Comprehensive Telehealth Model to Support Diabetes Self-Management.

Importance: As the number of patients with diabetes continues to increase in the United States, novel approaches to clinical care access should be considered to meet the care needs for this population, including support for diabetes-related technology. Objective: To evaluate a virtual clinic to facilitate comprehensive diabetes care, support continuous glucose monitoring (CGM) integration into diabetes self-management, and provide behavioral health support for diabetes-related issues. Design, Setting, and Participants: This cohort study was a prospective, single-arm, remote study involving adult participants with type 1 or type 2 diabetes who were referred through community resources. The study was conducted virtually from August 24, 2020, to May 26, 2022; analysis was conducted at the clinical coordinating center. Intervention: Training and education led by a Certified Diabetes Care and Education Specialist for CGM use through a virtual endocrinology clinic structure, which included endocrinologists and behavioral health team members. Main Outcomes and Measures: Main outcomes included CGM-measured mean glucose level, coefficient of variation, and time in range (TIR) of 70 to 180 mg/dL, time with values greater than 180 mg/dL or 250 mg/dL, and time with values less than 70 mg/dL or 54 mg/dL. Hemoglobin A1c was measured at baseline and at 12 and 24 weeks. Results: Among the 234 participants, 160 had type 1 diabetes and 74 had type 2 diabetes. The mean (SD) age was 47 (14) years, 123 (53%) were female, and median diabetes duration was 20 years. Median (IQR) CGM use over 6 months was 96% (91%-98%) for participants with type 1 diabetes and 94% (85%-97%) for those with type 2 diabetes. Mean (SD) hemoglobin A1c (HbA1c) in those with type 1 diabetes decreased from 7.8% (1.6%) at baseline to 7.1% (1.0%) at 3 months and 7.1% (1.0%) at 6 months (mean change from baseline to 6 months, -0.6%, 95% CI, -0.8% to -0.5%; P < .001), with an 11% mean TIR increase over 6 months (95% CI, 9% to 14%; P < .001). Mean HbA1c in participants with type 2 diabetes decreased from 8.1% (1.7%) at baseline to 7.1% (1.0%) at 3 months and 7.1% (0.9%) at 6 months (mean change from baseline to 6 months, -1.0%; 95% CI, -1.4% to -0.7%; P < .001), with an 18% TIR increase over 6 months (95% CI, 13% to 24%; P < .001). In participants with type 1 diabetes, mean percentage of time with values less than 70 mg/dL and less than 54 mg/dL decreased over 6 months by 0.8% (95% CI, -1.2% to -0.4%; P = .001) and by 0.3% (95% CI, -0.5% to -0.2%, P < .001), respectively. In the type 2 diabetes group, hypoglycemia was rare (mean [SD] percentage of time <70 mg/dL, 0.5% [0.6%]; and <54 mg/dL, 0.07% [0.14%], over 6 months). Conclusions and Relevance: Results from this cohort study demonstrated clinical benefits associated with implementation of a comprehensive care model that included diabetes education. This model of care has potential to reach a large portion of patients with diabetes, facilitate diabetes technology adoption, and improve glucose control.

Diabetes Education and Support Tele-Visit Needs Differ in Duration, Content, and Satisfaction in Older Versus Younger Adults.

Background: Diabetes education and support are critical components of diabetes care. During the COVID-19 pandemic, when telemedicine took the place of in-person visits, remote Certified Diabetes Care and Education Specialist (CDCES) services were offered to address diabetes education and support. Specific needs for older adults, including the time required to provide education and support remotely, have not been previously reported. Methods: Adults with diabetes (primarily insulin-requiring) were referred to remote CDCESs. Utilization was individualized based on patient needs and preferences. Topics discussed, patient satisfaction, and time spent in each tele-visit were evaluated by diabetes type, age, sex, insurance type, glycosylated hemoglobin (HbA1c), pump, and continuous glucose monitor (CGM) usage. t-Tests, one-way analysis of variance, and Pearson correlations were employed as appropriate. Results: Adults (n = 982; mean age 48.4 years, 41.0% age ≥55 years) with type 1 diabetes (n = 846) and type 2 diabetes mellitus (n = 136, 86.0% insulin-treated), 50.8% female; 19.0% Medicaid, 29.1% Medicare, 48.9% private insurance; mean HbA1c 8.4% (standard deviation 1.9); and 46.6% pump and 64.5% CGM users had 2203 tele-visits with remote CDCESs over 5 months. Of those referred, 272 (21.7%) could not be reached or did not receive education/support. Older age (≥55 years), compared with 36-54 year olds and 18-35 year olds, respectively, was associated with more tele-visits (mean 2.6 vs. 2.2 and 1.8) and more time/tele-visits (mean 20.4 min vs. 16.5 min and 14.8 min; p < 0.001) as was coverage with Medicare (mean 2.8 visits) versus private insurance (mean 2.0 visits; p < 0.001) and lower participant satisfaction. The total mean time spent with remote CDCESs was 53.1, 37.4, and 26.2 min for participants aged ≥55, 36-54, and 18-35 years, respectively. During remote tele-visits, the most frequently discussed topics per participant were CGM and insulin pump use (73.4% and 49.7%). After adjustment for sex and diabetes type, older age was associated with lack of access to a computer, tablet, smartphone, or internet (p < 0.001), and need for more education related to CGM (p < 0.001), medications (p = 0.015), hypoglycemia (p = 0.044), and hyperglycemia (p = 0.048). Discussion: Most remote CDCES tele-visits were successfully completed. Older adults/those with Medicare required more time to fulfill educational needs. Although 85.7% of individual sessions lasted <30 min, which does not meet current Medicare requirements for reimbursement, multiple visits were common with a total time of >50 min for most older participants. This suggests that new reimbursement models are needed. Education/support needs of insulin-treated older adults should be a focus of future studies.

2022 National Standards for Diabetes Self-Management Education and Support.

PURPOSE: The National Standards for Diabetes Self-Management Education and Support (DSMES) provide guidance and evidence-based, quality practice for all DSMES services. Due to the dynamic nature of health care and diabetes research, the National Standards are reviewed and revised approximately every 5 years by key stakeholders and experts within the diabetes care and education community. For each revision, the Task Force is charged with reviewing the current National Standards for appropriateness, relevance, and scientific basis and making updates based on current evidence and expert consensus. In 2021, the group was tasked with reducing administrative burden related to DSMES implementation across diverse care settings. CONCLUSION: The evidence supporting the 2022 National Standards clearly identifies the need to provide person-centered services that embrace cultural differences, social determinants of health, and the ever-increasing technological engagement platforms and systems. Payers are invited to review the National Standards as a tool to inform and modernize DSMES reimbursement requirements and to align with the evolving needs of people with diabetes (PWD) and physicians/other qualified health care professionals. The American Diabetes Association and the Association of Diabetes Care & Education Specialists strongly advocate for health equity to ensure all PWD have access to this critical service proven to improve outcomes both related to and beyond diabetes. The 2022 National Standards update is meant to be a universal document that is easy to understand and can be implemented by the entire health care community. DSMES teams in collaboration with primary care have been shown to be the most effective approach to overcome therapeutic inertia.

Diabetes Telehealth Solutions: Improving Self-Management Through Remote Initiation of Continuous Glucose Monitoring.

The purpose of this study was to evaluate feasibility of initiating continuous glucose monitoring (CGM) through telehealth as a means of expanding access. Adults with type 1 diabetes (N = 27) or type 2 diabetes using insulin (N = 7) and interest in starting CGM selected a CGM system (Dexcom G6 or Abbott FreeStyle Libre), which they received by mail. CGM was initiated with a certified diabetes care and education specialist providing instruction via videoconference or phone. The primary outcome was days per week of CGM use during the last 4 weeks. Hemoglobin A1c (HbA1c) was measured at baseline and 12 weeks. Participant self-reported outcome measures were also evaluated. All 34 participants (mean age, 46 ±â€…18 years; 53% female, 85% white) were using CGM at 12 weeks, with 94% using CGM at least 6 days per week during weeks 9 to 12. Mean HbA1c decreased from 8.3 ±â€…1.6 at baseline to 7.2 ±â€…1.3 at 12 weeks (P < .001) and mean time in range (70-180 mg/dL, 3.9-10.0 mmol/L) increased from an estimated 48% ±â€…18% to 59% ±â€…20% (P < .001), an increase of approximately 2.7 hours/day. Substantial benefits of CGM to quality of life were observed, with reduced diabetes distress, increased satisfaction with glucose monitoring, and fewer perceived technology barriers to management. Remote CGM initiation was successful in achieving sustained use and improving glycemic control after 12 weeks as well as improving quality-of-life indicators. If widely implemented, this telehealth approach could substantially increase the adoption of CGM and potentially improve glycemic control for people with diabetes using insulin.