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Improving access to Endocrinologists for Diabetes Care through Telemedicine

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Previous Beam blog posts described the ways in which telemedicine lends itself to the management of complicated Diabetic Foot Infection (DFI) and COVID-19 care preparations. Both of these cases are relevant to diabetes care, primarily in inpatient settings. This blog post investigates the impact potential of delivering endocrinology specialty care through telemedicine platforms, primarily in the context of outpatient care delivery and chronic disease management.

Improving diabetes care remains of national importance regardless of location and mode of care delivery. Diabetes is the seventh leading cause of death in the United States1. National public health priorities, as represented in the Healthy People 2030 Initiative, rank improvements in diabetes care and its clinical outcomes highly2. Patient priorities parallel this call to action. According to the Rural Health People National Survey 2020 the top three most important priorities identified by rural communities are access to care, nutrition and weight loss, and diabetes care3. Tele-endocrinology is one way to address these priorities both directly and simultaneously. Additionally, this care model is increasingly relevant in the era of COVID-19 infection.

Tele-endocrinology is an effective form of care delivery that creates notable impacts in diabetes care outcomes. It is associated with high patient and provider satisfaction, time and costs savings, high appointment adherence, and improved clinical outcomes4. Telemedicine diabetes programs also have been shown to improve disease self management in rural populations5. Finally, the Telemedicine for Reach, Education, Access, and Treatment (TREAT) model utilizing remote endocrinologist and local providers showed a robust effect on decreasing average blood sugar levels in its participants, demonstrating the vital impact direct endocrinologist involvement via telehealth had on patient outcomes6.

Telemedicine aims to increase access to care. Tele-endocrinology situated in outpatient clinics brings diabetic specialists to patients, while lowering barriers to care delivery. It can also decrease clinic appointment wait times for rural populations. Mean wait times for an initial nonurgent consultation visit with an adult endocrinologist is 37 days compared with an average wait time of 15 to 22 days for a visit with family medicine, cardiology, or dermatology provider7. We suspect these times vary greatly both across the country as well as within and between rural and urban communities. Anecdotally, we know very few endocrinologists with wait times less than two months and have had personal wait times in urban areas of three months. Areas with fewer endocrinologists likely suffer from both longer wait times and further distance to access said specialists. Our tele-endocrinology programs seek to reduce wait times and required travel distances for rural populations.

telemedicine on a laptop

A study by the Veterans Administration found telemedicine visits saved patients 145 miles and 142 minutes per visit

Telemedicine also allows modern healthcare to respond to ongoing cultural shifts and increasing adoption of virtual communications. These changes are enabled by telemedicine care delivery models and benefit patients. Benefits include enhanced care coordination and feasibility of appointment visits, supporting social distancing efforts, safely evaluating frail patients, and lowering other barriers to access for patients such as child care issues or employment commitments.

One of the most palpable outcomes for patients engaging in telemedicine includes reductions in transportation costs. While increasing local access to specialists such as endocrinologists, telemedicine saves patients time and money. Multiple studies have demonstrated the great extent to which rural communities can dramatically reduce travel requirements via telemedicine services (see Table 1: Telemedicine Distance, Time and Cost Savings Summary). A study by the Veterans Administration found telemedicine visits saved patients 145 miles and 142 minutes per visit, saving their travel reimbursement program an average annual cost saving of over $18,000 per year8. Rural residents and their families, who otherwise would have to travel to obtain expert medical care or visit hospitalized loved ones, save time and money.

Table 1: Telemedicine Distance, Time and Cost Savings Summary
Reference Population Served Distance Savings (in miles per visit) Time Savings (minutes per visit) Cost Savings (annual)
Russo (2016)9 Rural Vermont, Across disciplines 145 142 $18,555 average/$63,804 final year
Thaker (2013)10 Remote Australia, Oncology 2,089 n/a $165,737
Dullet(2017)11 California, University-based outpatient clinics 278 245 $443,393
Chu (2015)12 Greater Los Angeles, Urology 277 290 $12,998
Samii (2006)13 Washington State, Parkinson's Patients 621 900 $12,333

Telemedicine, COVID-19, and Diabetes Care

The COVID-19 pandemic has brought into stark relief the advantages of telemedicine in terms of the need for increased access to specialty care and the improvements it brings to care delivery. As our knowledge of the clinical impacts and outcomes of COVID-19 infection continues to evolve, it’s increasingly clear improved diabetic care remains important to improved patient outcomes in the management of COVID-19 infection. Simultaneously, endocrinology care delivered via telemedicine lowers pandemic-related barriers to care.

pexels-anna-shvets-3962283The profound effects of COVID-19 on social life have implications for health habits and chronic disease management. Social distances and quarantine measures have led to increased stress, isolation, and physical inactivity. Unemployment and income loss could affect care engagement. These disruptions in both our personal lives and routine care delivery could lead to downstream changes in health related behaviors such as care engagement, medication adherence, and risk factor control. Moreover, said changes are likely to exacerbate underlying health disparities related to access to care, disparities known to directly affect diabetes care and its clinical outcomes14.

Medically, our emerging understanding of the relationships COVID-19 infection and diabetes warrants increasing our commitments to improving the quality of diabetes care. Individuals with poorly controlled diabetes are at risk of having more severe COVID-19 related illnesses. These include: higher risk of severe pneumonia, release of tissue injury‐related enzymes, excessive uncontrolled inflammation responses, and an increased likelihood to suffer from hypercoagulable states15. All of which lead to poorer outcomes. Additionally, these patients require more medical interventions and increased insulin requirements16. Fortunately, early studies indicate improved diabetic care can improve COVID-19 related outcomes. Inpatient data suggests diabetes control pre-infection could improve overall covid-19 outcomes and well controlled glucose correlated with improved outcomes in infected patients17.

Improving diabetes care is a national priority and its importance has only been highlighted by the COVID-19 pandemic. Telemedicine offers the opportunity to improve diabetic care and is uniquely situated to do so during times in which infection control has become an every day, every person problem. By creating telemedicine programs that increase access to endocrinology, Beam Healthcare seeks to expand the ability of health systems to improve both engagement and outcomes of diabetic patients. It does so while creating cost saving opportunities for both patients and health systems that respond and align to ongoing cultural shifts in modes of communication, public health priorities, and the realities of a pandemic.

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1 Centers for Disease Control and Prevention. (2017). National Diabetes Statistics Report, 2017: Estimates of Diabetes and its Burden in the United States [PDF file]. Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

2 https://health.gov/healthypeople/objectives-and-data/browse-objectives/diabetes

3 Bolin, J. N., Bellamy, G. R., Ferdinand, A. O., Vuong, A. M., Kash, B. A., Schulze, A., & Helduser, J. W. (2015). Rural healthy people 2020: New decade, same challenges. The Journal of Rural Health, 31(3), 326-333.

4 McLendon, S. F. (2017). Interactive video telehealth models to improve access to diabetes specialty care and education in the rural setting: a systematic review. Diabetes Spectrum, 30(2), 124-136; Xu, T., Pujara, S., Sutton, S., & Rhee, M. (2018). Peer reviewed: Telemedicine in the management of type 1 diabetes. Preventing chronic disease, 15.

5 Holloway, B., Coon, P. J., Kersten, D. W., & Ciemins, E. L. (2011). Telehealth in rural Montana: promoting realistic independent self-management of diabetes. Diabetes Spectrum, 24(1), 50-54.

6 Toledo, F. G., Ruppert, K., Huber, K. A., & Siminerio, L. M. (2014). Efficacy of the Telemedicine for Reach, Education, Access, and Treatment (TREAT) model for diabetes care. Diabetes Care, 37(8), e179-e180.

7 White paper Endocrine Clinical Workforce: Supply and Demand Projections 2014, June

8 Russo, J. E., McCool, R. R., & Davies, L. (2016). VA telemedicine: an analysis of cost and time savings. Telemedicine and e-Health, 22(3), 209-215.

9 Russo, J. E., McCool, R. R., & Davies, L. (2016). VA telemedicine: an analysis of cost and time savings. Telemedicine and e-Health, 22(3), 209-215.

10 Thaker, D. A., Monypenny, R., Olver, I., & Sabesan, S. (2013). Cost savings from a telemedicine model of care in northern Queensland, Australia. Medical Journal of Australia, 199(6), 414-417.

11 Dullet, N. W., Geraghty, E. M., Kaufman, T., Kissee, J. L., King, J., Dharmar, M., ... & Marcin, J. P. (2017). Impact of a university-based outpatient telemedicine program on time savings, travel costs, and environmental pollutants. Value in Health, 20(4), 542-546.

12 Chu, S., Boxer, R., Madison, P., Kleinman, L., Skolarus, T., Altman, L., ... & Shelton, J. (2015). Veterans Affairs telemedicine: bringing urologic care to remote clinics. Urology, 86(2), 255-261.

13 Samii, A., Ryan-Dykes, P., Tsukuda, R. A., Zink, C., Franks, R., & Nichol, W. P. (2006). Telemedicine for delivery of health care in Parkinson's disease. Journal of telemedicine and telecare, 12(1), 16-18.

14 Gaskin, D. J., Thorpe Jr, R. J., McGinty, E. E., Bower, K., Rohde, C., Young, J. H., ... & Dubay, L. (2014). Disparities in diabetes: the nexus of race, poverty, and place. American journal of public health, 104(11), 2147-2155.

15 Guo, W, Li, M, Dong, Y, et al. Diabetes is a risk factor for the progression and prognosis of COVID‐19. Diabetes Metab Res Rev. 2020; 36:e3319.

16 Diabetes Care 2020 Jul; 43(7): 1399-1407.

17 Cell Metabolism,Volume 31, Issue 6, 2020, Pages 1068-1077.e3,