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The rapid escalation of telemedicine due to COVID-19 is likely to shift paradigms in the way type 1 diabetes care is delivered in the future, regardless of how the pandemic unfolds, experts say.
"Because of COVID-19 there's been a need to keep people out of the physician's office and keep them at home, and that's opened up the opportunity for telemedicine to flourish," David C. Klonoff, MD, medical director of the Dorothy L. and James E. Frank Diabetes Research Institute of Mills-Peninsula Health Services in San Mateo, California, told Medscape Medical News.
But use of digitally transmittable continuous glucose monitoring (CGM) among patients with diabetes mostly in type 1 diabetes but some with type 2 diabetes as well was already happening pre-pandemic.
So the phenomenon of "tele-diabetes" including communication via video conferencing, telephone, secure smartphone apps, email, or patient portal is likely here to stay, say Klonoff and others.
That is, as long as the loosening of the red tape that has enabled this both in the US and Europe is maintained long-term, they say.
Gregory P. Forlenza, MD, a pediatric endocrinologist at the Barbara Davis Center (BDC), Aurora, Colorado, agrees: "We believe that type 1 diabetes is especially well-suited for telehealth when this pandemic is over, whereas some other areas of medicine might not be ideal for home-based care and not having physical exams."
Both Forlenza and Klonoff nevertheless say there will still be limitations for certain aspects of diabetes care patients will still need to make in-person visits for physical exams and laboratory work,including A1c measurement at least annually.
Those people who are less technically inclined may need additional in-person help with using the devices and uploading data, at least initially. Current integration of the various device data into electronic health records is also still very clunky.
For patients with low health literacy and/or lack of access to technology"tele-diabetes" may not be feasible at all.
And data will be needed to show that tele-diabetes is both effective and cost-effective.
"Just as we're doing an experiment with social isolation and we hope it's right, we're doing an experiment with telemedicine and we hope it's right. We have no data," Klonoff observed.
To address this issue, three newly published articles describe some interesting cases of diabetes telecare delivered during COVID-19 through a variety of platforms.
The first article, by lead author Satish K. Garg, MD, also of the BDC, and colleagues, describes two patients one adult, one pediatric with new-onset type 1 diabetes managed remotely following initial hospitalization during the pandemic. It was recently featured in Diabetes Technology & Therapeutics, and Forlenza is a senior author.
Garg is also an author of another article published in the same journal, which covers two adults with type 1 diabetes with ketosis and hyperglycemia in whom hospitalization for diabetic ketoacidosis (DKA) was successfully avoided during the pandemic with remote management. One of them was newly diagnosed with type 1 diabetes.
The third article, a commentary by Thomas Danne, MD, of the Diabetes Centre for Children and Adolescents, Hannover, Germany, and Catarina Limbert, MD, PhD, of Central Lisbon University Hospital Centre, Portugal, offers a European perspective with a focus on pediatric type 1 diabetes telemedicine, and was published in Lancet Diabetes & Endocrinology.
Forlenza said that in new-onset type 1 diabetes, unless the patient and family are already familiar with the condition, the first visit really does need to be in-person.
"Especially in pediatrics you need to deal with needle phobia and the anxiety, and letting parents do it themselves with saline so they can see that the microneedles we use really aren't painful. Those things really need to be done under the direct supervision of a healthcare professional," he said.
But after that, with CGM, the data can be uploaded via phone or computer. Currently with most insulin pumps the data can only be uploaded via computer, but that will change with time, as closed-loop technologies progress.
Forlenza has been using tele-diabetes for the past 5 years for his patients in remote areas.
"I think the biggest advantage is limiting missed time from school and work. The physicians are still keeping normal business hours, but at least there's no travel time," he said.
"Also, with home telemedicine, kids are in their home environment and feel a lot more comfortable, relaxed, and conversive. I think that's a big benefit of this framework."
Drilling down into the details of individual patients, one of the reported new-onset cases was a 20-year-old man initially admitted to hospital with DKA who was in intensive care for 2 days.
He was then seen in person for new-onset diabetes education. He was started on multiple daily insulin injections and given a Dexcom G6 CGM sensor for free by the BDC to avoid insurance hassles.
Because of the COVID-19 lockdown, his follow-up visits every day for 7 days were conducted virtually.
The man shared his data with the team via the Dexcom Clarity app, and his insulin doses were adjusted based on the data. His time-in-range went from 16% at the time of his hospitalization to 37% with no time below range at his 2-week virtual visit. (He subsequently had a honeymoon phase with 90% time-in-range on very low insulin doses.)
The pediatric new-onset case was a 12-month-old girl from rural Wyoming who was medevaced to the BDC with moderate DKA.
She was put on an Omnipod Eros insulin pump and a Dexcom G6 CGM. The family was taught how to use the devices andupload the data the pump via the Glooko app and the Dexcom via the Clarity app, both linked to the respective BDC accounts.
Both the parents and the BDC physician were able to follow the child's blood glucose levels using the Dexcom Follow app. Using the data and the child's anticipated food intake, the physician instructed the mother by phone and email to make daily insulin dose adjustments and provided education for future dosing. The child's glucose levels improved over the subsequent 2 weeks.
One of two patients at risk for DKA was a 21-year-old college student who developed COVID-19 symptoms soon after returning home from college after his campus had closed because of the pandemic.
He had been on an insulin pump and obtained unused CGM sensors and a transmitter from a friend.
Despite weakness, nausea, and strongly positive urine ketones, he managed to take fluids and insulin doses at home while his diabetes team monitored his glucose remotely, and was able to recover without needing to physically interact with the healthcare system.
The other case was a 26-year-old woman already diagnosed with diabetes insipidus who then developed new-onset type 1 diabetes in mid-April, with hyperglycemia and ketosis but not DKA.
She made just one outpatient visit for basic education and was provided with insulin and technology (again, the CGM was provided free), with subsequent remote management including daily insulin adjustments for 7 days, with subsequent periodic tele-visits with a certified diabetes care and education specialist. Her time-in-range went from 13% to 51% at day 6 to 90% subsequently.
The physicians say it's not clear yet whether the emergency regulatory changes that have facilitated telemedicine use during the COVID-19 pandemic will be continued once the threat has eased.
These include changes by the US Centers for Medicare & Medicaid Services allowing physicians to be reimbursed for tele-health visits during the COVID-19 pandemic and some changes by the US Department of Health & Human Services "easing previous restrictions on communication via popular technologies such as FaceTime or Skype," Klonoff explained.
Forlenza has been lobbying local representatives in Colorado to keep the new rules.
"For us in diabetes, it would be very useful. We hope to see that it stays and those emergency provisions are kept in place," he says.
In their article, Danne and Limbert see the same thing happening in Europe.
"Before the COVID-19 pandemic, it was thought that telemedicine approaches would only become established...if it was possible to show in long-term studies that the use of telemedicine leads to significant savings in time and costs," they write.
"However, according to the COVID-19 forum on the International Society for Pediatric and Adolescent Diabetes website, the establishment of these approaches is now happening within days in pediatric diabetes centers around the globe," they explain.
Now, they say, "Rules for access to telemedicine have become more relaxed, families and hospitals have fewer concerns regarding data safety, and remunerations appear to be less important."
Klonoff believes the same will be true of new rules that allow patients' own diabetes devices, including some CGMs, in the hospital during the pandemic.
"The longer that something is used, be it CGM in the hospital or telemedicine for medical care, and the more established it is, the more people are going to be upset to give it up. I think both of those are going to become established, and I think the regulators and payers will go along with it," he said.
Forlenza has reported conducting research supported by Medtronic, Dexcom, Abbott, Insulet, Tandem, and Lilly, and serving as a speaker, consultant, and/or advisory board member for Medtronic, Dexcom, Abbott, Insulet, Tandem, and Lilly. Klonoff has reported being a consultant for Abbott, Ascensia, Dexcom, EOFlow, Fractyl, Lifecare, Novo Nordisk, Roche, and Thirdwayv. Danne has reported receiving grants and personal fees from AstraZeneca, Lilly, and Sanofi, and personal fees from Novo Nordisk, Medtronic, Roche, Boehringer Ingelheim, and Dexcom; and being a shareholder of DreaMed Diabetes, which develops commercial algorithms for dosing advisors. Limbert has reported receiving grants and personal fees from Abbott, Ipsen, and Sanofi.
Diabetes Technol Ther. Published online April 17 and May 5, 2020. Article 1, Article 2
Lancet Diabetes Endocrinol. Published online May 5, 2020. Full text
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