For Diabetes Care, Telehealth is a Keeper

Many experts believe that diabetes care is ideally suited to telehealth, given the fact that glucose readings and other data guide disease management — and that can easily be jointly reviewed and discussed by doctors and patients over digital platforms.

While there is mounting evidence that the explosion in telehealth due to COVID-19 is a boon to people with diabetes (PWDs), there's also a fight underway to make sure that new policies supporting this virtual care stay in place when the pandemic eventually subsides.

New data on diabetes telehealth experiences

In its 2020 State of Telemedicine Report published by physician network company Doximity, endocrinology got the top ranking for the specialty that's using telemedicine the most since the onset of COVID-19. Among the other findings is how Americans with chronic conditions like diabetes increased their use of telemedicine to 77 percent during the pandemic.

This isn't surprising, and it confirms research done by Dr. Larry Fisher at the University of California, San Francisco (UCSF). In a clinical study published in December 2020 that looked at COVID-19 and diabetes, Fisher and fellow researchers examined the changing role of telehealth in the first months of the pandemic, by talking with nearly 1,400 PWDs.

Many said they are happy to do telehealth because they don't have to travel to an appointment or be exposed to a health risk. But digging into the experience, the feedback was also much more nuanced.

"The responses are generally positive, that (telehealth) didn't detract from their overall level of satisfaction," Fisher said, adding that diabetes data review from insulin pumps, continuous glucose monitors (CGMs), and glucose meters are a big part of what makes for a productive telehealth appointment.

He reminds us that "telehealth is not one thing," so it's not as easy as simply asking, "How do people with diabetes respond to telehealth?"

First, it comes down to the relationship a patient has with their clinician, and in large part, whether that's an established relationship. Someone going into a virtual visit with a new doctor will have a quite different experience than if it's a continued doctor-patient relationship over time.

"It's much better, and you get so much more satisfaction when there's an ongoing relationship because the telehealth is an extension of that ongoing relationship," Fisher said.

He said follow-up surveys of study participants found that after a visit, a large majority said they felt listened to, weren't pressured by time limitations as they often felt during in-person visits, and they saw an efficient use of time.

But some patients said they didn't care for telehealth because they missed the element of physical contact. Clinicians have also reported that issue, he said.

"These findings suggest the need for greater attention to the emotional and psychosocial impact of the pandemic on this population and its implications for disease management and diabetes-related healthcare delivery," Fisher's study concluded.

Of the PWDs who indicated they had other issues with telehealth, the reasons generally broke down into two main categories:

• 30 percent are simply less satisfied and see it as less productive than in-person appointments
• 70 percent noted technical difficulties in audio and video functions for the appointment
• some also mentioned trouble uploading glucose and diabetes device data for the clinician to review and discuss during the appointment

Fisher says he expects that the number of clinics doing data downloads from CGM and diabetes devices has increased significantly during the pandemic, although he doesn't have any data on this trend specifically.

Meanwhile, lab visits have of course dropped significantly since the beginning of the pandemic. But interestingly, Fisher says many patients and clinicians are reporting that a decrease in lab work may be OK because they have a sense that tests were ordered more often than necessary previously.

"We may have been doing A1Cs way too frequently for many people, but obviously that isn't the case for everyone," he said.

The fight for telehealth support post-pandemic

Due to the pandemic restrictions, Medicare and private insurers have been forced to embrace telehealth and even began reimbursing it at the same rate as traditional in-person appointments.

Unfortunately, these are temporary changes. What the Centers for Medicare and Medicaid Services (CMS) put into place because of COVID-19 is set to expire in April 2021, and if that happens, doctors and clinics may be less willing to do virtual appointments without full reimbursement.

But efforts are underway to cement those COVID-19 era changes in telehealth.

Groups like the diaTribe Foundation, American Diabetes Association, and the Diabetes Policy Collaborative are working to persuade policy-makers to make the new telehealth improvements permanent.

For example, diaTribe has been crafting a community advocacy letter that will be sent to the new Biden Administration and Congress at the end of February 2021, emphasizing the need for permanent telehealth legislation. Nearly 2,000 people had signed the letter by mid-month.

diaTribe also joined the Patient & Provider Advocates for Telehealth (PPATH) initiative, recently launched by the Alliance for Patient Access (AfPA) coalition, as a way to build more collaboration in pushing for policy change.

"Telehealth is not a perfect option for everyone with diabetes, but it gives people more healthcare options," said Julia Kenney, an associate at the San Francisco-based diaTribe Foundation. "We want to make sure it's an option... so that people with diabetes can access their healthcare in whatever way works best for them."

For some PWDs, this is a big deal — including for Emily Ferrell in Kentucky, who tells DiabetesMine that she's found a new fondness for telehealth in the past year. At one point, her insurer even waived copays for telehealth during the pandemic. She hopes this option won't go away once the COVID-19 crisis starts fading.

"I know that telehealth has existed for many years, mainly to increase access to care in rural areas, and it's awful that it took a pandemic for it to become mainstream," she said. "I only hope that once the pandemic is over, our healthcare systems and insurers will work together to not only continue but improve telehealth and other remote service delivery options."

Loving virtual visits

Before the global pandemic began, Ferrell didn’t have much exposure to virtual visits with her healthcare team. Diagnosed with type 1 diabetes (T1D) as a child back in 1999, she generally wasn’t a fan of the idea of seeing her providers over a screen.

But the COVID-19 crisis changed that. Now, the 30-something says she is successfully using telehealth with her endocrinology team and prefers it for many reasons.

Not only does it save time on travel, but Ferrell is able to review her insulin pump and CGM data alongside her doctor virtually with ease.

“I plan on utilizing it as long as it’s available,” she told DiabetesMine.

Like Ferrell, Mariana Gómez in Los Angeles hadn't done any telehealth visits before the pandemic. Diagnosed with T1D at 6 years old in 1984 when her family lived in Mexico City, she strongly believed that consulting with an HCP would always be better in person because of the human contact.

But once the pandemic hit in 2020 and she started working from home, Gómez found herself driving almost an hour to her appointment and needing to take time off and deal with the stress. That also led to other expenses like travel, and all of that impacted her emotional health — which of course, impacted her blood sugars and diabetes management.

"I thought telehealth would be complicated but it turned out it was just what I needed," Gómez said, noting her endo analyzes her diabetes data using the Tidepool platform and shares the screen to go through everything together.

"Not only am I able to see the trends, but also I have been able to learn how to interpret my data in a new way," she said. "I am sitting in my own living room, with a coffee next to me and my family sometimes really close and listening, as well. I feel no stress whatsoever. Which is also nice during a pandemic."

These PWDs are certainly not alone. When DiabetesMine recently queried our Facebook community on what COVID-related changes in healthcare people might want to keep post-pandemic, we heard a lot about loving telehealth. Comments included:

• “Telehealth for sure. I usually drive 45 min each way to see my endo. Now the whole appointment takes a half-hour at most, and I felt like I had more time to talk to my doctor.”
• “I do not drive, so the telephone or video appointments have helped. I email my Dexcom reports before the appointment. My insurance doesn’t cover any endocrinologists, so this is a little cheaper too.”
• “Telehealth should have been done ages ago. COVID has allowed this to be mainstream… need this to stay.”

The downsides

With the good, there can also be bad — or challenging, at the least.

Healthcare professionals can experience their own hurdles in navigating virtual visits, from typical tech glitches to patients not being as focused on engaging with the doctor.

There can also be physical demands, according to many doctors.

Dr. Jennifer Dyer, a pediatric endocrinologist in Columbus, Ohio, says she’s generally pleased to be using telehealth quite regularly nowadays.

That said, downloads can complicate virtual visits and there’s also no way to address pump site issues or complaints like neuropathy pains or tingling.

If something like that arises, she has to ask the patient and family to make an in-person office appointment for a further look.

Administratively, Dyer says telemedicine is more work for the office in preparation for the appointment. But other than that, it’s a great way to continue excellent diabetes care for the patients she knows well; it’s not as personal a medium for new patients.

Longtime T1D Katarina Yabut in Union City, California, can attest to that. When she went back to nursing school and had to transition to Medi-Cal coverage just before COVID-19 hit, she found herself searching for new doctors in an online environment. Her experience was less than ideal.

She found a primary care provider who referred her to an endo, who she said was difficult to get along with. The typical challenges of starting with a new doctor seemed to be exacerbated online, she says, such as having only a 15-minute appointment in which the physician talks nothing but numbers.

"You have concerns about being at home and no gym access, you have to get tapered off your thyroid meds, and you have concerns about basal rates and bolus settings..." she said. "But the only thing discussed was, 'Well, I don't really work with your insulin pump or insurance company but I'll try to get you supplies for the CGM.'"

At UCSF, Fisher has also done research on clinicians using telehealth and says they are reporting some downsides too, such as more eye and back complications — leading to headaches, eye strain, and other physical ailments as a result of the surge in virtual appointments. One trick he's embraced is limiting the number of telehealth appointments in a given day; he won't do more than 3 hours at a time, before switching to in-person or taking a break.

"It's taxing to do virtual appointments, and it can be a lot more exhausting," he said.

Disparities exist in telehealth, too

Not surprisingly, systemic racism and implied bias in healthcare show up in telehealth settings, as well.

Recent research conducted in New York City points to lower levels of telemedicine usage since the pandemic's onset among Black and Latinx patients — particularly those older than 65 — as compared with white patients.

In Los Angeles, where Gómez lives, she said language barriers are a huge problem when considering telemedicine. Most platforms are in English, and email communication is often the same. When visiting in person, there's a likelihood patients can be assisted by an interpreter or bilingual nurse. But that's more complex in telehealth.

"Language has always been a barrier, and that is now more evident," she said. "Access to devices are also a thing to consider, as most families will have one computer but... priorities are sometimes not the best when it comes to access to healthcare."

Some hope may be on the horizon, though, in using telehealth to address disparities.

Another 2020 New York City-based study on telehealth and disparities suggests creating a standardized screen design that could possibly reduce providers' biases and the resulting disparities in healthcare.

The authors also call for the development of "culturally and structurally appropriate tools and technology, representative provider presence and capacity, positive targeted outreach, and research."

Finally, the study found that suspected COVID-19 diagnoses among Black patients, who on average were sicker at the time of seeking care, were more likely to be caught during telehealth visits than in-person appointments. As a result, the study authors believe it could offer a more equal playing field for Black and white patients to be treated the same.

That's the hope Ferrell has, too, when thinking about health inequities.

"I know that my experiences with healthcare are different than many others in the diabetes community who have faced discrimination and bias," she said. "I think telehealth has tremendous potential to promote health equity, but it will take thoughtful planning to make sure that these new advances minimize disparities instead of contributing to them."