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Telemedicine in diabetes care
Is this a solution to the work force shortage in pediatric endocrinology?
There are more fellows in pediatric endocrinology training than there have been in a decade. The number of first-year fellows increased from 32 to 80 between 1997 and 2003, and the number of fellows in all years of training increased from 96 to 213 between 1997 and 2005. Despite these reassuring numbers, pediatric endocrinology is experiencing a workforce shortage of crisis proportions, mainly driven by the increase in patient volume.
A survey of subspecialists conducted by Future of Pediatric Education found that 46% of all pediatric endocrinologists said they were seeing increasing referrals, 75% said that the referrals were more complex and 61% thought that there would be a need for more pediatric endocrinologists in their area over the next five years. It is difficult, however, to recruit pediatric endocrinologists, with many positions remaining unfilled for a year or more.
The average wait time for a patient to obtain an appointment with a pediatric endocrinologist is nine weeks, another indicator of manpower constraints. Also driving the need for more endocrinologists is the increasing amount of time needed to provide diabetes care in this era of intensive management.
With most patients receiving basalbolus insulin regimens, we are asking that they check their blood glucose levels frequently, adjust their insulin based on predetermined algorithms, and contact their health care team frequently with blood glucose results.
The time spent reviewing blood glucose records and making dosage recommendations is largely nonreimbursed. In addition, the amount of time spent evaluating and educating patients has increased because we are seeing increasing numbers of patients with both type 1 diabetes and type 2 diabetes.
Finally, although we are training more pediatric endocrinologists than we had previously, there is an uneven distribution of practice location. Rural areas are understaffed. Only 26 states have at least one pediatric endocrinologist per 100,000 children. Two states, Montana and Wyoming, have none.
Thus, we must find ways to serve such areas without compromising care for those in urban environments. Concomitantly, we must make our practices more efficient, using technology to provide some of the education and some of the outreach care that we currently do ourselves or have our educators do.
The Florida Initiative in Telehealth and Education Program was established in 2001 at the University of Florida in partnership with the Florida Department of Health Children’s Medical Services Network to develop a program to improve diabetes care for children in an underserved area of the state. The project had three components: clinical care, diabetes education and behavior intervention.
Clinical care
Clinical care was provided biweekly using videoconferencing. A pediatric endocrinologist trained the CMSN nurses in the community to use videoconferencing equipment and hand cameras. They were also taught how to extract blood glucose data from home meters, obtain vital signs and growth information and perform basic physical evaluations of children with diabetes and endocrine disorders.
A nursing evaluation is performed using a template for obtaining the history and diabetes self-management data. The nurse sends the downloaded blood glucose values and the history form to the pediatric endocrinologist via fax, and the physician completes the history, performs the additional physical examination via video and audio technology and makes a treatment plan based on information obtained during the telemedicine visit.
All patients are seen in person by the pediatric endocrinologist in the clinic for an initial visit and annually thereafter. Follow-up blood glucose readings are done via e-mail or telephone. Patients are instructed to telephone for all emergent issues.
Before initiation of the telemedicine program, diabetes care was provided by pediatric endocrinologists from the university who had to travel four hours every three months to see these patients. Patients needing to be seen between clinic visits had to come to Gainesville. The average interval between clinic visits was 149 days, and the large numbers of patients made it necessary to keep the appointment times short, and education and discussions brief.
During the first two years of the telemedicine program, the interval between visits decreased to 89 days, concordant with American Diabetes Association guidelines. The number of hospitalizations decreased from 13 per year (47 days) to 3.5 per year (5.5 days), representing a cost-savings of $44,419. Visits to the emergency department decreased from eight to 2.5 per year, resulting in an annual cost savings of $2,267 compared with Medicaid costs for the two years preceding the initiation of the project.
Thus, even when the line charges and equipment costs of $18,826 were considered, the telemedicine program resulted in an annual cost savings of $27,860 per year in this small community. Most importantly, metabolic control was unchanged compared with pretelemedicine values.
Before telehealth was introduced, there was concern that patients would feel the care was too impersonal, that the doctor-patient relationship would be compromised and that patients would feel their privacy was being violated. To address this issue, a satisfaction questionnaire was completed by patients and their parents before and after their first telemedicine visit and annually thereafter.
More than 90% of patients and parents were satisfied with the telemedicine visits and wished to continue using it. They felt their privacy was respected and were pleased with the convenience of not having to travel long distances for medical care, not having to miss work and school, and with the personal cost savings this means of receiving care afforded them.
Education
Child-friendly cartoons, with accompanying narration and text, were developed to provide basic education about diabetes care. The Web-based modules cover every aspect of diabetes care, from basic physiology and insulin action to basic and advanced nutrition. These modules are online in both English and Spanish versions and allow patients and their families to receive education at their own pace and to return to the modules as frequently as needed. Patients were provided with computers, if needed.
The patients and their families were given pre- and post-tests to determine the efficacy of the education modules. The post-test scores increased and patients reported high satisfaction and noted the modules were easy to use. The modules have also been used to educate health department and school nurses and prospective diabetes camp counselors. The nurses are given continuing education credits if they complete all modules.
Studies are currently underway at the Medical College of Georgia and the University of Florida to evaluate the efficacy of these modules in providing education to newly diagnosed patients following a single session of face-to-face education. The results of the first two years of this program will be presented this month at the American Diabetes Association Scientific Session by Andrew Muir, MD, and Toree Malasanos, MD.
Behavioral intervention
Patients with diabetes often have psychosocial problems that interfere with their ability to adhere to their prescribed diabetes regimen, with resultant poor metabolic control requiring psychological intervention. However, patients often do not have access to a psychologist, are not able to pay for counseling, are not able to miss school or work to receive psychological help or lack transportation to come to visits.
For that reason, psychologists at the University of Florida developed an intervention called the virtual Diabetes Project Unit (vDPU), named for its predecessor — a highly successful but defunct residential project consisting of twice-weekly telephone contact with a psychologist from the University of Florida diabetes program. In this program, the psychologist arranges for a time for the scheduled phone calls with the patient and the parents.
The frequent contact has resulted in an average decrease in HbA1c values of 1.8% during the first year of the project. This is impressive because the patients referred to this program are those most resistant to performing diabetes-related tasks and most poorly motivated. The results of the vDPU were presented recently at the Therapeutic Patient Education Conference 2006.
Challenges for the future
Telemedicine can be a useful adjunct to traditional office-based practice, saving physicians and health educators time in travel to outreach clinics and providing care to patients who live far from subspecialty clinics. However, in many states (including Florida), Medicaid and many private insurers don’t reimburse for telemedicine encounters. Therefore, providers are not likely to embrace its use, despite the efficiency of this mode of diabetes care.
Unless we can obtain reimbursement for nontraditional means of providing care, the manpower able to adequately care for diabetes will continue to be inadequate, the metabolic status of many of our patients will suffer and the costs of care will be far greater than would have been expended for a telemedicine outreach program.
For more information:
- Janet Silverstein, MD, is Chief of the Division of Endocrinology, Department of Pediatrics at the University of Florida. She is also a member of Endocrine Today’s Editorial Advisory Board.
- Toree Malasanos, MD, is an Assistant Professor in the Division of Endocrinology, Department of Pediatrics at the University of Florida.
- Storch EA, Geffken G, Adkins J, et al. Telehealth behavioral intervention for adolescents with type 1 diabetes: Preliminary results of a wait-list controlled trial. Presented at Therapeutic Patient Education 2006. April 27-30. Florence, Italy.