Telemedicine for the Clinical Management of Diabetes; Implications and Considerations After COVID-19 Experience

Clinical and cost-effectiveness of telemedicine among patients with type 2 diabetes in primary care: A systematic review and meta-analysis

AIMS

Telemedicine has been promoted as an effective way of managing type-2 diabetes (T2DM) in primary care. However, the effectiveness of telemedicine is unclear. We investigated the clinical and cost-effectiveness of different telemedicine interventions for people with T2DM, compared to usual care.

METHODS

We searched Medline, Embase, Cochrane, CINHAL, ProQuest and EconLit for randomized controlled trials (RCTs) that examined the effectiveness of telemedicine interventions on clinical outcomes (HbA1c, body mass index [BMI], weight, diastolic blood pressure [DBP], systolic blood pressure [SBP], fasting blood glucose, high-density lipoprotein [HDL] cholesterol, low-density lipoprotein [LDL] cholesterol, total cholesterol and triglyceride) in adults with T2DM, published in English from inception until 31 December 2022. Meta-analyses were conducted using random-effects models pooling mean differences, heterogeneity was quantified using the I2 statistic. Publication bias was assessed using funnel plots, Egger tests and trim and fill. Subgroup analyses included type of telemedicine intervention, telemedicine mode of delivery and type of healthcare professionals. This study was registered with PROSPERO, CRD 42022375128.

RESULTS

Of the 4093 records identified, 21 RCTs, 10,732 participants from seven regions, were included. Reported interventions included telephone (k = 16 studies), internet-based (k = 2), videoconference (k = 2) and telephone and emails (k = 1). We observed no statistically significant differences between synchronous or asynchronous telemedicine interventions compared to usual care for HbA1c (-0.08% (-0.88 mmol/mol); 95% CI: -0.18, 0.02), BMI (0.51 kg/m2; 95% CI: -0.21, 1.22), SBP (-1.48 mmHg; 95% CI: -3.22, 0.26), DBP (3.23 mmHg; 95% CI: -0.89, 7.34), HDL-cholesterol (0.01 mmol/L; 95% CI: -0.03, 0.05), LDL-cholesterol (0.08 mmol/L; 95% CI: -0.22, 0.37), triglycerides (-0.08 mmol/L, 95% CI: -0.31, -0.15), total cholesterol (-0.10 mmol/L; 95% CI: -0.25, 0.04) and weight (-0.50 kg; 95% CI: -1.21, 0.21).

CONCLUSIONS

Telemedicine was as effective as usual care in improving health outcomes of people with T2DM. They can provide a safe solution in times of rising demands for primary healthcare services, or in extreme events, like a global pandemic. More high-quality RCTs are needed on the cost evaluation of telemedicine.

Type 1 and Covid-19: Diagnosis, Clinical Care, and Health Outcomes during the Pandemic

The coronavirus disease 2019 (COVID-19) pandemic disrupted health care, creating challenges for people with diabetes and health care systems. Diabetes was recognized as a risk factor for severe disease early in the pandemic. Subsequently, risk factors specific for people with type 1 diabetes were identified, including age, hemoglobin A1c level, and lack of continuous glucose monitoring . Telemedicine, especially when accompanied by diabetes data, allowed effective remote care delivery. However, pre-existing racial disparities in access to diabetes technology persisted and were associated with worse outcomes. Events of the COVID-19 pandemic underscore the importance of continuing to develop flexible and more equitable health care delivery systems.

A Hybrid Model of In-Person and Telemedicine Diabetes Education and Care for Management of Patients with Uncontrolled Type 2 Diabetes Mellitus: Findings and Implications from a Multicenter Prospective Study

Background

Patients with uncontrolled type 2 diabetes mellitus (T2DM) require close follow-up, support, and education to achieve glycemic control, especially during the initiation or intensification of insulin therapy and self-care management. This study aimed to describe and evaluate the impact of implementing a hybrid model of in-person and telemedicine care and education on glycemic control for patients with uncontrolled T2DM (hemoglobin A1c [HbA1c] ≥9%) during the coronavirus disease pandemic.

Methods

This prospective multicenter-cohort pre-/post-intervention study was conducted on patients with uncontrolled T2DM. This study included three chronic illness centers affiliated with the Family and Community Medicine Department at Prince Sultan Military Medical City in Riyadh, Saudi Arabia. A hybrid model of in-person (onsite) and telemedicine care and education was developed. This involved implementing initial in-person care at the physicians' clinic and initial in-person education at the diabetes education clinic, followed by telemedicine services of tele-follow-ups, support, and education for an average 4-month follow-up period.

Results

Of the enrolled 181 patients, more than half of the participants were women (n = 103, 56.9%). The mean age of participants (standard deviation) was 58.64 ± 11.23 years and the mean duration of diabetes mellitus was 13.80 ± 8.55 years. The majority of the patients (n = 144; 79.6%) were on insulin therapy. Overall, in all three centers, the hybrid model had significantly reduced HbA1c from 10.47 ± 1.23% to 7.87 ± 1.59% (mean difference of reduction 2.59% [95% confidence interval (CI) = 2.34-2.85%], p < 0.001). At the level of each center, HbA1c was reduced significantly with mean differences of 3.17% (95% CI = 2.81-3.53%), 2.49% (95% CI = 1.92-3.06%), and 2.16% (95% CI = 1.76-2.57%) at centers A, B, and C, respectively (all p < 0.001).

Conclusion

The findings showed that the hybrid model of in-person and telemedicine care and education effectively managed uncontrolled T2DM. Consequently, the role of telemedicine in diabetes management could be further expanded as part of routine diabetes care in primary settings to achieve better glycemic control and minimize nonessential in-person visits when appropriate.

The Effect of Pharmacist-Led Telemedicine on A1c Reduction During the COVID-19 Pandemic

Purpose: Diabetes remains a prevalent metabolic chronic condition. The pandemic promoted the use of telemedicine for patients with chronic conditions. Telemedicine offers innovative methods to achieve glycemic control for these patients. This study evaluates the effectiveness of telemedicine with pharmacists in reduction of glycated hemoglobin (A1C) for patients with diabetes. Methods: This study (n = 112) was a single-center, retrospective study that evaluated the effectiveness of patients enrolling in pharmacist-led diabetes management utilizing telemedicine during the COVID-19 pandemic. Patients with an A1C >9 mg/dL were contacted for telemedicine with the pharmacy team. The three groups included: patients agreeing to the telemedicine visit (n = 28), patients that declined the telemedicine visit (n = 42), and patients that did not answer the telephone when offered the telemedicine visit (n = 28). Results: Our study revealed a significant change in the primary endpoint A1C (2.6 + 2.4, p = 0.0144) for the patients who accepted telemedicine visits when compared with the other study groups. The secondary endpoints, changes in A1C (when evaluating employment status, number of clinic visits, number of chronic conditions, gender, race) and changes in body mass index, revealed no significant changes. Conclusion: Diabetes management using telemedicine with pharmacists impacts glycemic control in patients with type 2 diabetes. This study demonstrates patients who accepted pharmacist-led telemedicine had a reduction in A1C. Further research may reveal long-term benefits on clinical outcomes after utilizing this service during the COVID-19 pandemic.

Telehealth and cardiometabolic-based chronic disease: optimizing preventive care in forcibly displaced migrant populations

The number of migrants, which includes forcibly displaced refugees, asylum seekers, and undocumented persons, is increasing worldwide. The global migrant population is heterogeneous in terms of medical conditions and vulnerability resulting from non-optimal metabolic risk factors in the country of origin (e.g., abnormal adiposity, dysglycemia, hypertension, and dyslipidemia), adverse travel conditions and the resulting stress, poverty, and anxiety, and varying effects of acculturation and access to healthcare services in the country of destination. Therefore, many of these migrants develop a high risk for cardiovascular disease and face the significant challenge of overcoming economic and health system barriers to accessing quality healthcare. In the host countries, healthcare professionals experience difficulties providing care to migrants, including cultural and language barriers, and limited institutional capacities, especially for those with non-legal status. Telehealth is an effective strategy to mitigate cardiometabolic risk factors primarily by promoting healthy lifestyle changes and pharmacotherapeutic adjustments. In this descriptive review, the role of telehealth in preventing the development and progression of cardiometabolic disease is explored with a specific focus on type 2 diabetes and hypertension in forcibly displaced migrants. Until now, there are few studies showing that culturally adapted telehealth services can decrease the burden of T2D and HTN. Despite study limitations, telehealth outcomes are comparable to those of traditional health care with the advantages of having better accessibility for difficult-to-reach populations such as forcibly displaced migrants and reducing healthcare associated costs. More prospective studies implementing telemedicine strategies to treat cardiometabolic disease burden in migrant populations are needed.

Telemedicine and Digital Medicine in the Clinical Management of Hypertension and Hypertension-Related Cardiovascular Diseases: A Position Paper of the Italian Society of Arterial Hypertension (SIIA)

High blood pressure is the leading cause of death and disability globally and an important treatable risk factor for cardiovascular, cerebrovascular and chronic kidney diseases. Digital technology, including mobile health solutions and digital therapy, is expanding rapidly in clinical medicine and has the potential to improve the quality of care and effectiveness of drug treatment by making medical interventions timely, tailored to hypertensive patients' needs and by improving treatment adherence. Thus, the systematic application of digital technologies could support diagnosis and awareness of hypertension and its complications, ultimately leading to improved BP control at the population level. The progressive implementation of digital medicine in the national health systems must be accompanied by the supervision and guidance of health authorities and scientific societies to ensure the correct use of these new technologies with consequent maximization of the potential benefits. The role of scientific societies in relation to the rapid adoption of digital technologies, therefore, should encompass the entire spectrum of activities pertaining to their institutional role: information, training, promotion of research, scientific collaboration and advice, evaluation and validation of technological tools, and collaboration with regulatory and health authorities.

Telemedicine and HIV Care Quality Measures During the COVID-19 Pandemic

BACKGROUND

During the COVID-19 pandemic, telemedicine was adopted to ensure continuity of HIV care. We examined how introducing televisits affected technical quality of care for people with HIV (PWH) during this time.

METHODS

PWH receiving HIV care at Howard Brown Health Centers and Northwestern University in Chicago, Illinois were included. HIV care quality indicators were calculated using data extracted from electronic medical records during 4 timepoints every 6 months from March, March 1, 2020 to September 1, 2021. Generalized linear mixed models estimated differences in indicators across timepoints within each site while controlling for multiple observations of individuals. Generalized linear mixed models were also used to compare differences in outcomes among PWH who attended all versus a combination of in-person and televisits versus no televisits across the study time periods.

RESULTS

6447 PWH were included in the analysis. Compared with prepandemic levels, there were significant declines in care utilization and processes of care measures. Measures of HIV virologic suppression, blood pressure control, and HbA1C <7% (in both people with and without diabetes) were stable with no significant differences noted across the study timepoints. Similar trends were observed across all age, race, and sex subgroups. In multivariable models, televisits were not associated with decreased HIV viral suppression.

CONCLUSIONS

During the COVID-19 pandemic and rapid implementation of televisits, indicators of care utilization and processes of care decreased compared with prepandemic levels. Among PWH who remained in care, televisits were not associated with worse virologic, blood pressure, and glycemic control in PWH.

The Effect of Telemedicine in Glycemic Control in Adult Patients with Diabetes during the COVID-19 Era-A Systematic Review

Telemedicine can be an effective tool for managing chronic diseases. The disruption in traditional diabetes care resulting from the COVID-19 pandemic led to global interest in telemedicine. With this manuscript, we evaluated the use of telemedicine for the management of diabetes during the pandemic and its impact on glycemic control, focusing on retrospective and prospective studies which included adult, non-pregnant patients with diabetes. We evaluated whether there was an improvement in HbA1c, time in range (TIR), glucose management indicator (GMI), mean glucose values, hypoglycemic episodes, time below range (TBR), or hospitalizations for hypoglycemia/DKA, depending on the available information provided. This review article highlights the benefits of telemedicine during the global state of emergency, which altered the standard of healthcare delivery. Across the studies reported in this review, telemedicine was shown to be an effective tool for the management of diabetes, illustrating its potential to be the new standard of care. Although these improvements may be confounded by potential extraneous factors present during the pandemic, telemedicine was shown to positively impact glycemic control. Overall, this article highlights the benefits of telemedicine on glycemic control during the global state of emergency, which altered the standard of care. With the rollback of COVID-19 restrictions, and a return to the office, this article emphasizes the necessity to study how telemedicine can be best utilized for diabetes management when compared to the traditional standard of care.

The metabolic control and laboratory evaluation in patients with type 2 diabetes during the COVID-19 pandemic and the impact of telemedicine: a single-center experience

Objective: The study aimed to evaluate the metabolic control during the COVID-19 pandemic in subjects with type 2 diabetes mellitus (T2DM) and whether care through telemedicine significantly impacted it.

Material and methods: This was a retrospective study for which three time-periods were prespecified: the COVID-19 pandemic period, pre-COVID-19 period, and before pre-COVID-19. The following information were collected: anthropometric and laboratory parameters (glycated hemoglobin (HbA1c), blood glucose, lipid profile, creatinine, eGFR, etc.), self-measured blood glucose (SMBG), blood pressure (BP), diabetes therapy, number of on-site and of telemedicine consultations. The mean values of all available measurements for HbA1c, SMBG, BP, weight, and body mass index (BMI) were calculated.

Results: During the COVID-19 pandemic, the HbA1c values increased (6.78±0.77% to 6.96±0.87%, p<0.0001; + 0.18±0.67%), despite treatment intensification (p<0.01), while BMI and total cholesterol values slightly decreased (32.01±5.5 kg/m2 to 31.7±5.4 kg/m2, p<0.0001, and 178.1±40.8 mg/dl to 170.5±38.4 mg/dl, p<0.05). The deterioration of glycemic control (to HbA1c >7%) were rather seen in males (to 7.01±0.92%, p<0.0001), patients from rural areas (to 7.08±0.96%, p<0.001) and younger than 65 y.o. (to 7.05±0.82%, p<0.001). More male patients had a mean HbA1c increase of >0.5% during the COVID-19 pandemic (32.3% vs 21.5%, p<0.05). Patients who received more diabetes care visits through telemedicine had a more attenuated increase in HbA1c (6.79±0.80% to 6.90±0.83%, p<0.05 vs 6.76±0.72% to 7.08±0.92%, p<0.0001).

Conclusions: The glycemic control slightly deteriorated during the COVID-19 pandemic (but with overall HbA1c within target), with certain patient categories being more affected. Diabetes care though telemedicine allowed the maintenance of the metabolic control.

Systematic Review and Meta-Analysis of Telecoaching for Self-Care Management among Persons with Type 2 Diabetes Mellitus

BACKGROUND

In response to the need for safe care for people with diabetes mellitus in the current outbreak of COVID-19, it is critical to evaluate the model, service delivery, feasibility, and efficiency of diabetes mellitus telecoaching.

OBJECTIVE

This study aimed to conduct a systematic review and meta-analysis of the model and efficacy of telecoaching to improve self-care and clinical outcomes.

METHODS

This study uses the Preferred Reporting Item for Systematic Review and Meta-Analysis (PRISMA). We searched on 22 March 2022, using keywords that matched the MeSH browser in four databases to find relevant studies, namely, PubMed/Medline, Proquest, Scopus, and EBSCOhost. Additionally, we collected randomized controlled trials (RCTs) on Google Scholar using the snowball technique. A quality assessment was performed using the Cochrane Collaboration's Risk of Bias tool (RoB)2. The meta-analysis used the DerSimonian-Laird random-effects model to analyze the pooled mean difference (MD) and its p-value.

RESULTS

Thirteen RCT studies were included for the systematic review and meta-analysis with a total number of participants of 3300. The model of telecoaching is a form of using nurses-led telephone and mobile apps, which are relatively cost-effective. The meta-analysis showed a positively improved statistically significance in clinical outcomes, including in HbA1c (a pooled MD of -0.33; 95% CI: -0.51--0.15; p = 0.0003), blood glucose (-18.99; 95% CI: -20.89--17.09; p = 0.00001), systolic blood pressure (-2.66; 95% CI: -3.66--1.66; p = 0.00001), body mass index (-0.79; 95% CI: -1.39--0.18; p = 0.01), and weight (-2.16 kg; 95% CI: -3.95--0.38; p = 0.02). It was not, however, statistically significant in diastolic blood pressure (-0.87; 95% CI: -2.02-0.28; p = 0.14), total cholesterol (-0.07; 95% CI: -0.26-0.12; p = 0.46), low-density lipoprotein (-2.19; 95% CI: -6.70-2.31; p = 0.34), triglycerides (-13.56; 95% CI: -40.46-13.35; p = 0.32) and high-density protein (0.40; 95% CI: -1.12-1.91; p = 0.61).

CONCLUSIONS

The telecoaching with nurses-led telephone and mobile apps significantly affected clinical outcomes on HbA1c, systolic blood pressure, weight, and BMI. Moreover, there was no significant effect on the total cholesterol, low-density lipoprotein, triglycerides, and high-density lipoprotein. Thus, telecoaching has the potential as a care model in diabetes mellitus during COVID-19 and similar pandemics to improve self-care and clinical outcomes, but all the studies analyzed involved non-COVID-19 patients, limiting the generalizability of the results to COVID-19.

Changing Patterns of Antihyperglycaemic Treatment among Patients with Type 2 Diabetes in Hungary between 2015 and 2020-Nationwide Data from a Register-Based Analysis

Background and objectives: In the last couple of years, pharmacological management of patients with type 2 diabetes mellitus (T2DM) have been markedly renewed. The aim of this study was to analyse the changes in prescribing patterns of antidiabetic drugs for treating patients with T2DM in Hungary between 2015 and 2020. Material and Methods: In this retrospective, nationwide analysis, we used the central database of the National Health Insurance Fund. We present annual numbers and their proportion of T2DM patients with different treatment regimens. Results: In the period of 2015−2020, the number of incident cases decreased from 60,049 to 29,865, while prevalent cases increased from 682,274 to 752,367. Patients with metformin (MET) monotherapy had the highest prevalence (31% in 2020). Prevalence of insulin (INS) monotherapy continuously but slightly decreased from 29% to 27% while that of sulfonylurea (SU) monotherapy markedly decreased from 37% to 20%. Dipeptidyl peptidase (DPP-4) inhibitors remained popular in 2020 as monotherapy (5%), in dual combination with MET (12%) and in triple combination with MET and SU (5%). The prevalence of patients with sodium-glucose co-transporter-2 (SGLT-2) inhibitors increased from 1% to 4% in monotherapy, from <1% to 6% in dual combination with MET, and from <1% to 2% in triple oral combination with MET and SU or DPP-4-inhibitors. The prevalence of patients using glucagon-like peptide-1 receptor agonists (GLP-1-RAs) also increased but remained around 1−2% both in monotherapy and combinations. For initiating antihyperglycaemic treatment, MET monotherapy was the most frequently used regime in 2020 (50%), followed by monotherapy with SUs (16%) or INS (10%). After initial MET monotherapy, the incidence rates of patients with add-on GLP-1-RAs (2%, 3%, and 4%) and those of add-on SGLT-2 inhibitors (4%, 6%, and 8%) slowly increased in the subsequent 24, 48, and 72 months, respectively. Conclusions: In the period of 2015−2020, we documented important changes in trends of antihyperglycaemic therapeutic patterns in patients with T2DM which followed the new scientific recommendations but remained below our expectations regarding timing and magnitude. More efforts are warranted to implement new agents with cardiovascular/renal benefits into therapeutic management in time, in a much larger proportion of T2DM population, and without delay.