#ADA2020 VA telehealth intervention improves glycemic response for rural adults with diabetes

Senior woman consults a e-health doctor with tablet computer sitting in soft chair. In touchscreen, male doctor: With telehealth application patient can reach relevant specialist remotely.

A structured intervention that utilized the Department of Veterans Affairs network of home telehealth nurses was associated with a significant reduction in HbA1c that was sustained for 18 months among rural adults with type 2 diabetes.

Compared with their urban counterparts, adults living in rural areas have an increased diabetes prevalence, are more likely to experience poor glycemic response, are less likely to receive recommended diabetes health care measures, and are more likely to lack access to specialty care and intensive self-management programs, all of which perpetuate poor diabetes outcomes, Elizabeth Kobe, a study investigator and MD candidate at Duke University Medical School, said during a presentation at the virtual American Diabetes Association Scientific Sessions.

“This is where telehealth may be able to help,” Kobe said. “Telehealth represents a potential strategy for extended specialized diabetes care to rural areas. However, while telehealth has proven efficacious for diabetes in research settings, intensive telehealth interventions have rarely been implemented in standard care. This implementation gap is due to multiple factors, including a lack of trained staff, insufficient availability of and heterogeneity in telehealth equipment, inadequate integration of telehealth data with electronic health records and limited options for reimbursement of telehealth-based care.”

Using the existing VA home telehealth infrastructure and clinical staff, Kobe and colleagues designed a program called Advanced Comprehensive Diabetes Care (ACDC), a 6-month telehealth intervention that combines telemonitoring with module-based self-management support and medication management. VA clinical staff delivered ACDC through 30-minute calls every 2 weeks. Patients self-monitored their blood glucose and transmitted the data daily with home telehealth-issued equipment. During phone call encounters, telehealth nurses reviewed the data and medication use, while also delivering self-management education. All data were documented in the EHR, allowing a medication manager, usually a PharmD, to review and recommend changes to medications, Kobe said.

In collaboration with the VA Office of Rural Health, researchers analyzed data from 125 veterans with type 2 diabetes from five VA sites across the U.S. between 2017 and 2019 (94.4% men; mean age, 59 years; 88.5% white; 13.7% Hispanic). Within the cohort, 61.6% lived in rural areas and mean baseline HbA1c was 9.25%.

Across all locations, mean HbA1c improved to 7.89% at 6 months, for a mean change of –1.36 percentage points (95% CI, –1.61 to –1.11), with the benefit persisting at 18 months (–1.07 percentage points; 95% CI, –1.4 to –0.73), Kobe said.

“ACDC represents a classic example of effectiveness research progressing to implementation research and then into clinical practice,” Kobe said, adding that feedback from users has guided implementation at new sites, which is ongoing.

“Despite the drastic changes that COVID-19 has forced us to make, ACDC delivery has continued unabated,” Kobe said. “Given all this, ACDC has truly made a difference for rural patients with diabetes, and is well positioned for further dissemination.”