By Melinda Young
Standard care for patients with persistently poor control of type 2 diabetes does not always work well. For whatever reasons, these patients sometimes report poor outcomes and fail to reach disease management goals.
Investigators studied different telehealth interventions designed for this group. They found comprehensive telehealth improved multiple outcomes in patients with persistently poorly controlled type 2 diabetes.1
“These patients had elevated A1c levels, despite getting what VA had to offer in standard practice,” says Matthew J. Crowley, MD, lead study author and core investigator at Durham Veterans Affairs Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT) in Durham, NC. “We focused specifically on VA care. Most veterans do receive some care outside of the VA, but for the most part, the majority of their care is delivered through the VA itself.”
For instance, many VA patients receive their primary care, endocrinology care, standard telehealth care, and nutrition and diabetes education through the VA. “We compared a couple of different telehealth interventions specifically designed for this group,” says Crowley, an associate professor of medicine at Duke University.
One was a telehealth monitoring intervention in which nurses would contact patients about scheduled appointments and continuously track patient data, including glucose levels. They would help patients when an issue arose.
“This is a service widely available in the VA,” Crowley says. “The other arm was a more complex telehealth intervention, delivered by existing telehealth nurse staff.”
The intervention used these five components:
- Telemonitoring;
- Self-management support;
- Diet and activity support;
- Medication management;
- Depression support.
“One of the key things about this study is both interventions were designed to be delivered by existing clinical staff in VA, using existing infrastructure — no new hiring or equipment purchases required,” Crowley says. “The whole idea was to study approaches that were very practical and were amenable to implementation and practice, should they be successful.”
For example, they used existing technology to provide integration with the patient’s blood glucose monitor and upload glucose data to the vendor site for incorporation in the electronic health record. The same device was used for both standard care and the intervention.
The intervention included more contact between the telehealth nurse and patients. But the nurses seeing these patients were performing these new tasks in a way that was consistent with their clinical duties.
“Minimal training was required for them to deliver care to these patients in this study,” Crowley says. “Telemonitoring care coordination was delivered as part of existing care in VA. Nurses are trained to monitor diabetes patients as well as other patients.”
The nurses’ skill sets are similar to care managers or care coordinators. As RNs, they do not require advanced training in telehealth, as any nurse can do this. “They did use templated notes to deliver the intervention, and the notes walked them through the intervention for each encounter,” Crowley adds.
Nurses delivered self-management support modules by phone at two-week intervals. “They were scripted modules that were provided to nurses in hard copy that they would read through and deliver to the patient,” Crowley says. “The calls took 30 minutes each.”
Both groups improved, but the comprehensive telemonitoring arm recorded significantly greater improvement. “We did a cost analysis, and it was $1,500 per patient to deliver the intervention over the course of a year,” Crowley says.
The intervention proved so successful the VA began to implement an earlier version at sites nationwide. “It seems to be helping people become more aware of their diabetes control and also helps them improve,” Crowley says. “The comprehensive intervention is very successful in helping patients build new self-management routines that translate into new diabetes control.”
Telehealth expanded for all organizations during the COVID-19 pandemic. But the VA handled these visits the same as clinic-based care, except appointments were virtual.
The intervention showed telehealth should be designed to allow more frequent contact between providers and patients. “Patients need more frequent provider contact to build relationships and to have more accountability and optimal self-management,” Crowley says. “If you think about it, patients are continuously gathering data that could be acted on to improve their care, but with clinic-based care and telehealth, we have missed opportunities where data are accruing, but no one was acting on them.” Instead, telehealth visits every two weeks or when a problem arises would work better and provide better care coordination.
The research shows how this approach can produce positive results at a relatively low resource expense. “It’s nice to see this make a difference for real people in the real world,” Crowley says.
REFERENCE
- Crowley MJ, Tarkington PE, Bosworth HB, et al. Effect of a comprehensive telehealth intervention vs. telemarketing and care coordination in patients with persistently poor type 2 diabetes control: A randomized clinical trial. JAMA Intern Med 2022;182:943-952.
Standard care for patients with persistently poor control of type 2 diabetes does not always work well. Investigators studied different telehealth interventions designed for this group. They found comprehensive telehealth improved multiple outcomes in patients with persistently poorly controlled type 2 diabetes.
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