Multidisciplinary, Virtual Endocrinology Care Improves Outcomes in Diabetes

Personalized virtual endocrinology care has been shown to improve outcomes among 53 individuals with poorly controlled diabetes who are novice users of continuous glucose monitoring (CGM), according to new findings published in JMIR Diabetes.

The persons in this analysis—66% of whom had type 1 diabetes, 34% who had type 2 diabetes, 83% of whom were being treated with insulin, and who had a mean (SD) age of 39.8 (11.7) years—had yet to see consistent time-in-range (TIR) values, coming in at under 70% according to the first 4 weeks of CGM data available from their participation in Steady Health, a virtual endocrinology clinic for individuals with diabetes living in California and Washington state. They all were onboarded by February 2021, and the investigators compared outcomes from their latest 4 weeks of CGM data to their first 4 weeks for these outcomes, with all care provided through the Steady Health app:

• Change in TIR
• Time below range (TBR)
• Average blood glucose

“Ongoing efforts have yet to translate into better clinical outcomes as the percentage of patients with diabetes achieving glycemic targets remains stagnant over time,” the study authors wrote. “Geographic barriers are minimized, and multidisciplinary care becomes convenient and continual when it is provided over telemedicine and messaging.”

The overall analysis showed a mean of 11 (range, 3-27) months of care, with most participants being Caucasian (67.9%) and having commercial insurance (98.1%).

When comparing outcomes from the latest 4 weeks to the earliest 4 weeks, most patients either increased their TIR by at least 5% or 10% or more, at 75.5% and 64.2%, respectively. More than two-thirds (67.9%) also reduced their TBR while increasing/maintaining their TIR, and among the 7 patients who first had a TBR mark of greater than 4%, just 2 were unable to better that number. Utilization of multiple daily insulin injections was most likely to lead to the greatest reduction of TBR.

Just over half (50.9%) achieved a 70% or more TIR goal, and TIR increase had a positive correlation with lower baseline TIR. For example, baseline TIR below 30% had the highest median TIR increase of 35.1% (16.8%-68.4%) while baseline TIR of 60.1% to 69.9% had an 8.2% (1.1%-19.8%) TIR jump. Further, of the 50.9% who switched to a new method of insulin delivery during the study (pump or algorithm change, smart pen, inhaled insulin), 85.2% bettered their TIR.

At baseline, the most common disease-related complication was diabetic retinopathy (20.8%), the median (IQR) glycated hemoglobin A_1c (HbA_1c) was 8.5 (7.5-11.2), median TIR was 53.0% (40.9%-61.7%), and median TBR was 0.9% (0.2%-2.5%). For the 83% being treated with insulin, 56.8% were using injections and 43.2% utilized pumps.

Participants also reported they felt that Steady Health bettered their diabetes management, that they felt greatly supported and received the training they needed, and that it was easy and convenient to make provider appointments.

Overall, the more that study participants were actively engaged in their care, the greater their reductions in HbA_1c and average blood glucose and the greater their increase in TIR—all without increasing their TBR.

“The real-world data presented in this analysis suggest that virtual diabetes care that integrates enhanced analysis of CGM and continual close collaboration with endocrinologists and diabetes care and education specialists can be associated with significant improvements in TIR and HbA1c for patients with uncontrolled diabetes,” the authors concluded. “The positive findings also strongly affirm the notion that the education, training, and support for CGM, smart pens, insulin pumps, algorithms, and inhaled insulin can be delivered both safely and effectively in a virtual care setting.“

Reference

Wu CC, Wu KC, José AS, Novin N. Virtual endocrinology care emphasizing data-driven insights and continuous engagement and its impact on glycemic outcomes in patients with uncontrolled diabetes: a real-world retrospective case series. JMIR Diabetes. Published online March 24, 2022. doi:10.2196/30626