648343
research-article2016
DSTXXX10.1177/1932296816648343Journal of Diabetes Science and TechnologyLiu et al
Original Article
Endocrinology Telehealth Consultation Improved Glycemic Control Similar to Face-to-Face Visits in Veterans
Journal of Diabetes Science and Technology 2016, Vol. 10(5) 1079–1086 © 2016 Diabetes Technology Society Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1932296816648343 dst.sagepub.com
Winnie Liu, MD1,*, David R. Saxon, MD2,4,*, Bryan McNair, MS3, Rebecca Sanagorski, FNP-BC4, and Neda Rasouli, MD2,4
Abstract Background: Rates of diabetes for veterans who receive health care through the Veterans Health Administration are higher than rates in the general population. Furthermore, many veterans live in rural locations, far from Veterans Affairs (VA) hospitals, thus limiting their ability to readily seek face-to-face endocrinology care for diabetes. Telehealth (TH) technologies present an opportunity to improve access to specialty diabetes care for such patients; however, there is a lack of evidence regarding the ability of TH to improve glycemic control in comparison to traditional face-to-face consultations. Methods: This was a retrospective cohort study of all new endocrinology diabetes consultations at the Denver VA Medical Center over a 1-year period. Results: A total of 189 patients were included in the analysis. In all, 85 patients had received face-to-face (FTF) endocrinology consultation for diabetes and 104 patients had received TH consultation. Subjects were mostly males (94.7%) and the mean age was 62.8 ± 10.1 years old. HbA1c improved from 9.76% (9.40% to 10.11%) to 8.55% (8.20% to 8.91%) (P < .0001) for the TH group and from 9.56% (9.16% to 9.95%) to 8.62% (8.22% to 9.01%) (P < .0001) for the FTF group after 1 visit. This change in HbA1c was not significantly different in the TH and FTF groups (P = .24). TH visits were associated with a hypothetical savings in median distance traveled of 231.2 miles per trip (which equates to $94.79 saved per trip). Conclusions: Endocrinology TH consultations improved short-term glycemic control as effectively as traditional FTF visits in a veteran population with diabetes. Keywords diabetes, hemoglobin A1c, telehealth, telemedicine, veterans
In 2012, 9.3% of the US population (29.1 million individuals) had diabetes and the disease ranked as the 7th leading cause of death.1 The diabetes burden is even greater in the Veterans Health Administration (VHA), the nation’s largest integrated health care system, where at least 20% of veterans have diabetes.2 As of August 2015, 22.8% of veterans with diabetes were considered “uncontrolled” having HbA1c values greater than 9% (from internal VA data). A significant challenge to achieving better diabetes control within the VHA system is that 3.2 million veterans—36% of the total veteran population—live in rural communities where access to specialty care is often limited.3 Recognizing the need to incorporate new technologies to improve timely care delivery, the US Department of Veterans Affairs (VA) invested $90 million in its telehealth (TH) expansion plan in 2011.4 TH is a broad term, encompassing telemedicine and mobile health technologies used for physician-patient interactions, diagnostics, care delivery, education, information sharing,
monitoring, and reminders.5 Currently up to 50% of US hospitals have some form of active TH program6 and up to 57% or providers surveyed are willing to see patients over video.7 A 2013 Cisco survey found that greater than 70% of patients are
1
University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA 2 Division of Endocrinology, Metabolism, and Diabetes, University of Colorado School of Medicine, Aurora, CO, USA 3 Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, CO, USA 4 Denver Veterans Affairs Medical Center, Denver, CO, USA * Winnie Liu and David R. Saxon contributed equally to this article. Corresponding Author: Neda Rasouli, MD, Division of Endocrinology, Metabolism, and Diabetes, University of Colorado School of Medicine, 1055 Clermont St, Denver, CO 80220, USA. Email: [email protected]
1080
Journal of Diabetes Science and Technology 10(5)
Figure 1. Number of patients in each care delivery modality and reasons for exclusion. Received both telehealth and face-to-face visit modalities.
comfortable communicating with doctors via texting, email, or video instead of being seen in person, suggesting that TH services will continue to expand.8 However, despite escalating use and good acceptance amongst providers and patients, TH care faces substantial barriers such as state-by-state variability in TH reimbursement, medical license portability, and privacy issues.9-11 Furthermore, evidence is currently insufficient to determine the ability of TH interventions to reduce overall cardiovascular disease risk, but a study is under way to address this issue.12,13 While TH holds great promise for improving access and delivery of care, there has been a call for further investigation into whether TH delivers similar outcomes as traditional face-to-face (FTF) encounters (ie, usual care) at either the same or lower costs.14 This study’s purpose was to investigate the impact of TH versus FTF endocrinology consultations on glycemic control for veterans referred for diabetes evaluation. We hypothesized that improvement in glycemic control would be similar in patients receiving care through TH as compared to those seen by FTF.
Methods We performed a retrospective cohort study of all new endocrinology diabetes consultations at the Denver VA Medical
Center (DVAMC) between October 1, 2013, and September 30, 2014. Consults were identified in VA’s Computerized Patient Records System (CPRS) by using ICD-9 codes. The local institutional review board, the Colorado Multiple Institutional Review Board, approved the study prior to data collection. Patients who had not been seen by endocrinology providers for 2 years prior to the visit were considered to be new consultations. Selection for either FTF or TH care took place during the course of routine primary care and was offered to patients who lived far from the DVAMC. The primary care providers placed a consult depending on the patients’ preference. Primary care providers were responsible for explaining the process of TH to the patients. Figure 1 outlines the breakdown of the number of patients in each care delivery modality and reasons for exclusion. A total of 250 initial diabetes consultations within the aforementioned time period were identified. Of these patients 119 received FTF consultations and 131 received TH visits depending on their distance to DVAMC. Sixteen patients from the FTF group and 7 patients from the TH group were excluded for the reasons listed in Figure 1. To compare the effects of different methods of care delivery on glycemia, subjects who received both TH and FTF care (“mixed visit modalities”) were excluded in this analysis. Eighteen patients in the FTF
1081
Liu et al Table 1. Patient Baseline Characteristics (N = 189) Characteristic Male (n, %) Diagnosis of hypertension (n, %) Diagnosis of dyslipidemia (n, %) Insulin use (n, %) Oral blood glucose medication use (n, %) Statin use (n, %) Baseline HbA1C ≥9% (n, %) 7-8.9% (n, %)
research-article2016
DSTXXX10.1177/1932296816648343Journal of Diabetes Science and TechnologyLiu et al
Original Article
Endocrinology Telehealth Consultation Improved Glycemic Control Similar to Face-to-Face Visits in Veterans
Journal of Diabetes Science and Technology 2016, Vol. 10(5) 1079–1086 © 2016 Diabetes Technology Society Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1932296816648343 dst.sagepub.com
Winnie Liu, MD1,*, David R. Saxon, MD2,4,*, Bryan McNair, MS3, Rebecca Sanagorski, FNP-BC4, and Neda Rasouli, MD2,4
Abstract Background: Rates of diabetes for veterans who receive health care through the Veterans Health Administration are higher than rates in the general population. Furthermore, many veterans live in rural locations, far from Veterans Affairs (VA) hospitals, thus limiting their ability to readily seek face-to-face endocrinology care for diabetes. Telehealth (TH) technologies present an opportunity to improve access to specialty diabetes care for such patients; however, there is a lack of evidence regarding the ability of TH to improve glycemic control in comparison to traditional face-to-face consultations. Methods: This was a retrospective cohort study of all new endocrinology diabetes consultations at the Denver VA Medical Center over a 1-year period. Results: A total of 189 patients were included in the analysis. In all, 85 patients had received face-to-face (FTF) endocrinology consultation for diabetes and 104 patients had received TH consultation. Subjects were mostly males (94.7%) and the mean age was 62.8 ± 10.1 years old. HbA1c improved from 9.76% (9.40% to 10.11%) to 8.55% (8.20% to 8.91%) (P < .0001) for the TH group and from 9.56% (9.16% to 9.95%) to 8.62% (8.22% to 9.01%) (P < .0001) for the FTF group after 1 visit. This change in HbA1c was not significantly different in the TH and FTF groups (P = .24). TH visits were associated with a hypothetical savings in median distance traveled of 231.2 miles per trip (which equates to $94.79 saved per trip). Conclusions: Endocrinology TH consultations improved short-term glycemic control as effectively as traditional FTF visits in a veteran population with diabetes. Keywords diabetes, hemoglobin A1c, telehealth, telemedicine, veterans
In 2012, 9.3% of the US population (29.1 million individuals) had diabetes and the disease ranked as the 7th leading cause of death.1 The diabetes burden is even greater in the Veterans Health Administration (VHA), the nation’s largest integrated health care system, where at least 20% of veterans have diabetes.2 As of August 2015, 22.8% of veterans with diabetes were considered “uncontrolled” having HbA1c values greater than 9% (from internal VA data). A significant challenge to achieving better diabetes control within the VHA system is that 3.2 million veterans—36% of the total veteran population—live in rural communities where access to specialty care is often limited.3 Recognizing the need to incorporate new technologies to improve timely care delivery, the US Department of Veterans Affairs (VA) invested $90 million in its telehealth (TH) expansion plan in 2011.4 TH is a broad term, encompassing telemedicine and mobile health technologies used for physician-patient interactions, diagnostics, care delivery, education, information sharing,
monitoring, and reminders.5 Currently up to 50% of US hospitals have some form of active TH program6 and up to 57% or providers surveyed are willing to see patients over video.7 A 2013 Cisco survey found that greater than 70% of patients are
1
University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA 2 Division of Endocrinology, Metabolism, and Diabetes, University of Colorado School of Medicine, Aurora, CO, USA 3 Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, CO, USA 4 Denver Veterans Affairs Medical Center, Denver, CO, USA * Winnie Liu and David R. Saxon contributed equally to this article. Corresponding Author: Neda Rasouli, MD, Division of Endocrinology, Metabolism, and Diabetes, University of Colorado School of Medicine, 1055 Clermont St, Denver, CO 80220, USA. Email: [email protected]
1080
Journal of Diabetes Science and Technology 10(5)
Figure 1. Number of patients in each care delivery modality and reasons for exclusion. Received both telehealth and face-to-face visit modalities.
comfortable communicating with doctors via texting, email, or video instead of being seen in person, suggesting that TH services will continue to expand.8 However, despite escalating use and good acceptance amongst providers and patients, TH care faces substantial barriers such as state-by-state variability in TH reimbursement, medical license portability, and privacy issues.9-11 Furthermore, evidence is currently insufficient to determine the ability of TH interventions to reduce overall cardiovascular disease risk, but a study is under way to address this issue.12,13 While TH holds great promise for improving access and delivery of care, there has been a call for further investigation into whether TH delivers similar outcomes as traditional face-to-face (FTF) encounters (ie, usual care) at either the same or lower costs.14 This study’s purpose was to investigate the impact of TH versus FTF endocrinology consultations on glycemic control for veterans referred for diabetes evaluation. We hypothesized that improvement in glycemic control would be similar in patients receiving care through TH as compared to those seen by FTF.
Methods We performed a retrospective cohort study of all new endocrinology diabetes consultations at the Denver VA Medical
Center (DVAMC) between October 1, 2013, and September 30, 2014. Consults were identified in VA’s Computerized Patient Records System (CPRS) by using ICD-9 codes. The local institutional review board, the Colorado Multiple Institutional Review Board, approved the study prior to data collection. Patients who had not been seen by endocrinology providers for 2 years prior to the visit were considered to be new consultations. Selection for either FTF or TH care took place during the course of routine primary care and was offered to patients who lived far from the DVAMC. The primary care providers placed a consult depending on the patients’ preference. Primary care providers were responsible for explaining the process of TH to the patients. Figure 1 outlines the breakdown of the number of patients in each care delivery modality and reasons for exclusion. A total of 250 initial diabetes consultations within the aforementioned time period were identified. Of these patients 119 received FTF consultations and 131 received TH visits depending on their distance to DVAMC. Sixteen patients from the FTF group and 7 patients from the TH group were excluded for the reasons listed in Figure 1. To compare the effects of different methods of care delivery on glycemia, subjects who received both TH and FTF care (“mixed visit modalities”) were excluded in this analysis. Eighteen patients in the FTF
1081
Liu et al Table 1. Patient Baseline Characteristics (N = 189) Characteristic Male (n, %) Diagnosis of hypertension (n, %) Diagnosis of dyslipidemia (n, %) Insulin use (n, %) Oral blood glucose medication use (n, %) Statin use (n, %) Baseline HbA1C ≥9% (n, %) 7-8.9% (n, %)
