Technology Gap Deepened by Coronavirus Pandemic

I have learned that COVID-19 has expanded the diabetes technology gap. The coronavirus pandemic is being especially punishing for older patients with comorbidities. Diabetes has been established as one of the main risk factors from the very beginning.¹ Even in not affected people, confinement, physical activity reduction, and psychological stress are conditions that difficult glycemic control. Additionally, the emergency has driven to the cancellation of the majority of clinical appointments. In Spain, most of the endocrinologist staff and also medical residents have been forced to leave their usual activity—and work schedules—to assist patients admitted with hypoxemia while learning about ventilatory support at full speed. Several contingency plans have been written to adapt local facilities, human resources as well as scaling protocols trying to anticipate needs and requirements to fight against coronavirus. On the contrary, no contingency plans have been systematically implemented to give support to patients with diabetes facing glucose control, diet compliance, activity reduction, uncertainty about the availability of diabetes-related supplies, and, at the same time, suffering as well the fears of a potentially lethal disease. Diabetes represents comorbidity, and such a condition does not help when intensive care access is not fully guaranteed. In this challenging scenario, coronavirus has been deepening technological inequality. While patients wearing glucose sensors and pumps can be monitored remotely, those using pens and glucometers hardly have the opportunity to be counseled for adapting therapy to in-home prolonged lockdown or even to COVID-19 infection. Support groups through social networks are incredibly relevant in this scenario when face-to-face contact with healthcare providers have been reduced to emergencies. However, diabetes-related social network users are almost always technology users at the same time.

Patient empowerment has become nowadays more crucial than ever. Regarding diabetes, the current paradigm of the patient’s starring role in self-care is, without doubt, artificial pancreas do-it-yourself users. Data from the 12 patients followed in our department corresponding to the first 30 confinement days (from the 14th March to the 12th April) are very impressive—mean glucose: 135.6 ± 37, the mean percentage of time in range: 81.1%, mean percentage of time <70 mg/dL: 2.3%, and estimated HbA1c: 6.4%. The other side of the coin are those patients under the same stressors but treated with rigid basal-bolus schedules and neither particularly skilled nor having good external medical support. As a consequence, apart from being a population at risk of COVID SARS complications, people with diabetes could also be affected by the current health support parenthesis in which nothing but fight against coronavirus seems to have value.

In the future, I predict that smart telemedicine solutions will become an essential part of diabetes health care. Pregnancy in COVID pandemic times has concerned us very much. The higher risk of acquiring COVID infection by women with diabetes may also be partly related to a higher risk of exposure during follow up, which usually requires frequent visits. Some years ago, we developed a web-based smart telemedicine system² for remote gestational diabetes management. A randomized clinical study validated the application. Very recently, we started the clinical trial to evaluate the efficacy and safety of the mobile version. In the current circumstances, the alternative was to follow patients’ status by phone; we decided to discontinue the ongoing clinical study and offer our mobile app for smart gestational diabetes management to any patient referred because of this condition. This application allows the automated control of patients while insulin is not required. Patients download glucose data from the glucometer, and the platform enables doctors to automatically determine which patients have adequate glycemic control and, therefore, do not need to go to face-to-face visits. The system anticipates treatment adjustments, as diet prescriptions are automatically made as soon as the requirements needed are detected by the decision support tools, and the physicians are informed about the need to start insulin therapy in specific patients. Once insulin has been initiated, the app proposes changes in the doses to the patient after being validated remotely by the doctor. Up until now, 13 patients are using the app. Sometimes a crisis is a driving force behind change, executing solutions that otherwise would have taken much longer to be implemented.