Advancing telemedicine in diabetes management in the post-COVID-19 pandemic era

According to the World Health Organization (WHO), telemedicine was defined as the delivery of healthcare services using information and communication technologies.1 At the European Association for the Study of Diabetes (EASD) Annual Meeting 2023, Professor Chan, Chung-Ngor Juliana from the Department of Medicine and Therapeutics, The Chinese University of Hong Kong, discussed the latest research on diabetes management with telemedicine.

Prof. Chan started by explaining that telemedicine had been applied to monitoring glycemic data, empowering lifestyle modification, conducting teleconsultation and promoting provider-patient communication in diabetes care for more than two decades before the coronavirus disease 2019 (COVID-19) pandemic.2 She further emphasized the broad coverage of the term ‘telemedicine’ encompassing a myriad of communication methods including telephone calls, emails or text messages. These communication technologies form part of an integrated care plan and have been shown to enhance the quality of conventional care in patients with diabetes (DM).

In a multinational meta-analysis of 55 randomized controlled trials (RCTs) including 9,258 patients with DM, the efficacy of telemedicine was evaluated by changes in HbA1c when compared with conventional care.3 With up to 5 years of follow-up, 40% of the studies favored telemedicine over conventional care alone.3 Patients who received telemedicine had greater HbA1c reductions over conventional care especially in patients with type 2 DM, age ≥40 years, and intervention for <6 months. Of note, the majority of participants in these RCTs received teleconsultation instead of telemonitoring with teleconsultation being provided on top of conventional care.3

COVID-19 prompted worldwide uptake of telemedicine to prioritize healthcare resources for patients with acute conditions while minimizing interpersonal contacts for patients with chronic illnesses without disrupting care. According to figures from the Hong Kong Hospital Authority, as of May 2022, there were 13,000 teleconsultations as compared to 13.5 million outpatient attendances per year in the public sector. In a retrospective cohort study conducted in the United States (US) in 2020-2021, researchers compared the Health Care Effectiveness Data and Information Set (HEDIS) quality performance measures between patients who attended office visits only (n=409,732) versus those using telemedicine (n=117,142).3 The telemedicine cohort had better testing-based measures including blood pressure, blood lipids, HbA1c and markers of nephropathy among patients with DM.4 However, the telemedicine group had lower attainment in medication-based measures (e.g., patients with cardiovascular disease [CVD] receiving antiplatelet drugs and patients with upper respiratory infection [URI] receiving antibiotic treatments) than the office-visit group.3 These data support the utility of telemedicine in monitoring clinical progress but the initiation of medications requires more in-depth discussion during face-to-face consultation.4

Prof. Chan highlighted the importance of context in the use of telemedicine in chronic care, such as DM. Telemedicine can be a valuable component within an integrated healthcare system in this post-COVID-19 pandemic era. However, several quality-related issues need to be considered.

Firstly, telemedicine should achieve comparable safety and effectiveness as conventional care or add value to conventional care. Secondly, it should increase efficiency in terms of reducing technical manpower, set-up costs, and time needed for implementation, thereby enhancing the acceptability, affordability, and impacts of telemedicine-augmented care, relevant to patients, providers, and payors. Lastly, it should be patient-oriented to ensure that the use of this technology reduces health inequity rather than widening it. These quality issues should be evaluated on an ongoing basis with various metrics supported by outcomes in real-world practice.

In a survey among patients with DM (n=569) in Italy, there was a positive relationship between perceived quality (PQ) of telemedicine and willingness to continue by patients.5 Perceived quality was determined by a composite related to patient experiences including continuing care from the same healthcare provider (HCP), perceived support from HCPs, willingness of HCP to listen and usefulness of information as well as improvement in self-management among other items.4 In total, 64% of patients reported that they were willing to continue telemedicine in the post-pandemic period.5 Older patients (≥65 years old) had a lower PQ while patients with higher education as well as unemployed patients were more willing to continue telemedicine.4 Patients reporting a higher empowerment level at baseline also had higher PQ and were more likely to adhere to recommendations provided during telemedicine.5

Prof. Chan concluded the presentation by reaffirming that telemedicine in patients with DM had potential values although context, integration and evaluation are important considerations. She reminded that even for teleconsultation, there are considerable barriers that need to be addressed including low eHealth literacy among HCPs, technological and regulatory issues such as cybersecurity, standardization of platforms, legal framework, incentives, reimbursement and cost-effectiveness. In the final analysis, the COVID-19 pandemic has offered an opportunity for the world to re-evaluate the role of telemedicine in a broader context in our pursuit of increasing the quality, efficiency and cost-effectiveness of diabetes management and beyond.

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