The switch from intermittently scanned continuous glucose monitoring (isCGM) to real-time (rt) CGM could improve glycemic management in suboptimal controlled type 1 diabetes patients, but long-term study is lacking. We evaluated retrospectively the ambulatory glucose profile (AGP) in such patients after switching from Free Style Libre 1 (FSL1) to Dexcom G4 (DG4) biosensors over 1 year. Patients (n = 21, 43 ± 15 years, BMI 25 ± 5, HbA1c 8.1 ± 1.0%) had severe hypoglycemia and/or HbA1c ≥ 8%. AGP metrics (time-in-range (TIR) 70–180 mg/dL, time-below-range (TBR) 180 mg/dL or >250 mg/dL, glucose management indicator (GMI), average glucose) were collected the last 3 months of FSL1 use (M0) and of DG4 for 3, 6 (M6) and 12 (M12) months of use. Values were means ± standard deviation or medians [Q1;Q3]. At M12 versus M0, the higher TIR (50 ± 17 vs. 45 ± 16, p = 0.036), and lower TBR < 70 mg/dL (2.5 [1.6;5.5] vs. 7.0 [4.5;12.5], p = 0.0007), TBR < 54 mg/dL (0.7 [0.4;0.8] vs. 2.3 [0.8;7.0], p = 0.007) and %CV (39 ± 5 vs. 45 ± 8, p = 0.0009), evidenced a long-term effectiveness of the switch. Compared to M6, TBR < 70 mg/dL decreased, %CV remained stable, while the improvement on hyperglycemia exposure decreased (higher GMI, TAR and average glucose). This switch was a relevant therapeutic option, though a loss of benefit on hyperglycemia stressed the need for optimized management of threshold alarms. Nevertheless, few patients attained the recommended values for AGP metrics, and the reasons why some patients are “responders” vs. “non-responders” warrant to be investigated.

Benefits of a Switch from Intermittently Scanned Continuous Glucose Monitoring (isCGM) to Real-Time (rt) CGM in Diabetes Type 1 Suboptimal Controlled Patients in Real-Life: A One-Year Prospective Study §

Telehealth has traditionally been viewed as the lesser of the two when compared to in-person health care. Studies on telehealth often compare a remote to an in-person approach and aim to achieve at least non-inferiority. This comparison implies that in-person health care is the gold standard, which can be questioned, given suboptimal glycaemic outcomes with this traditional model of care.1Kazemian P Shebl FM McCann N Walensky RP Wexler DJ Evaluation of the cascade of diabetes care in the United States, 2005–2016.JAMA Intern Med. 2019; 179: 1376-1385Crossref PubMed Scopus (90) Google Scholar, 2Chan JCN Lim L-L Wareham NJ et al.The Lancet Commission on diabetes: using data to transform diabetes care and patient lives.Lancet. 2021; 396: 2019-2082Summary Full Text Full Text PDF PubMed Scopus (82) Google Scholar This Comment hopes to push us, as providers of diabetes care, to advocate for prioritising telehealth over in-person care and to consider a hybrid model of in-person and telehealth for people with diabetes. In 1997, JAMA published a systematic review of distance-medicine technology, in which the data from clinical trials revealed significant improvements in outcomes in several disease groups that included diabetes.3Balas EA Jaffrey F Kuperman GJ et al.Electronic communication with patients. Evaluation of distance medicine technology.JAMA. 1997; 278: 152-159Crossref PubMed Google Scholar This improvement was before smartphones, remote data uploads, and (in diabetes specifically) real-time monitoring of glucose values became available. Very few studies in that review would have relied on technology that was a recent breakthrough at the time—ie, glucose finger sticks instead of urine tests. Yet, connecting remotely with people with diabetes improved outcomes. Fast forward to the present day, and multiple reports4Danne T Limbert C Puig Domingo M et al.Telemonitoring, telemedicine and time in range during the pandemic: paradigm change for diabetes risk management in the post-COVID future.Diabetes Ther. 2021; 12: 2289-2310Crossref PubMed Scopus (5) Google Scholar show robust beneficial effects of telehealth for people with diabetes, particularly when coupled with remote telemonitoring. Although there has been a renewed interest in telehealth as a result of growing technological capabilities and infrastructure and potential cost-savings,5Lee JY Lee SWH Telemedicine cost-effectiveness for diabetes management: a systematic review.Diabetes Technol Ther. 2018; 20: 492-500Crossref PubMed Scopus (63) Google Scholar the COVID-19 pandemic has accelerated that interest. The authors of a review6Bhaskar S Bradley S Chattu VK et al.Telemedicine across the globe-position paper from the COVID-19 Pandemic Health System Resilience Program (REPROGRAM) international consortium (part 1).Front Public Health. 2020; 8556720Crossref PubMed Scopus (59) Google Scholar of the global telehealth landscape noted several key takeaways: first, that telehealth can improve both individual outcomes and the performance of health-care systems; and second, that coordinated efforts are needed to democratise access to telehealth across highly variable geographical regions and health-care systems. In this Comment, we draw attention to areas with growing infrastructures and discuss how to share telehealth wealth (eg, technological knowledge and best practice) towards furthering public health. Given the high rates of diabetes globally, our field is primed to be a global leader in this space. It is increasingly clear that people with diabetes view telehealth as a viable and desirable alternative to in-person care. In a paper from the USA,7Tilden DR Datye KA Moore DJ French B Jaser SS The rapid transition to telemedicine and its effect on access to care for patients with type 1 diabetes during the COVID-19 pandemic.Diabetes Care. 2021; 44: 1447-1450Crossref PubMed Scopus (10) Google Scholar the transition from in-person to telehealth in a paediatric diabetes care centre happened rapidly and with high rates of patient satisfaction. Similarly, a review8Choudhary P Bellido V Graner M et al.The challenge of sustainable access to telemonitoring tools for people with diabetes in Europe: lessons from COVID-19 and beyond.Diabetes Ther. 2021; 12: 2311-2327Crossref PubMed Scopus (3) Google Scholar about telehealth based mostly in Europe also suggested high interest, and the benefits for people with diabetes included improved autonomy over the management of their condition and a substantial improvement in their quality of life. A global study9 showed a strong consensus among survey respondents who found telehealth consultations to be useful and they hoped to continue telehealth in the future. Globally, people with diabetes are telling us as health-care providers and institutions who are able to push telehealth that they want us to do this. We should oblige. The added value of telehealth extends to us health-care providers and our systems in various ways. First, interacting with patients who are located in their natural environments, in which more than 99% of their diabetes self-management takes place, offers increased ecological validity. For the clinician, this approach offers a glimpse into the daily demands of, and potential barriers to, patients taking care of their diabetes. In the past 2 years, how many of us have commented on (or apologised for) some remote-meeting intrusion (eg, children, pets, or home delivery)? Telehealth allows us to afford people with diabetes whom we work with the same approach—ie, normalising daily events and potential intrusions—while also providing us with increasingly accurate appraisals of the environments and life context in which their diabetes management happens. Second, a decrease in the need to travel to in-person visits will increase the time that people with diabetes have available to address competing needs, such as family, work, and social demands. This remote approach also offers an opportunity to assist with problem-solving strategies connected with diabetes outcomes, in the environments where real-world problems arise. Third, data sharing is largely done remotely now, with uploads to the cloud or hardwired uploads from a remote device. Remote glucose-sensing technologies, such as continuous glucose monitoring, are highly effective in changing health outcomes in both children and adults with diabetes. Telehealth can pull such information into the remote visit to offer real-time assessment, problem solving, and treatment planning to promote positive change. As we flip the priority from in-person to remote diabetes care, there are needs that require attention. Telehealth can be a vehicle to broaden access, increase use of diabetes-care services, and optimise health outcomes in people with diabetes. However, people can be resistant to change, and for those patients with diabetes who prefer in-person care and do not want it any other way, that should be the way in which their care is delivered. Using short, infrequent, telehealth check ins might foster familiarity and increased acceptance of remote consultations in the future. Telehealth might not be new to us as diabetes care providers, but a model that both prioritises it and integrates it in a hybrid manner will be new to many people, including those with diabetes who are receiving care. Furthermore, being flexible with modes of telehealth (eg, audio-only, smartphone versus laptop or desktop) is necessary to ensure patient engagement and comfort. Scaling telehealth models to be inclusive of multiple languages and to provide increased support for people without state-funded insurance can ensure that those at risk of lower uptake6Bhaskar S Bradley S Chattu VK et al.Telemedicine across the globe-position paper from the COVID-19 Pandemic Health System Resilience Program (REPROGRAM) international consortium (part 1).Front Public Health. 2020; 8556720Crossref PubMed Scopus (59) Google Scholar have equitable access and are able to receive the benefits. Telehealth and this approach to care cannot be allowed to become another variable that widens the access gap for people with diabetes. In summary, telehealth being offered first (before in-person visits), and integrated with an annual in-person visit, has the potential to improve health outcomes and quality of life for people with diabetes. Telehealth can also optimise the performance of health-care systems and create a network of health-care providers that is better poised to deal with the next global health crisis. We as healthcare providers should be advocates and agents of change, to improve access to and use of diabetes care, and telehealth and remote monitoring are our best option for achieving this new approach to health care. KKH declares consultancy fees from Cecelia Health for helping to design and support the behavioural component of an observational study. JJW declares no competing interests. 

Telehealth for people with diabetes: poised for a new approach

Objective: This study aimed (1) to study the effects of health education on preventive behaviors and cancer literacy among women with cervical intraepithelial neoplasia (CIN); (2) to compare the effects of mobile application program (App)-assisted health education with traditional book-form health education. Participants: A total of 132 women ages 20 to 69 years women. Methods: This prospective longitudinal study enrolled 132 CIN women who were evaluated three times. Propensity score matching was used by controlling subjects’ age strata, body mass index, education level, occupation, and type of surgery. Results: The influences of various educational tools were investigated. Four domains were assessed, including health behavior, attitude towards behavior change, self-efficacy of behavior, and cervical cancer (CCa) literacy. Significant improvements in behavior change and CCa literacy due to a health education program were observed (p ≤ 0.002). The App combined with a traditional booklet had the highest score for behavior change and was significantly greater than the booklet-only learning (p = 0.002). The App-assisted form, either App alone or combined with booklet, had a significantly better impact on health promotion when compared to the booklet alone (p = 0.045 and 0.005, respectively). App-only learning had the highest score of CCa literacy (p = 0.004). Conclusion: Health education interventions can have positive effects in terms of change of behavior and CCa literacy. App-assisted learning could be used as a supportive technology, and App learning alone or combined with a traditional booklet may be an innovative model of clinical health promotion for women with CIN.

Effects of Mobile Application Program (App)-Assisted Health Education on Preventive Behaviors and Cancer Literacy among Women with Cervical Intraepithelial Neoplasia.

http://www.diabetesresearchclinicalpractice.com/article/S0168822722009494/pdf

Monthly video consultation for children and adolescents with type 1 diabetes mellitus during the COVID-19 pandemic

http://www.diabetesresearchclinicalpractice.com/article/S0168822722007628/pdf

Efficacy of the mHealth application in patients with type 2 diabetes transitioning from inpatient to outpatient care: a randomized controlled clinical trial.

Telemedicine in diabetes care has been evolving over several years, particularly since the advent of cloud-connected technologies for diabetes management, such as glucose monitoring devices, including continuous glucose monitoring (CGM) systems, that facilitate sharing of glucose data between people with diabetes and their healthcare professionals in near-real time. Extreme social distancing and shielding in place for vulnerable patients during the COVID-19 pandemic has created both the challenge and the opportunity to provide care at a distance on a large scale. Available evidence suggests that glucose control has in fact improved during this period for people with diabetes who are able to use CGM devices for remote glucose monitoring. The development of telemedicine as part of the standard of care in diabetes faces significant challenges in the European context, particularly in terms of providing consistent and effective care at a distance to large populations of patients while using robust systems that can be supported by large regional and national healthcare services. These challenges include a fragmented approach to healthcare technology assessment and reimbursement, lack of eHealth education and literacy, particularly amongst healthcare professionals, lack of data integration, as well as concerns about electronic health records, patient consent and privacy. Here we review the benefits of and challenges to wider application of telemedicine and telemonitoring in the post-pandemic future, with the aim to ensure that the value of these eHealth services is provided to patients, healthcare providers and health systems.

/pdf/the-challenge-of-sustainable-access-to-telemonitoring-tools-153p76dzx8.pdf

Matthijs Graner

Papers

The Challenge of Sustainable Access to Telemonitoring Tools for People with Diabetes in Europe: Lessons from COVID-19 and Beyond.