If you have diabetes and live in rural America, the closest specialist may be hours away. But new research shows that effective help may be as close as your phone.
The study found that a six-month telehealth program led to a significant drop in blood sugar levels. Participants had an average A1C level of 9.25% at the study’s start and an average of 7.89% at the end. That benefit was maintained a year after the study ended.
A1C tests estimate average blood sugar levels over two to three months. Targets are individualized, but the goal for most adults is under 7%, according to the American Diabetes Association.
“In general, diabetes is an extremely self-management-intensive disease,” said study senior author Dr. Matthew Crowley. He’s a staff physician at the Durham VA Health Care System in North Carolina.
For some people, occasional appointments with their primary care doctor may provide enough support. But it’s far more difficult for those on more complex insulin regimens to manage on their own.
“You have to inject insulin multiple times a day, and check your blood sugar by pricking your finger for blood multiple times a day. You may need to eat food at a certain time, and you may need to restrict foods too,” Dr. Crowley said. “When you compare that to people who just need a simple medicine, and then add other conditions like (high blood pressure and abnormal cholesterol), it can really be overwhelming for a lot of folks. For this group, clinic-based care doesn’t always cut it.”
Luis Casas, M.D., is a Sanford Health endocrinologist in Fargo, North Dakota, specializing in pediatric endocrinology. He tells Sanford Health News he’s not surprised by the findings of this study.
“The more providers review blood sugars and make insulin adjustments for those not in target, the better the overall control,” Dr. Casas said.
Helping veterans with telehealth intervention
The study included 125 people with type 2 diabetes. Most were male and most were white. Every two weeks, participants uploaded data from their blood sugar meters or other diabetes devices. After the information was reviewed, the patients were provided support and education over the phone to help them better manage their diabetes. If needed, medications were adjusted.
“For some people, the medication management piece was critical, but I think the improvements were more than the medication,” Dr. Crowley said. “A lot of our patients told us that just knowing someone was reviewing the data made them more committed to self-management.”
During the maintenance phase, researchers moved to monthly review of blood sugar. Though less frequent, Dr. Crowley said, the continued review probably helped patients maintain their improved blood sugar.
But, he added, they likely gained skills along the way that helped, too.
Along came COVID-19
This study started in 2017, long before the emergence of the novel coronavirus. While health care via phone and internet has flourished since the pandemic began, Dr. Crowley said this study shows that “diabetes is well-suited to telehealth management. It allows for more frequent contacts in a way that is more efficient.”
According to the U.S. Centers for Disease Control and Prevention, having type 2 diabetes increases your risk of severe illness from COVID-19. Also, based on current evidence, having type 1 or gestational diabetes may increase your risk of severe illness from COVID-19.
Dr. Leslie Eiland, an endocrinologist at the University of Nebraska Medical Center in Omaha, reviewed the findings. She praised the VA as a leader in telehealth interventions.
“The study was really efficient and used existing infrastructure, so they really didn’t have to reinvent the wheel,” Dr. Eiland said. “And, they certainly achieved clinically significant drops in A1C, and those improvements were sustained.”
But Dr. Eiland said the study had some limitations: The VA population isn’t always representative of the country as a whole, so the findings might differ in a more diverse population. Plus, access to telehealth hasn’t always been easy for patients with private insurance, she noted.
Dr. Eiland has also been involved in a telehealth study for rural residents. Her study focused on people with type 1 diabetes.
In many parts of the Midwest, access to a diabetes specialist is difficult. Instead of driving far, study volunteers went to a local community hospital and met with a registered nurse. During the visit, they were connected by phone to Dr. Eiland or another endocrinologist. The study showed a modest decline in their A1C levels over at least three telehealth visits.
Both studies were presented at an online meeting of the American Diabetes Association. Findings presented at meetings are typically viewed as preliminary until they’ve been published in a peer-reviewed journal.
Virus’ impact on patients, telehealth
With heightened restrictions during the coronavirus pandemic, Dr. Casas’ Sanford Health clinic offered video visits with an excellent response from families with diabetes patients.
“Many of our pumps and continuous glucose sensors can be downloaded and uploaded from home or available on the cloud for us to view all their data so that we can review with the patient while having discussions about how they are doing, concerns, pitfalls, et cetera,” Dr. Casas explained.
“During the pandemic, I had one newly diagnosed child in Bismarck that were unable to come to Fargo and were able to do all of her initial and follow up visits by Zoom while she worked closely with the local diabetes educator. She’s doing great and shows how well you can do with combining telehealth with local services.”
Sanford will continue to offer telehealth visits for those who cannot come to his Fargo clinic or are afraid because of the pandemic. But patients are encouraged to call regularly to review glucose patterns.
“All of our children with diabetes are complex in that they have complicated insulin regimens where they take injections usually no less than four times a day or on insulin pumps, plus or minus continuous glucose monitors,” Dr. Casas said.
“When a child or adolescent is first diagnosed and start insulin, we insist on them calling almost daily if not every two or three days to review their blood glucose levels. All other patients are encouraged to call at least once every two weeks or per month or if they note unusual glucose pattern trends so that our diabetes educators make insulin adjustments over the phone.”
He says this allows adjustments of insulin even between visits.
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