March 2, 2021

Concerns about quality of care have remained top of mind for health care providers as they have adapted practices, especially around telemedicine, in response to the coronavirus pandemic. For pediatric diabetes clinics worldwide, the pivot to remote care via telemedicine has been challenging, but it has also presented opportunities for improved care, according to a new study led by a team of nutrition researchers at UNC-Chapel Hill.

Angelica Cristello Sarteau

Angelica Cristello Sarteau

Katherine Souris

Katherine Souris

Published in Pediatric Diabetes, the study is part of a Type 1 diabetes (T1D) data initiative that monitors a cohort of pediatric clinics in places across the globe, including the United States, Sweden, India, China and Australia. Since 2017, a team from the UNC Gillings School of Global Public Health has been coordinating the initiative, led by Department of Nutrition research associate Katherine Souris, MPH, doctoral fellow Angelica Cristello Sarteau, MSPH, and Elizabeth Mayer-Davis, PhD, department chair and Cary C. Boshamer Distinguished Professor. Bachelor of Science in Public Health student Jessica Wang and pediatric endocrinology fellow Amira Ramadan, MD, also contribute to the initiative.

Dr. Elizabeth Mayer Davis

Dr. Beth Mayer-Davis

When COVID-19 forced the world to shelter in place, the team collaborated with international researchers within the initiative to survey pediatric diabetes clinics on the processes they adopted to comply with physical distancing guidance and how these processes have affected both providers and patients.

“At the beginning of 2020, we were in the middle of gathering data about standard care processes across clinics,” said Souris. “When it became clear that COVID-19 was becoming a pandemic, we decided to rapidly shift our focus to examine how adaptations that clinics were forced to make had changed usual care. As with all the research in our department, translational and timely results are paramount, so we were very lucky to have such an engaged and organized collaborative in place. Because of this, we were able to quickly obtain a complete dataset across our nine sites that highlighted some of the key changes, challenges and successes that these clinics had experienced.”

The survey contained both quantitative and qualitative questions and covered areas that required rapid adaptations to COVID-19, such as provider roles and workload, clinical encounter and team meeting formats, care delivery platforms, self‐management technology education and patient‐provider data sharing.

One common point of concern reported by providers centered around the effect that telemedicine had on patient care. In addition to the challenges faced by patients with technological barriers, providers were concerned that the lack of in-person visits made it harder to collect glucose data, perform physical examinations and routine tests, and establish rapport with patients. Some clinics reported that rapidly adapting to new teleconferencing platforms was time-consuming. Others encountered challenges related to the learning curve involved in sharing T1D data electronically for patients and providers alike.

While most providers did not report a negative impact on patient outcomes, some providers expressed concern about the severity of diabetic ketoacidosis (DKA) that might result from delays in care-seeking due to the pandemic. Greater still was the concern about widening disparities in care that could negatively affect the health of patients with challenging home lives, food insecurity and other social and economic difficulties.

Concerns about widening disparities stemmed from changes to clinic-level processes and to care outside of the clinic that reduced the safety net in place for the most vulnerable patients. A noticeable example within clinics included repurposing the hours of staff, including social workers, to assist in COVID-19-related protocols for in-person visits.

An example from outside the clinic related to school nurses, who often play a significant role in ensuring that patients who might not otherwise engage in recommended diabetes self-management behaviors are able to achieve a basic level of diabetes care. With the transition to virtual education, these patients were losing the care routine that school helped to provide.

Despite the challenges, clinics also reported some opportunities highlighted by the pandemic that have the promise to improve care in the long run. The rapid shift to telemedicine has prompted clinics to refine their processes in order to utilize remote platforms more efficiently. It has also improved processes around data-sharing and presented opportunities to better educate patients on best practices for telehealth and data-sharing.

COVID-19 also prompted several lifestyle changes that could benefit patients, such as less travel, consistent schedules and more opportunities for parents to take an active role in at-home monitoring and maintaining a meal schedule.

“Our glimpse into the adaptations undertaken by pediatric diabetes care teams around the world in response to COVID-19 underscored the still-nascent evidence base around telemedicine practices,” Cristello Sarteau explained. “Although providers refined their processes as the months progressed and reported the intention to maintain certain adopted telemedicine processes even after in-person care could resume to prior levels, further research is needed to understand for which services and patient sub-groups telemedicine is equal to or superior to in-person care when it comes to short- and long-term health outcomes.”

The international collaborative was already poised to collect data electronically through online survey platforms and zoom interviews with providers. However, Cristello Sarteau noted that “related to data collection, the study highlighted the need for clinics to have the rapid ability to mine data about acute complications experienced by their patient population during emergencies like COVID-19. This information would help them understand in ‘real time’ the health impacts experienced by patients and respond expediently through modifying or adding to care processes.”

The study also highlighted some best practices in preparedness, such as keeping an updated list of patients most at risk of poor health outcomes to target for follow-up during times when routine care is disrupted.

Further research into processes put into place in response to COVID-19 has the potential to help clinics produce evidence-based emergency response protocols that facilitate rapid reconfiguration of care processes while limiting negative effects on patient health.

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