Diabetes and Telemedicine (Telehealth)
As all people with diabetes are aware, the management of diabetes is a labor-intensive endeavor with multiple visits to the diabetes care team in association with major expense. Without some form of insurance, diabetes care is often prohibitive and may lead to poor control with acceleration of micro and macrovascular complications. In an attempt to maximize care and provide cost controls, many healthcare teams are thinking out of the box to determine efficient means of providing care. In view of the government's health care overhaul, all health care providers are concerned about the sacrifice of compassionate, evidenced-based medical care to pare down costs. One way to decrease costs, in association with more productivity in terms of healthcare teams and patients, is to consider telehealth intervention. Diabetes healthcare teams are starting to incorporate this form of communication into their programs and now several pediatric diabetes programs are espousing this form of care.
In a Journal of Pediatrics 2006 study by Dr. Janet Silverstein's pediatric diabetes team in Miami, Florida, telehealth intervention was conducted with adolescents with T1DM, there was an average reduction of HbA1c level of 0.7 percent from the beginning of the intervention to the conclusion of treatment. (Paired t-tests indicated significance.) Their approach was to incorporate telehealth interventions by using intensive video and phone conferencing of psychology services to adolescents and family members, targeting adherence and maladaptive family processes. Participants included 27 adolescents with T1DM who had recurrent hospitalization for diabetic ketoacidosis or elevated hb A1c greater than 9.0 percent. After the initial session, participants and family members were contacted 3 to 4 times per week during the first month and twice per week prior to the conclusion of the trial (5 to 6 months) by videophone or telephone by their telehealth provider. Sessions lasted 15 to 20 minutes and involved speaking with the adolescent and then the parent to discuss problems and behaviors. Education was provided when necessary. Of major importance, no diabetes related hospitalizations occurred during this treatment. In this study, it was felt that the major reason for change was the intervention on adherence behaviors and diabetes-specific family issues related to adherence.
Additional application of diabetes telemedicine could theoretically include 1 out of 4 yearly visits with a diabetes team member (diabetes educator or physician) to discuss insulin regime and dosing, and blood sugars-downloaded to the home and diabetes team computer through a software program. Educational and behavioral concerns could be discussed as well.
What are the advantages of diabetes telemedicine?
- Reduction of time spent in traveling to diabetes outpatient centers for physician/team visits and psychological therapy.
- Avoidance of the need to actually go to the outpatient site with less school/work time lost in transit and in the waiting room.
- Less strain on financial resources.
- Less provider access difficulties.
- Increased flexibility and ease of participation with the diabetes care team.
What are the disadvantages of diabetes telemedicine?
- Via phone or video-conferencing, conducting a physical exam looking at diabetes related findings (vital signs, including height and weight, injection sites, thyroid exam, skin findings, foot exam in older patients, etc.) is difficult or impossible.
- Loss of body language or cues that is difficult to see via phone or televideo.
- Avoidance of phone calls when parental presence or supervision is minimal.
- Inability to do "point of care testing" such as an HbA1c (although one could theoretically get the lab work ahead of time).
- Loss of patient/team relationship in terms of face-to-face contact.
- Insurance issues.
- Lack of technology in the home (computer/equipment).
- Unknown barriers.
In several weeks, I will have the opportunity to learn more about the application of telemedicine in relationship to our diabetes program after a presentation by one of our foundation directors. The key is to try to develop new strategies to capture improved methods to care for our children and families in terms of medical and psychosocial issues. No one strategy is all-inclusive; but rather a mix of different techniques to engage patients and family to conduct the best diabetes care possible while attempting to defray costs and minimize disruption of family life.
I am most interested to hear what our community thinks about using diabetes related telemedicine as an adjunct to their health care. I would appreciate any thoughts you have--please use the comments section to enlighten us!