Case study
Alex was a 53-year-old Hispanic male with a history of type 2 diabetes, essential hypertension, dyslipidemia, chronic lower back pain, and lower extremity peripheral neuropathy. He was recently diagnosed with bilateral nonproliferative diabetic retinopathy (NPDR). He had no known allergies, was a single parent to his 9-year-old son, and worked in construction. His medications included a glucagon-like peptide-1 receptor agonist, liraglutide, and the biguanide metformin.1,2 Other medications included enteric-coated aspirin, amlodipine, lisinopril, atorvastatin, and pregabalin. He saw a neurologist for his back pain, which was stable at the time.
Alex had a telephone visit with his NP in March 2020. His last documented vitals were in November 2020. Alex did not have his BP machine at the time of the visit, but he reported his BP to be controlled at home; his systolic BP ranged from 113 to 129 mm Hg, his diastolic BP of 77-86 mm Hg, and a pulse of 90-95 beats/minute. Alex could not measure his temperature as he did not own a thermometer. Pertinent lab results were reviewed, and his A1C was 9.4%. He and his NP agreed to a hemoglobin A1C goal of less than 7%. Annual urine microalbumin and monofilament tests were completed within the year.3,4 Alex was on lisinopril for both his BP and microalbuminuria. He was seen by an ophthalmologist in December 2019 for his bilateral NPDR. His Patient Health Questionnaire (PHQ)-9 depression screen was 1, indicating minimal depression.5
Alex reported no adverse reactions from liraglutide, so the medication was increased. Although the clinic did not have a Diabetes Self-management Education (DSME) program, he was referred to a nutritionist and clinical pharmacist for follow-up diabetes medication management care consultation. Subsequently, he requested a telephone visit for his 3-month follow-up appointment due to heightened fear of contracting SARS-CoV-2 and his limited availability for in-person visits.
His NP emphasized social distancing, consistent and frequent hand hygiene, facial masks, and COVID-19 vaccination.
On a telephone visit with his NP in June 2020, Alex reported medication adherence, and his A1C was 12.3%. Alex was instructed to continue the current medication regimen with the addition of empagliflozin, a sodium-glucose co-transporter 2 inhibitor.6 He reported a decrease in exercise due to his chronic back pain. He was also unable to monitor his finger-stick blood glucose levels due to a malfunctioning glucometer. His NP sent a prescription for a new glucometer, and he was advised to monitor his fasting and 2-hour postprandial glucose levels. He declined the referral to physical therapy at the time since he had an upcoming appointment with his neurologist.
Alex indicated a strong desire to be healthier to continue supporting his son and provide him with a good education. He denied smoking or using any recreational drugs. He also reported that his ex-wife was an alcoholic and that he did not want his son to see another parent with a similar issue. Alex's depression and anxiety screen did not meet the clinic's guideline for referral to collaborative care; however, information on available free mental health services was provided.
During a telephone visit in April 2020, his dietitian introduced the concept of the Diabetes Plate Method, 1/2 of the plate for nonstarchy vegetables, 1/4 of the plate for protein foods, and 1/4 of the plate for carbohydrate foods.7,8
In July 2020, Alex had a telephone visit with the clinical pharmacist who is also the clinic's certified diabetes care and education specialist (CDCES).
A 24-hour dietary recall was conducted, and the 15-15 rule was discussed, which is recommended when blood glucose is low, below 70 mg/dL. This can be raised by consuming 15 grams (g) of simple carbohydrates and checking blood glucose after 15 minutes.9
When Alex said that he did not have an opportunity to pick up his glucometer from the pharmacy, a referral for a follow-up call with a nursing care manager was placed to ensure he obtained it.
At his telephone visit with his NP in August 2020, Alex's A1C had improved to 8.5% and his labs were reviewed (see Vital signs and test results from November 2019 to August 2021). Empagliflozin was increased and he was told to continue liraglutide and metformin.
Home finger-stick glucose results were obtained by the clinical pharmacist in the same month. Averages included a before-breakfast glucose of 198 mg/dL, a before-lunch glucose of 186 mg/dL, an after-lunch glucose of 229 mg/dL, a before-dinner glucose of 155 mg/dL, and an after-dinner glucose of 274 mg/dL. He reported increased activities with frequent walks in the park with his son. However, the NP cautioned Alex to limit strenuous aerobic exercise due to his NPDR.10
A 24-hour dietary recall was conducted and the 15-15 rule was reviewed. By the time of an October 2020 telephone visit with his NP, Alex's A1C was 8.0%. His NP congratulated him on the achievement and advised him to continue his current medication regimen. Alex declined a referral back to the dietitian and is still hesitant to come into the clinic for his follow-up appointments.
His NP noted his enrollment in the clinic's patient portal and offered him 3 months of telemedicine follow-up. Alex agreed and reported having access to his son's computer for the visits.
Alex continued to have his 3-month video follow-up with his NP and bimonthly telephone visits with the clinical pharmacist. Alex liked the initial video visit as it allowed him to avoid crowds and it made him feel safe when at home.
During his video visit in April 2021, Alex said he was able to pick up odd jobs other than his construction work for extra income and appreciated the convenience of seeing his provider without taking a whole day off from work.
Alex's home finger-stick glucose monitoring averages were as follows: before-breakfast 151 mg/dL, before-dinner 129 mg/dL, and after-dinner 203 mg/dL, and an A1C, 8.3%.
Glimepiride, an oral blood-glucose-lowering drug of the sulfonylurea class, was added for additional prandial control in March 2021.11 Education on hypoglycemia risk with further reinforcement by the clinical pharmacist was provided.5
Alex worked with his NP to set reminders on his phone to schedule eye and dental appointments and downloaded a food diary app. Recommended COVID-19 vaccination and other concerns were also addressed.
In August 2021, Alex met with his NP in person. Vital signs were obtained and labs were reviewed. Alex had reached his goal A1C of 6.7%. Monofilament testing was performed and annual urine microalbumin was collected. Alex completed the COVID-19 vaccination regimen in May 2021.
At the end of the visit, he said that he would like to continue with telemedicine visits. Alex's satisfaction with telemedical care contributed to his willingness to productively engage in efforts for better glycemic control.
The NP also felt the experience was positive since it allowed her to engage with and more closely monitor an at-risk patient who was not willing or able to travel to the office as often as necessary. She and Alex plan to continue the telemedicine visits for health interventions and health promotion measures.
Diabetes and telehealth
About 451 million people are living with diabetes worldwide; by 2045 this number is expected to reach 693 million.12 Diabetes is the seventh leading cause of death in the US with over 34. 2 million adult Americans affected by the disease.13 Diabetes is associated with both macrovascular complications such as atherosclerotic cardiovascular and cerebrovascular diseases; microvascular complications such as neuropathy, nephropathy, and retinopathy; and leads to decreased quality of life and premature death.14 The American Diabetes Association (ADA) recommends a multidisciplinary team approach to managing patients with diabetes in primary care.15 This team should consist of primary care physicians, subspecialty physicians, NPs, physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals.15 The ADA also recommends Diabetes Self-Management Education and Support (DSMES) to assess and address diabetes distress.8
Challenges during the COVID-19 pandemic
The COVID-19 pandemic challenged the delivery of healthcare, particularly face-to-face medical encounters. In an anonymous global survey conducted from March 24 to May 5, 2020, 30% of medical appointments were canceled during the outbreak, threatening healthcare access and continuity of care between providers and their patients.16 The Secretary of the Department of Health and Human Services temporarily authorized and provided a modification to certain Medicare, Medicaid, and Children's Health Insurance Program regulations, resulting in an extension through July 15, 2022.17,18 Upon regulatory policy approval of the waiver, private insurers adopted similar policies. As a result, the Centers for Medicare and Medicaid Services created the Coronavirus Aid, Relief, and Economic Security (CARES) Act, temporarily expanding the roles of providers.17,19 The CARES Act granted all providers permission to remotely manage common health problems, mental health counseling, annual wellness visits, educational services, and renal dialysis facilities.20,21 Before the CARES Act, only certain rural or designated authorized medical facilities could provide virtual care and receive reimbursement.20 While the pandemic presented unprecedented challenges, it catalyzed the rapid adoption of telehealth.
Telehealth
Telehealth is a broad term that encompasses all electronic information primarily distributed via electronic communication channels to provide care.22 Telemedicine, a subset of telehealth, is a remote clinical service for diagnosing and monitoring health conditions through video, audio, or a combination of the two.22
The Office for Civil Rights, the government agency that enforces the Health Insurance Portability and Accountability Act (HIPAA) of 1996, waived potential penalties against healthcare providers that serve patients using non-HIPAA-compliant, non-public-facing remote communication technologies.23 Only remote communication products intended for participating parties are considered non-public facing.24 Remote applications such as Zoom allow encrypted, non-public-facing one-to-one communication.23,25 Public-facing products such as TikTok are not acceptable platforms.23
Legislation has since been introduced to address the broadening and widespread use of telehealth. S.3993 - Equal Access to Care Act temporarily authorized a healthcare provider physically located and duly licensed in one state to provide telehealth services to individuals in one or more additional states in which the provider was not licensed during the COVID-19 emergency period.21,26
Exceptions currently exist within Veterans Affairs (VA) hospitals, specifically for VA healthcare providers who can provide telehealth and telemedicine services regardless of where the VA providers or the VA patients are located.25
H.R. 9035 - Permanency for Audio-Only Telehealth Act, permanently expanded Medicare coverage of telehealth services to include audio-only services for at-home evaluation and management services and mental and behavioral health services.27,28 In California from February 2019 to August 2020, 534 federally located health centers assessed data on the type of services provided from billable outpatient primary care.27 Across visit types, 48.1% were done in person, 48.5% via telephone, and 3.4% via video.27 In April 2020, telephone visits accounted for 65.4% of primary care visits.27
Technology-related issues
Upgrades to existing technology systems are needed to ensure high-quality distance care. Additional expenditures include the increased costs of maintaining necessary equipment and the costs for the physical spaces to accommodate remote visits. Legacy technology infrastructure, reliable internet and phone service resources, patient and provider telehealth education, and the need for standardization require additional consideration.29
By 2019, 81% of American adults owned a smartphone, with 84% of US households also owning either a desktop or a laptop computer.30 Those least likely to have internet in their homes include older adults, those of lower socioeconomic status, and those less educated.25 Current legislation fails to remedy inadequate infrastructure and the lack of financial incentives for private providers and network companies to expand broadband nationwide.29 Further health disparities are seen in those with cognitive disabilities, mental illness, autism spectrum disorder, and auditory and visual limitations.25,29 The Americans with Disabilities Act addresses the need for expanded physical space in healthcare facilities, but not across virtual spaces or within the context of remote services like telemedicine.29
Website and mobile application accessibility standards include applied sign language, captions, magnification, color and contrast, manual dexterity, or physical device mobility; however, telehealth accessibility standardization is relatively new and lacking.29
Some major telehealth use concerns include identity theft and cybersecurity, which can be addressed by using more secure, HIPAA-compliant telehealth platforms.
In one study, data revealed that telemedicine requires staffing levels comparable to in-person care to achieve parity.31 The limitations of virtual physical assessments include: a reliance on visual and auditory observations, additional possible out-of-pocket costs to patients, equipment purchases such as automatic BP devices, and, other devices for a digital physical assessment. These additional elements can decrease patient satisfaction.25
Benefits of telehealth for diabetes management
The CDC suggests that those with diabetes are at a higher risk of developing serious illness due to complications related to COVID-19.32 Telehealth provides safe access to quality care, limits exposure to communicable diseases, reduces time off from work, patients' travel time, and alleviates personal assistance service expenses.25
A global survey of 7,477 individuals living with diabetes type 1 in 89 countries, conducted between March and May of 2020, found that 28% received remote care. Of those who received remote care, 72% recieved it by telephone and 28% received it by video call.16 The survey also found that 86% of these remote appointments were useful and 75% of respondents planned more remote appointments in the future.16 There was no difference in the perception of quality of care, the usage between age groups, or across patient education levels, suggesting future telemedicine adoption to be useful across a large sample of the population.16
A systematic review in 2016 looked at participants 18 years and older with diabetes (type 1 and type 2) and found 10 studies (n = 879) suggesting telemedicine reduced the risk of hypoglycemia.33 Thirteen studies (n = 1,224) showed improved A1C, and seven studies (n = 708) showed no effect on BMI when telemedicine was employed.33 The review also observed higher rates in the reduction of A1C across interventions within 6 months versus 3 months, noting initial problems encountered with the use of a remote device.33
Another systematic review in 2017 identified 111 studies (n = 23,648) with adults with diabetes (type 1 and type 2) in which patients received clinical feedback and communication from healthcare providers using technology or devices.34 These telemedicine modalities ranged from simple generic management messages for patients to more comprehensive interventions such as videoconferencing with a healthcare provider, including a nurse, nurse case manager or pharmacist, and remote glucose monitoring with electronic data capture within an electronic medical record.34 There was a significant but modest reduction in A1C when compared with usual care to additional telemedicine, 0.57% within 3 months and 0.28% beyond 4 months.34 Telemedicine interventions that facilitated medication adjustments by a clinical nurse or pharmacist were more effective in improving glycemic control by 0.23%.34 Additional findings noted text messaging and web portals to be potentially effective when utilized to link providers to patients diagnosed with diabetes.34
A 9-month randomized trial of 40 patients with type 2 diabetes mellitus that compared telemedicine with a standard in-person visit found that the telemedicine group showed lower mean blood glucose, A1C, BP, and total cholesterol.14 Additionally, this same study compared the time spent between visits, with telemedicine averaging 18 minutes compared with in-person visits averaging 23 minutes.14
Receiving DSME through technology-based programs to promote effective coping and self-management requirements is correlated with improved confidence in provider communication and increased patient access to other medical staff for information and ongoing support.35
Employing a multidisciplinary team approach to telehealth and telemedicine's management of diabetes is beneficial during public health emergencies. A nurse employed for counseling on diabetes, when certified as a CDCES, greatly expands the number of providers mobilized across emergency areas.31 A 1-year pilot study was done with 46 veterans living with uncontrolled diabetes in rural communities throughout New Mexico and southern Colorado.36 Patients were given a choice of telephone services alone or mixed-channel consultations (telephone, video, or in-person visits) with a CDCES.36 The CDCES provided DSME (education on medication adherence, diet, exercise, hypoglycemia prevention and treatment, self-monitoring of blood glucose) and medication management.36 The study found no statistically significant difference in A1C reduction between telephone-only versus mixed-channel consultations across the observed 3 to 6 months of service.36
Feedback on the case study
This case study illustrates a gap: a clinical nurse's involvement in the telemedicine case. Herein, a clinical nurse can play a crucial role by employing established nursing protocols during the initial telemedicine intake with the patient. This includes establishing a patient's ability to log in to the video portal or remote application; entering the home vitals reported by the patient; conducting a depression screen; reviewing a daily finger-stick glucose log, reviewing medication, activity levels, and dietary habits; and updating the patient's health history.30
Focusing on patient empowerment with patient-centered approaches is important in providing optimal nursing care and achieving positive patient outcomes. Diabetes distress should be regularly monitored for it can affect medication-taking behaviors and is linked to higher A1C, lower self-efficacy, and poor dietary and lifestyle habits.8 Encounters in telemedicine should focus on establishing an increased understanding of emotional and psychosocial needs and promoting autonomy toward positive behavioral strategies and reducing diabetes distress.
Recommendation for clinical care
Advances in information technology, coupled with adaptations to the COVID-19 global public health emergency, have innovated healthcare delivery. Telehealth access benefits patients and is vital for the management of diseases such as diabetes.
Telehealth is not a new concept. Incentives tied to the CARES Act consequently expanded adoption across lower-income households and increased access to financially challenged populations and those with less flexible work schedules.
Family members are advised to be involved in the initial telemedicine visit or revisit to help with any log-in issues that may arise.
Necessary stakeholder investment to support the continued use of telehealth applications is a key challenge to success. Expenditures are impacted by evolving HIPAA compliance standards, cybersecurity concerns, and the creation of new remote patient-care privacy standards. Other variables include the availability of on-demand and on-hand technical support for appointment sessions, adequate tutorial video content for first-time users, and also the degree to which telemedicine platforms are user-friendly in their inherent design. Important user interface design and accessibility options include closed captioning capabilities and sign language video.
Monthly telemedicine follow-ups with a clinical pharmacist or with a CDCES are recommended for optimal uncontrolled diabetes care and those with controlled diabetes but with a noted elevated A1C. A follow-up call by the clinical nurse or nurse care manager is recommended to ensure the patient obtained their medications and to provide additional educational reinforcement. Referral to a dietitian should be a part of the care program for the management of diabetes.37
Consider employing the following processes and systems: user-friendly account creation sign-up flows; guides or training media to instruct self-recording of vital signs and blood glucose levels; logging personal food diaries; conducting daily foot checks; and, drafting checklist reminders for regular dental and eye care appointments.
Conclusions
Telemedicine correlates with improvements in A1C in patients with diabetes and improves overall access to care. While current studies cover brief observation periods with low numbers of participants, most of these studies were completed before the COVID-19 pandemic.
Nursing care that leverages the nonrestrictive benefits of telehealth has been shown to improve patient outcomes.38 The impact of these nursing strategies highlights the need for systemic reconsiderations concerning telehealth, factoring in racial and socioeconomic disparities, improvements in patient education, and the degrees of overall patient access to telemedicine. Additional studies are needed to further understand the benefits of telehealth in diabetes management.
REFERENCES