Examining a Diabetes Self-Management Education and Support Telemedicine Model With High-Risk Patients in a Rural Community.

BACKGROUND: Ongoing support is critical to diabetes self-management education and support (DSMES) effectiveness, but difficult to realize, particularly in areas with limited resources. The objective of this feasibility study was to assess the impact of a virtual support model on diabetes outcomes and acceptability with high-risk patients with type 2 diabetes in a rural community. METHODS: In a 12-month nonrandomized trial in federally qualified health centers (FQHCs), patients with hemoglobin A1c (HbA1c) >9% were referred to the Telemedicine for Reach, Education, Access, Treatment, and Ongoing Support (TREAT-ON) program where a Diabetes Care and Education Specialist provided DSMES through videoconferencing. HbA1c change was compared in 30 patients in the intervention group (IG) to a propensity score-matched retrospective control group (CG) of patients who received in-person DSMES delivered by a DCES. Changes in HbA1c, diabetes distress, empowerment, self-care and acceptability were assessed within the intervention group (IG) between those who did and did not meet self-management goals. RESULTS: The IG experienced similar significant reductions in HbA1c as the CG. Most (64%) IG participants achieved their self-management goal. Goal attainers had a significant HbA1c decrease of 0.21% every 3 months as well as significant reduction in diabetes distress and improvement in general dietary intake. Regardless of goal attainment, IG participants reported high levels of acceptability with TREAT-ON. CONCLUSIONS: This feasibility study suggests that TREAT-ON was well-received and as effective as traditional in-person DSMES. While findings augment ample evidence regarding DSMES benefits, the TREAT-ON model offers additional advantages and provides validation for telehealth to inform future practice in reaching and supporting self-management for high-risk patients in underserved areas. TRIAL REGISTRATION: Clinicaltrials.gov, # NCT04107935.

Diabetes Care Network: A Novel Model to Disseminate Team-Based Diabetes Specialty Care in a Rural Population.

PURPOSE: The purpose of the study was to examine the impact of a novel approach to provide diabetes specialty team care to rural patients with type 2 diabetes (T2DM) on clinical outcomes and processes of care. METHODS: Diabetes Care Network (DCN) provides Veterans with T2DM and elevated A1C an initial 6-week period of remote self-management education and support and medication management by a centrally located team of diabetes specialists. Participants are then comanaged by remote liaisons embedded in rural primary care facilities for the remainder of the 12-month intervention. In this pre-post intervention study, 87 Veterans enrolled in DCN from 2 different clinical sites had baseline and 12-month postenrollment A1C, systolic blood pressure, weight, and LDL cholesterol levels collected and compared using paired t tests. RESULTS: Participants were mostly male and White with elevated baseline A1C. Participants from both sites had significant improvement in A1C over the 12-month intervention period compared to an increase in the 12 months prior to enrollment. There were also significant improvements in LDL and systolic blood pressure at 1 site, with no significant change in weight at either site. CONCLUSIONS: DCN participants had significant improvement in A1C after not meeting similar goals previously in a robust primary care setting. A technology-enabled collaborative partnership between centrally located diabetes care teams and local liaisons is a feasible approach to enhance access to diabetes specialty care for rural populations.

Advancing Patient Safety and Access to Concentrated Insulin (U-500 Regular Insulin) in the Veterans Health Administration: A Clinician Education Program in the Primary Care Setting.

IN BRIEF The national epidemic of diabetes and the exposure of Vietnam veterans to Agent Orange has led to insulin resistance requiring concentrated insulin (U-500 regular [U-500R] insulin) for glycemic control. Initiation of U-500R insulin is limited to endocrinology expertise housed at "hub" Veterans Health Administration locations hours away from smaller "spoke" facilities. To overcome potential health care disparities and improve patient safety, a program was developed ensuring that all clinicians could co-manage U-500R insulin. This program evaluation was undertaken to improve patient safety and access to U-500R insulin by improving spoke clinicians' knowledge of safe delivery and management of U-500R insulin.

Liver triglyceride secretion and lipid oxidative metabolism are rapidly altered by leptin in vivo.

Leptin has potent lipid-lowering effects in peripheral tissues and plasma that are proposed to be important for the prevention of cellular lipotoxicity and insulin resistance. The current study addressed in vivo the effects of acute leptin delivery on liver triglyceride (TG) metabolism, the consequence of hepatic leptin action on whole-body TG homeostasis, and the mechanisms of leptin action. A 120-min iv leptin infusion (plasma leptin, approximately 14 ng/ml) decreased liver TG levels (53 +/- 3%; P = 0.001), but not skeletal muscle TG levels, and increased liver phosphatidylinositol 3-kinase activity (341 +/- 95%; P = 0.01) in lean rats. Leptin had no effect on liver TG levels or phosphatidylinositol 3-kinase activity in diet-induced obese rats. In lean animals, leptin decreased the plasma TG concentration (20 +/- 7%; P = 0.017), the rate of TG accumulation in plasma after tyloxapol administration (26 +/- 6%; P = 0.003), and TG secretion from isolated liver (51 +/- 8%; P = 0.004). To determine possible metabolic fates of depleted hepatic TG, we assessed leptin effects on liver oxidative metabolism. Leptin increased hepatic acetyl-coenzyme A carboxylase phosphorylation (85 +/- 13%; P = 0.006), fatty acid oxidation (49 +/- 7%; P = 0.001) and ketogenesis (69 +/- 15%; P = 0.004). Finally, intracerebroventricular delivery of leptin for 120 min had no effect on liver TG levels, but did increase signal transducer and activator of transcription 3 phosphorylation (162 +/- 40%; P = 0.02). These data present in vivo evidence for a role for leptin in the acute regulation of hepatic TG metabolism, and whole body TG homeostasis. A likely contributing mechanism for these effects is leptin-induced partitioning of TG into oxidative pathways.