House Calls: Using “Telediabetes” to Improve Veterans’ Health

The telediabetes program used by the VA Pittsburgh Healthcare System combines electronic consulting with ongoing telephone-based care. The results show that this form of healthcare could improve outcomes in patients with type 2 diabetes, especially in rural areas where endocrinologists are scarce.

The number of endocrinologists continues to dwindle while rates of two of the main conditions these physicians treat – obesity and diabetes – trend ever upward. It’s an uphill battle, to be sure, but endocrinologists are adding new weapons to their arsenals all the time, especially as technological advancements make their way downstream. And some researchers hope these innovations paradoxically lead to a form of old-school medical practice, especially in underserved areas – a modern take on the house call.

A late-breaking abstract presented at ENDO 2018 in Chicago detailed the results of a study conducted at the Veterans Affairs (VA) Pittsburgh Healthcare System, where researchers are determining the efficacy of a telehealth program for diabetes self-management. Their “telediabetes” program merges an electronic consultation, or e-consult, from an endocrinologist specializing in diabetes with ongoing telephone-based care, and unlike a typical e-consult meant to be a one-time recommendation, this program provides team-based care with follow-up.

Archana Bandi, MD

The results presented at ENDO are promising. A research team led by Archana Bandi, MD, clinical director of Telehealth Services for VA Pittsburgh Healthcare System, compared results for 442 patients who participated in the e-consult program and another 407 patients who had a traditional face-to-face visit and follow-up care. All patients were veterans with type 2 diabetes who were referred from remote VA facilities between 2010 and 2015 for a consultation about improving their blood sugar control. On average, it took 37 days to obtain a face-to-face consultation, compared to just 10 days for an e-consult. Patients in both cohorts saw significant improvements in their A1c, even after a year.

“Without incurring any travel, our electronic consultation program provides equally efficacious diabetes care with significantly expedited access,” Bandi says. “This type of e-consult is a viable alternative to traditional face-to-face care delivery, especially in remote areas with a shortage of endocrinologists.”

“Given the chronic nature of diabetes, we decided to merge e-consult — i.e., one-time review and recommendations — with a brief (three to six month) telephonic continuity of care for an individualized goal driven care. If designed well, e-consults can be a very elegant solution for folks who have difficulty finding state-of-art care within reasonable driving distance.” — Archana Bandi, MD, clinical director of Telehealth Services, VA Pittsburgh Healthcare System

This team-based approach is especially beneficial to those with diabetes, according to Bandi. Patients need support on a number of fronts: adopting and maintaining a healthy lifestyle; management of risk factors such as dyslipidemia, hypertension, smoking cessation; and management of diabetes. “A team consisting of critical elements such as a nutritionist, diabetes educator/coach, mental health support services if needed, and a group of advanced practitioners supervised by the endocrinologist in a well-structured manner can support a larger body of patients than current care models allow,” she says.

Elegant Solution

In 2010, VA Pittsburgh Healthcare System participated in a pilot study funded by the Office of Rural Health to examine patient satisfaction of specialty care delivery via e-consult for diabetes, cardiology, and renal specialty care. Based on high satisfaction scores of patients and primary care providers, e-consults were incorporated as a standard care delivery modality for veterans across the board nationwide. And because Veteran Health Affairs (VHA) has a unified medical records system, it makes processes like e-consults efficient, safe, and reliable methodologies. “While traditionally e-consultation is considered a mechanism of consultation between primary care and specialist to provide brief chart review and limited recommendations, our approach at VA Pittsburgh Healthcare System for telediabetes/e-consult differed significantly,” Bandi says.

Here’s how it works: An endocrine provider reviews the patient’s medical record and conducts a 20- to 30-minute phone interview with the patient and family, before electronically sending the referring physician recommendations to share with the patient on lowering his or her blood sugar levels. A nurse on the diabetes care team monitors the patient’s progress via phone calls over the next three to six months, and the primary care provider obtains all needed laboratory tests and makes recommended changes in therapeutic regimen. Patients are also offered ancillary services such as nutrition counselling and diabetes education services close to home.

“Given the chronic nature of diabetes, we decided to merge e-consult — i.e., one-time review and recommendations — with a brief (three- to six-month) telephonic continuity of care for an individualized goal driven care,” Bandi says. “We used this period as an opportunity to provide education, intensify or de-intensify treatment, and address other standards of care, such as a retinal exam and foot care among others. We used our existing infrastructure of primary care services as our partners which helped us to decentralize the specialty care from centralized hub locations to remotely located patients. If designed well, e-consults can be a very elegant solution for folks who have difficulty finding state-of-art care within reasonable driving distance.”

A Method to Modernization

Bandi says she doesn’t see telediabetes programs as a means to deliver initial consultations for patients who have suffered major complications from long-standing diabetes such as retinopathy leading to blindness, patients requiring dialysis due to ESRD, elderly patients with hearing difficulties, or those who are at risk from hypoglycemia or have hypoglycemia unawareness, patients who are candidates for insulin pump therapy, or patients with major mental health issues like severe PTSD or schizophrenia.

“E-consults have a huge role to play in addressing the shortage of specialty care, improving timely access to quality care, and addressing the chronic problem of poor care of diabetes, especially where there is a shortage of providers.” — Archana Bandi, MD, clinical director of Telehealth Services, VA Pittsburgh Healthcare System

But she does see these programs as ways to modernize practices, especially with the arrival of newer therapies like GLP-1 analogs, SGLT-2 inhibitors, DPP-4 inhibitors, and the many newer basal insulins. “Anecdotally, primary care providers in Veteran Health Affairs have expressed difficulty in keeping up with such advances and incorporating them in routine patient care,” Bandi says. “I am sure this experience is not unique to VHA and likely shared by primary care providers in non-VA organizations. Thus, e-consults can be an excellent means to address well known primary care inertia of timely escalation or modification of therapies on a larger scale for patients with early diabetes to improve glycemic control and prevent long term complications.”

Still, she does expect some pushback, especially from endocrinologists who are overworked and underpaid. Reimbursement models vary from state to state, and even among institutions. Bandi was able to carry out this work and develop this model where care is not driven by revenue. “E-consults have a huge role to play in addressing the shortage of specialty care, improving timely access to quality care, and addressing the chronic problem of poor care of diabetes, especially where there is a shortage of providers,” she says. “However, it cannot be a successful strategy unless healthcare organizations, the insurance industry, and payers provide incentives for the endocrinologists to change their practices and mindset as well.”

Treating Patients Close to Home

Bandi may expect some pushback, but she has advice for endocrinologists considering adopting this telediabetes model or a similar one:

  1. Partner with administration to create an internal mechanism to capture time-based workload until reimbursement for e-consults becomes routine;
  2. Start slow with realistic goals and pick very low-hanging fruits, which will help decompress clinics by taking smaller issues off of face-to-face visits and open up slots for much-complicated issues thus reducing wait times for new patients, and
  3. Modernize medical record systems.

“A unified platform for care coordination is an important means to this type of healthcare delivery as very few specialty care services are data-driven like endocrinology,” she says. “Thus, if we were to be confident of our care processes and successful in creating newer models, we will need to have unhindered access to complete medical records, investments in virtual care delivery technologies, and a renewed look at reimbursement models for non-traditional care delivery.”

Indeed, adopting these models will take some time and a lot of effort, and with diabetes and obesity rates continuing to climb, the shortage of endocrinologists will probably not be addressed any time soon. But more telehealth technologies are emerging, and Bandi is optimistic. “With the availability of modern care delivery technologies,” she says, “we can once again take care of the patients closer to home, and possibly at home, as we did in past.”

 

 

 

 

 

 

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