Telemedicine Boosts Glycemic Control in Rural T2D Patients

A telehealth intervention improved glycemic control for patients with uncontrolled type 2 diabetes living in rural areas, researchers said.

Patients enrolled in Advanced Comprehensive Diabetes Care (ACDC) — an intensive, 6-month telehealth program for patients with poor glycemic control — had an average 1.36% reduction (95% CI -1.61 to -1.11) in HbA1c, reported Elizabeth Kobe, an MD candidate at the Duke University School of Medicine in Durham, North Carolina.

Across five healthcare sites, HbA1c improved from an average of 9.25% at baseline to 7.89% at 6 months, Kobe said in a presentation at the American Diabetes Association virtual meeting.

Improvements in glycemic control persisted at 12 months (-1.22%, 95% CI -1.48 to -0.97) and 18 months (-1.07%, 95% CI -1.40 to -0.73), Kobe and colleagues noted.

“We found that the significant improvement in A1c that we saw at 6 months was largely maintained at 12 and 18 months,” Kobe said, adding that the initial implementation of ACDC made a “substantial difference for rural patients with diabetes,” and that the program was well-positioned for further dissemination.

However, interviews with healthcare providers revealed that ACDC moderately increased their workload. “ACDC patients are way more time-involved than routine telehealth patients,” one provider said in an interview.

Compared with patients in urban areas, those in rural communities have an increased diabetes prevalence, Kobe said. Rural patients with diabetes are more likely to experience poor glycemic control and lack access to specialty care and intensive self-management programs, all leading to poorer outcomes.

An earlier randomized trial showed that ACDC improved HbA1c, blood pressure, and diabetes self-managment in 50 veterans. ACDC has since been implemented in North Carolina, Vermont, Colorado, New Mexico, Montana, Ohio, and Idaho.

“Telehealth represents a potential strategy for extending specialized diabetes care to rural areas,” Kobe said. “However, while telehealth has proven efficacious for diabetes in research studies, intensive telehealth interventions have rarely been implemented in standard care.”

Kobe and colleagues examined the rural implementation of ACDC for patients with type 2 diabetes. In partnership with the VA Office of Rural Health, they used existing telehealth technology, trained VA staff, and electronic health record infrastructure.

Nurses conducted 30-minute phone calls with patients every 2 weeks. During each call, nurses reviewed blood glucose data and medication adherence, and delivered a self-management education module on such topics as diabetes medication management, diet, and exercise. Following every 2-week call, a medication manager reviewed reports from nurses on patient progress. Medication managers adjusted treatment, but did not communicate directly with patients.

In addition to quantitative patient data, researchers collected qualitative data from interviews with patients and providers.

For the current analysis, they used data from 125 patients across five different healthcare sites. Approximately 94% of the study cohort was male, 89% were white, and the average age was 59. Around 70% of study participants lived in rural areas.

Kobe and colleagues reported that implementation was acceptable, and patients completed an average of eight to 10 of 12 scheduled ACDC calls. They also found that ACDC enhanced patient engagement and improved their awareness of glycemic control.

“ACDC represents a classic example of effectiveness research progressing to implementation research, and then into clinical practice,” Kobe stated.