Telemedicine in the Management of Type 1 Diabetes

Timothy Xu, BS; Shreya Pujara, MD; Sarah Sutton, PharmD; Mary Rhee, MD, MS


Prev Chronic Dis. 2018;15(1):e13 

In This Article


CAVHCS serves more than 134,000 veterans in 43 counties of Alabama and Georgia but does not employ a local endocrinologist. In 2014, the Atlanta VAMC Endocrinology Telehealth Clinic was established to increase access to specialty care for type 1 diabetes for CAVHCS patients. Without telehealth, CAVHCS patients have to travel to the Veterans Affairs (VA) medical centers in either Birmingham, Alabama, or Atlanta, Georgia, to receive in-person specialty care. With telehealth, patients travel to local community-based outpatient clinics for their telehealth appointment, where they check in as they would for a regular face-to-face appointment; they have their vital signs checked, go to a patient care room with a webcam or dedicated telehealth monitor, and have a CVT consultation from an Atlanta-based endocrinologist with in-person assistance from a telehealth pharmacist. Visits typically last 30 to 60 minutes.

We conducted a retrospective chart review of patients with type 1 diabetes who received care through the Atlanta VAMC Endocrinology Telehealth Clinic from June 2014 to October 2016. We collected data about changes in glycemic control, telemedicine's capacity to save costs for the VHA and time for patients, patient adherence to telemedicine appointments, and patient satisfaction with telemedicine. Data were stored in REDCap, a secure web-based database application. Our use of REDCap was sponsored by the Atlanta Clinical and Translational Science Institute. This study was approved by the Emory institutional review board and the Atlanta VA Research and Development Committee.

To assess diabetes management, we collected data on recommended processes of diabetes care: blood pressure management, eye screening, urine microalbumin-to-creatinine ratio, and lipid panels (triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol). We also assessed whether patients received drug prescriptions for which they were eligible, specifically statins and aspirin.

To assess diabetes outcomes, we collected data on change in glycemic control, specifically hemoglobin A1c levels, 2-week frequency and severity of hypoglycemia, 2-week frequency and severity of hyperglycemia, and plasma glucose variability. Hemoglobin A1c indicates average plasma glucose concentration over 2 to 3 months and predicts diabetes complications.[8,9] Hypoglycemia is defined as low plasma glucose concentration, and severe hypoglycemia may lead to unconsciousness.[9] We defined hypoglycemia as a plasma glucose level of less than 70 mg/dL and severe hypoglycemia as less than 40 mg/dL. Hyperglycemia is defined as high plasma glucose concentration, which may lead to long-term complications such as diabetic retinopathy, nephropathy, and neuropathy.[10] We defined hyperglycemia as a plasma glucose level of more than 250 mg/dL and severe hyperglycemia as more than 300 mg/dL. We reviewed patients' insulin pump downloads or patients' glucose logs over a 2-week period to determine frequency of hypoglycemia and hyperglycemia. Lastly, average glucose variability was defined as the standard deviation (SD) of all plasma glucose levels in the 2-week period. Data on glycemic control were collected at baseline visits, 6 month follow-up visits (±1 month), and 12 month follow-up visits (±1 month).

Cost savings for the VHA were calculated on the basis of the difference between patient travel reimbursement costs associated with in-person visits at VA medical centers in either Birmingham, Alabama, or Atlanta, Georgia, and costs associated with telemedicine visits at community-based outpatient clinics. Travel reimbursements were calculated using reimbursement rates published by the VHA's Beneficiary Travel Benefits program, which was 41.5 cents per mile with a $6 patient deductible.[11] Patients who traveled more than 75 miles one way were eligible for VA-reimbursed overnight lodging, and lodging costs of $75 were added to the travel cost for an in-person visit. Time savings for patients were calculated using Google Maps (Google Inc) and were based on the difference in estimated time to travel to community-based outpatient clinics versus the nearest VA medical center in either Atlanta, Georgia, or Birmingham, Alabama.

To evaluate telemedicine appointment adherence, we recorded the number of CVT appointments missed (patient did not show up), cancelled, and scheduled. Telemedicine appointment adherence was reported as the ratio of the number of CVT appointments in which the patient showed up to the number of CVT appointments scheduled, excluding the number of appointments cancelled by the patient in advance. To assess patient satisfaction with telemedicine, we administered via telephone a satisfaction survey published by the VA Telehealth Services Program. Patients were surveyed about telemedicine's usability and convenience, and their satisfaction was measured using a Likert Scale with scores ranging from 1 through 5 (1 = "strongly agree" and 5 = "strongly disagree").

Data analysis was performed using Microsoft Office Excel 2010 (Microsoft Corporation), SPSS version 23.0 (IBM Corp), and SAS version 9.4 (SAS Institute Inc). To analyze changes in diabetes outcomes, we conducted paired t tests from baseline data, 6-month follow-up data, and 12-month follow-up data. Significance was set at P < .05. To analyze patient satisfaction survey results, we calculated the median, mean, and SDs of patient responses to each survey question.