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Using Telehealth to Transform the Care of Rural Veterans with Diabetes

March 13, 2019

“Thanks for coordinating care for my father,” said Rachel, fighting back tears in her eyes. Rachel is a single mom and home health care nurse who had accompanied her father, Mr. Smith, to a local VA clinic in rural Pennsylvania for a video visit with an endocrinologist located over one hundred miles away at the VA Pittsburgh Healthcare System (VAPHS). Mr. Smith, a World War II veteran, was 83-years-old when his primary care provider (PCP) from James E. Van Zandt VA Medical Center in Altoona, Pennsylvania, first sought assistance from an endocrinologist for his poorly controlled diabetes. Being the sole caregiver for his elderly wife, Mr. Smith was unable to travel to Pitts burgh where the endocrinology team was located. He was, therefore, offered an initial electronic consultation and telephonic follow-up visits with an endocrinologist at the VAPHS. The endocrinology team then offered him continuity of care via clinical video teleconferencing, remote blood glucose monitoring services, and co-management of his diabetes with his PCP. This real-life story highlights the potential of emerging technologies and implementation of non-traditional collaborative care models in diabetes management.

Approximately 30.3 million people in the United States carry a diagnosis of diabetes, making it the seventh leading cause of death.1 Concurrent with the escalating prevalence of diabetes, there is an increasing shortage of physicians and other providers who are specifically trained to care for patients with diabetes. According to the endocrinology workforce analysis commis-sioned by the Endocrine Society in 2012, the shortage of adult endocrinologists is expected to increase from 1,500 in 2012 to 2,700 by 2025.2 Further exacerbating this problem, the 2017 National Diabetes Statistics Report produced by the Centers for Disease Control and Prevention (CDC) indicates that diabetes is 17 percent more prevalent in rural areas compared to urban areas, and yet the majority of endocrin-ologists serve metropolitan rather than rural areas. Not surprisingly then, the average wait time for a non-urgent new patient visit with an endocrinologist at the time of the CDC study was 37 days. Clearly, there is a tremendous need for new models of diabetes care, particularly for patients residing in rural areas.

Telehealth has emerged as a solution for these escalating challenges. While the term telehealth and telemedicine are often used interchangeably, telehealth encompasses a wide range of health care delivery modalities, as well as health administrative options such as tumor boards and medical education. Tele-medicine refers more specifically to medical care delivery processes and includes: 1) asynchronous modalities, such as remote patient monitoring (RPM) and electronic consultations (e-consults), or 2) synchronous modalities, such as virtual visits using clinical videoconferencing technology (CVT) or telephonic visits. Although telehealth implementation continues to face many challenges, patients are becoming increasingly capable of, and receptive to, these models of care. According to the fact-sheet published in February 2018 by the Pew Research Center, about three-fourths of U.S. adults own a desktop or laptop computer and nearly half own tablet devices.3 Likewise, the proportion of people who own and routinely use smartphones has risen from 35 percent in 2011 to 77 percent in 2018.3 Additionally, The Associated Press-NORC Center for Public Affairs recently conducted a survey to evaluate attitudes toward telemedicine among adults over the age of 40. This survey revealed that 88 percent of those surveyed would be comfortable using telemedicine to receive care, with a comfort level of ~87 percent for caregivers and ~50 percent for patients.4

In addition to the above, evidence supporting the clinical and cost effectiveness of telehealth services for diabetes is likewise growing. A systematic review of RPM of structured self-monitored blood glucoses (SMBG) and its impact on HbA1c showed that the impact was most significant when care providers incorporated specific predefined elements (spanning education, structured SMBG, and feedback) and incorporated computer decision support.5 RPM platforms for SMBG provide real-time support for improving quality of life (QOL), improving outcomes related to patient satisfaction, and reducing ED visits and inpatient days of care.6

The VAPHS has been providing telehealth diabetes services for more than a decade. The VAPHS team recently presented outcomes data at the 2018 Endocrine Society Annual Meeting and Expo7 in Chicago, IL and the 2018 American Diabetes Association Annual Scientific Sessions in Orlando, FL.8 These data demonstrate that, compared to traditional face-to-face visits, telephone-based 
e-consultation provides comparable reductions in A1c levels (from a baseline average of 10.1 percent to 8.9 percent at six months with sustained benefits at 12 months), but was able to do so with sub stantially improved access to care (27 days sooner), reduced travel distances (431 fewer miles traveled), and reduced time engaged in travel/care (9.4 hours less time).7 These data demonstrate the potential benefits of telehealth in diabetes care.

VAPHS is a hub location for specialty care for veterans enrolled in the western half of VISN-4 (Veterans Integrated Service Network) and serves veterans residing in upstate New York, western Pennsylvania, eastern Ohio, and adjoining West Virginia and Maryland. The majority of these veterans reside in rural areas and have a high prevalence of complex diseases, such as diabetes and obesity.

Given this acute need, the endocrinology service at the VAPHS has undergone a transformation to improve access to diabetes care for veterans closer to their homes using a variety of telehealth strategies. In addition to live, in-person consultations and follow-up care, endocrinologists at the VAPHS offer e-consults, CVT clinics, group telediabetes education, and RPM services for SMBG. Incorporation of RPM allows for safe therapy modification between appointments and for special circumstances, such as before surgical procedures, following hospital discharge, and/or during steroid use or chemotherapy. Alert guidelines for RPM for SMBG also are provided for home telehealth coordinators. Such partnerships have led to reliable care collaboration between primary care teams and hub endocrinologists.

Embedding CVT clinics as a part of the specialty care services allows for continuous care for stable yet complex needs of veterans with diabetes who live more than 50 miles away from the hub. Currently, CVT service at the VAPHS consists of five endocrine providers (three endocrinologists and two nurse practitioners) who serve four remote hospitals and more than 15 community-based outpatient clinics. These services are available five half days per week and serve more than 120 veterans per month. Such robust partnerships led to the creation of a more specialized Insulin U-500 CVT clinic in Clarksburg, West Virginia. Complexity of care related to concentrated insulin results in a huge burden on PCPs and puts veterans at risk of medication errors, often precipitating
a need for long-distance travel. For this reason, an additional two half days per month are dedicated specifically to veterans requiring Insulin U-500. In this way, endocrinologists located at the hub can provide direct care via remote teams that coordinate the visit and long-term care.

Technological advances and the innovative application of telehealth hold promise in transforming care delivery and improving process efficiency for patients and providers alike. A well-designed telediabetes pro gram should be nimble and have elements that serve the unique needs of the populations being served. Such programs will be increasingly necessary as the gap between the number of available endocrin ologists and the patients requiring endocrine and diabetes care continues to rise.



2 Vigersky RA, Fish L, Hogan P, Stewart A, Kutler S, Ladenson PW, McDermott M, Hupart KH. The Clinical Endocrinology Workforce: Current Status and Future Projections of Supply and Demand. J Clin Endocrinol Metab. 2014 Sep; 99(9): 3112-21.



5 Greenwood DA, Young HM, Quinn CC. Telehealth Remote Monitoring Systematic Review: Structured Self-monitoring of Blood Glucose and Impact on A1c. J Diabetes Sci Technol. 2014; 8(2): 378-389.

6 Faruque LI, Wiebe N, Ehteshami-Afshar A, et al. Effect of Telemedicine on Glycated Hemoglobin in Diabetes: A Systematic Review and Meta-analysis of Randomized Trials. CMAJ: Can Med Assoc J. 2017; 189(9): E 341-E364.

7 Detoya K, Karajgikar N, Beattie J, Lutz-McCain S, Bourdeaux-Kelly M, Bandi A, et al. Impact of Electronic Consultation versus Face-to-face Encounters on Glycemic Control among Veterans with Type-2 Diabetes. Abstract presented at the Endo-2018-Endo Society Annual Meeting and Expo 2018, Chicago, IL. *1st Place in Presidential Poster Competition.

8 Karajgikar N, Detoya K, Beattie J, Lutz-McCain S, Boudreaux-Kelly M, Bandi A, et al. Comparison of E-consults and face-to-face care on costs and glycemic control among veterans with type-2 diabetes mellitus. Abstract presented at 78th Scientific Sessions of the American Diabetes Association, Orlando, FL.

Archana Bandi, MD
Clinical Director, Telehealth Services Director, E-Consult Services
Division of Endocrinology
VA Pittsburgh Healthcare System Clinical Assistant Professor
Division of Endocrinology and Metabolism University of Pittsburgh