Improving diabetes outcomes-at a distance

Telemedicine and telehealth are broad terms that refer to a range of technologies and services. At the heart of both of these is the ability to improve care through the easy exchange of information between patients and providers.

Some of the technologies that fall into this category include video conferencing with doctors, use of email or specialized websites, mobile applications on cell phones and automated transmission of data from devices and monitors to healthcare professionals. Telemedicine has become more common and more sophisticated over the past few years.

Telemedicine addresses a number of important overarching issues in our healthcare system as well as specific issues related to diabetes care.

1. Manpower. The Affordable Care Act and launch of insurance exchanges has increased the number of Americans with health insurance and the number seeking care. This is increasing the burden on a healthcare system with too few providers, and distribution issues in terms of medical specialties and geographic location. Telemedicine can help fill in some of these gaps.

2. Specialty care. Many medical specialties are short staffed or not available in remote or rural areas. Telemedicine programs can help make the specialists who reside in a large city and practice at a major center available to patients and primary care physicians anywhere in the country. This is of special interest in diabetes because endocrinologists and diabetologists are not available everywhere. In addition, diabetic patients may have need for ophthalmology and other services that may not be readily available.

3. Team care. The use of multispecialty teams has been shown to be advantageous in a number of healthcare settings but not all team members can be co-located. This is especially true of mental health professionals and social workers who may be in short supply in some locations.

4. Data transfer and monitoring. Glucose meters, continuous glucose meters, and insulin pumps generate a great deal more data and more accurate data than previously used hand written logs. This data can now be passed seamlessly from the patient’s devices to healthcare professionals who can use available software to analyze and interpret the data.

Important considerations

Protection of medical data is regulated by federal privacy laws (HIPAA) but more importantly should be of concern to all healthcare providers and entities for ethical reasons. Any electronic transfer of data should be through secure channels in which patients can have confidence in privacy.

Another important issue is that of effectiveness. Telemedicine may not be appropriate or helpful for certain patients or for certain conditions. Learning how and when to use telemedicine in diabetes will guide programs and willingness to use these technologies.

NEXT: Telemedicine and diabetes study results

Role in diabetes: some evidence

If telemedicine can solve some of the important issues of access to specialty care and improved transfer of timely data there could be a major impact on care and outcomes for patients with diabetes.

Can telemedicine improve outcomes? The answer is yes, according to a recent study published in Health Affairs, "Mobile Phone Diabetes Project Led To Improved Glycemic Control And Net Savings For Chicago Plan Participants,"

In this study of adult employees of an academic medical center, a mobile phone enabled program demonstrated improvements in all three components of the triple aim (improving population health, improving the patient experience and lowering cost).

The study yielded significant improvements in glycosylated hemoglobin with the average A1C dropping from 7.9 to 7.2 and larger improvements in the poorly controlled group from 10.3 to 8.5%. Patients had a good experience in the program with 77% saying they would participate in a similar program in the future. And, costs for participants fell by $893 from $2,624 to $1,754 in the six month study period.

In a different study, "Use of Telemedicine to Improve Adherence to American Diabetes Association Standards in Pediatric Type 1 Diabetes," Telemedicine was shown to improve access to care and reduce work and school loss for children with Type 1 diabetes. In this study, 54 patients in rural Colorado participated in a one-year study of telemedicine and compliance with American Diabetes Association guidelines. Although there was no change A1C, there was significant improvement in school attendance for the patients and work attendance for their adult caregivers.

Use of Skype for delivery of Behavioral Family Systems Therapy for Diabetes was shown to have similar results to face-to-face meetings, according to a study appearing in Diabetes Care, "Seeing Is Believing: Using Skype to Improve Diabetes Outcomes in Youth."

Data transfer and analysis is highlighted in a study on home telemonitoring for adults with Type 2 diabetes, "A Randomized Trial on Home Telemonitoring for the Management of Metabolic and Cardiovascular Risk in Patients with Type 2 Diabetes."

In this study from Italy, general practitioners enrolled 302 patients in a randomized study of home telemonitoring. The intervention group was monitored remotely for body weight, blood glucose and blood pressure over a 12-month period. The proportion of patients reaching the A1C goal of  less than 7% was 33% in the intervention group and just 18.7% in the control group. Body weight, blood pressure and lipid measures remained consistent between the groups but the intervention group did show a marked improvement in SF-36 scores.

In summary, several studies (many more than reviewed here) have demonstrated that telemedicine programs of different types can yield the same or better results than more traditional interventions. This may lead to better care in a variety of situations and help us reach the triple aim in diabetes.