Use of Telehealth Videoconferencing in Pediatric Type 1 Diabetes in Oregon

Introduction

Like many states, Oregon has few pediatric endocrinologists, most of them in a single urban center. A recent query to the Oregon Medical Board showed Portland addresses for 21 of 23 total licensed pediatric endocrinologists. ¹ To address this problem, Oregon Health and Science University (OHSU) Pediatric Diabetes started offering videoconferencing clinics in March 2014 at RiverBend Hospital in Springfield, OR, just about 100 miles away, supported by a Spirit Mountain Foundation Grant. The site of the telehealth clinic is an already established outreach site, where the faculty sees patients for in-person visits, for both general endocrine and diabetes services. The demand for diabetes visits at the site exceeds pediatric endocrinologists' availability, so by offering telehealth services we aimed to address that problem. The goal of our program was for our patients to have one in-person visit per year, with the rest of the visits offered by videoconferencing.

Because we were starting a new clinical service, we aimed to start small, recruiting 32 patients in the first year for whom the physical location of the clinic space was convenient, with a goal to achieve three to four visits with a subspecialist per year.

In Springfield, local medical assistants, trained by our telehealth coordinator, maintain equipment, download the data from patients' devices (glucometers, continuous glucose monitors, and pump devices), and perform point-of-care hemoglobin A1c testing. Pediatric endocrinologists connect securely from Portland and are able to review this information in real time while conducting the visit. This clinic does not yet have the capability to include participation of our multidisciplinary team, and we require all patients utilizing telehealth clinics to schedule at least one yearly visit with the multidisciplinary team at our Portland site.

We hypothesized that the improved access to care through telehealth clinics would (1) increase the number of yearly visits to our clinic, (2) decrease visits to emergency departments (EDs) and hospitals, and (3) improve metabolic control and compliance with recommended screening procedures. We also believed that (4) telehealth visits would not be inferior to face-to-face care from the patient/family perspective. We invited all patients with the duration of diabetes for >1 year at entry to participate in the study evaluating the impact of our new program. The project was approved by OHSU IRB. We had 27 patients participate, half (13) of whom were female. The median age was 13.5 years (range 5.4–17.8) and median duration of diabetes of 7 years (range 2–12 years). Fifteen percent of the patients were using insulin pump at the time of the study.

From the year before instituting telehealth service to the year after the services became available, clinic visits increased from 1.5 to 2.6 per year, with 1.9 telehealth visits per patient. We saw too few ED visits and hospitalizations to evaluate. Full results are available in Table 1.

In addition, our patients expressed high satisfaction score with telehealth service on the QI questionnaire that was distributed after their initial visit. The total for satisfaction scores averaged 24.5 out of 25 (n = 25). A total of 89% of patients (23/26) found telehealth visits to be equivalent to in-person visits and only 8% (2/25) expressed preference for in-person visits.

Our results are similar to those recently reported by Wood et al. ² who saw similar increase in number of visits per year with telehealth service availability (increasing from 2 to 2.9 visits per year in the sample of 42 patients). Similarly, we have not seen an improvement in metabolic control, as evidenced by no change in A1c trends. We believe this can be attributed to the median age of patients in both studies (12.1 years in Wood's study and 13.5 years in ours) and the known difficulties in obtaining optimal control in the teenage population. In addition, Wood's study reported a significant decrease in missed work and school hours after telehealth clinics implementation.

Although videoconferencing telehealth visits (also known as synchronous telecare) have been available to pediatric patients with type 1 diabetes since 2001, when the concept was pioneered at the University of Florida, ^3,4 not much evidence has accrued in the literature evaluating the impact of telehealth in this population in the United States. The pioneering Florida Initiative in Telehealth and Education diabetes project, aimed at the underserved region of Florida's rural Volusia and Flagler counties, showed the decrease in ED visits and shortening of the mean visit interval in the targeted population. The program is continuing to operate and has been self-sustaining from patient billing. ³ There is evidence that the delivery of behavioral therapy—Behavioral Family Systems Therapy for Diabetes—through Internet-based videoconferencing is a viable way for addressing nonadherence and suboptimal glycemic control in adolescents with type 1 diabetes. ⁴ Moreover, the use of mobile technologies is changing the management of chronic diseases across the spectrum, promising to better facilitate education and adherence necessary for improving outcomes. ^5,6

The advantage of telehealth videoconferencing for our practice was in improving access to service, which is a large barrier to care to many of our patients. In Oregon, telehealth services reimbursement is mandated for all insurers, which creates more opportunity for the providers to reach out to the communities in need of their services. Countrywide, however, ongoing barriers to telehealth implementation are abundant, and they include (but are not limited to) licensing requirements, privacy concerns, and the uneven reimbursement climate around the United States. ⁷

In conclusion, this review of the impact of our telehealth program in its first year of service indicates that it significantly increased the total number of encounters, and it had neutral effect on the metabolic control. Importantly, patients perceived telehealth visits to be equivalent to in-person encounters, and the vast majority expressed willing to continue utilizing telehealth services. Limitations of the study include nonrandomized design, small number of participants, and limited period of follow-up. At the time of writing this communication, our division continues to provide telehealth services in RiverBend location for the third year. We delivered 100+ patient visits so far. In addition, we are in the process of expanding telehealth services to other outreach locations around Oregon.

Based on our experience and the review of existing literature, we believe that, with more study to contribute to the evidence base, telehealth videoconferencing visits have the potential for integration into the standards of care for pediatric type 1 diabetes.