Randomized Study to Evaluate the Impact of Telemedicine Care in Patients With Type 1 Diabetes With Multiple Doses of Insulin and Suboptimal HbA1c in Andalusia (Spain): PLATEDIAN Study

Telemedicine in Improving Glycemic Control Among Children and Adolescents With Type 1 Diabetes Mellitus: Systematic Review and Meta-Analysis

BACKGROUND

Type 1 diabetes mellitus (T1DM) is the most common chronic autoimmune disease among children and adolescents. Telemedicine has been widely used in the field of chronic disease management and can benefit patients with T1DM. However, existing studies lack high-level evidence related to the effectiveness of telemedicine for glycemic control in children and adolescents with T1DM.

OBJECTIVE

This study aims to systematically review the evidence on the effectiveness of telemedicine interventions compared with usual care on glycemic control among children and adolescents with T1DM.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Embase, Web of Science (all databases), and CINAHL Complete from database inception to May 2023. We included randomized controlled trials (RCTs) that evaluated the effectiveness of a telemedicine intervention on glycemic control in children and adolescents with T1DM. In total, 2 independent reviewers performed the study selection and data extraction. Study quality was assessed using the Cochrane Risk of Bias 2 tool. Our primary outcome was glycated hemoglobin (HbA1c) levels. Secondary outcomes were quality of life, self-monitoring of blood glucose, the incidence of hypoglycemia, and cost-effectiveness. A random-effects model was used for this meta-analysis.

RESULTS

Overall, 20 RCTs (1704 participants from 12 countries) were included in the meta-analysis. Only 5% (1/20) of the studies were at high risk of bias. Compared to usual care, telemedicine was found to reduce HbA1c levels by 0.22 (95% CI -0.33 to -0.10; P<.001; I2=35%). There was an improvement in self-monitoring of blood glucose (mean difference [MD] 0.54, 95% CI -0.72 to 1.80; P=.40; I2=67.8%) and the incidence of hypoglycemia (MD -0.15, 95% CI -0.57 to 0.27; P=.49; I2=70.7%), although this was not statistically significant. Moreover, telemedicine had no convincing effect on the Diabetes Quality of Life for Youth score (impact of diabetes: P=.59; worries about diabetes: P=.71; satisfaction with diabetes: P=.68), but there was a statistically significant improvement in non-youth-specific quality of life (MD -0.24, 95% CI -0.45 to -0.02; P=.04; I2=0%). Subgroup analyses revealed that the effect of telemedicine on HbA1c levels appeared to be greater in studies involving children (MD -0.41, 95% CI -0.62 to -0.20; P<.001), studies that lasted <6 months (MD -0.32, 95% CI -0.48 to -0.17; P<.001), studies where providers used smartphone apps to communicate with patients (MD -0.37, 95% CI -0.53 to -0.21; P<.001), and studies with medication dose adjustment (MD -0.25, 95% CI -0.37 to -0.12; P<.001).

CONCLUSIONS

Telemedicine can reduce HbA1c levels and improve quality of life in children and adolescents with T1DM. Telemedicine should be regarded as a useful supplement to usual care to control HbA1c levels and a potentially cost-effective mode. Meanwhile, researchers should develop higher-quality RCTs using large samples that focus on hard clinical outcomes, cost-effectiveness, and quality of life.

Could Online Education Replace Face-to-Face Education in Diabetes? A Systematic Review

OBJECTIVE

Diabetes Self-Management Education and Support (DSMES) is a critical component of diabetes care. This study aims to examine the effect of online-based educational interventions on diabetes management compared to face-to-face interventions.

METHODS

A systematic review was conducted by searching three databases for studies in English or Spanish between December 2023 and March 2024. The inclusion criteria were studies that compared face-to-face DSMES with online interventions.

RESULTS

The follow-up duration of the trials ranged from 1 to 12 months. Multidisciplinary teams delivered online DSMES through various means, including Short Message Service (SMS), telephone calls, video calls, websites, and applications. Online DSMES was found to be comparable to face-to-face interventions in terms of glycated hemoglobin (HbA1c) levels in people with type 1 diabetes (T1D). In contrast, online interventions that focus on weight management in people with type 2 diabetes (T2D) have shown a significant reduction in HbA1c compared to face-to-face interventions. Online DSMES was found to be superior in terms of quality of life and cost-effectiveness in both T1D and T2D. None of the analyzed studies explored the differences between individual and group methodologies.

CONCLUSIONS

The current evidence indicates that online DSMES services provide at least comparable biomedical benefits to face-to-face interventions, suggesting that online interventions could be incorporated into clinical practice as a complement or reinforcement. However, further research is needed to explore the potential benefits and effectiveness of online group sessions in DSMES.

Delphi consensus on the use of telemedicine in rheumatology: RESULTAR study

BACKGROUND AND OBJECTIVES

There is growing interest in the potential of telemedicine (TM) as an alternative to physical consultation. Although numerous studies prove the benefits of TM in rheumatology, there are no recommendations on its implementation in Spain. The aim of this study was to analyze the application of TM in rheumatology consultations in Spain.

MATERIALS AND METHODS

Qualitative, cross-sectional, multicenter study with Delphi methodology in two rounds of queries. A structured ad hoc questionnaire was designed that included statements on teleconsultation, nursing teleconsultation, telecare, telerehabilitation, teleradiology, telehealth tele-education, main barriers, advantages and disadvantages of telehealth tele-education and TM in rheumatoid arthritis. The participants were rheumatology specialists practicing in Spain.

RESULTS

The participating rheumatologists (N = 80) had a mean age of 42.4 (±9.0) years, with 12.6 (±8.4) years of experience. Some of the aspects of TM that obtained the greatest consensus were: TM is useful for follow-up of some patients, to help determine if a face-to-face consultation is necessary, or to assist patients with rheumatoid arthritis if they present low activity or in remission; certain patients, such as those in their first consultation or those who present digital barriers or cognitive deterioration, should be seen face-to-face; TM presents some technical and patient access barriers; TM can be useful in nursing and in continued medical education.

CONCLUSIONS

TM can be beneficial for the treatment and follow-up of patients with rheumatic diseases, as well as for alleviating the face-to-face care burden in rheumatology.

Telemedicine maintains good glucose control in children with type 1 diabetes but is not time saving for healthcare professionals: KITES randomized study

AIMS

To evaluate glucose control non-inferiority and time benefits of telemedicine follow-up in children with type 1 diabetes (CwD).

METHODS

In a single-center 9-month-long randomized controlled study (clinicaltrials.gov NCT05484427), 50 children were randomized to either telemedicine group (TG) followed-up distantly by e-mail, or to face-to-face group (FFG) attending standard personal visits. The primary endpoint was non-inferiority of HbA1c at final visit (level of non-inferiority was set at 5 mmol/mol). The secondary endpoints were subcutaneous glucose monitoring parameters and time consumption from both study subjects' and the physicians' point of view.

RESULTS

Non-inferiority of HbA1c in the TG was proven (mean HbA1C 45.8 ± 7.3 [TG] vs. 50.0 ± 12.6 [FFG] mmol/mol, 6.3 vs. 6.7 % DCCT, p = 0.17; between groups HbA1C difference 95 % CI -10.2 to 1.9 mmol/mol). Telemedicine saved time for participants (mean visit duration [MVD] 50 [TG] vs. 247 min [FFG], p < 0.001). There were no other differences between groups neither in CGM parameters nor physician's time consumption (MVD 19 [TG] vs. 20 min [FFG], p = 0.58).

CONCLUSIONS

Nine-month telemedicine follow-up of the children with well-controlled T1D is not inferior to standard face-to-face visits. Telemedicine visits saved time for the participants but not for their diabetologists.

Overcoming Barriers to Diabetes Management in Young Adults with Type 1 Diabetes by Leveraging Telehealth: A Pilot Study

OBJECTIVE

The LIFT-YA (leveraging intensive follow-up treatment in young adults) quality improvement program was developed to address clinical and social barriers in young adults (YA) with type 1 diabetes (T1D), using telehealth visits to promote clinic attendance and improve diabetes care.

METHODS

LIFT-YA enrolled YA aged 18-30 with T1D and HbA1c >8% (64 mmol/mol) who had established adult care in our diabetes clinic. The 6-month, 7-visit hybrid program was facilitated by a case manager serving as the liaison between participants and the care team. The primary end-points were within-group and between-group changes from the baseline in HbA1c at the last visit and adoption of continuous glucose monitoring (CGM).

RESULTS

Of the 57 eligible YA, 24 were enrolled and 33 were unable to participate (UTP). Thirteen of the enrolled participants attended at least 4/7 visits ("completers", C), whereas 11 were noncompleters (NC). HbA1c at the end of the program was significantly lower in the C versus UTP group [median -1.0; IQR (-0.6, -2.5) vs -0.25 (0.2, -1.0) in UTP; P < .05]. The percentage of CGM users significantly increased by 70% in the C group (P < .05), but did not change in the NC and UTP groups. Limited access to telehealth and the high cost of frequent visits were the main hurdles preventing enrollment into or completion of the program.

CONCLUSIONS

The LIFT-YA pathway was associated with a significant HbA1c reduction and an increase in the adoption of CGM. Policy changes are necessary to expand access to LIFT-YA and other programs for high-risk YA with T1D in underserved communities and across all backgrounds.

[Consensus on criteria and minimum data set for the referral of candidate patients for home enteral nutrition teleconsultation: TELENUT project]

INTRODUCTION

teleconsultation is a useful healthcare tool in the multidisciplinary management of patients with indications of home enteral nutrition (HEN). The use of different teleconsultation platforms, as it happens in the Andalusian Health System (SAS), results in heterogeneous referral processes between Primary Care and hospital services in the same region.

OBJECTIVES

to establish a consensus on patient profiles and the minimum data set necessary to guarantee an adequate referral to NED teleconsultation regardless of the existing platform. These agreed aspects in Andalusia can serve as a reference in other regions.

METHODS

three consecutive steps were followed: a) non-systematic review of the indexed literature on teleconsultation in clinical nutrition in Spain; b) survey to know the implementation and unmet needs of teleconsultation platforms in Andalusian public hospitals; and c) working meetings and consensus of 14 health professionals of Primary Care (n = 4) and endocrinology and hospital clinical nutrition (n = 10).

RESULTS

three referral forms were agreed in which three patient profiles were defined, with the corresponding minimum set of data necessary to request NED teleconsultation. The Primary Care team should provide this set of data to the clinical nutrition specialist via a teleconsultation platform, implemented in the SAS.

CONCLUSIONS

three agreed forms between healthcare professionals involved in the referral process serve to standardize the request for teleconsultation of NED between healthcare teams based on patient profiles.

Management of Type 1 Diabetes in a school setting: effectiveness of an online training program for school staff

Background and aims

Since Type 1 Diabetes (T1D) onset usually occurs at a young age, a relevant number of affected people attend school for most of their time; it is necessary that school personnel receive appropriate education and training. We aimed to evaluate the effectiveness of the online training program offered by IRCCS Istituto Giannina Gaslini during and after COVID-19 pandemic.

Methods

The Institute's Diabetes team offered an online training program to school staff of the Region during COVID-19 pandemic. A validated questionnaire was proposed to all the schools in which training meetings were held in the previous 2 years (2020-2021 and 2021-2022). The questionnaire consisted of four sections: Section 1 (Socio-demographical data), Section 2 (Theoretical knowledge on T1D), Section 3 (Confidence in handling T1D), and Section 4 (Practical skills and Glucagon Administration). To evaluate the effectiveness of the online training program, the answers between participants (Group A) and non-participants (Group B) were then compared.

Results

225 subjects from 19 schools participated in the survey. People who participated to the training (Group A, n = 53) demonstrated better T1D theoretical knowledge compared to non-participants (Group B, n = 154; p < 0.001). Group A revealed to feel more confident in the management of children with T1D during scholastic (p = 0.006) and extra-scholastic activities (p = 0.01), in supporting the children in the administration of insulin (p < 0.001) and in recognizing hypoglycaemia (p = 0.006). Moreover, results confirmed good levels of confidence among scholastic personnel who participated in the training of administration of glucagon in case of severe hypoglycaemia.

Conclusion

School staff who took part in the online training program on management of T1D showed better theoretical knowledge and better confidence in the management of daily needs and possible emergencies of students with T1D. It appears essential to offer educational programs on T1D for school staff by implementing the use of technological tools to reach a wider population. Moreover, it is advisable to offer a more practical approach, involving educational nurses.

Advanced Hybrid Closed Loop users' satisfaction of telemedicine and telenursing in pediatric and young adult type 1 diabetes

Background and aims

The aim of the study was to evaluate the satisfaction of the use of telemedicine and telenursing in children and young adults with Type 1 Diabetes (T1D) using Advanced Hybrid Closed Loop systems (AHCL) with a focus on the role of connectivity, data download and the ease of technical steps in the set and sensor change procedures.

Methods

An online anonymous survey was administered to AHCL users. The questionnaire consisted of five Clusters: Cluster A-B-C included questions related to the general satisfaction in the use of telemedicine, Cluster D was focused on the role of data download and connectivity, Cluster E was related to satisfaction in telenursing and Cluster F to the perception of ease of execution of the technical steps like changing the infusion set and the sensor.

Results

We collected 136 completed questionnaires. 83.8% of AHCL users were overall satisfied with the quality of the telemedicine service. 88.2% of patients downloaded AHCL data before visits and the overall quality of televisits (data sharing, connectivity, ease of use) was satisfactory for 85.3% of users. Telenursing support during set and sensor change procedures was considered effective by 98% of AHCL users. The sensor and insulin infusion set change procedure is perceived as different for the two systems: set change simpler for Medtronic (p = 0.011) users, while sensor change was simpler for Tandem users (p = 0.009).

Conclusion

Telemedicine and telenursing have an essential role in diabetology and are highly appreciated in AHCL users. The nurse support in the education of the use of AHCL systems is effective and must be implemented. Unfortunately, not all patients have the technological tools needed for downloading data at home and using telemedicine services; this represents an important challenge for the future of diabetology and for the equity in accessibility to care.

Telehealth model versus in-person standard care for persons with type 1 diabetes treated with multiple daily injections: an open-label randomized controlled trial

Objective

Increasing evidence indicates that the telehealth (TH) model is noninferior to the in-person approach regarding metabolic control in type 1 diabetes (T1D) and offers advantages such as a decrease in travel time and increased accessibility for shorter/frequent visits. The primary aim of this study was to compare the change in glycated hemoglobin (HbA1c) at 6 months in T1D care in a rural area between TH and in-person visits.

Research design and methods

Randomized controlled, open-label, parallel-arm study among adults with T1D. Participants were submitted to in-person visits at baseline and at months 3 and 6 (conventional group) or teleconsultation in months 1 to 4 plus 2 in-person visits (baseline and 6 months) (TH group). Mixed effects models estimated differences in HbA1c changes.

Results

Fifty-five participants were included (29 conventional/26 TH). No significant differences in HbA1c between groups were found. Significant improvement in time in range (5.40, 95% confidence interval (CI): 0.43-10.38; p < 0.05) and in time above range (-6.34, 95% CI: -12.13- -0.55;p < 0.05) in the TH group and an improvement in the Diabetes Quality of Life questionnaire (EsDQoL) score (-7.65, 95% CI: -14.67 - -0.63; p < 0.05) were observed. In TH, the costs for the participants were lower.

Conclusions

The TH model is comparable to in-person visits regarding HbA1c levels at the 6-month follow-up, with significant improvement in some glucose metrics and health-related quality of life. Further studies are necessary to evaluate a more efficient timing of the TH visits.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

Diabetes mellitus and inequalities in the equipment and use of information technologies as a socioeconomic determinant of health in Spain

Inequalities in the equipment and use of information and communications technology (ICT) in Spanish households can lead to users being unable to access certain information or to carry out certain procedures. Accessibility to ICT is considered a social determinant of health (SDOH) because it can generate inequalities in access to information and in managing access to health services. In the face of a chronic illness such as diabetes mellitus (DM)-for which a comprehensive approach is complex and its complications have a direct impact on current healthcare systems-all the resources that patients may have are welcome. We aimed to analyze hospitalizations and amputations as direct consequences of DM among the autonomous communities of Spain (ACS) in 2019, along with socioeconomic factors related to health, including inequalities in access to ICT between territories, as well as citizens' interest in online information searches about DM. We used different databases such as that of the Ministerio de Sanidad (Spain's health ministry), Ministerio de Asuntos Económicos y transformación (Ministry of Economic Affairs and Digital Transformation), Google Trends (GT), and the Instituto Nacional de Estadística (Spain's national institute of statistics). We examined the data with R software. We employed a geolocation approach and performed multivariate analysis (specifically factor analysis of mixed data [FAMD]) to evaluate the aggregate interest in health information related to DM in different regions of Spain grounded in online search behavior. The use of FAMD allowed us to adjust the techniques of principal component analysis (PCA) and multiple correspondence analysis (MCA) to detect differences between the direct consequences of DM, citizen's interest in this non-communicable disease, and socioeconomic factors and inequalities in access to ICT in aggregate form between the country's different ACS. The results show how SDOH, such as poverty and education level, are related to the ACS with the highest number of homes that cite the cost of connection or equipment as the reason for not having ICT at home. These regions also have a greater number of hospitalizations due to DM. Given that in Spain, there are certain differences in accessibility in terms of the cost to households, in the case of DM, we take this issue into account from the standpoint of an integral approach by health policies.

Evaluation of telehealth support in an integrated respiratory clinic

Supporting self-management is key in improving disease control, with technology increasingly utilised. We hypothesised the addition of telehealth support following assessment in an integrated respiratory clinic could reduce unscheduled healthcare visits in patients with asthma and COPD. Following treatment optimisation, exacerbation-prone participants or those with difficulty in self-management were offered telehealth support. This comprised automated twice-weekly telephone calls, with a specialist nurse triaging alerts. We performed a matched cohort study assessing additional benefits of the telehealth service, matching by: confirmed diagnosis, age, sex, FEV1 percent predicted, smoking status and ≥1 exacerbation in the last year. Thirty-four telehealth participants were matched to twenty-nine control participants. The telehealth cohort generated 165 alerts, with 29 participants raising at least one alert; 88 (53.5%) alerts received a call discussing self-management, of which 35 (21%) received definitive advice that may otherwise have required an unscheduled healthcare visit. There was a greater reduction in median exacerbation rate across both telehealth groups at 6 months post-intervention (1 to 0, p < 0.001) but not in control groups (0.5 to 0.0, p = 0.121). Similarly, there was a significant reduction in unscheduled GP visits across the telehealth groups (1.5 to 0.0, p < 0.001), but not the control groups (0.5 to 0.0, p = 0.115). These reductions led to cost-savings across all groups, but greater in the telehealth cohorts. The addition of telehealth support to exacerbation-prone patients with asthma or COPD, following comprehensive assessment and treatment optimisation, proved beneficial in reducing exacerbation frequency and unscheduled healthcare visits and thus leads to significant cost-savings for the NHS.

Clinical Trial Registration: ClinicalTrials.gov: NCT03096509

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Improved CGM Glucometrics and More Visits for Pediatric Type 1 Diabetes Using Telemedicine During 1 Year of COVID-19

PURPOSE

The COVID-19 pandemic led to rapid adoption of telemedicine for the care of youth with type 1 diabetes (T1D). We assessed the utility of a primarily virtual care model by comparing glucometrics from a pediatric sample with T1D using continuous glucose monitoring (CGM) both before and during the pandemic.

METHODS

Pediatric patients aged 1 to 17 years with T1D duration ≥ 1 year if ≥ 6 years old or ≥ 6 months if < 6 years old, with ≥ 1 visit with recorded CGM data both prepandemic (April 1, 2019-March 15, 2020) and during the pandemic (April 1, 2020-March 15, 2021) were included. Data were extracted from the electronic health record.

RESULTS

Our sample comprised 555 young people (46% male, 87% White, 79% pump-treated), mean age 12.3 ± 3.4 years, T1D duration 5.9 ± 3.5 years, baseline glycated hemoglobin A1c 8.0 ± 1.0% (64 ± 10.9 mmol/mol). Diabetes visit frequency increased from 3.8 ± 1.7 visits/prepandemic period to 4.3 ± 2.2 visits/pandemic period (P < 0.001); during pandemic period, 92% of visits were virtual. Glucose management indicator (GMI) improved slightly from 7.9% (63 mmol/mol) prepandemic to 7.8% (62 mmol/mol) during the pandemic (P < 0.001). Those with equal or greater visit frequency (n = 437 [79% of sample]) had significant improvement in GMI (8.0% to 7.8% [64 to 62 mmol/mol], P < 0.001), whereas those with lower visit frequency did not (7.8 [62 mmol/mol], P = 0.86).

CONCLUSIONS

Children and adolescents with T1D using CGM before and during the pandemic showed an overall increase in visit frequency using primarily telemedicine-based care and improved CGM glucometrics. Further research is needed to understand factors associated with successful use of telemedicine for pediatric T1D.

Patient Satisfaction with Telemedicine in Adults with Diabetes: A Systematic Review

Patient satisfaction assessment is essential for improving the quality of healthcare. Diabetes management using telemedicine technology is promising in the 21st century. However, the number of randomised controlled trials (RCTs) examining the effect of telemedicine on satisfaction in patients with diabetes is limited. This systematic review aimed to summarise the current evidence on patient satisfaction with telemedicine in adults with diabetes and discuss related issues and future directions of telemedicine in patients with diabetes. The author systematically searched PubMed/MEDLINE, Embase and The Cochrane Library, and a total of six RCTs were eligible for this review. Patient satisfaction with telemedicine was as high as conventional face-to-face care; however, telemedicine appeared not to significantly increase patient satisfaction compared with conventional face-to-face care in the included studies. Significant heterogeneity was noted between the studies, including participants’ age, study duration, the method of assessing patient satisfaction and types of telemedicine. Further studies are required to provide firm evidence to healthcare providers who are willing to use telemedicine in diabetes management. Telemedicine technology has been advancing and is a key tool in providing high-quality healthcare to patients with diabetes in the 21st century.

Metabolic Benefit of Teleconsultation for Diabetes Management During the COVID-19 Pandemic: A French Observational Prospective Study

Aim: To investigate the impact of teleconsultation on glycemic control in patients with diabetes during the COVID-19 pandemic. Methods: In this observational prospective study, the main outcome was the comparison of glycated hemoglobin (HbA1c) between patients with or without teleconsultation at 6-month follow-up. Results: From March 17 to May 31, 2020, 610 patients were included, 456 were followed-up using Teleconsultation présent (TC+) and 154 not using No Teleconsultation (TC-). Patients of TC+ Group were younger, 57 ± 17 versus 65 ± 15.5 years (p < 0.001), with a lower body mass index, 28 ± 6.2 kg/m² versus 30 ± 5.8 kg/m², compared to those of TC- Group (p < 0.001). HbA1c were comparable between the two groups: 7.35 ± 0.27% for TC+ versus 7.48 ± 0.22% for TC- Group. At 6-month follow-up, HbA1c was lower in TC+ versus TC- Group: 7.21 ± 0.15% versus 7.6 ± 0.18% (p = 0.004). Conclusion: Our findings point toward the feasibility and usefulness of teleconsultation for the follow-up of patients with diabetes in such exceptional circumstances.

Physician Satisfaction With Telehealth: A Systematic Review and Agenda for Future Research

BACKGROUND AND OBJECTIVES

The use of telehealth has risen dramatically due to the Covid-19 pandemic and is expected to be a regular part of patient care moving forward. We know little currently about how satisfied physicians are with this type of patient care. The present systematic review examines physician satisfaction with telehealth, as physician acceptance remains vital to telehealth gaining wider and more permanent adoption.

METHODS

A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)-guided systematic review of empirical articles published between 2010 and 2020 that contain a finding examining physician satisfaction with using telehealth, using 4 article databases (PubMed, Web of Science, COCHRANE, and CINAHL), to identify relevant studies. A standardized data abstraction Excel sheet was used to extract relevant information from each of the included studies. Relevant study findings related to physician satisfaction with telehealth were reviewed for each of the 37 studies by the coauthors.

RESULTS

A total of 37 published studies were included in the review. Thirty-three of the 37 (89%) studies reviewed were classified as having findings showing moderate to high levels of physician satisfaction with telehealth. Just under 60% of the studies focused on physician satisfaction with providing telemedicine to patients (21/37). Twelve other studies focused on physician satisfaction with teleconsultations with other providers. Four studies examined physician satisfaction with both. The type of patient telemedicine or provider teleconsultation performed varied greatly across the 37 studies, with several different diagnoses or care situations included. Research designs used in the studies were less robust, with all studies using primary data for assessing physician satisfaction but only one study providing any type of multivariate analysis of physician satisfaction with telehealth.

CONCLUSION

The results of this review support the observation that physicians across different specialties, geographic locations, practice locations, and care situations appear satisfied with engaging in telehealth for both patient care and consultations with other physicians. The research on telehealth should be enhanced, given how ubiquitous telehealth has become due to the Covid-19 pandemic. This enhancement should include larger physician sample sizes in studies of telehealth satisfaction; more research focused on telehealth in the primary care setting; and the types of virtual modalities that have become more commonplace for physicians to use due to the Covid-19 pandemic.

A role for the diabetes nurse educator to telemedically support children with type 1 diabetes on continuous glucose monitoring? The COVID-19 lockdown experience

The role of diabetes nurse educators during the COVID-19 lockdown to telematically provide routine reviews of glycaemic control in children with type 1 diabetes (T1D) using continuous glucose monitoring systems is evaluated. Implementing these routines in the day-to-day clinical practice could reduce in-person clinic visits and improve glucose control.

Randomized controlled study to evaluate the impact of flexible patient-controlled visits in people with type 1 diabetes: The DiabetesFlex Trial

AIM

The objective of this study was to assess the impact of health care-initiated visits versus patient-controlled flexible visits on clinical and patient-reported outcomes in people with type 1 diabetes.

METHODS

The DiabetesFlex trial was a randomized controlled, pragmatic non-inferiority 15-month follow-up study comparing standard care (face-to-face visits every 4 months) with DiabetesFlex (patient-controlled flexible visits using patient-reported, outcome-based telehealth follow-up). Of 343 enrolled participants, 160 in each group completed the study. The primary outcome was mean change in HbA_1c from baseline to 15-month follow-up. Secondary outcomes were blood pressure, lipid levels, frequency of visits, the World Health Organization score-five well-being-index (WHO-5), the Problem Areas In Diabetes (PAID) scale and experience of participation in own care (participation score).

RESULTS

The adjusted mean difference in HbA_1c between standard care and DiabetesFlex was similar and below the predefined non-inferiority margin of 0.4% (-0.03% [95%CI: 0.15, 0.11]/-0.27 mmol/mol [-1.71, 1.16]). No intergroup mean changes in lipid or blood pressure were observed. Conversely, DiabetesFlex participants presented an increased mean WHO-5 index of 4.5 (1.3, 7.3), participation score of 1.1 (0.5, 2.0), and decreased PAID score of -4.8 (-7.1, -2.6) compared with standard care. During follow-up, DiabetesFlex participants actively changed 23% of face-to-face visits to telephone consultations, cancelled more visits (17% vs. 9%), and stayed away without cancellation less often (2% vs. 8%).

CONCLUSION

Compared with standard care, flexible patient-controlled visits combined with patient-reported outcomes in participants with metabolic controlled type 1 diabetes and good psychological well-being further improved diabetes-related well-being and decreased face-to-face visits while maintaining safe diabetes management.

Effectiveness of video consultations in type 1 diabetes patients treated with insulin pumps in the outpatient clinic: protocol for a randomised controlled trial

INTRODUCTION

The purpose of the study is to assess the effectiveness of video consultations in patients with type 1 diabetes mellitus (DM) treated with insulin pumps in the outpatient clinic.

METHODS AND ANALYSIS

A 52 weeks' duration, open-label, randomised controlled trial will be conducted, enrolling 100 patients with type 1 DM currently treated with insulin pump.Patients will be recruited from the diabetes outpatient clinic at Hospital of Southern Jutland, Department of internal medicine, Sønderborg. Participants will be randomised to either video consultations (experimental intervention) or standard care (control comparator). Participants in the video consultation group will follow their standard care treatment but will have all of their scheduled and non-scheduled appointments by video consultation. The control group will follow their standard care treatment as usual, having all their appointments at the outpatient centre. Primary outcome will be change from baseline of time in range (3.9-10.0 mmol/L).

ETHICS AND DISSEMINATION

The study has been approved by the Regional Committe on Health Research Ethics for Southern Denmark, S-20200039G Acadre 20/12922. We will present the results of the trial at international conferences as well as publish the results of the trial in (a) peer-reviewed scientific journal(s).

TRIAL REGISTRATION NUMBER

NCT04612933.

COVID-19 pandemic lockdown in young people with type 1 diabetes: Positive results of an unprecedented challenge for patients through telemedicine and change in use of continuous glucose monitoring

There has been little data published related to glucose control in adolescents and young adults with type 1 diabetes (T1D) during lockdown, but rarely focusing on telemedicine's role. During this unpreceded period, glucose control and self-monitoring improved in our young patients, with better results associated with telemedicine.

Adoption of Telemedicine for Type 1 Diabetes Care During the COVID-19 Pandemic

Background: We describe the utilization of telemedicine visits (video or telephone) across the type 1 diabetes (T1D) Exchange Quality Improvement Collaborative (T1DX-QI) during the COVID-19 pandemic. Metrics, site-level survey results, and examples of interventions conducted to support telemedicine in T1D are shown. Materials and Methods: Thirteen clinics (11 pediatric, 2 adult) provided monthly telemedicine metrics between December 2019 and August 2020 and 21 clinics completed a survey about their telemedicine practices. Results: The proportion of telemedicine visits in T1DX-QI before the pandemic was <1%, rising to an average of 95.2% in April 2020 (range 52.3%-99.5%). Three sites initially used mostly telephone visits before converting to video visits. By August 2020, the proportion of telemedicine visits decreased to an average of 45% across T1DX-QI (range 10%-86.6%). The majority of clinics (62%) performed both video and telephone visits; Zoom was the most popular video platform used. Over 95% of clinics reported using CareLink™, Clarity^®, Glooko™, and/or t:connect^® to view device data, with only one center reporting automated data upload into the electronic medical record. The majority of centers had multidisciplinary teams participating in the video visits. All sites reported reimbursement for video visits, and 95% of sites reported coverage for telephone visits early on in the pandemic. Conclusions: There was rapid adoption of telemedicine in T1DX-QI during the COVID-19 pandemic. Future insurance reimbursement for telemedicine visits and the ideal ratio of telemedicine to in-person visits in T1D care remain to be determined.

Impact of a Remote Monitoring Programme Including Lifestyle Education Software in Type 2 Diabetes: Results of the Educ@dom Randomised Multicentre Study

INTRODUCTION

Telemonitoring in type 2 diabetes (T2D) is mainly based on glucose monitoring. A new type of connected device which routinely gathers data on weight, physical activity and food intake could improve patients' diabetes control. The main aim of this study was to assess the efficacy of an at-home interventional programme incorporating such devices and lifestyle education software on diabetes control, i.e., change in HbA1c, compared to standard care.

METHODS

This multicentre study randomly assigned 282 people with T2D to either a telemonitoring group (TMG) or a control group (CG) for a 1-year intervention period. While routine follow-up was maintained in the CG, TMG subjects were provided with interactive lifestyle educational software (with artificial intelligence algorithms) and connected objects (blood glucose meters, scales and actimeters) for use in their own homes and were remotely monitored by their diabetologists. Changes in HbA_1c were compared between groups using a mixed linear model.

RESULTS

The mean HbA_1c dropped from 7.8 ± 0.8% (62 mmol/mol) to 7.4 ± 1.0% (57 mmol/mol) in the TMG and from 7.8 ± 0.8% (62 mmol/mol) to 7.6 ± 1.0% (60 mmol/mol) in the CG, resulting in an intergroup difference of - 0.16 (p = 0.06) in favour of TMG, after adjustment for confounding factors. Within TMG, the decrease in HbA_1c was greater in frequent users: - 0.23% (p = 0.03) in the case of connections to telemonitoring synthesis above the median and - 0.21% (p = 0.05) in the case of connections to tele-education software above the median compared to the CG. Significant weight loss was observed in the TMG but only in women (p = 0.01).

FINDINGS

The EDUC@DOM telemonitoring and tele-education device did not highlight a significant decrease in HbA1c levels compared to routine management although a slight, albeit significant improvement in glycaemic control was observed in the frequent user subgroup as well as significant weight loss but only in women. A high level of satisfaction with the connected device was recorded amongst all participants.

TRIAL REGISTRATION

This trial was registered in the Clinical Trials Database on September 27, 2013, under no. NCT01955031 and bears ID-RCB number 2013-A00391-44.

American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus

OBJECTIVE

To provide evidence-based recommendations regarding the use of advanced technology in the management of persons with diabetes mellitus to clinicians, diabetes-care teams, health care professionals, and other stakeholders.

METHODS

The American Association of Clinical Endocrinology (AACE) conducted literature searches for relevant articles published from 2012 to 2021. A task force of medical experts developed evidence-based guideline recommendations based on a review of clinical evidence, expertise, and informal consensus, according to established AACE protocol for guideline development.

MAIN OUTCOME MEASURES

Primary outcomes of interest included hemoglobin A1C, rates and severity of hypoglycemia, time in range, time above range, and time below range.

RESULTS

This guideline includes 37 evidence-based clinical practice recommendations for advanced diabetes technology and contains 357 citations that inform the evidence base.

RECOMMENDATIONS

Evidence-based recommendations were developed regarding the efficacy and safety of devices for the management of persons with diabetes mellitus, metrics used to aide with the assessment of advanced diabetes technology, and standards for the implementation of this technology.

CONCLUSIONS

Advanced diabetes technology can assist persons with diabetes to safely and effectively achieve glycemic targets, improve quality of life, add greater convenience, potentially reduce burden of care, and offer a personalized approach to self-management. Furthermore, diabetes technology can improve the efficiency and effectiveness of clinical decision-making. Successful integration of these technologies into care requires knowledge about the functionality of devices in this rapidly changing field. This information will allow health care professionals to provide necessary education and training to persons accessing these treatments and have the required expertise to interpret data and make appropriate treatment adjustments.

The value of physical examination in the era of telemedicine

Telemedicine use has expanded rapidly to cope with increasing demand on services by delivering remote clinical review and monitoring of long-term conditions. Triaging individual patients to determine their suitability for telephone, video or face-to-face consultations is necessary. This is crucial in the context of COVID-19 to ensure doctor-patient safety. Telemedicine was shown to be safe and feasible in managing certain chronic diseases and providing patient education. When reviewing newly referred or long-term patients, different specialty clinics have different requirements for physical examination. Clinicians prefer face-to-face consultations at the initial visit to establish a doctor-patient relationship; telephone or video consultations are reasonable options for long-term patients where physical examination may not be needed. Video consultations, often aided by sophisticated devices and apps or medical assistants, are useful to facilitate remote physical examination. Most patients prefer telemedicine as it saves time and travel cost and provides better access to appointments.

Effects of remote care of patients with poorly controlled type 1 diabetes included in an experimental telemonitoring programme

AIM

To assess, in a real-life setting, the effectiveness of telemonitoring adults with type 1 diabetes (T1D) using continuous glucose monitoring in a telemedicine experiment.

METHODS

Experimentation in Telemedicine for the Improvement of Healthcare Pathways (ETAPES), an experimental telehealth programme for five chronic diseases, is supported by the French national healthcare system to promote telemedical care. Using data from a single university hospital centre, 72 adults were studied, including 42 subjects (58%) receiving insulin pump therapy and 30 (42%) receiving multiple daily injections, with a median age of 35.5 years [28.0; 45.0] and poorly controlled type 1 diabetes (T1D) with a mean ± standard error of mean (SEM) HbA1c value of 8.69 ± 0.13%. The primary study outcome was the difference in HbA1c values between baseline and the end of a 6-month follow-up. Other end points of interest were mean blood glucose, glucose management indicator (GMI) level and % time in range (3.9-10 mmol/L) or below or above range.

RESULTS

At month 6, mean HbA1c levels were significantly reduced by -0.5% (P < 0.001) as were also mean blood glucose levels (P = 0.015), with a significant increase of 6.75 ± 1.36% of time in range at month 3 and of 4.98 ± 1.4% at month 6. Such improvements did not depend on age, gender or type of insulin therapy, but were inversely correlated to initial HbA1c values on multivariate analysis (P < 0.001).

CONCLUSION

Although the use of telehealth monitoring offers efficacy and safety in the metabolic control of patients with T1D, it does not fulfil all of these patients' clinical needs. As such, this new healthcare pathway cannot replace, but is a useful complement to, face-to-face in-person clinical visits.

Telemetric Interventions Offer New Opportunities for Managing Type 1 Diabetes Mellitus: Systematic Meta-review

BACKGROUND

The prevalence of diabetes mellitus (DM) is increasing rapidly worldwide. Simultaneously, technological advances are offering new opportunities for better management of type 1 diabetes mellitus (T1DM). Telemetry, the remote acquisition of patient data via a telecommunication system, is a promising field of application in eHealth and is rapidly gaining importance.

OBJECTIVE

The aim of this study was to summarize the current evidences available on the effectiveness of telemetric approaches in T1DM management. This systematic meta-review examined different types of interventions of the technologies used in communication between health care professionals and patients as well as the key outcomes.

METHODS

We performed a systematic search in Web of Science Core Collection, EMBASE, Cochrane Library, MEDLINE via PubMed, and CINAHL databases in April 2020 with regard to the effectiveness of telemetric interventions for T1DM. We classified the interventions into 4 categories according to the technology used: (1) real-time video communication, (2) real-time audio communication, (3) asynchronous communication, and (4) combined forms of communication (real-time and asynchronous). We considered various study designs such as systematic reviews, clinical trials, meta-analyses, and randomized controlled trials and focused on the key outcomes. Additionally, a funnel plot based on hemoglobin A_1c (HbA_1c) values and different quality assessments were performed.

RESULTS

We identified 17 (6 high quality and 9 moderate quality) eligible publications: randomized controlled trials (n=9), systematic reviews and meta-analyses (n=5), cohort studies (n=2), and qualitative publications (n=1). Of 12 studies, 8 (67%) indicated a (significant or nonsignificant) reduction in HbA_1c levels; 65% (11/17) of the studies reported overall (mildly) positive effects of telemetric interventions by addressing all the measured outcomes. Asynchronous interventions were the most successful for patients diagnosed with T1DM, but no technology was clearly superior. However, there were many nonsignificant results and not sustained effects, and in some studies, the control group benefited from telemetric support or increased frequency of contacts.

CONCLUSIONS

Based on the currently available literature, this systematic meta-review shows that telemetric interventions cause significant reduction in HbA_1c levels and result in overall positive effects in T1DM management. However, more specified effects of telemetric approaches in T1DM management should be analyzed in detail in larger cohorts.

Telehealth in type 1 diabetes

PURPOSE OF REVIEW

The role of telehealth in the care of people with type 1 diabetes (T1D) has expanded dramatically during the coronavirus pandemic, and is expected to remain a major care delivery modality going forward. This review explores the landscape of recent evidence for telehealth in T1D care.

RECENT FINDINGS

Telemedicine for routine T1D care has shown equivalence to standard in-person care, with respect to glycemic control, while also increasing access, convenience, and satisfaction. Telehealth use promotes increased engagement of adolescents with T1D. Telehealth platforms have successfully been used in the care of microvascular complications and to support mental health related to diabetes. Machine learning and advanced decision support will increasingly be used to augment T1D care, as recent evidence suggests increasing capabilities to improve glycemic control. A spectrum of digital connected care services are emerging to support people with diabetes with daily management of diabetes. Finally, policy and systems are required that promote data interoperability, telemedicine provision, and reimbursement to support the ongoing growth of telehealth in T1D.

SUMMARY

A developing field of evidence supports use of telehealth in T1D. As this care modality scales, it has the potential to increase access to high-quality diabetes care for many people with T1D.

Awareness regarding COVID-19 and problems being faced by young adults with type 1 diabetes mellitus amid nationwide lockdown in India: A qualitative interview study

AIMS

To assess the awareness about COVID-19 and the problems being faced by young adults with T1DM amid nationwide lockdown in India.

METHODS

A cross-sectional telephone-based qualitative interview study was conducted in young adults (aged 18-30 years) with T1DM amid lockdown. Following verbal consent, participants were asked 8 open-ended questions, 5 on awareness about COVID-19 and 3 catering to problems being faced concerning diet, physical activity and treatment amid lockdown. On average, 3 interviews were conducted per day with each lasting for 15-20 min. Interviews were recorded, transcribed and analyzed by qualitative content analysis.

RESULTS

Thirty-two participants were interviewed; after exclusion of two poorly recorded interviews, 30 were finally analyzed. Mean age of participants was 22.4 ± 4.0 years (M:F = 8:7). Only 30%, 40% and 53% of participants were aware of modes of transmission (respiratory droplets and fomites), cardinal symptoms (fever, cough and breathing difficulty) and means of prevention (staying indoors, social distancing and regular hand washing), respectively. Majority of participants were unaware of additional risks associated with COVID-19 in diabetes mellitus. Most participants could continue with their routine diet and prescribed treatment regime, however, 90% reported a reduction in physical activity and 72% experienced worsening of glycemic control amid lockdown.

CONCLUSIONS

Young adults with T1DM lack adequate awareness about COVID-19. Increasing awareness and imparting diabetes self-management education via digital/print media is needed.

People living with type 1 diabetes point of view in COVID-19 times (COVIDT1 study): Disease impact, health system pitfalls and lessons for the future

AIMS

To analyse the effects of confinement among people with type 1 diabetes (T1D) and their caregivers over the course of the COVID-19 crisis and to evaluate contemporary changes in medical assistance and patient preferences.

METHODS

An observational cross-sectional study designed as a self-reported web-based survey was conducted over the course of the COVID-19 pandemic.

RESULTS

A total of 769 subjects participated in the survey (603 people with T1D and 166 caregivers). Changes in glycaemic control were reported in 66% of cases, weight gain in 40.4% of cases and decreased exercise levels in 65.4% of cases. Of the cohort, 53% maintained contact with the healthcare team, and 23% received specific information related to COVID-19. Emotional support was requested by 17% of respondents. Regarding telemedicine, 97.9% agreed with its use with the following preferences regarding the future: telephone call (84.5%), video-call (60.6%) and platform devices (39.7%).

CONCLUSIONS

Over the course of the COVID-19 pandemic, at least two-thirds of people with T1D underwent changes in the management of their condition. Almost all participants agreed with the concept of telemedicine, favouring telephone and video calls as their preferred means of communication.

Outcomes of monthly video consultations as an add-on to regular care for children with type 1 diabetes: A 6-month quasi-randomized clinical trial followed by an extension phase

OBJECTIVE

To explore the outcomes of monthly video consultations for children with diabetes.

METHODS

The Virtual Outpatient Diabetes Clinic for Children and Youth (VIDIKI) was a 6-month multicenter controlled clinical trial followed by an extension phase. The 240 participants (1-16 years), all using a CGM, were quasi-randomized by residence location to the intervention group (IG) or the waitlist-control group (WG). The IG started immediately after enrollment with monthly video consultations as an add-on to regular care, while the WG received regular care for 6 months before starting the intervention. The extension phase lasted between 12 months and 2 years, depending on the enrollment date. Linear regression was applied to model the primary outcome of HbA1c after 6 months and other metabolic and psychosocial outcomes.

RESULTS

After covariate adjustments, the HbA1c at 6 months-corresponding to the controlled treatment phase-was 0.11% lower in the IG than that in the WG (95% CI -0.31 to 0.09, P = .277). For the total study sample, a significant HbA1c improvement was found after 12 months of video consultations, which increased further until month 15. The diabetes burden of the main caregivers was lower, and parental treatment satisfaction was significantly higher in the IG than that in the WG.

CONCLUSIONS

The VIDIKI study found no significant HbA1c difference between IG and WG after 6 months in the controlled phase, but there was a decreased diabetes burden and increased treatment satisfaction for the parents. In the longitudinal perspective, a significant HbA1c improvement was found after 12 and 15 months.

Review of Randomized Controlled Trials Using e-Health Interventions for Patients With Eating Disorders

BACKGROUND

In a world of technological advancements, electronic devices and services seem to be a promising way to increase patients' engagement in treatment and to help manage their symptoms. Here, we identified and analyzed the current evidence of RCTs to evaluate the effectiveness and acceptability of e-health interventions in the eating disorder (ED) field.

METHODS

We screened an initial cluster of 581 papers. In the end, 12 RCTs in clinical ED cohorts were included.

RESULTS

Some studies were conceived as stand-alone interventions, while others were presented as add-ons to ED-specific treatments. Studies varied in the type of EDs under investigation and in the e-health intervention applied (with vs. without therapist support vs. blended interventions; smartphone- vs. web-based). Only four studies reported explicit acceptability measures. Out of those, two reported high acceptability, one reported low acceptability, and one reported no significant difference in acceptability between groups. Four studies reported higher effectiveness of the e-health intervention compared to the control condition, e.g., reduction in maladaptive eating behaviors. Regarding control groups, three used a wait list design and nine had another kind of intervention (e.g., face-to-face CBT, or treatment as usual) as control.

DISCUSSION

So far, the evidence for acceptability and effectiveness of e-health interventions in EDs is very limited. There is also a lack of studies in older patients, adolescents, men, sexual and ethnic minorities. Shame/stigma is discussed in the context of e-health interventions for EDs. It remains unclear how severity of EDs affects the effectiveness of e-health interventions, how patients can channel the knowledge they acquire from e-health interventions into their actual behaviors, and how such interventions can better fit the needs of the individual patient to increase acceptability and effectiveness.