What is Diabetes?
Diabetes is one of the most prevalent diseases in the USA and is expected to increase as the population ages, with 1.5 million cases diagnosed annually (1). Diabetes is a chronic disease that causes hyperglycemia, which reduces the size of red blood vessels, leading to premature death, vision loss, heart disease, stroke, kidney failure, and amputation of the lower extremities if left untreated (3, 8). There are two main types of diabetes; type 1 is more common in children and is characterized by the body’s immune system attacking itself by destroying insulin producing cells, while type 2 is more prevalent in older people and is defined by the body producing insufficient insulin or becoming insulin-resistant (8). However, diabetics can manage their condition through healthy habits such as exercising, consuming a healthy diet, and using insulin and medication to control blood sugar (3).
Objective
Rates of type 2 diabetes continues to rise with the aging US population while type 1 is increasingly prevalent in children, which, in conjunction with the shortage of appropriately trained medical personnel trained, is likely to lead to a diabetes epidemic. Patients in rural areas especially will require alternative ways to seek care (3). Video-conferencing applications can provide patients with remote, real-time, face-to-face appointments with diabetes specialists, which in conjunction with teleconsultation applications, will allow physicians to remotely monitor clinical data and lifestyle habits to use for patient diagnosis, monitoring diabetes progression, providing patient feedback, and education (15,16). Video-conferencing is useful in diagnosing conditions arising from diabetes, such as diabetic retinopathy, and is most effective when supplemented with asynchronous application features (10,15). The aim of this paper is to prove that though video-conferencing reduces overall costs, increases equity, and is a promising solution to help the rising number of people living with diabetes, it can only provide diabetes diagnoses and management in conjunction with collected clinical data, and cannot be a solution for diabetes diagnosis on its own.
Diabetes and aging
The aging US population coupled with the fact that diabetes rates increase with age suggests there is likely to be a diabetes epidemic in the coming years (3). As of 2015, 30.3 million Americans live with diabetes, of which 7.2 million diabetics remained undiagnosed (1). Diabetes prevalence in Americans over age 65 was at an all-time high in 2015, with 25.2% of the demographic living with diabetes, and has continued to rise since (1). Additionally, 84.1 million people had prediabetes, meaning blood sugar levels are elevated but below diabetic threshold (1). Untreated prediabetes can develop into type 2 diabetes within five years, a major concern as diabetes is the 7th leading cause of death in the US (1,8).
Pediatric diabetes
An increasing number of children are diagnosed with diabetes annually, adding to the burden of disease in the US (4). This problem is amplified by the shortage of specialist endocrinologists who can treat the pediatric diabetes, with only one per 290 children with type 1 diabetes (4,5). Endocrinologists tend to work in cities, far from rural patients, leading to long wait times and reduced quality of care. Though the American Diabetes Association (ADA) recommends patients with type 1 visit their physician every three months, children in rural areas are at greater risk of missing appointments due to miscommunication with their physician’s office or personal conflict (4). As endocrinologists have to cater to their other patients, children can easily wait 6 months before seeing the doctor (5). Many patients also report appointments leave little time for proper diabetes management or education (4).
Rural populations and diabetes
People living in rural parts of the US experience greater rates of diabetes while having less and lower quality care available than in urban areas (14). Distance from clinics, bad weather, lack of public transport, and provider shortage all intermingle to reduce the care diabetics in rural areas can access (9). Despite these challenges, it is crucial that all patients with diabetes receive care to prevent the disease progression. As US physicians are stretched to capacity and the increasingly expensive and long medical education is not producing enough, it is apparent that traditional healthcare delivery will not be sufficient in providing care to the growing population of diabetics in rural areas (6,7).
Telehealth
Telehealth offers a potential solution to the growing population of diabetics in rural areas, by allowing patients to receive treatment remotely. Telehealth offers promise as studies show telehealth applications to reduce hospitalizations of diabetic patients through telemonitoring, which utilizes patient information about blood sugar and insulin levels to identify signs of deterioration and prevent hospital admission, in conjunction with real-time video-conferencing (6).
Teleconsultations allow patients and physicians to communicate with one another through email, phone calls, messaging systems, or the internet to monitor conditions and discuss feedback without face-to face contact (15). Teleconsultation applications are asynchronous, meaning patients and providers do not communicate in real time (15). Video-conferencing is synchronous, as it allows real-time face-to-face contact through televisions, cameras or videophones (15,16). Synchronous applications have been shown to increase usability of technology, reduce costs, and reduce unscheduled visits to the hospital, while asynchronous applications have allowed greater improvements in clinical values of blood sugar and insulin while promoting self-management of disease in conjunction with caregiver support (15). Telehealth applications utilizing both synchronous and asynchronous aspects had the most positive influence on patient quality of life and equity by encouraging daily monitoring of individualized data, providing educational tools, and providing feedback specific to the patients’ needs (15, 16). Telehealth applications involving video-conferencing were particularly beneficial to rural populations, who could access previously unavailable care and specialists (15).
Benefits
Telehealth applications and video-conferencing offer cost-effective solutions to diagnosing, monitoring, and treating diabetes patients in rural areas. In 2017, the US spent $327 billion dollars to treat patients with diagnosed diabetes, with $237 billion going to direct medical costs and $90 billion to cover reduced productivity from acquired disability, time lost from work, and premature death (1,7). The ADA reports that even after adjusting for age and sex, diabetes increases medical expenditure by 2.3 times on average as compared to a person without diabetes. Telehealth applications reduce the cost of diabetes by eliminating travel time and allowing for more comprehensive and personalized care using daily monitoring and remote feedback (16).
Telehealth technology allows patients in rural areas increased access to diabetes care by overcoming the associated problems of distance to health facilities and socioeconomic status (5). According to a study by Malasanos and Ramnitz, telehealth consultations for diabetes allow more rapid diagnoses to patients while reducing the costs patients previously paid for in-person appointments (5). This cost saving stems from reduced wait times and decreased travel time, meaning that diabetics in rural areas are not as likely to miss work or school for an appointment (2,5). In this way, telehealth applications provide equity to rural diabetic patients, allowing them to receive quality care without compromising wages or education.
A systematic review of 6 randomized control trials (RCTs) shows that teleconferencing in conjunction with teleconsultation for diabetes offers comprehensive, effective care in underserved and remote areas (16). In most cases, a team of caregivers comprising of doctors and nurses interacted with diabetic patient as they used telehealth technologies. Video-conferencing allows doctors to provide highly specific and individual feedback based on teleconsultation data, and is also used to diagnose and treat ulcers, provide care for patients discharged from the hospital, aid in blood sugar control and injection, and to provide general diabetes management (16). As RCTs are the most reliable type of study, Verhoeven, van Gemert-Pijnen, and Steehouder’s systematic review of 6 RCTs prove that video-conferencing benefitted patients in terms of cost reduction, clinical improvement, usability of technology, self-care, and increased quality of life (16).
Patients who used video-conferencing for education in conjunction with self-monitoring found their diabetes to improve clinically. This is evidenced by a reduction in glycosylated hemoglobin (HBA1c) found in the systematic review previously mentioned (16). Additionally, a matched cohort study of rural veterans showed the combination of synchronous and asynchronous telehealth applications allowed physicians to monitor subtle changes in diabetic patients, leading to problems being resolved before they required a trip to the clinic (2). Another RCT of older Americans living in rural USA showed telemedicine improved hemoglobin A1C, blood pressure, and LDL cholesterol in those with type 2 diabetes (9). Clearly, there is a plethora of evidence proving video-conferencing and teleconsultations together improve clinical outcomes in rural patients with diabetes.
More people have access to smart phones or computers than ever before, which combined with improved technology allows for ease in accessing telehealth and video-conferencing applications (4). Telehealth apps can take inputs from videos, medical records, and other peripheral devices like ophthalmoscopes, which provides key information to healthcare providers (5). Video-conferencing for diabetes is beneficial regarding diagnosing diabetic retinopathy. Ultrawide field retinal imagine (UWFI) scanning laser ophthalmoscopes allow a greater retinal area to be captured and reduce time needed for evaluation, even without pupil dilation, and can be conducted remotely (10). These scans allow doctors to diagnose peripheral lesions unable to be captured by traditional retinal photos, allowing them the opportunity to discuss treatment and courses of action more accurately than traditionally possible.
Using self-monitoring apps that feed information to physicians allows video-conferencing appointments to target the clinical needs of the patients, while forging strong social bonds between provider and patient and amongst diabetics (11,16). As evidenced by the Florida Initiative in Telehealth and Education (FITE), video-conferencing allowed healthcare providers to spend more time on education, leading to healthier habits and better diabetes management (4). More frequent virtual calls made possible by video-conferencing allow doctors to learn about each patient as an individual, leading to more quality care (16). Group educational video-conferencing could have a group element in which diabetic patients can learn about management together, increasing social networks and interactions among rural diabetics, ultimately helping patients develop a more positive view of their disease (16).
Limits
While video-conferencing and telehealth apps are cost-saving in the long run, initial costs can put off implementation. For telehealth applications to be functional, more rural nurses must act as intermediaries between doctors and patients and require training to provide education and assist with telehealth applications (6,11). Additionally, setting up new telehealth systems involve investing in technology, support, and service redesign, which, depending on the population targeted, may not be cost-effective in the short-run (6). For instance, home telemedicine devices cost around $3,425 dollars per person, a cost that has the potential to overburden the US healthcare system (9). Though this cost is high, just one visit to the emergency department can cost upwards of $1000, demonstrating the long-term cost saving and quality of life telehealth provides when one recalls severity of unmonitored diabetes.
Centering diabetes care around the internet and smartphone applications comes with the assumption that all patients have access to these resources and know how to use technology. The rural elderly in particular may be less likely to know how to use internet-based technology or own smartphones, which would hinder their video-conferencing capability (16). This limitation can be overcome if local clinics set up video-conferencing centers to connect patients with urban specialists (11). Video-conferencing centers would also allow nurses to assist those with insufficient computer literacy and those with impaired agility and hand-eye coordination (12).
Implications and Conclusion
Telemedicine is a viable alternative to conventional diabetes treatment, achieving equal or better results in RCTs and may be a solution to diagnose and treat diabetes as prevalence increases and the endocrinologist shortage continues (12). Video-conferencing in conjunction with teleconsultation provides diagnoses and behavioral therapy to patients based on clinical information garnered by telemonitoring is the most effective intervention and should be used in patients at high risk for diabetes (12). Research shows that patients with formal diabetes education have better selfcare, better eating habits, and have lower blood glucose and HBA1c levels, which reduces diabetes incidence by 58% in three years (13). Patients report satisfaction with the convenience and individualization video-conferencing allows and tend not to mind the lack of proximity to the doctor (13). The acceptance of telehealth technology combined with its cost-saving effects and superior outcomes stemming from the focus on preventative care suggests that video-conferencing and telemedicine will benefit diabetic patients in rural USA and should be utilized at a greater scale (16).