1. In this randomized controlled trial, a comprehensive telehealth intervention was linked to a greater improvement in HbA1c% level at 12 months follow up in patients with persistently poorly controlled diabetes (PPDM) when compared to a simpler telehealth model.

2. In patients with PPDM, comprehensive telehealth intervention when compared to a simpler telehealth model was associated with greater improvement in diabetes distress, diabetes self-care, and self-efficacy, but was no associated with greater improvement in depressive symptoms or BMI.

Evidence Rating Level: 1 (Excellent)

Persistently poorly controlled diabetes is defined as HbA1C greater than 8.5% despite receiving clinic-based type 2 diabetes (T2DM) care. Drivers of PPDM include unavailable blood glucose data, medication non-adherence, suboptimal diet or activity, complex medication regimen, and depression, which are factors that are challenging to address in clinic. Given that PPDM is associated with disproportionately negative outcomes, it is important to consider optimal care delivery for this patient population. Telehealth has been found previously to improve outcomes in PPDM, but there is inconsistent data with respect to multicomponent T2D interventions. This randomized controlled trial compared the effect of a comprehensive telehealth intervention and a simpler telehealth approach on patient HbA1c level. Patients were randomized to receive either a comprehensive telehealth intervention, which consisted of an extensive multidisciplinary team including multiple nurses, diabetes physicians, and psychiatry based on issues that needed to be addressed for individual patients, or a simpler telehealth approach with telemonitoring and care coordination. 200 patients recruited from December 2018 to January 2020 in 2 Veterans Affairs healthcare systems were randomized to either the comprehensive telehealth intervention or the simple telehealth group. The primary outcome was patient HbA1c level, and secondary outcomes included diabetes distress, diabetes self-care, self-efficacy, BMI, and depression symptoms. After one year of follow up, the estimated difference of HbA1c change between the two groups was -0.61%, which was statistically significant favouring comprehensive telehealth (P=.02). With respect to secondary outcomes, the comprehensive telehealth group resulted in greater improvement in diabetes distress, diabetes self-care, and self-efficacy, while there was no statistically significant difference in depressive symptoms at 12 months or BMI at 6 months following initiation of the interventions. With respect to limitations, the results may have limited generalizability to healthcare systems that do not have funding or capacity for telehealth, especially in the comprehensive interventions group. Overall, this article suggests that a comprehensive telehealth approach is associated with a greater improvement in HbA1c level. With the rise of telehealth following the COVID-19 pandemic, reassessment of care delivery systems will be important to determine optimal management of PPDM going forwards.

Click to read the study in JAMA Internal Medicine

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