Use of Telemedicine to Improve Glycemic Management in a Skilled Nursing Facility: A Pilot Study

Abstract

The objective of this study was to evaluate the feasibility of using telemedicine to improve glycemic control (reduce episodes of hypoglycemia and severe hyperglycemia) for residents with diabetes in a skilled nursing facility. This randomized pilot study enrolled residents with diabetes (n=23; mean age, 83 years; 91% insulin-treated) and compared usual care (control; n=11) with usual care plus weekly/biweekly teleconsultations with an endocrinologist (n=12) for up to 6 months. A nurse and dietitian from the skilled nursing facility were at all televisits. Residents who were able and willing attended the televisits. Family members were also invited and occasionally were present. The endocrinologist reviewed glucose levels from point-of-care glucose meter downloads, dietary intake, medications, and medical status and recommended changes in glycemic therapy as needed. Measurements included glucose levels from point-of-care glucose meter downloads, hemoglobin A1c (A1c) levels, and a nurse satisfaction survey. Results showed that 7 of 10 insulin-treated intervention subjects had basal doses reduced (18–69%) compared with 2 of 11 control subjects (reduced 10% and 25%, respectively). There was a decrease in percentage of intervention participants with episodes of hypoglycemia (<80 mg/dL) over the previous month from baseline (42%) to end of study (22%) versus a rise in the control group (from 36% to 45%) and less hyperglycemia (>400 mg/dL) (intervention, from 33% to 22%; control, from 22% to 55%). There were no end-of-study A1c values >8.0% in the intervention group versus 44% in controls. Nursing staff at the skilled nursing facility expressed high satisfaction. Results suggest that telemedicine diabetes consultations to skilled nursing facilities can improve glycemic management.

Introduction

A third of residents in skilled nursing facilities (SNFs) have diabetes.¹ Diabetes management can be especially challenging in SNFs where physical and/or cognitive impairment, multiple comorbidities, polypharmacy, and erratic food intake are common.^2,3 Hypoglycemic episodes may be unrecognized, because of poor counterregulation and difficulties with communication. Both hypoglycemia and hyperglycemia can cause acute complications and lead to increased morbidity and mortality. The treatment of diabetes in SNFs is suboptimal.^4,5

Telemedicine has been used to increase access to diabetes care,^6
–8 but there have been no randomized studies using telemedicine to assist in the treatment of diabetes in SNFs. We report here the results of a prospective, randomized pilot study examining the feasibility and utility of teleconferencing to provide diabetes consultations for residents in an SNF.

Subjects and Methods

Residents receiving pharmacological therapy for type 2 diabetes at the Presbyterian Home, New Hartford, NY, were offered participation if they had a ≥6-month anticipated residency, were medically stable, and did not have stage 4 chronic renal disease. All participants and/or their legal guardians provided written informed consent. This study was approved by the Institutional Review Board for the Protection of Human Subjects at SUNY Upstate Medical University. Volunteers were randomized to receive usual care (n=11) or usual care supplemented by a telemedicine intervention (n=12) for up to 6 months (December 2011–July 2012). One-Touch^® Ultra^®2 (LifeScan, Milpitas, CA) glucose monitoring devices for each participant were used, and individual downloads were transmitted prior to televisits. The intervention involved weekly or biweekly teleconsultations between the endocrinologist at the Joslin Diabetes Center at Upstate Medical University and the resident's nurse and dietitian. Residents and family members who were able and willing attended the televisits. At televisits, point-of-care glucose levels, diet, medications, and changes in medical conditions were reviewed, and recommendations related to changes in glycemic control medications and diet were delivered. Glucose data for 1 month prior to baseline and conclusion of study intervention are reported. Hemoglobin A1c (A1c) (target <8.0%⁹) levels were obtained at baseline and at 3 and 6 months after beginning the intervention. Nursing staff completed a satisfaction survey at the end of study.

Laptop computers (Latitude™ E6410; Dell, Round Rock, TX) with secure videoconferencing (VITAL™; Govsphere^®, Syracuse, NY) and Skype™ (Microsoft, Redmond, WA) freeware (for audio) were used. Signals originating or terminating at the Diabetes Center were conveyed over the Internet via Intel (Santa Clara, CA) ProSet/wireless WIFI at up to 54 megabits per second (Mbps) and over distance along broadband Internet (Time Warner, New York, NY) at 10 Mbps or Clearwire (Bellevue, WA) 3ZG/4G WIMAX Internet to Govsphere's dedicated Dell 2950 data center server, using https://secure sockets layer encryption over port 443. Signals originating or terminating at the SNF were conveyed locally over a Cisco (San Jose, CA) wireless router through their intranet network and for distance transmission using the Time Warner open public node or Clearwire 3G/4G WIMAX Internet.

Results

Of 24 eligible subjects, 1 withdrew prior to randomization, 1 withdrew at 4 weeks (transfer to palliative care), and 2 were in the study for <12 weeks (died). Five patients died during the study (3 in the intervention group, 2 in the control group) from comorbidities unrelated to the intervention. Participants (n=23) were white, 70% female, and 57% confused, 8% aphasic, 35% oriented and had a mean age of 83 years (range, 65–93 years), body mass index of 28 kg/m² (range, 20–38 kg/m²), baseline A1c of 7.3% (range, 5.2–9.3%), and daily food intake of 71% (range, 20–89%; but individual intake was 0–100% per meal for several subjects). Only 1 participant consistently ate 75–100% of all his meals. At baseline, glycemic therapy was as follows: insulin treatment (91% of subjects; 11 control, 10 intervention), basal/bolus insulin with or without an oral agent for 54% (45% using the same short-acting doses before meals as at bedtime), basal insulin with or without an oral agent (9%), oral agent plus short-acting insulin (4%), or premixed insulin (18%). Oral agent alone (glipizide) was used by 9%; oral agents used with insulin included metformin (n=5), sulfonylurea (n=4), and sitagliptin (n=7). Data are reported for those with participation of at least 12 weeks.

From baseline to the end of study, 7 of 10 insulin-treated intervention subjects had basal doses reduced (by 18–69%) compared with only 2 control subjects (reduced by 10% and 25%, respectively). In the intervention group, 3 of the 4 subjects on premixed insulin were changed to basal/bolus regimens. From baseline to end of study, the proportion of residents with a glucose level of <80 mg/dL in the intervention group decreased from 42% to 22%, whereas in the control group it increased from 36% to 45%. The percentage of participants with glucose levels >400 mg/dL decreased in the intervention group (from 33% to 22%) but increased in control subjects (from 36% to 55%).

In the intervention group, there were 2 participants with an A1c level of >8% at baseline and none at 6 months, compared with the control group, which had 3 residents with elevated A1c levels at baseline, all of whom remained >8.0% at 6 months. There were 3 intervention subjects with baseline A1c levels of <6.5% (2 subjects with A1c values of 5.4% and 5.5% who had basal insulin doses reduced by 56% and 40%, respectively, and 1 [A1c, 6.4%] on oral agent only), and 2 control subjects with A1c levels of <6.5% (A1c values of 6.0% and 6.1%) who had basal insulin doses reduced by 25% and increased by 25%, respectively.

SNF nurses reported that the videoconferences were a good use of their time and skills and were effective for delivery of endocrinology consults (three of five nurses completed the survey).

Discussion

There is a high prevalence of diabetes in SNF residents. Their glycemic management is complex and challenging because of multiple comorbidities, erratic eating, and difficulties with communication. Hypoglycemia and hyperglycemia are common but poorly recognized and treated. This problem is receiving increasing recognition, with new consensus statements emphasizing the importance of avoiding hypoglycemia and severe hyperglycemia.¹⁰ Televisits with diabetes experts are one way to increase access to specialists who can assist in achieving appropriate glycemic goals in this vulnerable population. The results from our pilot study are encouraging and suggest that diabetes teleconsultations can reduce episodes of hypoglycemia and severe hyperglycemia.

Conclusions

The use of telemedicine to provide diabetes consultations is feasible and can assist in improving glycemic management in this vulnerable population. Larger studies are needed to further evaluate the effectiveness of this approach in SNFs.

Footnotes

Acknowledgments

This work was supported, in part, by the New York State Department of Health, the Presbyterian Home and Rehabilitation Center (New Hartford, NY), and the Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, SUNY Upstate Medical University (Syracuse, NY). Govsphere, Inc. (Syracuse) donated technical support and the videoconference solution, the Learning Paradigm (Hamlin, NY) donated WIFI connectivity and hardware, and LifeScan, Inc. (Milpitas, CA) donated glucose monitoring devices, blood glucose test strips, and associated glucose report management software. We thank Anthony Joseph, MSW, MPA, LNHA, Administrator, Presbyterian Home and Rehabilitation Center, for his support and initiation of this project, the Presbyterian Home staff, including Sandra A. Smith, BPS, Director of Information Technology, for her operational support, and, most importantly, the participants and their families.

Disclosure Statement

No competing financial interests exist.

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