Am Fam Physician. 2022;105(3):281-288
Author disclosure: No relevant financial relationships.
Telemedicine can be useful for the management of diabetes mellitus. Remote monitoring of glucose levels improves A1C levels in people with poor glucose control. When multiple daily injections of insulin are required, continuous glucose monitoring improves glycemic control and increases patient satisfaction. Telemedicine diabetes prevention programs can be cost-effective. Teleretinal screening allows for the remote evaluation of retinal photos obtained at the primary care office to facilitate the timely completion of annual screening. Telemedicine for patients who have diabetes requires administrative and patient preparation before the visit. The physical examination should focus on the skin and extremities, especially the feet. Patients receiving telediabetes care require at least annual in-person visits for complete foot examinations, sensory screenings, and to address issues noted during previous telemedicine visits.
Telemedicine uses the electronic exchange of health information to improve a patient’s health and is classified into three categories. Synchronous telemedicine encompasses virtual care that is performed in real time. Asynchronous telemedicine involves acquiring medical data that are transmitted for assessment later. Remote monitoring is any health data continuously collected from the patient (e.g., remote blood pressure monitor, continuous glucose monitor). The use of telemedicine increased during the COVID-19 pandemic. The Veterans Health Administration was an early adopter to improve access to care and outcomes for a primarily rural population of veterans with multimorbidity, including diabetes mellitus.1
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Telemedicine should be used in addition to in-person visits to optimize glycemic control in patients with uncontrolled diabetes mellitus.2,19,20 | C | Consistent evidence from systematic reviews showing improvement in A1C levels |
| Continuous glucose monitoring can be helpful in patients who require insulin to reduce A1C levels, avoid hypoglycemia, and improve patient satisfaction.28–31 | C | Clinical review; disease-oriented studies evaluating glycemic control and hypoglycemia |
| Teleretinal screening should be considered in patients with diabetes as a cost-effective option for retinopathy screening in those who have access to this technology.43–45,48,49 | B | Consistent evidence from systematic reviews shows improved screening rates, cost effectiveness, and reduced rates of blindness |
Telemedicine used for the comprehensive management of diabetes (i.e., telediabetes care) has been shown to improve blood glucose control and some diabetes-related outcomes.2 Incorporating telemedicine into primary care can be challenging and requires an investment in staffing and training to establish the clinical workflows and workforce to care for patients remotely; however, it can improve the quality of care for patients with diabetes.2
Role of Telemedicine in Diabetes Care
The American Diabetes Association recommends improving care delivery at the systems level, offering self-management support, and using shared decision-making in the care of patients with diabetes.3 Telemedicine addresses these goals by increasing patient access to care through decreased travel requirements. It also improves outcomes by adding video visits and virtual nurse check-ins between physician visits, which improves diabetic glycemic outcomes.4 Remote monitoring allows the patient to communicate real-time blood glucose data to their physician to support diabetes self-management and recognize problems early. Telemedicine provides an opportunity to improve patient-centered approaches in diabetes care. In addition to eliminating the burden of travel, clinicians gain a glimpse into a patient’s living situation, which can facilitate discussions on food, housing, and economic security.
Medicare now pays for most telemedicine visits at the same rate as in-person visits for all types of telemedicine and patient locations.5 Private insurers have made similar accommodations.6 Medicaid and private insurer coverage of telehealth services is variable, and state Medicaid agency and insurance representatives can verify those policies. The future success of telediabetes care will depend on continued financial reimbursement and requires systemic solutions to overcome gaps in digital literacy.
Considerations for the Use of Telemedicine for Diabetes Care
Telemedicine poses challenges that require unique solutions in the care of patients with diabetes. Adaptations are required by the physician, ancillary staff, and health care organizations to ensure equitable and cost-effective care.
Office staff must be able to teach and troubleshoot telehealth technology. Relevant previsit information and home data about blood glucose levels and vital signs should be collected before the visit, which can offset the time saved from rooming patients and measuring their vital signs.
Plans for follow-up from the physician should be detailed and include the laboratory tests and measurements required before the next visit. Between visits, electronic messaging or telephone calls to the patient may be needed from nursing staff, diabetes educators, and office staff. Patients may require an in-person visit to address needs identified in a prior telemedicine visit.
The rapid increase in telemedicine use has revealed barriers to implementation.7 Internet limitations, especially in rural areas, can preclude the use of video technology. Telemedicine implementation could further isolate patients at high risk and exacerbate health care disparities. Physicians may struggle to use telemedicine if they lack resources for implementation and support (Table 17–16).
| Considerations | Challenges | Interventions | Evidence |
|---|---|---|---|
| Cultural competency | Telediabetes interventions are not universally applicable across cultures without modification | Communicate in the local language, involve indigenous health care workers, encourage community engagement, respect local cultures Use remote interpreter services | In one survey-based study, patients were equally satisfied with remote interpreter services and in-person interpretation8,9 |
| Digital literacy | Ability to use telemedicine can be affected by age and limiting comorbidities such as a visual or hearing impairment | Implement technical support and troubleshooting before, during, or after a visit Identify patients who are not good candidates for telemedicine | In one qualitative study, all age groups acknowledged independence and convenience as key benefits of diabetes care, but patients older than 50 years preferred in-person care10 |
| Physician practice setting | Telediabetes encounters may be difficult and time-consuming if technological issues arise during the visit | Screening for ability and willingness to use technology can be done by office staff before the visit and triaged accordingly | A survey of primary care physicians identified diabetes management as among the three most appropriate reasons for a video visit; factors that made telemedicine more difficult included poor cognitive function, non-English speakers, advanced age, and new patient visits7 |
| Psychosocial | Patients who have diabetes generally fare worse in measures of quality of life and emotional well-being | Telemedicine can support good physician-patient communication and trust, use of wearable diabetes technologies (continuous glucose monitors, insulin pumps), and disease-specific coping mechanisms | Smaller survey-based studies suggest a small improvement in quality of life and self-efficacy with the use of telemedicine11–13 |
| Systemic | Lack of telephone or internet access in rural areas and low socioeconomic status can lead to poor follow-up and difficulty using telediabetes care | Medicaid and Medi-Cal offer coverage or fee waivers for telemedicine consultation Veterans have access to programs that lend devices to patients to connect with clinicians14 Remote access stations and video-conference clinics can reduce travel time for patients without a home telephone or internet connection | A cohort study in 2020 identified lower use of telemedicine care among patients with lower household income and Latino and Black populations15 A systematic review of rural telemedicine interventions associated shorter travel distance and greater frequency of interventions with better glycemic outcomes16 |
Efforts to address these challenges are ongoing. The U.S. Department of Veterans Affairs ATLAS (Accessing Telehealth Through Local Area Stations) program partnered with organizations such as Walmart and the American Legion to establish telemedicine locations for patients without stable internet in their homes. There are 12 stations in the United States with plans to expand.17
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