Comprehensive Telehealth Boosts Outcomes in Poorly Controlled Diabetes

Comprehensive Telehealth Boosts Outcomes in Poorly Controlled Diabetes

July 26, 2022 0 By Jennifer Walker

A comprehensive approach to telemonitoring type 2 diabetes bolstered glucose control in tough-to-manage patients, according to a randomized trial.

Among 200 patients with persistently poorly controlled type 2 diabetes (PPDM), change in HbA1c was -1.59% in those included in the comprehensive diabetes monitoring program versus -0.98% with a more simplified telehealth approach, for an estimated mean difference of -0.61% (95% CI -1.12 to -0.11, P=0.02) from baseline to 12 months, reported Matthew J. Crowley, MD, MHS, of Duke University School of Medicine in Durham, North Carolina, and colleagues.

“These findings demonstrate that practically designed telehealth can be effective for patients whose type 2 diabetes remains persistently poorly controlled despite clinic-based care,” the group wrote in JAMA Internal Medicine.

Beyond reductions in HbA1c, patients in the comprehensive telehealth program also reaped other diabetes-related benefits, including improvements in diabetes distress, diabetes self-care, and self-efficacy.

However, when comparing the comprehensive and simplified programs, patients didn’t see a difference in regards to BMI changes or depressive symptom scores. Likewise, neither group experienced more adverse events — such as hyperglycemia, hypoglycemia, and diabetic ketoacidosis — than the other.

One notable, and unsurprising, difference between the two programs was the price tag, with the comprehensive program coming in at an additional $1,519 per patient each year. For the 1-year intervention, the comprehensive program cost $2,465 per patient, while the simplified telehealth care cost $946 per patient.

“While the comprehensive telehealth intervention was more expensive … this incremental cost is less than most branded glucose-lowering medications, and the comprehensive approach came with added benefits,” Crowley’s group pointed out.

They suggested that “[g]iven the high complication rates characteristic of PPDM and the long-term cost benefits of HbA1c reduction, implementing comprehensive telehealth in practice may represent an appropriate investment for health care systems in which the requisite infrastructure is or can be made available.”

The active-comparator, parallel-arm trial took place across two Veterans Health Administration (VHA) healthcare systems from 2018 to 2020, and included 200 patients with PPDM, defined as an HbA1c of 8.5% or higher for at least 1 year despite regular engagement with primary care or specialized diabetes care. Mean age was 57.8, 22.5% were women, 72% were Black, and 5.5% were Hispanic/Latinx.

The researchers noted that they developed this study because they wanted to leverage the VHA’s already existing telehealth infrastructure to better serve diabetes patients struggling with glycemic control.

“Because this comprehensive telehealth intervention was delivered by clinical staff using existing resources, it may warrant clinical implementation in systems with appropriate infrastructure,” Crowley and team noted.

Both programs were delivered by clinical VHA Home Telehealth nurses by phone every 2 weeks. The comprehensive program hinged on five main clinical components, involving telemonitoring, self-management support, diet and activity support with a dietitian, medication management with a medication manager, and depression support with a psychiatrist. Patients also shared self-monitoring blood glucose data from their blood glucose meter up to four times per day with their nurse.

The simplified program only consisted of telemonitoring of blood glucose paired with care coordination, which involved communication about upcoming appointments, notification of primary clinicians regarding acute needs, and compiling blood glucose data prior to appointments.

“This study was not designed to evaluate the effectiveness of each individual component of the comprehensive intervention. Future mediator analyses will examine how each component contributes to the overall intervention effect,” Crowley and colleagues noted.

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    Kristen Monaco is a staff writer, focusing on endocrinology, psychiatry, and nephrology news. Based out of the New York City office, she’s worked at the company since 2015.

Disclosures

This study was supported by a grant from Veterans Affairs Health Services Research and Development.

Crowley reported grants from the National Institutes of Health, VA Quality Enhancement Research Initiative, VA Office of Rural Health, and VA Health Services Research & Development. Other study authors also reported relationships with government organizations and multiple pharmaceutical companies.