.
What are some ways in which telemedicine is currently being used in diabetes management in the United States?
Dr Schutta: Prior to COVID-19, telemedicine was uncommon but had increased to some extent over the past 2 years. Surgical practices use it for postsurgical follow-up checkups because they are compensated by a single bundled payment. My understanding is that mental health visits, followed by primary care, are the fastest growing televisits, with improved coverage particularly from the Centers for Medicare and Medicaid Services (CMS). Coverage varies from state to state.
Antinori-Lent: Telehealth had been used in diabetes care prior to COVID-19. However, its use was limited due to CMS rules. Only patients in rural designated areas where a shortage of healthcare professionals exists have had such services available. Patients also had to travel to an approved location, such as a provider office, rural health clinic, or dialysis center, for example.
As of March 3, 2020, everything changed. The 1135 waiver of the Coronavirus Preparedness and Response Supplemental Appropriations Act removed these limitations.2 As such, there is no restriction on location of where the patient lives [to be eligible to] receive the care from home. This permits medical visits with endocrinologists as well as remote services for diabetes self-management education and support (DSMES). I should mention that it also permits visits with primary care, which is where most patients with diabetes receive care. Other studies have also shown benefits [of telemedicine] for gestational diabetes and monitoring of retinopathy.9,10
Prior to COVID-19, several companies had been successfully delivering chronic care and population health management via virtual digital platforms. Some examples are Livongo, One Drop, mySugr, and Cecelia Health. Some diabetes device companies, including Tandem and Valeritas/Zealand, have also moved to offering trainings via technology platforms such as Zoom for Healthcare, Skype, and GoToMeeting. Although not for everyone, it is an option that — especially during a pandemic — can enable safe continued care without missing a beat.
What does research and your own experience suggest thus far about telemedicine’s benefits and drawbacks for diabetes management?
Dr Schutta: At Penn, a pilot study for urgent primary care issues drew praise from patients who viewed the care as equal to an in-person visit without the associated obstacles of an office visit.
In the diabetes world where data from meter, pump, and sensor downloads are critical to management, telemedicine is an ideal way to interact with patients. The missing pieces are vital signs, especially blood pressure and weight, but often the patient can monitor these at home and provide trends. Diabetes experts can manage the majority of patients using the HbA1c test and other data the patient has recorded and downloaded to a website. These are easily accessible. I have had patients write down their glucose readings and fax the results as well.
Patients with diabetes are immune-compromised, and telemedicine offers the advantage of shielding them from healthcare environments containing high concentrations of communicable infections. In addition, many patients with diabetes are challenged to ambulate easily; for them, the convenience of telemedicine cannot be underestimated. Patients can schedule a visit that takes place at home or at work, saving transportation time and cost. This is most helpful for patients who live in remote areas of the country and must travel considerable distances for diabetes visits. [However, it is important to remember that patients with diabetes] may have comorbid conditions requiring care from specialists that must occur in person, such as annual (or more frequent) ophthalmology visits.
Antinori-Lent: Patients and providers both enjoy the simplicity and efficiency of this new way of interacting. When you realize the enormous continued growth of diabetes and the availability of resources, telehealth has shown promise. It has also demonstrated the ability to improve access and clinical outcomes with [potential reported] cost savings per interaction. Providers who have been doing this for years have mastered the skill. This takes time, however. When implementing amidst a pandemic, there will be some quick adaptation and subsequent wrinkles to iron out. The challenge focuses mainly on incorporating the new technology into the practice or healthcare system while maintaining privacy and security.
What are some key recommendations for clinicians regarding this topic, whether they are interested in offering services via telemedicine or simply wish to start referring certain patients for telemedicine services?
Dr Schutta: Unfortunately, telemedicine is only viable if the visits are appropriately compensated. One of the benefits of the coronavirus pandemic is that insurers and the CMS have quickly allowed healthcare systems and private practitioners to bill for telemedicine. This is long overdue. The country has an epidemic of diabetes and an unmet demand for diabetes experts to care for them. Video visits are compensated more than telephone visits, but it is simple to use FaceTime or a video app such as Vidyo or Bluejeans to effectively interact with patients. It is helpful for patients to download their data in advance, and like anything new, the process improves with experience on both the provider and patient side.
Antinori-Lent: For Diabetes Care and Education Specialists (formerly known as Diabetes Educators) who are permitted (right now only registered dieticians, nurse practitioners, and clinical nurse specialists are listed in the guidance) and interested in learning how to get started with DSMES telemedicine visits, I would recommend reviewing the Association of Diabetes Care and Education Specialists (ADCES) Coronavirus, Facts, Guidance & Updates for Your Practice resource, along with the Q&A sessions on the same topic.11
For those interested in referring, keep in mind that not all patients are going to be interested in telemedicine, nor will all patients have access to the necessary technology, such as a smartphone, computer, or tablet with camera-ready, audio-capture speakers and an email address. Patient appropriateness must also consider visual or hearing deficits.
What are some additional potential uses of telemedicine in diabetes management, and what are needs in this area?
Dr Schutta: My sense is that telemedicine is more effective for established patients. Patients will need to be seen in person at least once a year, but when possible, initial visits should be done in person because this helps to establish a trusting relationship. Telemedicine can still be used for some elements of physical exam such as rashes and simple podiatric problems, but there will be instances where an in-person visit is absolutely necessary.
In our diabetes center, we constantly provide telephone and email care for patients who contact us with acute concerns and problems. In addition, when we make adjustments to pharmacologic regimens, we ask patients to provide us with an update of their glycemic control and any side effects. Many of these calls could be done via telemedicine, which, when utilized, would be more comprehensive and personal and would hopefully [allow for appropriate compentation for] the clinicians for their time and expertise.
At present, telemedicine must be a minimum of 15 minutes, but this is not practical or reflective of the real world. In today’s healthcare environment, many clinicians are seeing patients for a shorter time yet are billing at a high level for these visits.
Antinori-Lent: [Potential topics for future research on telemedicine include] cost-effectiveness, sustainability, patient engagement and empowerment, and quality of life. [In addition, researchers should investigate] which types of visits are best left face-to-face vs telehealth, and which type of visit encourages relationship-based care and more meaningful interactions.
References
1. Farr C. Telemedicine has a big role in the coronavirus fight, but doctors say the laws remain murky. CNBC. March 18, 2020. https://www.cnbc.com/2020/03/18/telemedicine-has-role-to-play-in-covid-19-fight-but-laws-are-murky.html
2. Centers for Medicare & Medicaid Services. Medicare telemedicine health care provider fact sheet. March 17, 2020. Accessed April 7, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
3. McLendon SF, Wood FG, Stanley N. Enhancing diabetes care through care coordination, telemedicine, and education: evaluation of a rural pilot program. Public Health Nurs. 2019;36(3):310-320.
4. Benson GA, Sidebottom A, Hayes J, et al. Impact of ENHANCED (Dieticians Helping Patients Care for Diabetes) telemedicine randomized controlled trial on diabetes optimal care outcomes in patients with type 2 diabetes. J Acad Nutr Diet. 2019;119(4):585-598.
5. Tchero H, Kangambega P, Briatte C, Brunet-Houdard S, Retali G-R, Rusch E. Clinical effectiveness of telemedicine in diabetes mellitus: a meta-analysis of 42 randomized controlled trials. Telemed J E Health. 2019;25(7):569-583.
6. Wu C, Wu Z, Yang L, et al. Evaluation of the clinical outcomes of telehealth for managing diabetes: a PRISMA-compliant meta-analysis. Medicine (Baltimore). 2018;97(43):e12962.
7. Hammett J, Sasangohar F, Lawley M. Home telemonitoring platforms for adults with diabetes mellitus: a narrative review of literature. Proc Hum Factors Ergon Soc Annu Meet. 2018;62(1):508-512.
8. Haider R, Sudini L, Chow CK, Cheung NW. Mobile phone text messaging in improving glycaemic control for patients with type 2 diabetes mellitus: a systematic review and meta-analysis. Diabetes Res Clin Pract. 2019;150:27-37.
9. Rasekaba TM, Furler J, Blackberry I, Tacey M, Gray K, Lim K. Telemedicine interventions for gestational diabetes mellitus: a systematic review and meta-analysis. Diabetes Res Clin Pract. 2015;110(1):1-9.
10. Gao X, Park CH, Dedrick K, et al. Use of telehealth screening to detect diabetic retinopathy and other ocular findings in primary care settings. Telemed J E Health. 2019;25(9):802-807.
11. Association of Diabetes Care & Education Specialists. Coronavirus facts, guidance & updates for your practice. Accessed April 7, 2020. https://www.diabeteseducator.org/practice/practice-tools/app-resources/covid-19-information
