Telemedicine visits rapidly increase at type 1 diabetes clinics during COVID-19 pandemic
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The proportion of telemedicine visits at diabetes clinics in the T1D Exchange Quality Improvement Collaborative increased dramatically from less than 1% before the COVID-19 pandemic to about 95% in April 2020, according to study data.
“Type 1 diabetes is a medical condition most suited for the telemedicine format given the connected diabetes devices that patients use, and the key role of diabetes data in guiding medical decision making,” Joyce Lee, MD, MPH, a pediatrician, diabetes specialist, and clinical and health services researcher in the Susan B. Meister Child Health Evaluation and Research Center at the University of Michigan, told Healio. “Given the rapid success that was achieved, there is opportunity for continued use of telemedicine for diabetes care.”
In March 2020, clinics in the T1D Exchange Quality Improvement Collaborative began attending virtual meetings to share progress and best practices with the shift to telemedicine. Researchers collected the monthly number of type 1 diabetes visits and HbA1c values collected from a subset of 11 pediatric clinics and two adult clinics from December 2019 to August 2020. Visits were labeled as in clinic, telephone visit or video visit, with both telephone and video visits considered telemedicine. In addition, 16 pediatric and five adult clinics answered a center-level survey discussing key telemedicine topics, such as access to technology, institutional support, standardizing telemedicine visits, patient-centered care, insurance coverage and reimbursement, and population management.
Clinics pivot to telemedicine
Compared with before the pandemic, clinics had a 22% reduction in overall visits in March and April 2020, followed by an increase back to pre-pandemic levels by June 2020. From December 2019 to February 2020, less than 1% of visits were conducted through telemedicine. That proportion increased to 95.2% in April 2020. The proportion of telemedicine visits slowly decreased in the final 4 months of the study, reaching about 45% in August 2020.
The researchers noted the proportion of telemedicine visits varied widely at each clinic.
“It was interesting to discover a range of telemedicine use, even between clinics in the same state, which would have been influenced by similar state and private insurer policies,” the researchers wrote. “For example, centers in one state reported telemedicine rates of 9.9% at one site and 22.2% at another; in another, state centers reported telemedicine rates of 19.3% at one site and 62.1% at another.”
About 62% of clinics performed both video and phone visits. Zoom was the most popular platform, used by 62% of centers. More than 95% of clinics also used CareLink, t:connect, Clarity or Glooko to view diabetes data remotely.
Most centers had diabetes educators, registered dietitians and social workers participating in telemedicine. However, only 15% of clinics said a psychologist participated in telemedicine. All clinics provided continuous glucose monitor training through telemedicine and 70% provided insulin pump training.
In April, more than 60% of visits had missing HbA1c laboratory results. The percentage decreased over time as clinics developed workflows for obtaining lab results.
Future of telemedicine still uncertain
Most clinics were able to shift to telemedicine quickly during the early months of the COVID-19 pandemic, but the researchers noted that a lot of questions remain as to whether telemedicine will continue to be a major part of clinics moving forward. Of the 21 clinics that completed the study survey, 12 reported that they were unsure of their institution’s goal for the proportion of telemedicine visits in the future.
“There are two major concerns,” Lee said about the future of telemedicine for type 1 diabetes. “First, will insurance continue to pay for virtual visits for patients with diabetes, and will it pay at the same rates as in person clinic visits? If telemedicine visits are not reimbursed or if they are paid at a lower rate, health systems will be reluctant to continue virtual visits. Even if visits are virtual, patients still need multidisciplinary care from certified diabetes educators, nurses, dietitians, and psychologists, which is expensive; facility fees from visits help to subsidize this cost. Second, will there be inequities in virtual care? Lack of access to technology — whether it’s diabetes devices and mobile/broadband access — and unequal coverage of video visits may further exacerbate health disparities in diabetes care.”
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