Uploadable data from insulin pumps and continuous glucose monitors (CGM) makes transitioning to telemedicine during COVID-19 lockdown relatively smooth for some [1], yet most people with diabetes (PWD) around the globe have no access to such technology. We piloted home A1c testing plus telemedicine in Slovenia during April and May 2020 with Commission for Medical Ethics approval. PWD with upcoming appointments were identified from a private diabetes centre in Ljubljana (serving ~2000 patients within ~30 km by primary roads) and a public diabetes clinic in Koper (serving ~8000 patients within ~ 80 km by secondary roads). Staff invited patients by telephone who were: an established patient; aged ≥18 years; diagnosed type 1 or type 2 diabetes; and, performed self-monitoring of blood glucose (SMBG; therefore experienced with fingersticks). Excluded PWD (n = 19 did not SMBG, n = 3 had relevant physical limitations) and those who declined (n = 41) were rescheduled (~2.5 months) (see Table 1 ).
Table 1.
PWD attitudes toward home A1c test and telemedicine appointment. N = 98.
| % Yes | ||
|---|---|---|
| Questions regarding the home A1c test from the paper-and-pencil survey | ||
| 1 | It is convenient. | 99% |
| 2 | It is a relief to know I can get my A1c checked even during COVID-19. | 96% |
| 3 | The instructions were clear. | 100% |
| 4 | The materials were easy to use. | 100% |
| 5 | It was easy to receive the kit. | 100% |
| 6 | It was easy to send the blood sample to the lab. | 100% |
| 7 | The fingerprick was painful. | 10% |
| 8 | I think the results will be accurate. | 93% |
| 9 | I would recommend it to other people with diabetes. | 96% |
| Questions regarding the telemedicine appointment from the phone survey | ||
| 1 | It is convenient. | 100% |
| 2 | It created a communication barrier between my doctor and me. | 2% |
| 3 | I appreciate the extra effort that my doctor made. | 100% |
| 4 | It made me feel less isolated. | 76% |
| 5 | I would recommend it to other people with diabetes. | 99% |
| 6 | I disliked talking to my doctor remotely. | 1% |
| 7 | It is good to know I can get medical care for my diabetes even during COVID-19. | 100% |
| 8 | I would consider having this kind of appointment even after COVID-19 is over. | 72% |
| Qualitative Comments | ||
| Approximately 25% of respondents provided comments. Frequent positive comments pertained to convenience for time and travel, simplicity of methods, and clear instructions. Several requested the approach in the future, though some stated that it is suitable only under lockdown conditions, or that a hybrid schedule of in-person and remote appointments would be ideal. Negative comments were less frequent and pertained to the blood sampling supplies being difficult to handle, requiring a lot of blood, or that instructions did not address whether fasting was necessary. | ||
Participants (n = 100) were mailed a consent form, the A1c kit requiring fingerstick (Bio-Rad, Hercules, California), pictorial instructions, a survey regarding the A1c kit, and a postage-paid, return envelope to Koper where assays were conducted using Bio-Rad D-10TM. Participants chose telephone (90%), WhatsApp (6%), or Skype (2%) to discuss results with their physician. Finally, research staff surveyed participants by telephone.
One participant did not follow-up and one did not receive the consent form, leaving n = 98. Most were married (68%), women (60%), with type 2 (64%), not using insulin (57%), age mean = 52.0 (SD = 15.1) years, diabetes duration mean = 15.0 (SD = 9.7) years, and most recent A1c mean = 7.5% (SD = 1.5). Compared to Koper, Ljubljana had more type 1 PWD (46% vs 26%), insulin use (54% vs 32%), CGM use (18% vs 0%), and higher A1c (NGSP 8.2% [SD = 1.8] vs 7.0% [SD = 1.1]; IFCC 65.7 mmol/L [18.9] vs 52.5 mmol/L [11.6]), all *p’s < 0.05.
Satisfaction was high and did not differ by diabetes type, pump or GGM use, nor by site, except more Koper patients would consider the method after lockdown (98% vs 46%, *p < .01). Compared to audio + video, PWD using audio-only were older and more likely to report that telemedicine decreased isolation, *p’s < 0.05, suggesting that older individuals and those without access to video platforms experience more isolation under lockdown.
This is a useful strategy for PWD who do not use pumps or CGMs, those who travel far to clinic, or need/want more frequent provider contact, in order to mitigate likely glycemic deterioration during lockdown [2]. It may also continue to be beneficial after lockdown, should fears of public transit and healthcare settings persist. Eventually, a hybrid schedule of in-person examinations and at-home A1c checks with telemedicine may prove appropriate for some [3].
No funding to declare. JW is supported by a grant from the National Institute of Diabetes, Digestive, and Kidney Diseases (DK103663).
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
References
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