Feasibility of Implementing a Pediatric Diabetes Clinic via Telehealth

Diabetes Care and Mental Health During the COVID-19 Pandemic: Perspectives of Adolescents with Diabetes, Parents, and Providers

This study explored ways in which the COVID-19 pandemic impacted adolescents' diabetes management and psychosocial functioning, and how adolescents, parents, and providers viewed telemedicine. We present data from three studies: (1) a comparison of psychosocial functioning and glycemic levels before and after pandemic onset (n = 120 adolescents; 89% with type 1 diabetes), (2) an online survey of parents about pandemic-related stressors (n = 141), and (3) qualitative interviews with adolescents, parents, and medical providers about the pandemic's impacts on adolescents' diabetes care and mental health (n = 13 parent-adolescent dyads; 7 medical providers). Results suggested some adverse effects, including disrupting routines related to health behaviors and psychosocial functioning and impairing adolescents' quality of life. Despite these challenges, most participants did not endorse significant impacts. Some even noted benefits, such as increased parental supervision of diabetes management that can be leveraged beyond the pandemic. Furthermore, telemedicine offers benefits to continuity of diabetes care but presents challenges to care quality. These findings underscore the varied and unique impacts of the COVID-19 pandemic on adolescents with diabetes.

Diabetes Specialists Value Continuous Glucose Monitoring Despite Challenges in Prescribing and Data Review Process

BACKGROUND

Diabetes clinicians are key facilitators of continuous glucose monitoring (CGM) provision, but data on provider behavior related to CGM use and CGM generated data are limited.

METHODS

We conducted a national survey of providers caring for people with diabetes on CGM-related opinions, facilitators and barriers to prescription, and data review practices.

RESULTS

Of 182 survey respondents, 73.2% worked at academic centers, 70.6% were endocrinologists, and 70.7% practiced in urban settings. Nearly 70% of providers reported CGM use in the majority of their patients with type 1 diabetes. Half of the providers reported CGM use in 10% to 50% of their patients with type 2 diabetes. All respondents believed CGM improved quality of life and could optimize diabetes control. We found no differences in reported rates of CGM use based on providers' years of experience, patient volume, practice setting, or clinic type. Most providers reviewed CGM data each visit (97.7%) and actively involved patients in the data interpretation (98.8%). Only 14.1% of clinicians reported reviewing CGM data without any prompting from patients or their family members outside of visits. Most providers (80.7%) reported their CGM data review was valued by patients although only half reported having adequate time (45.1%) or an efficient process (56.1%) to do so.

CONCLUSIONS

Despite uniform support for CGM by providers, ongoing challenges related to cost, insurance coverage, and difficulties with prescription were major barriers to CGM use. Increased use of CGM in appropriate populations will necessitate improvements in data access and integration, clearly defined workflows, and decreased administrative burden to obtain CGM.

Telehealth and Type 1 Diabetes Care During COVID-19: Perceptions From Youth of Color, Caregivers, and Health Care Providers

Objective

At the outset of the coronavirus disease 2019 (COVID-19) pandemic, health care systems rapidly implemented telehealth services to maintain continuity of type 1 diabetes care. Youth of color are more likely to have suboptimal glycemic control and may benefit most from efforts to ensure continuity of care. However, research examining the perspectives of families of youth of color regarding telehealth for pediatric type 1 diabetes care is limited. We gathered perspectives from youth of color, their caregivers, and health care providers (HCPs) on telehealth for type 1 diabetes care during COVID-19.

Methods

Fifty participants (22 caregivers, 19 youth, and nine HCPs) completed semi-structured interviews conducted in English (n = 44) or Spanish (n = 6). Transcripts containing mentions of telehealth (n = 33) were included for qualitative analysis to extract themes pertaining to perceptions of type 1 diabetes care and telehealth use during COVID-19.

Results

Themes related to perceptions, feasibility, and quality of telehealth diabetes care were obtained. Most families had positive perceptions of telehealth. Families and HCPs described logistical and technical challenges and noted the potential for disparities in telehealth access and use. Furthermore, caregivers and HCPs felt that the lack of in-person interaction and limited access to clinical data affected the quality of care.

Conclusion

Families of youth of color with type 1 diabetes mostly had positive perceptions of telehealth but also identified issues with feasibility and quality of care. Our findings highlight a need for interventions promoting equal access to telehealth and quality care for all youth with type 1 diabetes to minimize disruptions in care.

A new approach to digital health? Virtual COVID-19 care: A scoping review

Aims

The use of virtual care enabled by digital technologies has increased, prompted by public health restrictions in response to COVID-19. Non-hospitalized persons in the acute phase of COVID-19 illness may have unique health needs while self-isolating in the community. This scoping review aimed to explore the nature of care, the use of digital technologies, and patient outcomes arising from virtual care among community-based self-isolating COVID-19 patients.

Methods

Literature searches for peer-reviewed articles were conducted in four bibliographic databases: CINAHL, Medline, Embase and Cochrane Database of Systematic Reviews between January and February 2022, followed by hand-searching reference lists of included articles. Two levels of screening using defined eligibility criteria among two independent reviewers were completed.

Results

Of the 773 articles retrieved, 19 were included. Results indicate that virtual care can be safe while enabling timely detection of clinical deterioration to improve the illness trajectory. COVID-19 virtual care was delivered by single health professionals or by multidisciplinary teams using a range of low-technology methods such as telephone to higher technology methods like wearable technology that transmitted physiological data to the care teams for real-time or asynchronous monitoring.

Conclusion

The review described the varied nature of virtual care including its design, implementation, and evaluation. Further research is needed for continued exploration on how to leverage digital health assets for the delivery of appropriate and safe virtual COVID-19 community care, which can support patient recovery, control transmission, and prevent intensifying the burden on the health care system, especially during surges.

An exploratory analysis of the impact of the COVID-19 pandemic on pediatric type 1 diabetes mellitus patient outcomes: A single-center study

Background

The COVID-19 pandemic led to substantial shifts in pediatric diabetes care delivery to virtual and hybrid models. It is unclear if these changes in care delivery impacted short-term patient outcomes.

Objectives

We aimed to explore glycemic control and other diabetes-related outcomes in children living with Type 1 Diabetes Mellitus (T1DM) during the first year of the COVID-19 pandemic at a tertiary pediatric academic center in Canada.

Subjects

Patients <18 years of age with a confirmed diagnosis of T1DM for at least one year were included.

Methods

This was a retrospective chart review. We compared data from two years pre-pandemic (March 15, 2018-March 14, 2020) to the first year of the pandemic (March 15, 2020-March 14, 2021). The data assessed included glycemic control [Hemoglobin A1c (HbA1c)], diabetic ketoacidosis (DKA), hospital attendance and hospitalizations, hypoglycemia, and hyperglycemia. The generalized estimating equation (GEE) analysis was used to model potential factors affecting the HbA1c and diabetes-related morbidities. Multiple imputations were conducted as a sensitivity analysis.

Results

There were 346 eligible patients included in the study. The HbA1c remained stable during the pandemic compared to the pre-pandemic phase (MD-0.14, 95% CI, -0.28, 0.01; p = 0.058). The pandemic saw an increase in the number of newly diagnosed patients (X2 = 16.52, p < 0.001) and a higher number of newly diagnosed patients presenting in DKA (X2 = 12.94, p < 0.001). In patients with established diabetes, there was an increase in hyperglycemia (OR1.38, 95% CI, 1.12,1.71; p = 0.003) and reduced DKA (OR 0.30, 95% CI, 0.12,0.73; p = 0.009) during the pandemic compared to the pre-pandemic phase. Stable rates of hospitalization (OR0.57, 95% CI, 0.31,1.04, p = 0.068) and hypoglycemia (OR1.11, 95% CI, 0.83,1.49; p = 0.484) were noted. These results were retained in the sensitivity analysis.

Conclusions

Glycemic control in children with T1DM remained stable during the first year of the pandemic. There were more newly diagnosed patients during the pandemic compared to the pre-pandemic phase, and more of these new patients presented in DKA. The latter presentation was reduced in those with established diabetes during the same period.Further studies are needed to assess the ongoing impact of the COVID-19 pandemic on T1DM care pathways and outcomes to allow children, families, and diabetes teams to personalize choices of care models.

ISPAD Clinical Practice Consensus Guidelines 2022: Type 2 diabetes in children and adolescents

Since the 2018 ISPAD guidelines on this topic, follow-up of large cohorts from around the globe have continued informing the current incidence and prevalence of co-morbidities and complications in young adults with youth-onset type 2 diabetes (T2D). This chapter focuses on the risk factors, diagnosis and presentation of youth-onset T2D, the initial and subsequent management of youth-onset T2D, and management of co-morbidities and complications. We include key updates from the observational phase of the multi-center Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial, the SEARCH for Diabetes in Youth (SEARCH) study and new data from the Restoring Insulin Secretion (RISE) study, a head-to-head comparison of youth onset vs adult-onset T2D. We also include an expanded section on risk factors associated with T2D, algorithms and tables for treatment, management, and assessment of co-morbidities and complications, and sections on recently approved pharmacologic therapies for the treatment of youth-onset T2D, social determinants of health, and settings of care given COVID-19 pandemic.

Anthropometric Measurements and Laboratory Investigations in Children and Youth With Type 1 Diabetes Before and During the COVID-19 Pandemic

OBJECTIVES

Our aim in this study was to compare rates of anthropometric, blood pressure (BP) and glycated hemoglobin (A1C) measurements and laboratory screening for hypothyroidism, nephropathy and dyslipidemia in children and youth with type 1 diabetes (T1D), 1 year before and after the onset of COVID-19.

METHODS

Clinical data were analyzed from a voluntary registry of children and youth with T1D followed at the BC Children's Hospital between March 2019 and 2021. Logistic and Poisson mixed-effect models were used.

RESULTS

Four hundred forty patients, with median (interquartile range) age and time since diagnosis 12.7 (9.5 to 15.4) and 4.7 (2.6 to 7.9) years, respectively, were included. Clinic visits were all in-person before March 2020, and 99% via telemedicine afterward. The number of visits per patient was 2 (2 to 3), with a 6% increase during the pandemic (relative risk [RR], 1.06; 95% confidence interval [CI], 1.01 to 1.10). There was a substantial decrease in height, weight and BP measurements (RR, 0.32; 95% CI, 0.28 to 0.36; RR, 0.34, 95% CI, 0.31 to 0.38; RR, 0.005, 95% CI, 0.002 to 0.014, respectively); only 49% of patients had anthropometric and 1% BP data during the pandemic year, compared with >97% before the pandemic. A1C measurements dropped from 3 (2 to 4) to 1 (1 to 2) per patient per year (RR, 0.53; 95% CI, 0.48 to 0.57). Rates of screening investigations were suboptimal before the pandemic, and these rates continued to decline.

CONCLUSIONS

Shifting to telemedicine allowed ongoing care during the pandemic, but the frequency of anthropometric, BP and A1C measurements decreased dramatically. A combined telemedicine/in-person model may be needed to ensure adequate care for this population.