Exclusive Telemedicine Use Linked to Less Favorable Glycemic Outcomes for T2D Endocrinology Care

For individuals with type 2 diabetes (T2D) undergoing endocrinology care, those who exclusively utilize telemedicine experience less favorable glycemic outcomes compared with those opting for in-person care or a combination of in-person and virtual care.

Woman having telemedicine visit on tablet | Image credit: rh2010 – stock.adobe.com

These findings are based on a retrospective cohort study published in JAMA Network Open. According to the researchers, while telemedicine can help increase care access, it may be necessary to implement supplementary approaches to assist individuals with T2D who depend solely on telemedicine for accessing endocrinology care, particularly those with intricate treatment regimens or elevated hemoglobin A_1c (HbA_1c) levels.

The study included 3778 adult patients who had a telemedicine endocrinology visit for T2D between May and October 2020, with 88% being White, 8% being Black, and 2% being Asian. Of this cohort, 1182 patients exclusively used telemedicine, 1049 exclusively used in-person care, and 1547 used a combination of both.

Patients using telemedicine only were slightly younger, with a mean age of 57.4 years, while patient using in-person care were older at 63 years, and those using both fell in the middle at 60.7 years. The researchers also noted a slight variation in the proportion of women using telemedicine, in-person care, or both, with 63%, 55%, and 57% of patients in each group being female, respectively.

There was also a slightly higher proportion of Black patients using telemedicine at 10% compared with in-person and mixed follow-up at 7% each, and Asian patients were slightly more likely to experience mixed follow-up at 3% compared with telemedicine (2%) and in-person follow-up (1%). With White patients making up the majority of the cohort, the differences in each group were more subtle with 87%, 90% and 88% using telemedicine, in-person care, and mixed follow-up, respectively. Additional research with more diverse patients would allow a deeper look into the differences in how Black, Asian, and Hispanic or Latino patients utilize each method of endocrinology care.

Rural-urban commuting area (RUCA) codes were used to assess rurality, which can affect T2D care and outcomes. When looking at RUCA codes, the researchers found that a significantly higher proportion of patients lived in urban areas compared with suburban or rural areas across the board, making up 78%, 64% and 68% of patients in the telemedicine, in-person, and combination groups, respectively. Patients in suburban areas were the second most prominent in each group, followed by patients in rural areas.

The use of telemedicine became a prominent method for delivering diabetes care amid the COVID-19 pandemic, however the patterns of utilization have evolved over time. According to the researchers, their findings regarding specific patient groups depending on telemedicine for specialized diabetes care align with previous research and reveal additional characteristics linked to persistent telemedicine usage.

Younger individuals, women, and those residing in urban areas were more likely to exclusively utilize telemedicine, aligning with similar trends observed in primary care and endocrinology contexts. Additionally, Black patients exhibited a greater likelihood for telemedicine-only usage, contrasting with mixed findings in previous research regarding the relationship between race and ethnicity with telemedicine utilization.

Additionally, the study showed that individuals with less complex T2D were more inclined to exclusively utilize telemedicine. The results also add new evidence suggesting that telemedicine could be especially crucial in facilitating access to endocrinology care for patients contending with psychological comorbidities. These comorbidities are acknowledged for their influence on diabetes self-management and outcomes, highlighting the potential need for extra support to attain treatment objectives.

Looking at glycemic outcomes based on care modality, the telemedicine-only group demonstrated no significant change in HbA_1c from baseline to 12 months at –0.06 (95% CI, ­–0.26 to 0.14; P = .55). Meanwhile, in-person and mixed cohorts had improvements of 0.37% (95% CI, 0.15-0.59; P < .001) and 0.22% (95% CI, 0.07-0.38; P = .004), respectively.

Individuals with a baseline HbA_1c level of 8% or higher demonstrated a comparable trend in glycemic outcomes. In cases where patients were prescribed multiple daily insulin injections compared with those not using insulin at all, the 12-month estimated change in HbA_1c was 0.25% greater (95% CI, 0.02-0.47; P = .03) for telemedicine compared with in-person care. The presence of comorbidities did not show an association with HbA_1c change in any cohort. After follow-up was extended to 24 months, there were no significant changes in HbA_1c across any care modality.

In contrast to the current study's results, earlier investigations during the COVID-19 pandemic in primary care or general diabetes populations indicated comparable glycemic control among patients receiving telemedicine and in-person diabetes care. Several potential explanations exist for the observed absence of HbA_1c improvement in patients exclusively utilizing telemedicine for endocrinology care, with the first being that patient-level factors influencing the preference for telemedicine may also affect overall T2D self-management and health care access.

“The telemedicine group was more urban dwelling, younger, more likely to be Black and female, and may face unmeasured competing demands to diabetes self-management, such as caregiving responsibilities, transportation barriers, or work schedules,” the researchers said. “Telemedicine-only users also had lower care utilization, including less frequent appointments and HbA_1c testing, which may lead to more clinical inertia and less intensification of treatment by endocrinology practitioners. Although it is not clear whether lower care utilization was driven by patients, practitioners, or systemic barriers, prior studies of diabetes telemedicine have found similar results.”

Another potential reason for the suboptimal glycemic outcomes in the telemedicine group is the inconsistent translation of strategies supporting glycemic improvement from in-person to telemedicine care. Essential care elements that are especially impactful for patients with elevated HbA_1c or complex insulin regimens—self-management education and support, sharing of home blood glucose data, and resources for adopting diabetes technology or new medications—may not be consistently provided in telemedicine visits. Previous research highlighted practitioners' challenges in intensifying treatment through telemedicine due to limited access to glucose data, emphasizing the need for implementation of solutions like team-based virtual care and technological tools for automated data sharing to ensure equitable access to high-quality diabetes care across care modalities.

“Since some patients with barriers to in-person endocrinology care will continue to rely on telemedicine to access care, structured approaches to ensure routine delivery of high-quality team-based diabetes care are needed,” the researchers said. “Translation of successful strategies from clinical trials into routine telemedicine care, especially targeted toward adults with more complex diabetes, is critical to improve clinical outcomes for patients who rely on this care modality.”

Reference

Zupa MF, Vimalananda VG, Rothenberger SD, et al. Patterns of telemedicine use and glycemic outcomes of endocrinology care for patients with type 2 diabetes. JAMA Netw Open. Published online December 6, 2023. doi:10.1001/jamanetworkopen.2023.46305