The Endocrine Society has been leading the charge for adopting innovative diabetes care models since 2018. However, the specter of the COVID-19 pandemic has forced the entire healthcare industry to rethink how patients are treated, resulting in an unprecedented wave of innovation that could revolutionize how care is delivered.
In early March, Robert A. Gabbay, MD, was sitting in his office where he was the chief medical officer of the Joslin Diabetes Center in Boston, when he got a knock (“more like a pound”) on his door. One of his staff members was relaying the news that someone on their team had tested positive for COVID-19.
“And that’s when it really hit,” he says. “We have to close this place down, and we have to transfer the care for 25,000 patients [with diabetes].”
Diabetes is and has been for a long time a global pandemic in its own right — a disease that now affects more than 500 million people worldwide, but an area of medicine that has not seen the strides many diabetes experts would have liked to see. More than 50% of those with diabetes fail to hit their glycemic targets, which minimize the risk of complications that can be made even more destructive by this novel coronavirus.
But in a year marked by a global pandemic, a sagging economy, civil unrest, and even murder hornets, there is at least one bright spot: COVID-19 has created an opportunity to rapidly implement and test models of diabetes care that were not possible before. These innovative models like telehealth have the potential to improve medical outcomes and the patient experience beyond the pandemic.
Gabbay and his team were able to pivot to new models of care for their patients with diabetes in just 10 days. This may sound like a familiar story; many of those treating diabetes in the year 2020 could probably tell their own version. “We need to change the way we provide care, considering that outcomes of people with diabetes have not improved over the last decade,” says Gabbay, who now serves as the chief scientific and medical officer of the American Diabetes Association in Arlington, Va. “Given the dual pandemics of COVID-19 and diabetes, adoption of these innovations has accelerated in the hopes of creating a ‘new normal’ and improvements in the care we provide for people with diabetes.”
“Necessity Is the Mother of Invention”
In 2018, the Endocrine Society convened a task force to examine and promote innovative models of care in diabetes, chaired by Gabbay, with members Shivani Agarwal, MD, MPH, of the Albert Einstein College of Medicine in Bronx, N.Y.; Michelle L. Griffith, MD, of Vanderbilt University in Nashville, Tenn.; Elizabeth J. Murphy, MD, PhD, of the University of California in San Francisco; M. Carol Greenlee, MD, of Western Slope Endocrinology in Grand Junction, Colo.; and Jeffrey Boord, MD, MPH, of the Parkview Health System in Fort Wayne, Ind.
“We need to change the way we provide care, considering that outcomes of people with diabetes have not improved over the last decade. Given the dual pandemics of COVID-19 and diabetes, adoption of these innovations has accelerated in the hopes of creating a ‘new normal’ and improvements in the care we provide for people with diabetes.” – Robert A. Gabbay, MD, chief scientific and medical officer, American Diabetes Association, Arlington, Va.
Last month, the Innovative Models of Diabetes Care Task Force of the Endocrine Society published an article in The Journal of Clinical Endocrinology & Metabolism that not only reviews several models of care like telemedicine and e-consultations, but describes how the COVID-19 pandemic has jump-started many of the models that have until now limped along or have been stuck in legislative limbo. “Diabetes is an age old disease that cross cuts disciplines and has the potential to integrate with the technology sector to improve health outcomes, but due to siloed health systems and reimbursement models that disincentivize innovation, treatment approaches have largely remained the same,” lead author of the JCEM paper Agarwal says. “While great strides in therapeutics have been made, these cutting-edge therapies are not reaching nearly enough people with diabetes to make a true impact on the global burden and to improve quality of life.”
“Prior to the pandemic, innovative models of diabetes care were slowly gaining recognition, aiming to achieve improvements in medical outcomes, patient experience, healthcare provider satisfaction, and reduction in costs,” the task force authors write. “However, typical roadblocks existed to impede meaningful change. With COVID-19, implementing alternative models of care on swift and iterative cycles became the norm.”
This “new normal” has been hard on patients with diabetes. The disease is already extremely demanding in a non-COVID-19 world for those living with diabetes as well as their families. Now, these patients face the added burden of a highly contagious and deadly virus that can be especially damaging to those already living with this chronic illness.
“The pandemic has introduced more health anxiety for many people with diabetes,” Griffith says. “My patients hear the reports that people with diabetes are at higher risk of complications, and while that motivates them to take appropriate precautions, it’s also a challenging thing to deal with. I’ve had individual discussions with patients to help them think through risks and benefits of different challenges they face. Some patients have had to modify their jobs to reduce their risk.”
Patients with diabetes may even forgo care for fear of contracting COVID-19 by visiting their clinician or presenting to a hospital. But as the pandemic extends into its ninth month, endocrinologists and other healthcare providers are doing everything they can to alleviate those concerns and continue to deliver the best of care to patients with diabetes.
“COVID made it necessary to figure out how to do things differently — they say ‘necessity is the mother of invention’ and many people have been very creative in figuring out how to deliver good care despite barriers such as PPE shortages and in-person clinic visits limited to only emergency care,” Greenlee says. “The advances in diabetes and other technology make virtual care possible and meaningful/beneficial. COVID also made the digital divide loom larger than ever — for access to education, working from home as well as medical care and follow-up.”
Virtual Reality
This past year saw the rapid rise and expansion of meetings and social calls done over a webcam. Financial presentations, brainstorming sessions, visits with grandparents, happy hours, all held in this new virtual reality. Why not see patients that way as well?
“The pandemic has introduced more health anxiety for many people with diabetes. My patients hear the reports that people with diabetes are at higher risk of complications, and while that motivates them to take appropriate precautions, it’s also a challenging thing to deal with.” – Michelle L. Griffith, MD, Vanderbilt University, Nashville, Tenn.
Telehealth had indeed already been adopted by some institutions around the country, but this model of care wasn’t as widespread pre-COVID-19, for several reasons — technical difficulties, the inertia of physicians and patients preferring to visit the way they always have, and legislative hurdles. But the pandemic allowed physicians to clear some of those hurdles, as barriers to payment for virtual visits were suspended and doctors were no longer constrained to having to do an in-person visit to bill a patient’s insurance for the services.
“[Telehealth] also helped us rethink, what does the patient really need and what’s a way that’s more patient-centered and flexible to meet the patient’s needs without them having to do all the work,” Boord says. “What aspects of an office visit add value for the patient and are a helpful experience versus what are not value added? And what can we do between visits and where can we change the model of care delivery so that we put the patients, education, services, and support where the patient needs them, not just where we put them.”
And as COVID-19 continues to push more diabetes care into this virtual space, some physicians are finding that they’re able to more effectively optimize their patients’ care. “Telemedicine visits are most effective when the information available to us for the visit matches what we have in the clinic,” Griffith says. “As more patients with both types of diabetes are using insulin pumps and continuous glucose monitors, we have an excellent source of detailed information available to us. When we gather that information from the patient by using a web-based service for them to download and share their information with us, and then discuss it with the patient, we have all we need to make glycemic management decisions.
“There is no way to get anything done without a team approach. This has never been more obvious than in COVID where internationally, scientists and healthcare professionals are putting their heads together to fight a common goal.” – Shivani Agarwal, MD, MPH, Albert Einstein College of Medicine, Bronx, N.Y.
But while telehealth has streamlined diabetes care and physicians and their patients have mostly positive things to say about this new virtual paradigm, the task force authors point out in their paper that COVID-19 has forced the dissolution of in-person huddles and team meetings, which has made it more difficult to sustain team-based approaches, which the authors all agree is vital to diabetes care, especially as the number of people with diabetes far outstrips the number of endocrinologists in the world.
Team Players
Here in 2020, team-based care is essential for treating patients with diabetes. As the population of people with diabetes grows and the number of endocrinologists remains stagnant, the need for those treating diabetes to team up is clearer than ever — not just for the patients, but for the medical professionals as well. And again, the novel coronavirus has seen a number of healthcare professionals recognize more than ever the need to work together. The authors write: “In COVID-19, both outpatient and inpatient e-consults have been pivotal in enabling the specialty endocrinologist to provide timely and efficient consultation. In addition, it enables endocrinologist-led foundational education to providers who benefit from real-time feedback on cases, which can bring back joy to endocrinology work.”
“One of the most effective interventions to help prevent or relieve burnout is true team-based care — having other members on the team take on roles and responsibilities for some of the aspects of care (and be accountable for their role in care),” Greenlee says. “This approach gets everyone working together — less chaos, more cooperation and communication — that, along with work distribution/load reduction, helps reduce job dissatisfaction which usually precedes burnout and helps everyone focus on the patient.”
Greenlee shares some examples of this kind of collaboration: systems that use inactivated workers like dental and radiology staff to help patients prepare for telemedicine visits and tribal communities hit hard by COVID-19 using diabetes educators and other support staff to make check-in calls with homebound people with diabetes, both to educate on precautions as well as close follow-up of those infected. “With these calls often helping the patient maintain glycemic control and hydration and likely helping these patients avoid hospitalization,” she says.
“COVID made it necessary to figure out how to do things differently — they say ‘necessity is the mother of invention’ and many people have been very creative in figuring out how to deliver good care despite barriers such as PPE shortages and in-person clinic visits limited to only emergency care.” – M. Carol Greenlee, MD, Western Slope Endocrinology, Grand Junction, Colo.
The task force authors also point to pharmacist-based interventions, since studies have shown that a pharmacist/physician collaborative care model can lead to significant improvements in diabetes care, as well as the tele-mentoring program Project ECHO, which aims to train more primary care providers in diabetes care and “enhances the reach of endocrinology far beyond specialist capacity, holding great promise for continued reach of new therapeutics to the masses.”
“There is no way to get anything done without a team approach,” Agarwal says. “This has never been more obvious than in COVID where internationally, scientists and healthcare professionals are putting their heads together to fight a common goal.”
Call to Action
When this issue goes to press, COVID-19 will have killed more than 220,000 people in the U.S. Make no mistake: This is a vicious, dangerous virus that has forced the entire world to adopt new ways of living. But again, endocrinologists are well positioned to take the lead on caring for patients who are most vulnerable to this pandemic.
“At Montefiore Medical Center in the Bronx, we had approximately 7,000 admissions for COVID from March to June 2020 and approximately 40% of those had diabetes,” Agarwal says. “I saw a tremendous amount of diabetes and hyperglycemia in the hospital in patients with coronavirus disease in a very short period of time and was able to appreciate how unique COVID’s effect on diabetes was both from a medical and operational perspective.”
“Failure to embrace innovation, we do at our own peril. But by being actively engaged in innovation and having Society members actively pursuing innovation in diabetes care, the Society and our Society membership and members of the endocrinology profession are leading the way. We’re not sitting back and waiting for others to define what innovation in endocrinology care looks like. We should define that and help chart the way for healthcare as a whole.” – Jeffrey Boord, MD, MPH, Parkview Health System, Fort Wayne, Ind.
The Endocrine Society was already taking steps to better care for patients with diabetes, and this novel coronavirus has forced those who treat patients with diabetes to adopt some novel models of care. Still, there’s more work to be done, and these innovations and their sustainability face threats. Once the pandemic ends, all the things that held up innovations prior COVID-19 could reemerge: lack of reimbursement, lack of infrastructure to sustain and generalize innovation, lack of training and efforts, lack of leadership interest.
“Failure to embrace innovation, we do at our own peril,” Boord says. “But by being actively engaged in innovation and having Society members actively pursuing innovation in diabetes care, the Society and our Society membership and members of the endocrinology profession are leading the way. We’re not sitting back and waiting for others to define what innovation in endocrinology care looks like. We should define that and help chart the way for healthcare as a whole.”
“For the first time, we have a unified global experience,” Agarwal says. “The piece we wrote [in The Journal of Clinical Endocrinology & Metabolism] is a call of action to push and maintain innovation together.”
— Bagley is the senior editor of Endocrine News. He wrote the September cover story on the use of artificial intelligence to treat osteoporosis.
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