Dialing Up Telehealth to Comprehensive Level Makes it More Effective: JAMA Internal Medicine Study

Results reported this week in JAMA Internal Medicine show a steeper decrease in HbA1C among people with poorly controlled type 2 diabetes who participated in a telehealth program that included telemonitoring, self-management support, medication management and services for depression. The comprehensive program cost about $1,500 more per year than the control program of standard telemonitoring and care coordination.

Thanks to the COVID-19 pandemic, telehealth is now a common way of delivering healthcare in the U.S. But might it be more effective if it were part of a comprehensive approach that included remote monitoring and other services instead of being used for the occasional video chat with a provider?

Researchers at the Durham Veterans Affairs Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT) set out to answer that question in a randomized trial of patients with poorly controlled type 2 diabetes.

Not surprisingly, the results they reported this week in the JAMA Internal Medicine showed a comprehensive program was, in fact, more effective when measured by the lowering of hemoglobin A1C (HbA1C) levels. HbA1C is a standard way of measuring how well a person’s type 2 diabetes is being controlled. From the start of the yearlong study to its end, the average HbA1C levels of 101 patients in intervention group fell by 1.59 percentage points (10.17% to 8.58%). The HbA1C levels of the 99 patients in the control group fell by .98 percentage points (10.17% to 9.19%).

The comprehensive approach had five components: telemonitoring (self-monitored blood glucose data transmitted up to four times a day and reviewed by a nurse), self-management support (nurses delivering self-management education during regularly scheduled telephone conversations), diet and activity support, medication management and depression support (study participants identified as having depression were entered into a depression protocol).

The researchers, led by Matthew J. Crowley, M.D., M.H.S., said the comprehensive care cost an additional $1,519 over 12 months ($2,465 vs. $946 for the standard telemonitoring and care coordination. But, they noted, “this incremental cost is less than most branded glucose-lowering medications.”

A large percentage (144 of 200, or 72%) of the study volunteers were Black patients. Crowley and his colleagues said this was a strength of the study and “may suggest that the pandemic-induced shift to telehealth need not exacerbate healthcare inequities.”

The intervention group also fared better when it came to secondary outcomes, including diabetes distress, diabetes self-care and self-efficacy. Crowley and his colleagues also reported that patients in the comprehensive care who had more than 20 encounters experienced larger decreases in HbA1C levels than those who completed 20 or fewer.

“There has always been a sound argument for using comprehensive telehealth when clinic-based chronic disease care falls short; now that telehealth has gained wider acceptance, systems have a clear mandate to maximize its value for those high-risk patients who respond insufficiently to clinic care,” wrote Crowley and his colleagues.