Mark W. True

The missing element of telemedicine for diabetes: decision support software.

Telemedicine is coming! President Obama has released a proposed fiscal year 2010 budget that indicates a commitment to advancing health care information technology as a way to cut health care costs and save lives.1 Interest in telemedicine from the business and insurance communities is climbing rapidly. Each week or month, a new telemedicine product for transmitting physiologic data and facilitating communication between patient and health care provider is announced. New trade organizations to promote the use of telemedicine have been formed, such as the CTIA and WWI. Each week brings an announcement of a new telemedicine system or collaboration between a technology company and a patient care organization to deliver telemedicine. New publications, Web sites, and meetings to discuss the implications of wireless communication, mobile health, telemedicine, and other terms for this phenomenon are springing up regularly. A small but rapidly expanding body of research has generally concluded that telemedicine for diabetes offers many benefits compared to in-person visits for selected types of clinical indications, such as for chronic follow-up, review of monitoring data, and assurance of adherence to practice guidelines.2

EVALUATION OF TOTAL DAILY DOSE AND GLYCEMIC CONTROL FOR PATIENTS TAKING U-500 REGULAR INSULIN ADMITTED TO THE HOSPITAL

OBJECTIVE Patients using U-500 regular insulin are severely insulin resistant, requiring high doses of insulin. It has been observed that a patients insulin requirements may dramatically decrease during hospitalization. This study sought to systematically investigate this phenomenon. METHODS We performed a retrospective chart review of patients with U-500 insulin outpatient regimens who were admitted to the San Antonio Military Medical Center over a 5-year period. Each patients outpatient total daily dose (TDD) of insulin was compared to the average inpatient TDD. The outpatient estimated average glucose (eAG) was calculated from the glycated hemoglobin (HbA1c) and compared to the average inpatient glucose. RESULTS There were 27 patients with a total of 62 separate admissions. The average age was 64.4 years, with a mean body mass index of 38.9 kg/m2 and eAG of 203 mg/dL (HbA1c, 8.7%, 71.6 mmol/mol). All patients were converted from U-500 to U-100 upon admission. The average inpatient TDD of insulin was 91 units, versus 337 units as outpatients (P<.001). Overall, 89% of patients received ≤50% of their outpatient TDD. The average inpatient glucose was slightly higher than the outpatient eAG, 234 mg/dL versus 203 mg/dL (P = .003). CONCLUSION U-500 insulin is prone to errors in the hospital setting, so conversion to U-100 insulin is a preferred option. Despite a significant reduction in insulin TDD, these patients had clinically similar glucose levels. Therefore, patients taking U-500 insulin as an outpatient can be converted to a U-100 basal-bolus regimen with at least a 50% reduction of their outpatient TDD. ABBREVIATIONS BG = blood glucose eAG = estimated average glucose HbA1c = glycated hemoglobin NPO = nil per os SPSS = Statistical Package for the Social Sciences TDD = total daily dose.

When Military Fitness Standards No Longer Apply: The High Prevalence of Metabolic Syndrome in Recent Air Force Retirees

BACKGROUND Metabolic syndrome (MetS) is strongly associated with cardiovascular disease. With MetS prevalence rates increasing in the U.S. population, prevention efforts have largely focused on diet and exercise interventions. Before retirement, military service members have met fitness requirements for at least 20 years, and have lower MetS rates compared to age-matched U.S. population controls (23.4% vs. 39.0%), which suggests a protective effect of the lifestyle associated with military service. However, MetS rates in military retirees have not been previously reported, so it is unknown whether this protective effect extends beyond military service. The purpose of this study was to examine the prevalence of MetS and individual diagnostic criteria in a population of recent U.S. Air Force (USAF) retirees. METHODS We obtained institutional review board approval for all participating sites at Wilford Hall Ambulatory Surgical Center. From December 2011 to May 2013, USAF retirees within 8 years of their date of retirement were recruited at five USAF bases. Consenting subjects underwent examination and laboratory studies to assess the five diagnostic criteria measures for MetS. We used binary logistic regression to examine the relationship between various factors and the presence of MetS. RESULTS The study population (n = 381) was primarily male (81.9%), enlisted (71.1%) and had a mean age of 48.2 years. When applying the American Heart Association MetS diagnostic criteria to this population, the MetS prevalence was 37.2%. When using alternative diagnostic criteria found in other published studies that did not include the use of cholesterol medications, the MetS prevalence was 33.6%. Per American Heart Association criteria, the prevalence of each of the MetS diagnostic criteria was as follows: central obesity, 39.8%; elevated fasting glucose, 32.4%; high blood pressure, 56.8%; low-high-density lipoproteins cholesterol, 33.3%; and elevated triglycerides, 42.7%. MetS was more common among males (odds ratio [OR] = 4.05; confidence interval [CI] = 1.94, 8.48) and enlisted (OR = 2.23; CI = 1.24, 4.01). It was also strongly associated with a history of participating in the Air Force Weight Management Program (OR = 2.82; CI = 1.41, 5.63) and increased weight since retirement (OR = 4.00; CI = 1.84, 8.70). However, the study did not find an association between the presence of MetS and time since retirement or self-reported diet and exercise changes since retirement. CONCLUSIONS The MetS prevalence among recent USAF retirees represents a shift from age-matched active duty rates toward higher rates described in the overall U.S. POPULATION This finding suggests the protective health effects of fitness standards may be reduced shortly after retirement. This is true despite activities such as screening before and during military service and exposure to USAF health promotion efforts and fitness standards throughout a period of active duty service lasting at least 20 years. In general, military members should be counseled that on retirement, efforts to maintain a healthy weight have continued benefit and should not be forgotten. The risk of MetS after retirement is particularly increased for those identified as being overweight during their active duty careers. Interventions that prevent and reduce unhealthy weight gain may be an appropriate investment of resources and should be studied further.

The Diabetes Center of Excellence: A Model to Emulate

INTRODUCTION Diabetes is an epidemic that deserves a strategic approach to its prevention and management in our military health system (MHS). The Centers for Disease Control and Prevention estimates that 29.1 million Americans have diabetes and 86 million, or 1 in 3 adults, have prediabetes. More troubling is the notion that 9 out of 10 of these individuals with prediabetes are unaware of their current condition and future risk. If consistent lifestyle changes are not enacted, 15 to 30% of these individuals will progress to Type 2 diabetes within 5 years. The Air Force, whose beneficiary population is not immune to the diabetes epidemic, finds itself with an ever-widening gap between the number of empaneled patients with diabetes (approximately 50,000) and the number of providers that can successfully manage the complex and ever-evolving diabetes standards. The AF Medical Operations Agency in 2011 determined that the Air Force lacked standardization in diabetes care and prevention among the Air Force medical treatment facilities (MTFs). This deficiency highlighted the need to bolster the AF Diabetes Center of Excellence (DCOE) mission and vision to encompass a three-tiered approach: Clinical Excellence, Translational Research, and Outreach/Training. While the DCOE is funded by the Air Force, housed at Wilford Hall Ambulatory Surgical Center in San Antonio, the intent is to develop Tri-Service participation and impact.

How do you get there with diabetes? Results of a survey of diabetic travelers.

Objective: Knowledge regarding risk of poor glucose control during travel among patients being treated for diabetes mellitus and the actions of their providers remains unclear. This study examined both patient knowledge gaps and provider practices. Design and Methods: We surveyed 228 military beneficiaries who had been diagnosed with diabetes mellitus. These surveys were administered prior to a routine diabetes clinic visit and addressed patient knowledge and behavior along with health care provider practice regarding disease management during travel. Results: The majority of our study population (85%) was > 50 years of age and had been living with diabetes for > 5 years. Only 18.5% had ever inquired about glucose monitoring during travel and among the study subset that required insulin, only 27.8% asked about insulin dosing during travel. Additionally, 76.5% had never been asked about upcoming travel by their provider during a routine clinic visit. Of the 51% of patients who sought travel advice, their sources included: nurse educators (35%) and American Diabetes Association materials (16.5%). Regarding travel outside the United States, 27.9% stated they would make pre-arrangements with a medical facility. The remainder would ask the United States Embassy or hotel staff for recommendations for medical care (72.1%) or prescription medication replacement (63%). Finally, <25% of patients surveyed would consider adjustments of medications while traveling between time zones. Conclusions: This study reveals a significant gap in health literacy among patients and a lack of attention by their providers regarding diabetes management during domestic and international travel.

U.S. Air Force Telehealth Initiative to Assist Primary Care Providers in the Management of Diabetes

M ore than 50,000 active-duty U.S. Air Force (USAF) service members, retirees, and family members with diabetes receive care at more than 50 military treatment facilities (MTFs) throughout the continental United States.1 Although many of these patients are referred to civilian network diabetes specialists because of a scarcity of military endocrinologists, most are managed by USAF primary care providers (PCPs). In an effort to assist PCPs in managing complex diabetes cases, a team from the USAF Diabetes Center of Excellence (DCOE) in San Antonio, Tex., adopted the Extension for Community Healthcare Outcomes (ECHO) model of care. The ECHO model of health care delivery was developed and implemented originally by Dr. Sanjeev Aurora and his team at the University of New Mexico2 to treat underserved patient populations with hepatitis C. The model uses technology, specifically video teleconferencing, to provide support to PCPs in remote areas who may lack the experience, knowledge, or confidence needed to manage this complex condition. Results demonstrated that patients treated remotely through ECHO experienced similar clinical improvement with fewer adverse events than those treated at the university specialty clinic. The University of New Mexico has adapted the ECHO model for ~ 20 other chronic illnesses, including diabetes. After training with the New Mexico team, DCOE endocrinologists and support personnel adapted the ECHO model to address the unique needs of military PCPs and their patients with diabetes. The USAF ECHO initiative was designed such that sessions, open to all military …

An Interview about Telemedicine with John Oxendine, Georgia Insurance and Fire Commissioner, and Paula Guy, R.N., Chief Executive Officer of the Georgia Partnership for Telehealth

On March 12, 2009, four representatives of Journal of Diabetes Science and Technology interviewed John Oxendine, one of the United States governments leading officials in the field of telemedicine legislation and regulation. Mr. Oxendine has been the Georgia Insurance and Fire Commissioner since 1994. In 2005, Mr. Oxendine spearheaded the Rural Georgia Healthcare Initiative. This initiative launched one of the largest and most comprehensive telemedicine networks in the United States, which is the Georgia Partnership for Telehealth. This program consists of 77 telemedicine and teleradiology sites across Georgia and provides residents of rural regions of Georgia with local access to specialty care that is usually found only in large urban areas. Paula Guy, R.N, who serves as the chief executive officer of the Georgia Partnership for Telehealth and who has 9 years of leadership experience in building telemedicine networks in the state of Georgia, also participated in the interview.

Who's Distressed : A Comparison of Diabetes Related Distress by Type of Diabetes and Medication

OBJECTIVE We hypothesized that diabetes-related distress would vary by type of diabetes and medication regimen [Type 1 diabetes (T1DM), Type 2 diabetes with insulin use (T2DM-i), Type 2 diabetes without insulin use (T2DM)]. Thus, the aim of this study was to identify groups with elevated diabetes-related distress. METHODS We administered the 17-item Diabetes-related Distress Scale (DDS-17) to 585 patients. We collected demographics, medications, and lab results from patient records. RESULTS Patients were categorized by type of diabetes and medication: T1DM (n = 149); T2DM-i (n = 333); and T2DM (n = 103). ANOVA revealed significant differences in sample characteristics. ANCOVA were conducted on all four DDS-17 domains [Emotional Burden (EB); Physician-related Distress (PD); Regimen-related Distress (RD); and Interpersonal Distress (ID)]; covariates included in the models were sex, age, duration of diabetes, BMI, and HbA1c. EB was significantly lower in T1DM than T2DM-i, p < 0.05. In addition, RD was significantly lower in T1DM than either T2DM-i, p < 0.05 and T2DM, p < 0.05. CONCLUSIONS EB and RD are higher for those with type 2 diabetes. Thus, interventions to reduce EB and RD need to be considered for patients with type 2 diabetes. IMPLICATIONS DDS-17 is useful in identifying diabetes-related distress in patients with diabetes. Efforts need to be made to reduce EB and RD.

Evaluation of the Group Lifestyle Balance Program in a Military Setting: An Investment Worth Expanding

Introduction The Diabetes Prevention Program (DPP) demonstrated that lifestyle intervention programs were effective in preventing or delaying the onset of diabetes. The Group Lifestyle Balance (GLB) program translated the DPP curriculum into a 12-wk group intervention for those at risk for diabetes. This retrospective evaluation examined clinical outcomes for patients in the Diabetes Center of Excellence GLB program located at Wilford Hall Ambulatory Surgical Center from 2009 to 2013. Objectives included determining rates of retention, demographic characteristics of program completers, and changes in metabolic surrogates of disease prevalence. Study Design Adults with prediabetes or metabolic syndrome (MetS) were referred to the GLB program. Updated participant metabolic data were collected at regular intervals during their participation. Results During the 5-yr study, 704 patients attended the initial class. Overall, 52% of all participants completed the program with the greatest decline in participation occurring by the fourth week (30%). Baseline prevalence of conditions of interest for those who completed the program was prediabetes (93.2%), obesity (56.1%), and MetS (31.5%). GLB completers were older and retired (p < 0.05). A significant number of active duty military members (44.9%, p < 0.01, n = 53) dropped out of the program before the fourth week. Furthermore, those who completed the program saw a 2.0% reduction in prediabetes prevalence (p < 0.001), obesity decreased by 8.7% (p < 0.001), and MetS decreased by 6.8% (p < 0.01). Significant differences were found for central obesity, triglycerides, and fasting blood sugar (p < 0.001). Conclusions The GLB program is a valuable DPP and was effective at improving clinical outcomes and reducing the incidence of prediabetes, obesity, and MetS for participants who completed the program. Every effort should be made to support and encourage GLB participants to complete the program.

Effect of Military Deployment on Diabetes Mellitus in Air Force Personnel.

Introduction Military deployments relocate service members to austere locations with limited medical capabilities, raising uncertainties whether members with diabetes can participate safely. Military regulations require a medical clearance for service members with diabetes prior to deployment, but there is a dearth of data that can guide the provider in this decision. To alleviate the lack of evidence in this area, we analyzed the change in glycated hemoglobin (HbA1c) and body mass index (BMI) before and after a deployment among active duty U.S. Air Force personnel who deployed with diabetes. Materials and Methods A retrospective analysis was conducted using HbA1c and BMI values obtained within 3 mo before and within 3 mo after repatriation from a deployment of at least 90 d between January 1, 2004 through December 31, 2014. The study population consisted of 103 and 195 subjects who had an available pre- and post-deployment HbA1c and BMI values, respectively. Paired t-tests were conducted to determine significant differences in HbA1C and BMI values. Results The majority (73.8%) of members had a HbA1c <7.0% (53 mmol/mol) prior to deployment. For the overall population, HbA1c before and after deployment decreased from 6.7% (50 mmol/mol) to 6.5% (40 mmol/mol) (p = 0.03). Subgroup analysis demonstrated a significant decline in HbA1c among males, those aged 31-40 yr, and those with a pre-deployment HbA1c of >7%. BMI declined for the overall population (28.3 kg/m2 vs. 27.7 kg/m2, p < 0.0001) and for most of the subgroups. Conclusion Air Force service members who deployed with diabetes, including those with a HbA1c > 7%, experienced a statistically significant improvement in HbA1c and BMI upon repatriation. A prospective study design in the future can better reconcile the effect of a military deployment on a more comprehensive array of diabetes parameters.