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


Demographic Characteristics

Among 54 patients enrolled in the Atlanta VAMC Endocrinology Telehealth Clinic, 32 patients had type 1 diabetes (Figure). Of the 32 patients with type 1 diabetes, 17 had follow-up visits at 6 months, and 9 had follow-up visits at 12 months. Telehealth patients with type 1 diabetes were predominately male (n = 29, 91%) and white (n = 27, 84%) (Table 1). Mean age was 53.5 years and mean body mass index was 27.6 kg/m2. Comorbidities and diabetes complications were highly prevalent at baseline in this patient population; most patients had hyperlipidemia (n = 26, 81%) and diabetic neuropathy (n = 23, 72%).


Diagram showing criteria for inclusion in a study of patients (N = 32) enrolled in the Atlanta VA Telehealth Endocrine Clinic, June 2014 to October 2016. Abbreviation: VAMC, Veterans Affairs Medical Center. [A text description of this figure is also available.]

Telehealth patients generally received the standard processes of diabetes care (Table 2).[12] At baseline, 94% patients (30 of 32) had a diabetic retinopathy eye screening within the preceding 2 years, and 100% (9 of 9) received the recommended eye screening at 12-month follow-up. Furthermore, 81% of patients (26 of 32) had their urine microalbumin-to-creatinine ratio measured at baseline, which increased to 89% (8 of 9) at 12-month follow-up. Of patients who were eligible for statin use, 89% (24 of 27) were prescribed a statin, and 64% patients who were eligible for aspirin use (14 of 22) were prescribed aspirin. At 12-month follow-up, 88% of eligible patients (7 of 8) were prescribed a statin, and 50% of eligible patients (1 of 2) were prescribed aspirin. When seen at baseline visits and at 6-month and 12-month follow-up visits, all patients had received the recommended blood pressure measurements and lipid panels.

Diabetes Outcomes and Glycemic Control

Mean hemoglobin A1c levels decreased overall from baseline (8.7%) to 6-month (8.2%) and 12-month (8.1%) follow-up, although the change was not significant. After 6 months and 12 months, patients also had a mean increase in average frequency of hypoglycemia per 2 weeks of blood glucose levels less than 70 mg/dL and less than 40 mg/dL, although these trends were not significant. The mean frequency of hypoglycemia of glucose less than 70 mg/dL was 3.3 hypoglycemic episodes per 2 weeks at baseline, 3.3 at 6-month follow-up, and 6.2 at 12-month follow-up. The average frequency of hypoglycemic episodes per 2 weeks of glucose less than 40 mg/dL was 0.2 at baseline, 0.2 at 6-month follow-up, and 0.6 at 12-month follow-up. Clinically, the difference in severe hypoglycemia (<40 mg/dL) was insignificant, but hypoglycemia of glucose less than 70 mg/dL increased overall.

The average frequency of hyperglycemia every 2 weeks increased from baseline to 6-month follow-up but was stable after 12 months. This trend was observed in hyperglycemic episodes of glucose greater than 250 mg/dL and greater than 300 mg/dL but was not significant. The mean frequency of hyperglycemia greater than 250 mg/dL was 16.3 at baseline, 22.5 at 6-month follow-up, and 16.2 at 12-month follow-up. For hyperglycemic episodes greater than 300 mg/dL, the mean frequency was 4.0 at baseline, 5.4 at 6-month follow-up, and 3.8 at 12-month follow-up.

Lastly, there was a nonsignificant trend toward a decrease in mean 2-week blood glucose levels at 6-month and 12-month follow-up. Mean daily blood glucose level was 79.2 mg/dL (SD, 20.4 mg/dL; n = 27) at baseline, 76.2 mg/dL (SD, 15.7 mg/dL; n = 16) at 6 months, and 76.4 mg/dL (SD, 19.7 mg/dL; n = 9) at 12 months.

Time and Cost Savings

Patients saved a median of 78 minutes of one-way traveling time, and the VHA saved a median of $72.94 per patient visit in travel reimbursement. If Atlanta VAMC Endocrinology Telehealth patients received follow-up appointments every 3 months as recommended, each patient would save 624 minutes of traveling time per year, which corresponds with VHA savings of $9,336.32 per year in reimbursements to the 32 patients with type 1 diabetes.

Telehealth Appointment Adherence and Patient Satisfaction With Telemedicine

Telehealth patients had a median of 5 scheduled appointments (range, 1–10 scheduled appointments). Patients were adherent to their telehealth appointments; at least half of the patients attended 100% of their appointments, and mean adherence rate was 87.8% (SD, 17.8%; range, 50.0%–100%).

Twenty-two (69%) telehealth patients with type 1 diabetes completed the survey about their satisfaction with telehealth care. Patients perceived the endocrinology care they received during their telemedicine appointments favorably; 100% of respondents agreed or strongly agreed that they were satisfied with telehealth (Table 3). Furthermore, 90.9% respondents strongly agreed with the statement that they would recommend telehealth to other veterans, and 90.9% respondents agreed or strongly agreed that they would rather use telehealth than travel long distances to see their providers. Two patients who preferred in-person care over telehealth stated that seeing their physician face-to-face was important to them.