Personal Experiences With Coronavirus Disease 2019 and Diabetes: The Time for Telemedicine is Now

I have learned that telemedicine can be of great help during a pandemic.

Soon after the word was around that Coronavirus Disease 2019 (COVID-19) had reached our region, there was the order from hospital management to cancel routine patient appointments and to only invite patients with urgent problems for an outpatient clinic visit. Also, the inpatient wards were emptied as fast as possible to have capacities available for the imminent COVID-19 outbreak with expected high numbers of infected patients requiring hospitalization. At the same time patient numbers in the diabetes outpatient clinic dropped as many patients called to cancel their scheduled outpatient clinic visit or simply did not show up because of fear of infection. The same was also observed in our joint internal medicine/neurology emergency room where patient numbers dropped drastically after first COVID-19 cases were confirmed in Austria.

The diabetes team was well aware that diabetes as a chronic condition also requires care during pandemic. Soon telemedicine with tele-counseling was introduced. Until that time the use of telemedicine was not widely spread in Austria for many reasons. For once, there was no reimbursement by insurance companies for this service. Other reasons were that—depending on the hospital regulation—data privacy rules and data protection limited the use of telemedicine. As Austria is a small country, distances to specialists are rather short, and travel time is not an important issue; thus, many patients preferred in-person visits over telemedicine until now. Only short-term follow-up after minor therapy adjustments was in many cases done via telephone with or without using data share platforms of continuous glucose monitors.

Efficacy of telemedicine has been already shown previously. ¹ With the COVID-19 outbreak patients adopted to telemedicine and were more than happy that they had an alternative to in-person visits to adjust their therapy. The move toward telemedicine was also observed in other regions of the world.^2-5 Especially patients on continuous glucose monitors benefited as both patient and healthcare provider could view the glucose trace and discuss therapeutic options and therapy adjustments. COVID-19 thus speeded up the implementation of telemedicine that might have otherwise taken years to adopt in Austria. Of course, not all in-person visits can be replaced with telemedicine visits as there is still a need for in-person interaction but visit intervals can be extended without observing deterioration in glycemic control by use of telemedicine. It also has to be considered that telemedicine does not reduce the duration of a consultation as the same procedure as during an in-person visit should be followed, and both patient and treating physician should be well prepared to maximize the effect of a telemedicine consultation.

At the same time communication with insurance companies with regard to first approval and renewal of permission for certain medication (glucagon-like peptide-1 receptor agonists [GLP-1-RA], proprotein convertase subtilisin/kexin type 9 [PSCK-9] inhibitors) and technology (glucose sensors) changed. Before COVID-19 this was a tiresome process that required in many cases not only submission of patient letters and laboratory results but a lot of back-and-forth between treating physician and insurance company representative. During COVID-19 outbreak permissions were swiftly granted upon first submission, which was a huge relief both for patients and treating physicians.

My largest worry of the three is the care for patients with diabetic foot syndrome. Diabetology could benefit from experiences in dermatology where telemedicine is already implemented and telemedicine use rose during the current pandemic. ⁶ So far, no telemedicine technology has been established in Austria that counselling in this field. There is technology out that can support also remote management of diabetic foot syndrome but adoption by this mainly elderly population will require huge effort.^7,8 As a result, most of the diabetes outpatient clinic visits that occurred during this first phase of COVID-19 outbreak were related to acute aggravation of diabetic foot syndrome or to the development of a new ulcer. In many cases this specific patient population suffers from other comorbidities as well; thus, they can be considered to be the ones at highest risk of adverse outcome in case of COVID-19 infection. Adoption of user-friendly telemedicine solutions for diabetic foot syndrome will be of utmost importance to allow best possible care for situations when in-person visits are hampered. This big challenge should already be addressed during the current COVID-19 outbreak so that we are prepared for potential future pandemics.

In the future I predict that telemedicine will play a major role in diabetology in Austria even when normal conditions have been reestablished. Many patients might prefer the flexibility of telemedicine consultations. To incorporate telemedicine into routine care, legal requirements, data protection, and reimbursement strategies need to be soon developed.