Hybrid care model: Combining telemedicine and office visits for diabetes management in older adults with type 1 diabetes

Main Article Content

Elena Toschi, MD Atif Adam, PHD, MPH, MD Nana Frimpong, BA Rebecca Hurlbert, BA Christine Slyne, BA Lori Laffel, MD, MPH Medha Munshi, MD

Abstract

Aims: To evaluate the use of hybrid (telehealth and in-person) care on visitation and glycaemia in older adults with type 1 diabetes (T1D). 


Methods: In this retrospective study, we examined clinical characteristics, number of visits (telehealth and in-person) and continuous glucose monitoring (CGM) metrics for older adults (≥65 years) with T1D from electronic health records during the pre-COVID-19 pandemic (March 1, 2019-March 1, 2020; in-person) and pandemic (September 1, 2020-August 31, 2021; hybrid) periods. Main outcomes were the number of visits and changes in glycaemic control (HbA1c), and in a sub-group of older adults using CGM, changes in CGM metrics between in-person and hybrid care.


Results: We analysed data of 661 older adults with T1D (age 72±5 years). The hybrid care resulted in an increased number of annual diabetes visits (6.3 vs 4.2 visits/person) without change in glycaemic control (HbA1c 7.4% vs 7.2%) compared with in-person care alone. In the sub-group of 299 older adults with T1D using CGM, hybrid care compared with in-person care resulted in an improvement of time-in-range (70-180 mg/dL) (68% to 71%; p<0.001) without increasing hypoglycaemia (<70 mg/dL).


Conclusion: Compared with in-person only visits, hybrid care maintained visit frequency and preserved glycaemic control measured as HbA1c. In a sub-group of older adults with T1D using CGM, time-in-range improved while time in hypoglycaemia did not change. These data suggest that a hybrid care model is efficacious in maintaining visitation and glycaemic control, and, as demonstrated in a sub-group of older adults with T1D using CGM, safe with respect to time in hypoglycaemia.

Keywords: type 1 diabetes, t1d, management, older adults, telehealth, telemedicine, hybrid care, A1C, hypoglycaemia, continuous glucose monitor

Article Details

How to Cite
TOSCHI, Elena et al. Hybrid care model: Combining telemedicine and office visits for diabetes management in older adults with type 1 diabetes. Medical Research Archives, [S.l.], v. 12, n. 9, sep. 2024. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/5728>. Date accessed: 03 oct. 2024. doi: https://doi.org/10.18103/mra.v12i9.5728.
Section
Research Articles

References

1. Sinclair AJ, Dunning T, Dhatariya K, an International Group of E. Clinical guidelines for type 1 diabetes mellitus with an emphasis on older adults: an Executive Summary. Diabet Med. Jan 2020;37(1):53-70. doi:10.1111/dme.14135
2. ElSayed NA, Aleppo G, Aroda VR, et al. 13. Older Adults: Standards of Care in Diabetes-2023. Diabetes Care. Jan 1 2023;46(Suppl 1):S216-S229. doi:10.2337/dc23-S013
3. Schutt M, Fach EM, Seufert J, et al. Multiple complications and frequent severe hypoglycaemia in 'elderly' and 'old' patients with Type 1 diabetes. Diabet Med. Aug 2012;29(8):e176-9. doi:10.1111/j.1464-5491.2012.03681.x
4. Fisher L, Hessler D, Polonsky W, Strycker L, Masharani U, Peters A. Diabetes distress in adults with type 1 diabetes: Prevalence, incidence and change over time. J Diabetes Complications. Aug 2016;30(6):1123-8. doi:10.1016/j.jdiacomp.2016.03.032
5. Mehrotra A, Bhatia RS, Snoswell CL. Paying for Telemedicine After the Pandemic. JAMA. Feb 2 2021;325(5):431-432. doi:10.1001/jama.2020.25706
6. Sotomayor F, Hernandez R, Malek R, Parimi N, Spanakis EK. The Effect of Telemedicine in Glycemic Control in Adult Patients with Diabetes during the COVID-19 Era-A Systematic Review. J Clin Med. Aug 31 2023;12(17)doi:10.3390/jcm12175673
7. Jaana M, Pare G. Comparison of Mobile Health Technology Use for Self-Tracking Between Older Adults and the General Adult Population in Canada: Cross-Sectional Survey. JMIR Mhealth Uhealth. Nov 27 2020;8(11):e24718. doi:10.2196/24718
8. Lam K, Lu AD, Shi Y, Covinsky KE. Assessing Telemedicine Unreadiness Among Older Adults in the United States During the COVID-19 Pandemic. JAMA Intern Med. Oct 1 2020;180(10):1389-1391. doi:10.1001/jamainternmed.2020.2671
9. Vigersky RA, Fish L, Hogan P, et al. The clinical endocrinology workforce: current status and future projections of supply and demand. J Clin Endocrinol Metab. Sep 2014;99(9):3112-21. doi:10.1210/jc.2014-2257
10. Lee JY, Lee SWH. Telemedicine Cost-Effectiveness for Diabetes Management: A Systematic Review. Diabetes Technol Ther. Jul 2018;20(7):492-500. doi:10.1089/dia.2018.0098
11. Bonora BM, Morieri ML, Avogaro A, Fadini GP. The Toll of Lockdown Against COVID-19 on Diabetes Outpatient Care: Analysis From an Outbreak Area in Northeast Italy. Diabetes Care. Jan 2021;44(1):e18-e21. doi:10.2337/dc20-1872
12. Bertuzzi F, Stefani I, Rivolta B, et al. Teleconsultation in type 1 diabetes mellitus (TELEDIABE). Acta Diabetol. Feb 2018;55(2):185-192. doi:10.1007/s00592-017-1084-9
13. Pratley RE, Kanapka LG, Rickels MR, et al. Effect of Continuous Glucose Monitoring on Hypoglycemia in Older Adults With Type 1 Diabetes: A Randomized Clinical Trial. JAMA. Jun 16 2020;323(23):2397-2406. doi:10.1001/jama.2020.6928
14. Xu T, Pujara S, Sutton S, Rhee M. Telemedicine in the Management of Type 1 Diabetes. Prev Chronic Dis. Jan 25 2018;15:E13. doi:10.5888/pcd15.170168
15. Kaushal T, Ambler-Osborn L, Turcotte C, Quinn H, Laffel L. Rapid Adoption of Telemedicine Along with Emergent Use of Continuous Glucose Monitors in the Ambulatory Care of Young Persons with New-Onset Type 1 Diabetes in the Time of COVID-19: A Case Series. Telemed J E Health. Jan 2022;28(1):107-114. doi:10.1089/tmj.2020.0554
16. Kaushal T, Tinsley L, Volkening LK, Ambler-Osborn L, Laffel L. Improvement in Mean CGM Glucose in Young People with Type 1 Diabetes During 1 Year of the COVID-19 Pandemic. Diabetes Technol Ther. Feb 2022;24(2):136-139. doi:10.1089/dia.2021.0258
17. Kaushal T, Tinsley LJ, Volkening LK, Turcotte C, Laffel LM. Improved CGM Glucometrics and More Visits for Pediatric Type 1 Diabetes Using Telemedicine During 1 Year of COVID-19. J Clin Endocrinol Metab. Sep 28 2022;107(10):e4197-e4202. doi:10.1210/clinem/dgac476
18. Toschi E, Adam A, Atakov-Castillo A, Slyne C, Laffel L, Munshi M. Use of Telemedicine in Adults with Type 1 Diabetes: Do Age and Use of Diabetes-Related Technology Matter? Telemed J E Health. Jan 24 2023;doi:10.1089/tmj.2022.0397
19. Nouri S, Lyles CR, Sherwin EB, et al. Visit and Between-Visit Interaction Frequency Before and After COVID-19 Telehealth Implementation. JAMA Netw Open. Sep 5 2023;6(9):e2333944. doi:10.1001/jamanetworkopen.2023.33944
20. Toschi E, Slyne C, Weinger K, et al. Use of Telecommunication and Diabetes-Related Technologies in Older Adults With Type 1 Diabetes During a Time of Sudden Isolation: Mixed Methods Study. JMIR Diabetes. Nov 18 2022;7(4):e38869. doi:10.2196/38869
21. Aleppo G, Gal RL, Raghinaru D, et al. Comprehensive Telehealth Model to Support Diabetes Self-Management. JAMA Netw Open. Oct 2 2023;6(10):e2336876. doi:10.1001/jamanetworkopen.2023.36876
22. Munshi M, Slyne C, Weinger K, et al. Self-care barriers and facilitators in older adults with T1D during a time of sudden isolation. Sci Rep. Apr 29 2023;13(1):7026. doi:10.1038/s41598-023-33746-3