Medication Optimization Among People With Type 2 Diabetes Participating in a Continuous Glucose Monitoring-Driven Virtual Care Program: Prospective Study.

BACKGROUND: The Onduo virtual care program for people with type 2 diabetes (T2D) includes a mobile app, remote lifestyle coaching, connected devices, and telemedicine consultations with endocrinologists for medication management and prescription of real-time continuous glucose monitoring (RT-CGM) devices. In a previously described 4-month prospective study of this program, adults with T2D and baseline glycated hemoglobin (HbA1c) ≥8.0% to ≤12.0% experienced a mean HbA1c decrease of 1.6% with no significant increase in hypoglycemia. OBJECTIVE: The objective of this analysis was to evaluate medication optimization and management in the 4-month prospective T2D study. METHODS: Study participants received at least 1 telemedicine consultation with an Onduo endocrinologist for diabetes medication management and used RT-CGM intermittently to guide therapy and dosing. Medication changes were analyzed. RESULTS: Of 55 participants, 48 (87%) had a medication change consisting of a dose change, addition, or discontinuation. Of these, 15 (31%) participants had a net increase in number of diabetes medication classes from baseline. Mean time to first medication change for these participants was 36 days. The percentage of participants taking a glucagon-like peptide-1 receptor agonist increased from 25% (12/48) to 56% (n=27), while the percentages of participants taking a sulfonylurea or dipeptidyl peptidase 4 inhibitor decreased from 56% (n=27) to 33% (n=16) and 17% (n=8) to 6% (n=3), respectively. Prescriptions of other antidiabetic medication classes including insulin did not change significantly. CONCLUSIONS: The Onduo virtual care program can play an important role in providing timely access to guideline-based diabetes management medications and technologies for people with T2D. TRIAL REGISTRATION: ClinicalTrials.gov NCT03865381; https://clinicaltrials.gov/ct2/show/NCT03865381.

Remote Application and Use of Real-Time Continuous Glucose Monitoring by Adults with Type 2 Diabetes in a Virtual Diabetes Clinic.

The Onduo Virtual Diabetes Clinic (VDC) for people with type 2 diabetes (T2D) combines a mobile app, remote lifestyle coaching, connected devices, and live video consultations with board-certified endocrinologists. Adults with T2D (n = 594) who were evaluated by a VDC endocrinologist, remotely prescribed and mailed a real-time continuous glucose monitoring (rtCGM) device and used ≥1 sensor completed a CGM satisfaction questionnaire. The CGM satisfaction score was 4.5 ± 0.8 out of 5. Most respondents (94.7%) agreed/strongly agreed that they were comfortable inserting the sensor remotely and that rtCGM use improved understanding of the impact of eating (97.0%), increased diabetes knowledge (95.7%), and helped improve diabetes control when not wearing the sensor (79.4%). HbA1c (n = 372) decreased from 7.7% ± 1.6% to 7.1% ± 1.2% (P < 0.001; 10.2 months). These data suggest that it is feasible to provide rtCGM directly to individuals with T2D through a VDC without in-office training. Intermittent use of rtCGM was well-received by adults with T2D and was associated with improvement in HbA1c.

Impact of Participation in a Virtual Diabetes Clinic on Diabetes-Related Distress in Individuals With Type 2 Diabetes.

The Onduo Virtual Diabetes Clinic is a telehealth program for people with type 2 diabetes that combines mobile app technology, remote personalized lifestyle coaching, connected blood glucose meters, real-time continuous glucose monitoring (rtCGM) devices, and clinical support from board-certified endocrinologists. This analysis evaluated change in diabetes distress among 228 program participants who reported moderate distress (score 2.0-2.9) or high distress (score ≥3.0) on the 17-item Diabetes Distress Scale (DDS17) at enrollment. Participants reported significant reductions in overall distress from 3.0 ± 0.8 at baseline to 2.5 ± 0.9 (P <0.001) at an average of 6 months of follow-up. Significant reductions in all DDS17 subscale scores were observed; most notable were reductions in the regimen-related and emotional distress subscales (-0.9 and -0.4, respectively; both P <0.001). Significantly greater reductions in overall distress (P = 0.012) and regimen-related distress (P <0.001) were reported by participants who were prescribed and used intermittent rtCGM (n = 77) versus nonusers (n = 151). Although the generalizability of these findings may be limited by the study's small sample size and potential for self-selection bias, these results do suggest that telemedicine programs such as the Onduo VDC could be a valuable tool for addressing the problem of diabetes-related distress.

Glycemic Outcomes in Adults With Type 2 Diabetes Participating in a Continuous Glucose Monitor-Driven Virtual Diabetes Clinic: Prospective Trial.

BACKGROUND: The Onduo virtual diabetes clinic (VDC) for people with type 2 diabetes (T2D) combines a mobile app, remote personalized lifestyle coaching, connected devices, and live video consultations with board-certified endocrinologists for medication management and prescription of real-time continuous glucose monitoring (RT-CGM) devices for intermittent use. OBJECTIVE: This prospective single-arm study evaluated glycemic outcomes associated with participation in the Onduo VDC for 4 months. METHODS: Adults aged ≥18 years with T2D and a baseline glycated hemoglobin (HbA1c) of ≥8% to ≤12% were enrolled from 2 primary care centers from February 2019 to October 2019. Participants were asked to engage at ≥1 time per week with their care team and to participate in a telemedicine consultation with a clinic endocrinologist for diabetes medication review. Participants were asked to use a RT-CGM device and wear six 10-day sensors (total 60 days of sensor wear) intermittently over the course of 4 months. The primary outcome was change in HbA1c at 4 months from baseline. Other endpoints included change in weight and in RT-CGM glycemic metrics, including percent time <70, 70-180, 181-250, and >250 mg/dL. Changes in blood pressure and serum lipids at 4 months were also evaluated. RESULTS: Participants (n=55) were 57.3 (SD 11.6) years of age, body mass index 33.7 (SD 7.2), and 40% (22/55) female. HbA1c decreased significantly by 1.6% (SD 1%; P<.001). When stratified by baseline HbA1c of 8.0% to 9.0% (n=36) and >9.0% (n=19), HbA1c decreased by 1.2% (SD 0.6%; P<.001) and 2.4% (SD 1.3%; P<.001), respectively. Continuous glucose monitoring-measured (n=43) percent time in range (TIR) 70-180 mg/dL increased by 10.2% (SD 20.5%; P=.002), from 65.4% (SD 23.2%) to 75.5% (SD 22.7%), which was equivalent to a mean increase of 2.4 hours TIR per day. Percent time 181-250 mg/dL and >250 mg/dL decreased by 7.2% (SD 15.4; P=.005) and 3.0% (SD 9.4; P=.01), respectively. There was no change in percent time <70 mg/dL. Mean weight decreased by 9.0 lb (SD 10.4; P<.001). Significant improvements were also observed in systolic blood pressure, total cholesterol, low-density lipoprotein cholesterol, and triglycerides (P=.04 to P=<.001). CONCLUSIONS: Participants in the Onduo VDC experienced significant improvement in HbA1c, increased TIR, decreased time in hyperglycemia, and no increase in hypoglycemia at 4 months. Improvements in other metabolic health parameters including weight and blood pressure were also observed. In conclusion, the Onduo VDC has potential to support people with T2D and their clinicians between office visits by increasing access to specialty care and advanced diabetes technology including RT-CGM. TRIAL REGISTRATION: ClinicalTrials.gov NCT03865381; https://clinicaltrials.gov/ct2/show/NCT03865381.

A Virtual Type 2 Diabetes Clinic Using Continuous Glucose Monitoring and Endocrinology Visits.

The Onduo Virtual Diabetes Clinic (VDC) telehealth technology/care model for adults with type 2 diabetes (T2D) combines connected devices, remote lifestyle coaching, and clinical support with a mobile App. Key differentiating program features are the availability of live video consultations with board-certified endocrinologists for medication management and real-time continuous glucose monitor use for higher-risk participants. Preliminary data (n = 740) suggest that participation was associated with a significant improvement in HbA1c with up to 6 months follow-up in those not meeting treatment targets. HbA1c decreased by 2.3% ± 1.9%, 0.7% ± 1.0%, and 0.2% ± 0.8% across baseline categories of >9.0%, 8.0%-9.0% and 7.0% to <8.0%, respectively (all P < .001). These findings suggest that the VDC has potential to support individuals with T2D and their clinicians in diabetes management between office visits.

Association of Structured Virtual Visits for Hypertension Follow-Up in Primary Care with Blood Pressure Control and Use of Clinical Services.

BACKGROUND: Optimal management of hypertension requires frequent monitoring and follow-up. Novel, pragmatic interventions have the potential to engage patients, maintain blood pressure control, and enhance access to busy primary care practices. "Virtual visits" are structured asynchronous online interactions between a patient and a clinician to extend medical care beyond the initial office visit. OBJECTIVE: To compare blood pressure control and healthcare utilization between patients who received virtual visits compared to usual hypertension care. DESIGN: Propensity score-matched, retrospective cohort study with adjustment by difference-in-differences. PARTICIPANTS: Primary care patients with hypertension. EXPOSURE: Patient participation in at least one virtual visit for hypertension. Usual care patients did not use a virtual visit but were seen in-person for hypertension. MAIN MEASURES: Adjusted difference in mean systolic blood pressure, primary care office visits, specialist office visits, emergency department visits, and inpatient admissions in the 180 days before and 180 days after the in-person visit. KEY RESULTS: Of the 1051 virtual visit patients and 24,848 usual care patients, we propensity score-matched 893 patients from each group. Both groups were approximately 61 years old, 44% female, 85% White, had about five chronic conditions, and about 20% had a mean pre-visit systolic blood pressure of 140-160 mmHg. Compared to usual care, virtual visit patients had an adjusted 0.8 (95% CI, 0.3 to 1.2) fewer primary care office visits. There was no significant adjusted difference in systolic blood pressure control (0.6 mmHg [95% CI, - 2.0 to 3.1]), specialist visits (0.0 more visits [95% CI, - 0.3 to 0.3]), emergency department visits (0.0 more visits [95% CI, 0.0 to 0.01]), or inpatient admissions (0.0 more admissions [95% CI, 0.0 to 0.1]). CONCLUSIONS: Among patients with reasonably well-controlled hypertension, virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.

Left in limbo - Experiences and needs among postmenopausal women newly diagnosed with osteoporosis without preceding osteoporotic fractures: A qualitative study.

Introduction Despite the fact that the first osteoporotic fracture is preventable, osteoporosis is still a major health challenge. The disease is highly prevalent among postmenopausal women. However little is known about how to meet and support women, when they are diagnosed with osteoporosis without preceding fractures. Therefore this study aims at gaining a deeper understanding of how women experience being diagnosed. Furthermore to describe and identify their needs, which should be met in future healthcare services. Methods We conducted a phenomenological qualitative study. We included 17 women aged 52-65 and collected data through semi-structured interviews. We analysed data following Giorgi's methodology. Findings Needs among the women were classified into three main themes: (1) needs of targeted and tailored information about osteoporosis, (2) needs of being prepared for GP visit to participate in treatment decision-making and (3) needs of being able to take care of bone health. Conclusion and implications In general the women experienced as been left 'in limbo', and they requested targeted and tailored information about osteoporosis. In particular, they want information about dual-energy X-ray absorptiometry (DXA) scan results and treatment options in advance of the GP visit. This will help them in being prepared and able to participate in treatment decisions. They ask for support in self-management of the disease with less focus on disease and risk of fracture. Instead, they demand more attention on the benefits of detecting early stage osteoporosis. The study highlights the call for new approaches to postmenopausal women newly diagnosed with osteoporosis without preceding fractures.

National Institute of Biomedical Imaging and Bioengineering Point-of-Care Technology Research Network: Advancing Precision Medicine.

To advance the development of point-of-care technology (POCT), the National Institute of Biomedical Imaging and Bioengineering established the POCT Research Network (POCTRN), comprised of Centers that emphasize multidisciplinary partnerships and close facilitation to move technologies from an early stage of development into clinical testing and patient use. This paper describes the POCTRN and the three currently funded Centers as examples of academic-based organizations that support collaborations across disciplines, institutions, and geographic regions to successfully drive innovative solutions from concept to patient care.

Asynchronous virtual visits for the follow-up of chronic conditions.

BACKGROUND: Both primary care and specialty care in many areas face access constraints. Tools to evaluate and engage patients with chronic disease, without having them present to the clinic, are needed. Asynchronous virtual care has been explored as one of the ways to deliver care more efficiently, yet this has not been integrated into a busy practice environment. This pilot study aims to assess the utility of a Web platform that allows patients with chronic disease to be evaluated for follow-up care, thereby avoiding an office visit. MATERIALS AND METHODS: Patients with 10 common chronic conditions were recruited into the study at a busy primary care clinic. Instead of booking an in-office follow-up visit, they were directed online to complete a questionnaire pertaining to their condition 7-28 days after their office visit. Their physician would review their responses and make treatment decisions, informing the patient online. Patient and physician satisfaction was measured using a validated Likert scale after each visit. RESULTS: Patients were satisfied with the Web site and process as a way to receive their follow-up care. Clinicians were satisfied in making clinical decisions with the information received via the Web site. The clinician time spent for the overall encounter was significantly shorter than for an in-person follow-up visit. CONCLUSIONS: Clinicians and patients are interested in tools that improve patient health, are convenient, and save time for both parties. Targeting patients with chronic illness and leveraging available technology to deliver the care are very satisfactory to both clinicians and patients. Asynchronous virtual visits for patients with chronic medical conditions are an effective way to evaluate and manage patients, while providing physicians significant time savings. These visits have the potential to reduce in-office follow-up visits across primary care, potentially improving access and reducing costs.

Enhancing primary care through online communication.

The effective delivery of primary care requires more frequent information exchange and communication than the typical office visit allows. Although industry leaders endorse health information technology (IT) to improve health outcomes and reduce costs, there has been less attention devoted to the use of this technology to deliver care. Using Internet-based technologies such as secure messaging, videoconferencing, and remote physiological monitoring can provide information to improve the patient-provider relationship and the quality of health care. Evidence has shown that patients and providers are willing to use these care delivery technologies. However, their success will require integration with electronic health records and payment models that support their implementation and growth.

Acceptability and willingness to pay for primary care videoconferencing: a randomized controlled trial.

We examined videoconferencing in comparison with face-to-face office visits in primary care. Four physicians took part in the study and 175 patients were recruited from a general medical practice. Patients were interviewed and examined in both face-to-face and virtual settings, the order being randomized. Patients and clinicians were surveyed by questionnaire after each visit. Physicians were very satisfied with videoconferencing but preferred face-to-face overall (P < 0.0001). For videoconferencing, the physical examination and the ability to order appropriate laboratory tests were the least satisfying elements of the encounter. Patients were also very satisfied with videoconferencing but overall preferred face-to-face (P < 0.0001). This difference was significant for gastrointestinal, musculoskeletal and respiratory complaints. However, in terms of willingness to pay (WTP) for videoconferencing access, patients with musculoskeletal and respiratory complaints were the most willing. Age and gender did not significantly predict WTP. The technical quality of the videoconference had a significant effect on satisfaction with the clinical encounter but did not correlate with the patients' WTP for videoconferencing. Travel costs up to $40 and travel times up to 4 hours did not influence the WTP of patients. For non-rural, relatively mobile patients, videoconferencing appears suitable for short visits for relatively simple complaints.

A randomized trial of virtual visits in a general medicine practice.

We compared desktop videoconferencing to conventional face-to-face visits for a range of commonly presenting problems in a general practice. A total of 175 patients were recruited. Patients were randomized to one of two arms of the study. In the first arm, the patients completed a visit (virtual or face-to-face) with a physician; they then completed a second visit via the other modality with another physician. In the second arm of the study, subjects had both visits face-to-face; different physicians conducted the two face-to-face consultations. Patients found virtual visits similar to face-to-face visits on most measures, including time spent with the physician, ease of interaction and personal aspects of the interaction. Physicians were also highly satisfied with the virtual visit modality. The diagnostic agreement between physicians was 84% between face-to-face and virtual visits; it was 80% between the two face-to-face visits. The study suggests that both patients and physicians could benefit if virtual visits were used as an alternative method of accessing primary care services.

Virtual visits in a general medicine practice: a pilot study.

The purpose of this pilot study is to investigate the feasibility, effectiveness, and acceptability of a patient-physician real-time encounter using videoconferencing technology (a virtual visit) compared to a face-to-face office visit in the general medical setting. The three broad aims of the study are (1) to compare the physician's ability to make diagnoses in both settings, (2) to compare the physician's ability to provide therapy in both settings, and (3) to examine both patient and physician satisfaction with both modalities. Thirty patients were recruited from a single practice to participate in the study. Patients were first interviewed and examined in the virtual setting, and then in the face-to-face setting. Both patients and physician were surveyed after each visit type with regard to quality of the history, quality of the examination, and satisfaction with the experience. The data were analyzed using two-tailed t-tests and analysis of variance. Patients significantly preferred the in-person visit (4.7 of 5), but were very satisfied with the virtual visit as well (4.1 of 5) (p < 0.0001) (scale: 1= poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). Physical examination effectiveness was significantly worse in the virtual visit modality (2.3 versus 4.9 for the face-to-face visit, p < 0.0001), but history and therapeutic effectiveness were not significantly different. Both patients and the physician felt comfortable with the technology: patients 4.1, physician 4.3. Results suggest that both patients and the physician found the virtual visit a potentially useful alternative to the traditional visit for many medical conditions. This may have significant implications for the general medical care environment. Patients may benefit from reduced opportunity costs associated with physician visits and clinicians may benefit from decrease overhead costs. Further research is ongoing to investigate the generalizability of these findings.