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Minsky N, Arnon Klug L, Kolobov T, Tarshish E, Shalev Many Y, Lipsitz A, Jabarin A, Morozov N, Halperin D, Shalom M, Nissanholtz-Gannot R, Aharon-Hananel G, Tirosh A, Tamir O. Glycemic outcomes and patient satisfaction and self-management improves in transition from standard to virtual multidisciplinary care. Diabetes Res Clin Pract 2024; 209:111587. [PMID: 38368948 DOI: 10.1016/j.diabres.2024.111587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/04/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
AIMS With advances in cloud-based technologies, there has been a rise in remote T1D care. We hypothesized that transitioning T1DM care to a virtual, multidisciplinary clinic could improve measures beyond HbA1c. METHODS To assess the impact of transitioning from standard to virtual T1DM care, we evaluated glycemic measures and patient reported outcomes. RESULTS Sixty-one adults with T1DM were included, with mean age 40.2 ± 13.5 years and diabetes duration 16.9 ± 9.0 years. Most patients were treated with insulin pumps and CGM. The number of annual diabetes care encounters rose from 2.1 ± 4.2 to 12.8 ± 5.5. Baseline HbA1c was 7.9 ± 1.6 %(63 ± 16.9 mmol/mol), declining to 7.3 ± 1.1 %(56 ± 8.5 mmol/mol) and 7.1 ± 1.0 %(54 ± 7.7 mmol/mol) at 6 and 12 months respectively (p < 0.001 for both). In parallel, TIR improved from 63.1 ± 19.3 % to 69.2 ± 13.8 % (p < 0.001) and 67.5 ± 19.4 % (p = 0.03) at 6 and 12 months respectively, while TBR declined. Scores from validated diabetes treatment and self-management questionnaires rose significantly and these rises were associated with a reduction in HbA1c, the latter score was also associated with increased TIR. There was a trend toward a correlation between encounter frequency and improvement in HbA1c and TIR. CONCLUSIONS Transitioning from standard to virtual, coordinated, multidisciplinary T1DM care is associated with increased visit frequency, improving glycemic control, treatment satisfaction and self-care behaviors.
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Affiliation(s)
- Noga Minsky
- Division of Endocrinology, Diabetes, and Metabolism, Sheba Medical Center, Ramat Gan, Israel; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Liat Arnon Klug
- Division of Endocrinology, Diabetes, and Metabolism, Sheba Medical Center, Ramat Gan, Israel
| | - Tatyana Kolobov
- The Pesach Segal Israeli Center for Diabetes Research and Policy in Diabetes, Sheba Medical Center, Tel Hashomer, Israel
| | | | - Yuval Shalev Many
- The Pesach Segal Israeli Center for Diabetes Research and Policy in Diabetes, Sheba Medical Center, Tel Hashomer, Israel
| | - Aviva Lipsitz
- The Pesach Segal Israeli Center for Diabetes Research and Policy in Diabetes, Sheba Medical Center, Tel Hashomer, Israel
| | - Amna Jabarin
- Division of Endocrinology, Diabetes, and Metabolism, Sheba Medical Center, Ramat Gan, Israel
| | - Nicole Morozov
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dania Halperin
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Moshe Shalom
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rachel Nissanholtz-Gannot
- Department of Health Systems Management, Ariel University, Israel; Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem, Israel
| | - Genya Aharon-Hananel
- Division of Endocrinology, Diabetes, and Metabolism, Sheba Medical Center, Ramat Gan, Israel
| | - Amir Tirosh
- Division of Endocrinology, Diabetes, and Metabolism, Sheba Medical Center, Ramat Gan, Israel; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Orly Tamir
- The Pesach Segal Israeli Center for Diabetes Research and Policy in Diabetes, Sheba Medical Center, Tel Hashomer, Israel
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Bazzano AN, Patel T, Nauman E, Cernigliaro D, Shi L. Optimizing Telehealth for Diabetes Management in the Deep South of the United States: Qualitative Study of Barriers and Facilitators on the Patient and Clinician Journey. J Med Internet Res 2024; 26:e43583. [PMID: 37976468 PMCID: PMC10790202 DOI: 10.2196/43583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/01/2023] [Accepted: 11/17/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The Deep South of the United States, and Louisiana in particular, bears a greater burden of obesity, diabetes, and heart disease compared with other regions in the United States. Throughout the COVID-19 pandemic, there has been a substantial increase in telehealth visits for diabetes management to protect the safety of patients. Although there have been significant advancements in telehealth and chronic disease management, little is known about patient and provider perspectives on the challenges and benefits of telehealth visits among people living with diabetes and providers who care for patients with diabetes in Louisiana. OBJECTIVE This study aimed to explore barriers, facilitators, challenges, and benefits to telehealth for patients with diabetes and health care providers as they transitioned from in-person to remote care during the early COVID-19 pandemic to understand potential optimization. METHODS A total of 24 semistructured qualitative interviews were conducted with 18 patients living with diabetes and 6 clinicians who served patients with diabetes to explore their experiences and perceptions of telehealth services for diabetes care. Approximately half of the participants identified as Black or African American, half as White, and 75% as female. Interviews were recorded, transcribed, and coded by experienced qualitative researchers using inductive and deductive techniques. A narrative, descriptive approach to the patient and clinician journey framed the study, including the development of internal journey maps, and reflexive thematic analysis was applied to the transcripts, with special attention to barriers and facilitators. RESULTS In total, 5 themes illustrated barriers and facilitators for participants: convenience, safety, and comfort are the benefits of telehealth for patients and clinicians; yet telehealth and in-person visits are valued differently; the convenience of telehealth may have a downside; technology acts as a double-edged sword; and managing expectations and efficiency of the visit experience was an important factor. Individual experiences varied in relation to several factors, including comfort level and access to technology, health system protocols for providing telemedicine, and level of diabetes control among patients. CONCLUSIONS Recommendations for optimization include providing support to help guide and inform patients about what to expect and how to prepare for telehealth visits as well as allowing clinicians to schedule telehealth and in-person visits during discrete blocks of time to improve efficiency. Further research should address how hybrid models of telehealth and in-person care may differentially impact health outcomes for patients with diabetes, particularly for people with multiple chronic conditions in settings where access to technology and connectivity is not optimal.
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Affiliation(s)
- Alessandra N Bazzano
- Department of Social, Behavioral, and Population Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, United States
| | - Tejal Patel
- Department of Social, Behavioral, and Population Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, United States
| | - Elizabeth Nauman
- Louisiana Public Health Institute, New Orleans, LA, United States
| | - Dana Cernigliaro
- Public Health Innovation and Action, New York, NY, United States
| | - Lizheng Shi
- Department of Health Policy and Management, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, United States
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Vimalananda VG, Arao K, Qian S, Leibowitz A, Zupa MF, Benzer J, Fincke BG, Zocchi M, Meterko M, Berlowitz D, Sitter KE, Wormwood JB. Variation in telehealth use for endocrine care: Patterns and predictors under the "new normal". J Telemed Telecare 2023:1357633X231203144. [PMID: 37828749 DOI: 10.1177/1357633x231203144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Use of telehealth for outpatient endocrine care remains common since onset of the COVID-19 pandemic, though the context for its use has matured. We aimed to describe the variation in telehealth use for outpatient endocrine visits under these "new normal" conditions and examine the patient, clinician-, and organization-level factors predicting use. METHODS Retrospective cross-sectional study using data from the U.S. Department of Veterans Affairs (VA) Corporate Data Warehouse on 167,017 endocrine visits conducted between 3/9/21 and 3/8/22. We used mixed effects logistic regression models to examine 1) use of telehealth vs. in-person care among all visits and 2) use of telephone vs. video among the subsample of telehealth visits. RESULTS Visits were in person (58%), by telephone (29%), or by video (13%). Unique variability in telehealth use at each level of the analysis was 56% patient visit, 24% clinician, 18% facility. The strongest predictors were visit type (first vs. follow up) and clinician and facility characteristics. Among telehealth visits, unique variability in telephone (vs. video) use at each level was 44% patient visit, 24% clinician, 26% facility. The strongest predictors of telephone vs. video were visit type, patient age, and percent of the facility's population that was rural. CONCLUSIONS We found wide variation in use of telehealth for endocrinology under the "new normal". Future research should examine clinician and facility factors driving variation, as many may be amenable to influence by clinical leaders and leveraged to enhance the availability of telehealth for all clinically appropriate patients.
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Affiliation(s)
- Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Section of Endocrinology, Diabetes and Metabolism, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Kevin Arao
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Section of Endocrinology, Diabetes and Metabolism, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Shirley Qian
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
| | - Alison Leibowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
| | - Margaret F Zupa
- Division of Endocrinology & Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Justin Benzer
- VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas VA Health Care System, Waco, TX, USA
- Department of Psychiatry and Behavioral Sciences, University of Texas at Austin Dell Medical School, Austin TX, USA
| | - B Graeme Fincke
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Mark Zocchi
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
| | - Mark Meterko
- VHA Office of Reporting, Analytics, Performance, Improvement and Deployment, (RAPID-10EA), Field-Based At The VA Bedford Healthcare System, Bedford, MA, USA
| | - Dan Berlowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Department of Public Health, University of Massachusetts, Lowell, MA, USA
| | - Kailyn E Sitter
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
| | - Jolie B Wormwood
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Department of Psychology, University of New Hampshire, Durham, NH, USA
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Lee JM, Ospelt E, Noor N, Mungmode A, Ebekozien O, Gupta M, Malik FS, Fogel NR, Accacha S, Hsieh S, Wilkes M, Neyman A, Vendrame F. Institutional Barriers to the Successful Implementation of Telemedicine for Type 1 Diabetes Care. Clin Diabetes 2023; 42:34-39. [PMID: 38230345 PMCID: PMC10788657 DOI: 10.2337/cd23-0056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
The aim of this study was to describe rates of telemedicine use 18 months after the start of the coronavirus disease 2019 pandemic and to assess the institutional barriers to its implementation for type 1 diabetes care across centers of the T1D Exchange Quality Improvement Collaborative. Observational electronic health record data capturing telemedicine rates from 15 U.S. centers between September 2020 and September 2021 and a survey of 33 centers capturing telemedicine rates and key components of telemedicine were analyzed. A capacity score was developed and summed to a total capacity score and compared with overall telemedicine rates across centers. Telemedicine visits decreased by 17.4% from September 2020 to September 2021. Generally, it was observed that the lower the average telemedicine capacity score, the lower the rate of telemedicine visits. Despite a decline in the utilization of telemedicine 18 months after the start of the pandemic, visit rates were still 20% higher than in the pre-pandemic period. However, there is a need to improve structural components to ensure telemedicine capacity and robust telemedicine utilization.
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Affiliation(s)
- Joyce M. Lee
- Susan B. Meister Child Health Evaluation and Research Center, C.S. Mott Children’s Hospital, Ann Arbor, MI
| | | | | | | | - Osagie Ebekozien
- T1D Exchange, Boston, MA
- University of Mississippi School of Population Health, Jackson, MS
| | - Meenal Gupta
- Seattle Children’s Hospital, University of Washington, Seattle, WA
| | - Faisal S. Malik
- Seattle Children’s Hospital, University of Washington, Seattle, WA
| | | | | | | | | | - Anna Neyman
- Indiana University School of Medicine, Riley Children’s Hospital, Indianapolis, IN
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Bouchi R, Sugiyama T, Goto A, Ohsugi M, Yoshioka N, Katagiri H, Mita T, Hirota Y, Ikegami H, Matsuhisa M, Araki E, Yokoyama H, Minami M, Yamazaki K, Jinnouchi H, Ikeda H, Fujii H, Nogawa M, Kaneshige M, Miyo K, Ueki K. Impact of COVID-19 pandemic on behavioral changes and glycemic control and a survey of telemedicine in patients with diabetes: A multicenter retrospective observational study. J Diabetes Investig 2023; 14:994-1004. [PMID: 37183588 PMCID: PMC10360386 DOI: 10.1111/jdi.14027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/05/2023] [Accepted: 04/25/2023] [Indexed: 05/16/2023] Open
Abstract
AIMS/INTRODUCTION To investigate whether the COVID-19 pandemic affected behavioral changes and glycemic control in patients with diabetes and to conduct a survey of telemedicine during the pandemic. MATERIALS AND METHODS In this retrospective study, a total of 2,348 patients were included from 15 medical facilities. Patients were surveyed about their lifestyle changes and attitudes toward telemedicine. Hemoglobin A1c (HbA1c) levels were compared among before (from June 1 to August 31, 2019) and in the first (from June 1 to August 31, 2020) and in the second (from June 1 to August 31, 2021) year of the pandemic. A survey of physician attitudes toward telemedicine was also conducted. RESULTS The HbA1c levels were comparable between 2019 (7.27 ± 0.97%), 2020 (7.28 ± 0.92%), and 2021 (7.25 ± 0.94%) without statistical difference between each of those 3 years. Prescriptions for diabetes medications increased during the period. The frequency of eating out was drastically reduced (51.7% in 2019; 30.1% in 2020), and physical activity decreased during the pandemic (48.1% in 2019; 41.4% in 2020; 43.3% in 2021). Both patients and physicians cited increased convenience and reduced risk of infection as their expectations for telemedicine, while the lack of physician-patient interaction and the impossibility of consultation and examination were cited as sources of concern. CONCLUSIONS Our data suggest that glycemic control did not deteriorate during the COVID-19 pandemic with appropriate intensification of diabetes treatment in patients with diabetes who continued to attend specialized diabetes care facilities, and that patients and physicians shared the same expectations and concerns about telemedicine.
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Affiliation(s)
- Ryotaro Bouchi
- Department of Diabetes, Endocrinology and Metabolism, Center HospitalNational Center for Global Health and MedicineTokyoJapan
- Diabetes and Metabolism Information Center, Research InstituteNational Center for Global Health and MedicineTokyoJapan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research InstituteNational Center for Global Health and MedicineTokyoJapan
- Department of Public Health/Health Policy, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Atsushi Goto
- Department of Health Data Science, Graduate School of Data ScienceYokohama City UniversityYokohamaJapan
| | - Mitsuru Ohsugi
- Department of Diabetes, Endocrinology and Metabolism, Center HospitalNational Center for Global Health and MedicineTokyoJapan
- Diabetes and Metabolism Information Center, Research InstituteNational Center for Global Health and MedicineTokyoJapan
| | | | - Hideki Katagiri
- Department of Metabolism and DiabetesTohoku University Graduate School of MedicineSendaiJapan
| | - Tomoya Mita
- Department of Metabolism & Endocrinology, Graduate School of MedicineJuntendo UniversityTokyoJapan
| | - Yushi Hirota
- Division of Diabetes and Endocrinology, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Hiroshi Ikegami
- Department of Endocrinology, Metabolism and DiabetesKindai University Faculty of MedicineOsakaJapan
| | - Munehide Matsuhisa
- Diabetes Therapeutics and Research Center, Institute of Advanced Medical SciencesTokushima UniversityTokushimaJapan
| | - Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life SciencesKumamoto UniversityKumamotoJapan
| | | | - Masae Minami
- Minami Diabetes Clinical Research CenterFukuokaJapan
| | | | | | | | | | | | | | - Kengo Miyo
- Center for Medical Informatics IntelligenceNational Center for Global Health and MedicineTokyoJapan
| | - Kohjiro Ueki
- Department of Diabetes, Endocrinology and Metabolism, Center HospitalNational Center for Global Health and MedicineTokyoJapan
- Diabetes Research CenterNational Center for Global Health and MedicineTokyoJapan
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Sun CA, Shenk Z, Renda S, Maruthur N, Zheng S, Perrin N, Levin S, Han HR. Experiences and Perceptions of Telehealth Visits in Diabetes Care During and After the COVID-19 Pandemic Among Adults With Type 2 Diabetes and Their Providers: Qualitative Study. JMIR Diabetes 2023; 8:e44283. [PMID: 37463021 PMCID: PMC10394605 DOI: 10.2196/44283] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/11/2023] [Accepted: 06/10/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Since the COVID-19 pandemic, telehealth has been widely adopted in outpatient settings in the United States. Although telehealth visits are publicly accepted in different settings, little is known about the situation after the wide adoption of telehealth from the perspectives of adults with type 2 diabetes mellitus (T2D) and their providers. OBJECTIVE This study aims to identify barriers and facilitators of maintaining continuity of care using telehealth for patients with T2D in a diabetes specialty clinic. METHODS As the second phase of a multimethod study to understand missed appointments among adults with T2D, we conducted semistructured, individual, in-depth phone or Zoom interviews with 23 adults with T2D (14/23, 61% women; mean age 55.1, SD 14.4, range 35-77 years) and 10 providers from diabetes clinics in a tertiary academic medical center in Maryland. Interviews were audio-recorded, transcribed, and analyzed using thematic content analysis by the research team. RESULTS Adults with T2D and their providers generally reported positive experiences with telehealth visits for diabetes care with some technical challenges resulting in the need for in-person visits. We identified the following 3 themes: (1) "perceived benefits of telehealth visits," such as convenience, time and financial efficiencies, and independence from caregivers, benefits shared by both patients and providers; (2) "perceived technological challenges of telehealth visits," such as disparities in digital health literacy, frustration caused by unstable internet connection, and difficulty sharing glucose data, challenges shared by both patients and providers; and (3) "impact of telehealth visits on the quality of diabetes care," including lack of diabetes quality measures and needs and preferences for in-person visits, shared mainly from providers' perspectives with some patient input. CONCLUSIONS Telehealth is generally received positively in diabetes care with some persistent challenges that might compromise the quality of diabetes care. Telehealth technology and glucose data platforms must incorporate user experience and user-centered design to optimize telehealth use in diabetes care. Clinical practices need to consider new workflows for telehealth visits to facilitate easier follow-up scheduling and lab completion. Future research to investigate the ideal balance between in-person and telehealth visits in diabetes care is warranted to enhance the quality of diabetes care and to optimize diabetes outcomes. Policy flexibilities should also be considered to broaden access to diabetes care for all patients with T2D.
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Affiliation(s)
- Chun-An Sun
- Johns Hopkins School of Nursing, Baltimore, MD, United States
| | - Zachary Shenk
- Johns Hopkins School of Nursing, Baltimore, MD, United States
| | - Susan Renda
- Johns Hopkins School of Nursing, Baltimore, MD, United States
| | - Nisa Maruthur
- Johns Hopkins School of Nursing, Baltimore, MD, United States
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Stanley Zheng
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Nancy Perrin
- Johns Hopkins School of Nursing, Baltimore, MD, United States
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
- Center for Data Science in Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Hae-Ra Han
- Johns Hopkins School of Nursing, Baltimore, MD, United States
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Arao KA, Fincke BG, Zupa MF, Vimalananda VG. Comparison of Endocrinologists' Physical Examination Documentation for In-person vs Video Telehealth Diabetes Visits. J Endocr Soc 2023; 7:bvad073. [PMID: 37384303 PMCID: PMC10299892 DOI: 10.1210/jendso/bvad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Indexed: 06/30/2023] Open
Abstract
Objective Outpatient diabetes mellitus (DM) care over video telehealth (TH) requires modifications to how endocrinologists complete physical examinations (PEs). But there is little guidance on what PE components to include, which may incur wide variation in practice. We compared endocrinologists' documentation of DM PE components for in-person (IP) vs TH visits. Methods Retrospective chart review of 200 notes for new patients with DM from 10 endocrinologists (10 IP and 10 TH visits each) in the Veterans Health Administration between April 1, 2020, and April 1, 2022. Notes were scored from 0 to 10 based on documentation of 10 standard PE components. We compared mean PE scores for IP vs TH across all clinicians using mixed effects models. Independent samples t-tests were used to compare both mean PE scores within clinician and mean scores for each PE component across clinicians for IP vs TH. We described virtual care-specific and foot assessment techniques. Results The overall mean (SE) PE score was higher for IP vs TH (8.3 [0.5] vs 2.2 [0.5]; P < .001). Every endocrinologist had higher PE scores for IP vs TH. Every PE component was more commonly documented for IP vs TH. Virtual care-specific techniques and foot assessment were rare. Conclusions Our study quantifies the degree to which Pes for TH were attenuated among a sample of endocrinologists, raising a flag that process improvements and research are needed for virtual Pes. Organizational support and training could help increase PE completion via TH. Research should examine reliability and accuracy of virtual PE, its value to clinical decision-making, and its impact on clinical outcomes.
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Affiliation(s)
- Kevin A Arao
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA 01730, USA
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA
| | - B Graeme Fincke
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA 01730, USA
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA 02118, USA
| | - Margaret F Zupa
- Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA 01730, USA
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA
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8
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Thomas C, Ramirez AP, Alderfer MA, Patton SR, Carakushansky M, Enlow PT. Telehealth and Type 1 Diabetes Care During COVID-19: Perceptions From Youth of Color, Caregivers, and Health Care Providers. Diabetes Spectr 2023; 36:245-252. [PMID: 37583556 PMCID: PMC10425226 DOI: 10.2337/ds22-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
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.
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Affiliation(s)
- Courtney Thomas
- Center for Healthcare Delivery Science, Nemours Children’s Hospital, Delaware, Wilmington, DE
| | - Alejandra Perez Ramirez
- Center for Healthcare Delivery Science, Nemours Children’s Hospital, Delaware, Wilmington, DE
| | - Melissa A. Alderfer
- Center for Healthcare Delivery Science, Nemours Children’s Hospital, Delaware, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Susana R. Patton
- Center for Healthcare Delivery Science, Nemours Children’s Health, Jacksonville, FL
| | - Mauri Carakushansky
- Division of Endocrinology, Nemours Children’s Hospital, Florida, Orlando, FL
- Department of Pediatrics, University of Central Florida College of Medicine, Orlando, FL
| | - Paul T. Enlow
- Center for Healthcare Delivery Science, Nemours Children’s Hospital, Delaware, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
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9
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Crossen SS, Romero CC, Lewis C, Glaser NS. Remote glucose monitoring is feasible for patients and providers using a commercially available population health platform. Front Endocrinol (Lausanne) 2023; 14:1063290. [PMID: 36817610 PMCID: PMC9931729 DOI: 10.3389/fendo.2023.1063290] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Remote patient monitoring (RPM) holds potential to enable more individualized and effective care for patients with type 1 diabetes (T1D), but requires population analytics to focus limited clinical resources on patients most in need. We explored the feasibility of RPM from patient and provider standpoints using a commercially available data analytic platform (glooko Population Health) among a cohort of youth with T1D. STUDY DESIGN Patients aged 1-20 years with established T1D (≥12 months) and CGM use (≥3 months) were recruited to participate. Participants' CGM devices were connected to the glooko app and linked to the research team's glooko account during a one-month baseline period. This was followed by a six-month intervention period during which participants with >15% of glucose values >250 mg/dl or >5% of values <70 mg/dl each month were contacted with personalized diabetes management recommendations. Participants were surveyed about their experiences, and effects on glycemic control were estimated via change in glucose management indicator (GMI) generated from CGM data at baseline and completion. Changes in time spent within various glucose ranges were also evaluated, and all glycemic metrics were compared to a non-randomized control group via difference-in-difference regression, adjusting for baseline characteristics. RESULTS Remote data-sharing was successful for 36 of 39 participants (92%). Between 33%-66% of participants merited outreach each month, and clinician outreach required a median of 10 minutes per event. RPM was reported to be helpful by 94% of participants. RPM was associated with a GMI change of -0.25% (P=0.047) for the entire cohort, and stratified analysis revealed greatest treatment effects among participants with baseline GMI of 8.0-9.4% (GMI change of -0.68%, P=0.047; 19.84% reduction in time spent >250 mg/dl, P=0.005). CONCLUSIONS This study demonstrates the feasibility of RPM for patients with T1D using a commercially available population health platform, and suggests that RPM with clinician-initiated outreach may be particularly beneficial for patients with suboptimal glycemic control at entry. However, larger randomized studies are needed to fully explore the glycemic impact of RPM. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT04696640, identifier NCT04696640.
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Affiliation(s)
- Stephanie S. Crossen
- Department of Pediatrics, University of California Davis, Sacramento, CA, United States
- Center for Healthcare Policy and Research, University of California Davis, Sacramento, CA, United States
- *Correspondence: Stephanie S. Crossen,
| | - Crystal C. Romero
- Department of Pediatrics, University of California Davis, Sacramento, CA, United States
| | - Carrie Lewis
- Center for Healthcare Policy and Research, University of California Davis, Sacramento, CA, United States
| | - Nicole S. Glaser
- Department of Pediatrics, University of California Davis, Sacramento, CA, United States
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Vimalananda VG, Brito JP, Eiland LA, Lal RA, Maraka S, McDonnell ME, Narla RR, Roth MY, Crossen SS. Appropriate Use of Telehealth Visits in Endocrinology: Policy Perspective of the Endocrine Society. J Clin Endocrinol Metab 2022; 107:2953-2962. [PMID: 36194041 DOI: 10.1210/clinem/dgac494] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This work aims to guide clinicians practicing endocrinology in the use of telehealth (synchronous patient-clinician visits conducted over video or telephone) for outpatient care. PARTICIPANTS The Endocrine Society convened a 9-member panel of US endocrinologists with expertise in telehealth clinical care, telehealth operations, patient-centered care, health care delivery research, and/or evidence-based medicine. EVIDENCE The panel conducted a literature search to identify studies published since 2000 about telehealth in endocrinology. One member extracted a list of factors affecting the quality of endocrine care via telehealth from the extant literature. The panel grouped these factors into 5 domains: clinical, patient, patient-clinician relationship, clinician, and health care setting and technology. CONSENSUS PROCESS For each domain, 2 or 3 members drew on existing literature and their expert opinions to draft a section examining the effect of the domain's component factors on the appropriateness of telehealth use within endocrine practice. Appropriateness was evaluated in the context of the 6 Institute of Medicine aims for health care quality: patient-centeredness, equity, safety, effectiveness, timeliness, and efficiency. The panel held monthly virtual meetings to discuss and revise each domain. Two members wrote the remaining sections and integrated them with the domains to create the full policy perspective, which was reviewed and revised by all members. CONCLUSIONS Telehealth has become a common care modality within endocrinology. This policy perspective summarizes the factors determining telehealth appropriateness in various patient care scenarios. Strategies to increase the quality of telehealth care are offered. More research is needed to develop a robust evidence base for future guideline development.
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Affiliation(s)
- Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts 01730, USA
- Section of Endocrinology, Diabetes, Nutrition & Weight Management, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Leslie A Eiland
- Division of Diabetes, Endocrinology & Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Rayhan A Lal
- Division of Endocrinology, Department of Medicine, Stanford University, Stanford, California, USA
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California, USA
| | - Spyridoula Maraka
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Endocrinology and Metabolism, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Section of Endocrinology, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA
| | - Marie E McDonnell
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Radhika R Narla
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, Washington, USA
- VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Mara Y Roth
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Stephanie S Crossen
- Division of Endocrinology, Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
- Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
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11
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Tanenbaum ML, Zaharieva DP, Addala A, Prahalad P, Hooper JA, Leverenz B, Cortes AL, Arrizon-Ruiz N, Pang E, Bishop F, Maahs DM. 'Much more convenient, just as effective': Experiences of starting continuous glucose monitoring remotely following Type 1 diabetes diagnosis. Diabet Med 2022; 39:e14923. [PMID: 35899591 PMCID: PMC9579993 DOI: 10.1111/dme.14923] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022]
Abstract
AIM Initiating continuous glucose monitoring (CGM) shortly after Type 1 diabetes diagnosis has glycaemic and quality of life benefits for youth with Type 1 diabetes and their families. The SARS-CoV-2 pandemic led to a rapid shift to virtual delivery of CGM initiation visits. We aimed to understand parents' experiences receiving virtual care to initiate CGM within 30 days of diagnosis. METHODS We held focus groups and interviews using a semi-structured interview guide with parents of youth who initiated CGM over telehealth within 30 days of diagnosis during the SARS-CoV-2 pandemic. Questions aimed to explore experiences of starting CGM virtually. Groups and interviews were audio-recorded, transcribed and analysed using thematic analysis. RESULTS Participants were 16 English-speaking parents (age 43 ± 6 years; 63% female) of 15 youth (age 9 ± 4 years; 47% female; 47% non-Hispanic White, 20% Hispanic, 13% Asian, 7% Black, 13% other). They described multiple benefits of the virtual visit including convenient access to high-quality care; integrating Type 1 diabetes care into daily life; and being in the comfort of home. A minority experienced challenges with virtual care delivery; most preferred the virtual format. Participants expressed that clinics should offer a choice of virtual or in-person to families initiating CGM in the future. CONCLUSION Most parents appreciated receiving CGM initiation education via telehealth and felt it should be an option offered to all families. Further efforts can continue to enhance CGM initiation teaching virtually to address identified barriers.
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Affiliation(s)
- Molly L Tanenbaum
- Division of Endocrinology, Gerontology, and Metabolism, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
| | - Dessi P Zaharieva
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Ananta Addala
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Priya Prahalad
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Julie A Hooper
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Brianna Leverenz
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Ana L Cortes
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Nora Arrizon-Ruiz
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Erica Pang
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Franziska Bishop
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - David M Maahs
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
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12
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Haynes SC, Marcin JP. Pediatric Telemedicine: Lessons Learned During the Coronavirus Disease 2019 Pandemic and Opportunities for Growth. Adv Pediatr 2022; 69:1-11. [PMID: 35985702 PMCID: PMC8979775 DOI: 10.1016/j.yapd.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The accelerated uptake of telemedicine during the coronavirus disease 2019 pandemic has resulted in valuable experience and evidence on the delivery of telemedicine for pediatric patients. The pandemic has also highlighted inequities and opportunities for improvement. This review discusses lessons learned during the pandemic, focusing on provider-to-patient virtual encounters. Recent evidence on education and training, developing and adapting clinical workflows, patient assessment and treatment, and family-centered care is reviewed. Opportunities for future research in pediatric telemedicine are discussed, specifically with regard to engaging pediatric patients, improving and measuring access to care, addressing health equity, and expanding the evidence base.
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Affiliation(s)
- Sarah C Haynes
- Department of Pediatrics, UC Davis School of Medicine, UC Davis Center for Health and Technology, 4610 X Street, Suite 2300, Sacramento, CA 95817, USA.
| | - James P Marcin
- Department of Pediatrics, UC Davis School of Medicine, UC Davis Center for Health and Technology, 4610 X Street, Suite 2300, Sacramento, CA 95817, USA
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13
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Crossen SS, Bruggeman BS, Haller MJ, Raymond JK. Challenges and Opportunities in Using Telehealth for Diabetes Care. Diabetes Spectr 2022; 35:33-42. [PMID: 35308158 PMCID: PMC8914589 DOI: 10.2337/dsi21-0018] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The ongoing coronavirus pandemic led to a rapid and dramatic increase in the use of telehealth for diabetes care. In the wake of this transition, we examine new opportunities and ongoing challenges for using telehealth within diabetes management, based on data and experiences from the pre-pandemic and pandemic time frames.
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Affiliation(s)
- Stephanie S. Crossen
- Division of Pediatric Endocrinology, University of California, Davis, Sacramento, CA
- Corresponding author: Stephanie S. Crossen,
| | | | - Michael J. Haller
- Division of Pediatric Endocrinology, University of Florida, Gainesville, FL
| | - Jennifer K. Raymond
- Division of Pediatric Endocrinology, Children’s Hospital Los Angeles, Los Angeles, CA
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