Efficacy of the Telemedicine for Reach, Education, Access, and Treatment (TREAT) Model for Diabetes Care

Videoconferencing-based telemedicine services have the potential to address the problem of poor access to diabetes specialists in remote rural communities. However, evidence of efficacy of telemedicine services on HbA_1c in the rural setting has been quite limited. We created the Telemedicine for Reach, Education, Access, and Treatment (TREAT) model—a system that combines videoconferencing consultations provided by an endocrinologist at an urban center in collaboration with a local diabetes educator. In this study, we tested the efficacy of TREAT on HbA_1c control.

Protocols were approved by the local institutional review board. Volunteers with type 2 diabetes with HbA_1c >7.0% and residing within a medically underserved rural Pennsylvania community were recruited. Referral, recruitment, and telemedicine consultations between urban and rural sites were conducted as in one of our previous studies (1). Seventy-one patients were referred, of which 40 expressed an interest in participating. Thirty-one patients consented and enrolled; two withdrew and four were lost to follow-up between the first and second follow-up assessment.

At each telemedicine visit at the rural site, participants were assisted by the local diabetes nurse educator. Each participant underwent a telemedicine visit with an urban center–based endocrinologist at baseline and 3 months later for adjustments in therapy. HbA_1c was measured at baseline, 3 months (first follow-up), and 6 months (second follow-up). Before enrollment, TREAT participants were not consistently self-monitoring blood glucose (SMBG), but all received diabetes education (including SMBG) with the baseline TREAT visit.

HbA_1c results were compared with control subjects who received usual care from primary care providers in the same community (usual-care group). This approach was chosen because of the low population density and number of primary care practices in the rural community, making it hardly feasible to conduct a randomized trial. Data were collected from electronic medical record visits between 2007 and 2011. All usual-care patients had documented diabetes self-management education.

Participant characteristics were statistically comparable between groups (Table 1). Most participants were older adults with obesity, typical of the type 2 diabetes population. Target-organ complications and use of insulin therapy were frequent.

In the TREAT model, participants experienced a significant improvement in HbA_1c from baseline (Fig. 1A). The improvement was statistically greater than that observed in the usual-care group. On multivariate analysis, differences between groups remained significant after adjustment for insulin use, BMI, age, sex, and duration of diabetes (Fig. 1B). Because TREAT was designed as a team approach, the relative impact of its subcomponents on the outcomes is hard to discern. However, it appears that both the physician and nurse respectively contributed to drive and support therapy intensification. In 84% of TREAT participants, therapy was intensified, as defined by one or more of the following: initiating insulin therapy, adding another insulin formulation, or increasing the total daily insulin dose or oral agents. In 29.0% of participants, basal insulin was started, whereas in 25.8%, prandial insulin was initiated. Insulin was started for the first time in 22.6% of the participants.

Based on glucose meter data downloads, 93% of TREAT subjects adhered to SMBG recommendations during the intervention. Mean incidence of hypoglycemia was 1.7 events/30 days/person. Mild cases (60–69 mg/dL) were the majority (1.0 events/30 days/person). Severe hypoglycemia (<50 mg/dL) was rare (0.13 events/30 days/person).

There is a national shortage of endocrinologists for the large burden of type 2 diabetes (2,3), and rural communities are at particular disadvantage. Videoconferencing-based consultations, a form of telemedicine, offer the potential to overcome geographical barriers to care in rural communities. Different models of videoconferencing telemedicine in the rural setting have been tried. However, to date there has been insufficient evidence that HbA_1c outcomes are meaningfully affected. Studies have either not reported HbA_1c outcomes (4), lacked a control group (1,5), or showed small differences (ΔHbA_1c ∼ −0.32%) (6). Furthermore, those studies have primarily relied on nurse-assisted education without direct endocrinologist involvement. Here, we demonstrate that the TREAT model delivers clinically meaningful HbA_1c improvements over that achieved by local usual care in the community. We attribute this success to greater intensification of therapy made possible by combining active participation and follow-up by the endocrinologist and diabetes nurse already integrated in the community. Serious hypoglycemia was rare, suggesting safety in the approach.

To our knowledge, this study is the first to demonstrate robust effectiveness on HbA_1c of a telemedicine model using endocrinologist and nurse collaboration. The TREAT model may be a viable option for rural communities suffering from a local shortage of endocrinologists.