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. 2023 Oct 2;6(10):e2336876.
doi: 10.1001/jamanetworkopen.2023.36876.

Comprehensive Telehealth Model to Support Diabetes Self-Management

Grazia Aleppo  1 , Robin L Gal  2 , Dan Raghinaru  2 , Davida Kruger  3 , Roy W Beck  2 , Richard M Bergenstal  4 , Terra Cushman  3 , Korey K Hood  5 , Mary L Johnson  4 , Teresa McArthur  6 , Amy Bradshaw  6 , Beth A Olson  7 , Sean M Oser  8 , Tamara K Oser  8 , Craig Kollman  2 , Ruth S Weinstock  9
Affiliations

Comprehensive Telehealth Model to Support Diabetes Self-Management

Grazia Aleppo et al. JAMA Netw Open. .

Abstract

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Aleppo reported grants from The Leona M. and Harry B. Helmsley Charitable Trust during the conduct of the study and personal fees from Bayer, Dexcom, and Insulet; nonfinancial support from Eli Lilly; and grants from Dexcom, Eli Lilly, Fractyl Health, Emmes, Mannkind, Tandem Diabetes Care, and Welldoc outside the submitted work. Ms Gal reported grants from The Leona M. and Harry B. Helmsley Charitable Trust during the conduct of the study. Ms Kruger reported grants from Abbott and advisor and/or speaking fees from Abbott, Dexcom, and Jaeb Center for Health Research outside the submitted work. Dr Beck reported grants from The Leona M. and Harry B. Helmsley Charitable Trust during the conduct of the study and grants from Insulet, Tandem Diabetes Care, Beta Bionics, Dexcom, and Bigfoot Biomedical; nonfinancial support from Insulet, Tandem Diabetes Care, Beta Bionics, Dexcom, Medtronic, Ascenia, Roche, Eli Lilly, and Novo Nordisk; and consulting fees paid to his institution from Insulet, Tandem Diabetes Care, Beta Bionics, Eli Lilly, Novo Nordisk, Embecta, Hagar, and Ypsomed outside the submitted work. Dr Bergenstal reported grants from Abbott Diabetes Care, Eli Lilly, Hygieia, Dexcom, Sanofi, Tandem Diabetes Care, Insulet, and Medtronic and consulting and/or advisory board fees paid to his institution from Abbott Diabetes Care, Dexcom, Onduo, Sanofi, Roche, Embecta, and Medtronic during the conduct of the study. Dr Hood reported behavioral expertise consulting fees from Cecelia Health during the conduct of the study. Ms Johnson reported grants from Jaeb Center for Health Research paid to HealthPartners Institute during the conduct of the study and grants from Dexcom given directly to HealthPartners Institute outside the submitted work. Ms Olson reported personal fees from Lagoon Health during the conduct of the study and stock ownership in Abbott Laboratories. Dr S. M. Oser reported grants from The Leona M. and Harry B. Helmsley Charitable Trust during the conduct of the study and consulting fees from Cecelia Health and advisory board fees from Dexcom outside the submitted work. Dr T. K. Oser reported grants from The Leona M. and Harry B. Helmsley Charitable Trust during the conduct of the study and consulting fees from Cecelia Health, advisory board fees from Dexcom, and an investigator-initiated grant from Abbott Diabetes Care outside the submitted work. Dr Kollman reported grants from The Leona M. and Harry B. Helmsley Charitable Trust and nonfinancial support from Dexcom during the conduct of the study; grants from JDRF, Diasome, and MannKind outside the submitted work; and nonfinancial support from Tandem, Dexcom, and Insulet outside the submitted work. Dr Weinstock reported personal fees from The Leona M. and Harry B. Helmsley Charitable Trust and Jaeb Center for Health Research during the conduct of the study; grants for participation in multicenter clinical trial through her institution from Eli Lilly, Novo Nordisk, Insulet, Tandem, Amgen, and MannKind outside the submitted work; and discounted devices for clinical research from DexCom outside the submitted work. No other disclosures were reported.

Figures

Figure.
Figure.. Boxplots of Hemoglobin A1c (HbA1c) Values for Study Participants With 6 Months of Follow-Up
Data shown represent 156 participants with type 1 diabetes (A) and 70 with type 2 diabetes (B). Dots denote mean values; horizontal lines inside the boxes, medians; bottom and top borders of the boxes, IQR; whiskers, range of values.
See this image and copyright information in PMC

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