One of the most significant changes to healthcare during the 2019 coronavirus disease (COVID-19) pandemic has been the widespread embrace of telemedicine across clinical specialties. NYU Langone’s Center for Diabetes and Metabolic Health was among the nation’s first outpatient diabetes practices to switch primarily to remote visits as the pandemic accelerated—with results that affirm this modality’s potential for improving patient outcomes after the crisis has passed.
A Rapid Transition to a New Modality
Over the past two decades, a growing body of research has shown that telemedicine can achieve therapeutic results equal or superior to in-person visits for a broad range of interventions. Diabetes management has long been seen as particularly well-suited to this approach. In the United States, however, obstacles to physician reimbursement have severely limited its adoption.
That began to change in early March 2020, when the Centers for Medicare and Medicaid Services (CMS) loosened restrictions on telemedicine coverage in response to the pandemic, leading private insurers to follow suit. The Center for Diabetes and Metabolic Health swiftly took advantage of this shift, spurred by mounting case numbers in New York City.
“With diabetes emerging as a major risk factor for COVID-19, we felt it was crucial to spare our patients the potential exposures that in-person visits would entail,” explains director Lauren H. Golden, MD, clinical associate professor in the Department of Medicine. In addition, as many of the center’s clinicians were recruited to inpatient floors as part of NYU Langone’s “COVID Army,” video visits enabled those remaining on the outpatient side to efficiently take over management of their colleagues’ established patients.
Before the pandemic, the outpatient diabetes practice had developed the technological infrastructure necessary for video visits, and had begun training patients to collect data on their blood sugars and insulin dosing from personal devices in order to streamline office visits. As a result, the transition proceeded smoothly. “We sent patients links to software downloads, and most of them were able to figure out how to transmit readings to us online,” Dr. Golden recalls. “We emailed logs to the others, so that they could fill them out and send them back.”
A small crew of physicians, nurses, and support staff remained in the office part-time, in case in-person visits were needed—for example, to instruct new patients in insulin injection. But by the last week of March, the vast majority of visits were taking place via video.
The Benefits of Remote Coaching
The Center for Diabetes and Metabolic Health takes an intensely multidisciplinary approach to clinical management, with a focus on treating the whole person. Video visits have proved ideal for this methodology, in which lifestyle coaching plays a central part. “Because visits don’t require travel, patients can check in more frequently than they would have before,” Dr. Golden notes. “Many have told us they’re thankful for that enhanced access to care.”
Early in the crisis, Dr. Golden and her team found that the COVID-19 stay-at-home orders affected patients in disparate ways. “Those who were used to being physically active and eating healthily didn’t have access to gyms or grocery stores, so their blood sugars often rose,” she explains. “Conversely, patients who’d previously been eating out a lot and getting insufficient exercise—often due to work demands—were cooking their own meals and finding more time for physical activity. That group typically experienced improvements in diabetes control.”
An added challenge for many patients with diabetes has been the emotional turmoil associated with the pandemic. Anxiety can raise glucose levels—an effect exacerbated by common responses such as overeating or insomnia. Patients may also respond to stress by eating less or becoming overly aggressive with their insulin dosing, leading to episodes of hypoglycemia.
“For the population as a whole,” Dr. Golden observes, “one of the greatest stressors during the pandemic has been dealing with the unknown. We’ve found that patients benefit from focusing on what they can control, including their own role in staying healthy. It’s empowering for them to understand that regulating their blood sugars not only mitigates their diabetes, but also puts them in a better position if they do become infected with the coronavirus.”
Keeping Patients Connected to Care
Video visits enhance the ability of NYU Langone’s diabetes team—including endocrinologists, nurse practitioners, diabetes educators, and nutritionists—to provide support that fits patients’ evolving needs. “If people need a new exercise routine, we’ll send links to workout videos tailored to their age and fitness level,” Dr. Golden says. “We talk to them about yoga, meditation, and other stress-relieving techniques, and help them find resources online. If they have unmet mental health needs, we try to arrange treatment for those issues as well.”
Another challenge facing numerous patients has been access to medications. Some have left the city for areas less affected by the pandemic, only to find their prescriptions are not accepted by local pharmacies; clinicians at NYU Langone have intervened successfully in such cases. Other patients have lost their jobs—along with their health insurance—due to the economic downturn. In such instances, Dr. Golden says, “we often prescribe alternative medications, such as older drugs or generics, that are more affordable. Our view is that the medications a patient can get are always better than the ones that are out of their reach.”
Carrying COVID-19’s Lessons Forward
Now that the pandemic is receding in New York City, the Center for Diabetes and Metabolic Health has begun to welcome more patients back for in-person visits (while maintaining stringent precautions to avoid contagion). Still, video visits will likely remain a popular option at the practice even after the epidemiological threat is eliminated.
Nor is this change the only potentially positive impact of COVID-19 for future diabetes management. “The pandemic has shone a spotlight on the things that were or weren’t working for people previously,” Dr. Golden observes. “I encourage all my patients to think about what they’ve learned from this experience. Maybe patients can bring dinner with them when they go back to the office, so they won’t have to eat restaurant meals when they work late. Maybe they can find a way to add exercise back into their schedule. We want every person we care for to take something positive from this crisis, and use it to improve things when we return to whatever the new normal is going to be.”