Using a Telehealth Model in the Management of Patients With Diabetes
In the United States, 11.6% of the US population—over 38 million individuals—are living with diabetes, according to the CDC.1 As that number continues to increase, access to proper care will become difficult for some patients. The number of patients with diabetes outweighs the approximate number of endocrinologists in the United States. Telehealth is an option that offers health care providers caring for patients with diabetes the opportunity to educate their patients and manage the disease remotely.
To learn more about the use of a telehealth model to aid in the management of patients with diabetes, Consultant360 spoke with Robin Gal, MSPH, CCRA, Grazia Aleppo, MD, FACE, FACP, and Teresa McArther, MS, RD, CDES, who studied the use of a virtual clinic to support, continuous glucose monitoring (CGM), and diabetes self-management.2
Consultant360: Please provide a brief overview of your study. How did this research question come about?
Often in the United States, patient access to endocrinology care is limited by geography, and with the increasing number of people with diabetes and a shortage of endocrinologists, it is important to find new ways to make clinical care and clinical education more accessible. Access to technology, combined with diabetes education, is crucial for people with diabetes, but this is not often feasible for a variety of circumstances or reasons. We developed the Virtual Diabetes Specialty Clinic (VDiSC) study to demonstrate the potential of a virtual diabetes clinic for adults with either type 1 (T1D) or type 2 diabetes (T2D) to provide remote specialty care to achieve proper self-management for better health outcomes. The virtual care model included support for diabetes-related technology like continuous glucose monitors (CGMs), insulin dosing including prescriptions, and behavioral health support to address diabetes-related challenges.
The VDiSC study, which was funded by The Leona M. and Harry B. Helmsley Charitable Trust, was developed before the COVID-19 pandemic to address access to care issues, but the potential impact of this type of telehealth model became even more apparent as the pandemic further highlighted the need to establish remote-care options for chronic diseases.
C360: What factors played a role in your results? How so?
The virtual clinic model included certified diabetes care and education specialists (CDCESs), a network of endocrinologists licensed to practice throughout the United States, and a behavioral health team that helped to support concerns related to living with a chronic condition, like diabetes. The CDCES team would participate in all encounters to reinforce physician-directed care plans.
Average hemoglobin A1C (HbA1c) for individuals with T1D decreased from 7.8% at baseline to 7.1% at 3 and 6 months, with an 11% mean time in range increase over 6 months. The mean time in range is the optimal target range for glucose. We saw similar improvements in individuals with T2D – average HbA1c decreased from 8.1% at baseline to 7.1% at 3 and 6 months, with an 18% mean time in range increase over 6 months.
Many participants in the study were already under the care of an endocrinologist, yet they had not been able to access diabetes technology, diabetes education, or both. A key factor of this model was the ability to provide multiple aspects of diabetes care in one setting in an individualized way. The ability to connect with participants in a remote fashion connected a health care provider at a time and location convenient and comfortable for the participant. It also allowed for support members to be included. Participants developed a trusted, personal relationship with their CDCES, which was key to uncovering barriers and challenges related to managing diabetes day to day. The care team was able to adapt their approach to accommodate comfort with technology use and understand participant goals — education was a key factor. Learning to use the CGM tool and understanding the data empowered participants to optimize their treatment. They were able to make more informed decisions and as a result, had better outcomes.
C360: How do the results of your study impact the clinical care of patients with diabetes?
The study results showed that this type of model can be successful in improving glycemic control. We saw clinical benefits, but perhaps more importantly, we also saw participant-reported benefits—the majority reported less diabetes distress, greater satisfaction with glucose monitoring, and more confidence in managing their diabetes.
The telehealth structure was able to support individual participant needs and minimize burden and stress that can be associated with traditional care. Participants were able to meet their providers from their homes or workplaces without the burden and cost of travel. Study findings further validate that the virtual diabetes specialty clinic model extends clinical reach to a large population of those who may not otherwise have access.
C360: What are the overall take-home messages from this study?
There were a few take-home messages from our study. The first is that the virtual specialty clinic model is feasible and beneficial — the participants achieved.
There were a few take-home messages from our study. The first is that the virtual specialty clinic model is feasible and beneficial—the participants achieved excellent clinical results, which demonstrated the potential to expand access to specialty care for people living with diabetes. We followed many of the VDiSC participants for an additional 6 months after their participation in this 6-month study and they were able to continue to sustain the positive clinical outcomes that they had achieved by continuing to apply what they had learned.
Another takeaway is that all individuals with diabetes should have the opportunity to utilize CGM technology. For individuals, understanding the information from the CGM data and acting upon it equips the person with diabetes to better self-manage their chronic condition. Despite its benefits, CGM adoption is not widespread—especially among individuals whose diabetes is managed in the primary care setting. This study concludes CGM training, onboarding, and support can be done on a fully remote basis.
Thirdly, virtual care can provide high-level subspecialty care, regardless of where the participants may be located, and minimize burden for participants living with diabetes. The CDCES-centric model allows more efficient use of an endocrinologist's time and supports broader access to care.
Lastly, diabetes is an excellent example of a chronic disease that can be almost wholly managed on a virtual basis. With proper support, education, and care through the understanding of data, individuals can successfully learn to manage diabetes on their own by making informed, personalized lifestyle and behavior changes.
We had an outstanding team supporting this study, including our Coordinating Center staff at the Jaeb Center, our study chair, Dr. Grazia Aleppo, our Virtual Clinic team from Cecilia Health under the direction of Teresa McArthur and Amy Bradshaw, RD, and our investigator group – Dr. Richard Bergenstal, Terra Cushman, BScN; Dr. Korey Hood, Davida Kruger, MSN, Mary L. Johnson, BS, Beth A. Olson, MHA, Dr. Sean Oser, Dr. Tamara Oser, and Dr. Ruth Weinstock.
- National Diabetes Statistics Report. Centers for Disease Control and Prevention. Published November 14, 2023. Accessed November 21, 2023. www.cdc.gov/diabetes/data/statistics-report/index.html
- Aleppo, G, Gal RL, Raghinaru D, et al. Comprehensive telehealth model to support diabetes self-management. JAMA Netw Open. Published online October 4, 2023. doi:10.1001/jamanetworkopen.2023.36876