Virtual Clinics for Diabetes Care.

Abstract

Diabetes Technology & TherapeuticsVol. 25, No. S1 Original ArticlesFree AccessVirtual Clinics for Diabetes CareSatish K. Garg, Abdulhalim M. Almurashi, and Erika RodriguezSatish K. GargBarbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA.Search for more papers by this author, Abdulhalim M. AlmurashiBarbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA.Search for more papers by this author, and Erika RodriguezBarbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA.Search for more papers by this authorPublished Online:20 Feb 2023https://doi.org/10.1089/dia.2023.2501AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail IntroductionTelehealth or virtual clinics have been present for delivering care to patients with a wide variety of illnesses, especially for patients with diabetes. Currently in the West (Europe and the United States) and many other emerging economies, virtual care that is based on their needs is available to the majority of patients with diabetes. In March of 2020, the COVID-19 pandemic forced many hospitals and clinical care facilities to be locked down for a period ranging from a few weeks to a few months. Since patients with diabetes, especially those with new onset type 1 diabetes (T1D), those with diabetic ketoacidosis (DKA), and other high-risk individuals, needed to be cared for during the lockdown, many clinics were forced to develop telehealth or virtual clinics to deliver care. In part, virtual care development was also facilitated by the emergency authorization by the regulators to practice medicine across the states in the United States; the reimbursements for such care were kept similar to in-person patient visits. We have learned a lot in the past 2.5 years from virtual clinics, and we think that such care, especially for people with diabetes, is here to stay in some form. Virtual care for patients with diabetes was in part expedited by development of remote glucose monitoring with the use of continuous glucose monitors (CGM) and hybrid closed-loop systems (HCL) that could be initiated remotely. We are delighted to author this critical article on virtual diabetes clinics in this year's Advanced Technologies and Treatments for Diabetes (ATTD) 2022 Yearbook.It is well known and reported in literature that people with diabetes and hypertension are at high risk of morbidity and mortality from COVID-19 infections. It is particularly true for patients whose glucose control is suboptimal (HbA1c >8.5%). The United Kingdom National Health Service data showed a 3.5-fold increased risk of death from COVID-19 infections in patients with type 1 diabetes. Many parts of diabetes care can be effectively delivered remotely and virtually. Doing so has several advantages for both the patients and the providers. For example, patients don't need to travel for their clinic visits and can save money related to travel (e.g., parking, gas, etc.). Most patients and providers have appreciated the availability of telehealth. We hope that the reimbursement rate for virtual care will continue to be similar to that for in-person care, like during the pandemic.It is known that ∼70% of diabetes care visits could be effectively accomplished remotely. It is true that there are situations when patient will need to be seen in person, such as when patients need laser surgery for proliferative diabetic retinopathy, when they need dialysis for end-stage kidney disease, and when patients with diabetes have high-risk pregnancies. Every visit cannot be accommodated by virtual clinics through phone calls, videos, emails, and text messages. Thus, we see a future for diabetes care that will include a combination of virtual diabetes clinics and in-person clinic visits. The frequency of these two options will vary based on a patient's needs.There are different aspects of virtual clinics that include patients having direct access to their digital data and being guided with different algorithms to adjust their medication themselves to improve their glucose control. For the providers, it is important to have patient's glucose data shared for video visits and remote monitoring for different aspects of diabetes care. It was difficult to choose only 14 out of about 10,000 abstracts we reviewed in this area, and thus unfeasible to cover all aspects of virtual clinics. The 14 abstracts for this article were divided into the following four categories: virtual clinics for type 1 diabetes, virtual clinics for type 2 diabetes, virtual clinics for obesity, and virtual clinics for the newly emerging cardiovascular complications associated with COVID-19. We hope readers find this article helpful for facilitating virtual clinics in their own settings.Key Articles ReviewedIs Telemedicine the Preferred Visit Modality in Patients with Type 1 Diabetes?Kirzhner A, Zornitzki T, Ostrovsky V, Knobler H, Schiller TExp Clin Endocrinol Diabetes 2022;130: 462–467Impact of the COVID-19 Pandemic on Management of Children and Adolescents with Type 1 DiabetesChoudhary A, Adhikari S, White PCBMC Pediatr 2022;22: 124Current Provision and HCP Experiences of Remote Care Delivery and Diabetes Technology Training for People with Type 1 Diabetes in the UK During the COVID-19 PandemicForde H, Choudhary P, Lumb A, Wilmot E, Hussain SDiabet Med 2022;39: e14755Telemonitoring, Telemedicine and Time in Range During the Pandemic: Paradigm Change for Diabetes Risk Management in the Post-COVID FutureDanne T, Limbert C, Domingo MP, Del Prato S, Renard E, Choudhary P, Seibold ADiabetes Ther 2021;12: 2289–2310Telemedicine and COVID-19 Pandemic: The Perfect Storm to Mark a Change in Diabetes Care. Results from a World-Wide Cross-Sectional Web-Based Survey.Giani E, Dovc K, Dos Santos TJ, Chobot A, Braune K, Cardona-Hernandez R, De Beaufort C, Scaramuzza AE; ISPAD Jenious GroupPediatr Diabetes 2021;22: 1115–1119Type 2 Diabetes Management, Control and Outcomes During the COVID-19 Pandemic in Older US Veterans: An Observational StudyAubert CE, Henderson JB, Kerr EA, Holleman R, Klamerus ML, Hofer TPJ Gen Intern Med 2022;3: 870–877Reliability of Virtual Physical Performance Assessments in Veterans During the COVID-19 PandemicOgawa EF, Harris R, Dufour AB, Morey MC, Bean JArch Rehabil Res Clin Trans 2021;3: 100146Long-term Effectiveness of the Time Intervention to Improve Diabetes Outcomes in Low-Income Settings: A 2-Year Follow-UpVaughan EM, Johnson E, Naik AD, Amspoker AB, Balasubramanyam A, Virani SS, Ballantyne CM, Johnston CA, Foreyt JPJ Gen Intern Med 2022;37: 3062–3069Management of Obesity Using Telemedicine During the COVID-19 PandemicWang-Selfridge AA, Dennis JFMo Med 2021;118: 442–445In-person and Virtual Multidisciplinary Intensive Lifestyle Interventions Are Equally Effective in Patients with Type 2 Diabetes and ObesityAl-Badri M, Kilroy CL, Shahar JI, Tomah S, Gardner H, Sin M, Votta J, Phillips-Stoll A, Price A, Beaton J, Davis C, Rizzotto J, Dhaver S, Hamdy OTher Adv Endocrinol Metab 2022;13: 20420188221093220Cardiovascular Risk Factors and Clinical Outcomes Among Patients Hospitalized with COVID-19: Findings from the World Heart Federation COVID-19 StudyPrabhakaran D, Singh K, Kondal D, Raspail L, Mohan B, Kato T, Sarrafzadegan N, Talukder SH, Akter S, Amin MR, Goma F, Gomez-Mesa J, Ntusi N, Inofomoh F, Deora S, Philippov E, Svarovskaya A, Konradi A, Puentes A, Ogah OS, Stanetic B, Issa A, Thienemann F, Juzar D, Zaidel E, Sheikh S, Ojji D, Lam CSP, Ge J, Banerjee A, Newby LK, Ribeiro ALP, Gidding S, Pinto F, Perel P, Sliwa K, on behalf of the World Heart Federation COVID-19 Study CollaboratorsGlob Heart 2022;17: 40COVID-19-Associated Coagulopathy and Antithrombotic Agents—Lessons After 1 YearLeentjens J, van Haaps TF, Wessels PF, Schutgens REG, Middeldorp SLancet Haematol 2021;8: e524–e533Pulmonary Vascular Thrombosis in COVID-19 PneumoniaDe Cobelli F, Palumbo D, Ciceri F, Landoni G, Ruggeri A, Rovere-Querini P, D'Angelo A, Steidler S, Galli L, Poli A, Fominskiy E, Grazia Calabrò M, Colombo S, Monti G, Nicoletti R, Esposito A, Conte C, Dagna L, Ambrosio A, Scarpellini P, Ripa M, Spessot M, Carlucci M, Montorfano M, Agricola E, Baccellieri D, Bosi E, Tresoldi M, Castagna A, Martino G, Zangrillo AJ Cardiothorac Vasc Anesth 2021;35: 3631–3641Prevalence, Characteristics, and Outcomes of COVID-19-Associated Acute MyocarditisAmmirati E, Lupi L, Palazzini M, Hendren NS, Grodin JL, Cannistraci CV, Schmidt M, Hekimian G, Peretto G, Bochaton T, Hayek A, Piriou N, Leonardi S, Guida S, Turco A, Sala S, Uribarri A, Van de Heyning CM, Mapelli M, Campodonico J, Pedrotti P, Barrionuevo Sánchez MI, Ariza Sole A, Marini M, Vittoria Matassini M, Vourc'h M, Cannatà A, Bromage DI, Briguglia D, Salamanca J, Diez-Villanueva P, Lehtonen J, Huang F, Russel S, Soriano F, Turrini F, Cipriani M, Bramerio M, Di Pasquale M, Grosu A, Senni M, Farina D, Agostoni P, Rizzo S, De Gaspari M, Marzo F, Duran JM, Adler ED, Giannattasio C, Basso C, McDonagh T, Kerneis M, Combes A, Camici PG, de Lemos JA, Metra MCirculation 2022;145: 1123–1139VIRTUAL CLINICS: TYPE 1 DIABETESIs Telemedicine the Preferred Visit Modality in Patients with Type 1 Diabetes?Kirzhner A, Zornitzki T, Ostrovsky V, Knobler H, Schiller TDepartment of Endocrinology, Diabetes and Metabolic Disease, Kaplan Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, IsraelExp Clin Endocrinol Diabetes 2022;130: 462–467IntroductionThe COVID-19 pandemic limits access to diabetes clinics. In the last few years, remote communication has been conducted through phone calls and WhatsApp messages. However, to avoid in-person visits, more robust media are needed for telemedicine. Insufficient data exist to determine whether virtual meetings are preferable to conventional office visits for patients with type 1 diabetes (T1D).Materials and MethodsT1D patients who are followed in a hospital-affiliated diabetes clinic were asked to fill a structured questionnaire aimed to determine their attitude towards telemedicine and their preference between virtual and conventional visits. The questionnaire was offered to consecutive T1D patients who visited the clinic between August 2020 and October 2020.ResultsSeventy-one T1D patients who fulfilled the questionnaire were included. The median age was 38 years, 39% were male, and the median duration of diabetes was 18 years. Fourteen percent of the participants preferred only virtual visits, 24% preferred only conventional visits, and 62% preferred a combination of these modalities. Sex, origin, education, duration of diabetes, mode of insulin treatment, and distance from the clinic were not associated with patients' preference, but older patients (≥61 years) tended to prefer conventional visits. Sixty-six percent felt confident in their ability to download data from their personal medical devices.ConclusionPatients from a wide range of treatment modalities are willing to use telemedicine. However, virtual meetings cannot fully replace conventional visits for patients with T1D, especially in the older age group.Impact of the COVID-19 Pandemic on Management of Children and Adolescents with Type 1 DiabetesChoudhary A, Adhikari S, White PCDivision of Pediatric Endocrinology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TXBMC Pediatr 2022;22: 124IntroductionThe COVID-19 pandemic affected the health of a wide range of people. We studied some of the effects on type 1 diabetes patients at a large urban pediatric teaching hospital.Materials and MethodsApproximately 1600 patients were included in the study. COVID-related restrictions were implemented on March 15, 2020; the “2019” data were gathered during the 1-year period before this date, and the “2020” data were gathered during the 1-year period after this date. We compared patient characteristics, glycemic control, Patient Health Questionnaire (PHQ)-9 depression screen scores, in-person and virtual outpatient encounters, hospitalizations, and continuous glucose monitor (CGM) use between the 2019 and 2020 periods.ResultsIn a generalized linear model, increasing age, noncommercial insurance, being Black, being Hispanic, and nonuse of CGMs were all associated with higher hemoglobin A1c (HbA1c), but there was no difference between the 2019 and 2020 groups. The time CGM users were in range was lower in noncommercial insurance patients and in Black and Hispanic patients; the in-range time improved slightly from 2019 to 2020. CGM use by patients with noncommercial insurance (93% of such patients were in government programs, 7% were uninsured or “other”) increased markedly. In 2020, patients with commercial insurance (i.e., private pay or provided by an employer) had fewer office visits, but insurance status did not influence use of the virtual visit platform. There was no change in hospitalization frequency from 2019 to 2020 in either commercially or noncommercially insured patients, but patients with noncommercial insurance were hospitalized at markedly higher frequencies in both years. PHQ-9 scores were unchanged.ConclusionHospitalization frequency, glycemic control, and depression screening scores were unchanged in our large urban pediatric teaching hospital during the COVID pandemic. Increased use of CGM and rapid adoption of telemedicine may have ameliorated the impact of the pandemic on disease management.Current Provision and HCP Experiences of Remote Care Delivery and Diabetes Technology Training for People with Type 1 Diabetes in the UK During the COVID-19 PandemicForde H1, Choudhary P1, Lumb A2,3, Wilmot E4,5, Hussain S6,7,81Leicester Diabetes Research Centre, Leicester General Hospital, Leicester, UK; Endocrinology and Obesity, King's Health Partners, London, UK2Oxford Centre for Diabetes Endocrinology and Metabolism, Oxford, UK; Endocrinology and Obesity, King's Health Partners, London, UK3NIHR Oxford Biomedical Research Centre, Oxford, UK; Endocrinology and Obesity, King's Health Partners, London, UK4Department of Diabetes, University Hospitals of Derby and Burton NHS FT, Derby, UK; Endocrinology and Obesity, King's Health Partners, London, UK5School of Medicine, Nottingham University, Nottingham, UK; Endocrinology and Obesity, King's Health Partners, London, UK6Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Trust, Guy's Hospital, London, UK; Endocrinology and Obesity, King's Health Partners, London, UK7Department of Diabetes, School of Life Course Sciences, King's College London, London, UK; Endocrinology and Obesity, King's Health Partners, London, UK8Institute of Diabetes, Endocrinology and Obesity, King's Health Partners, London, UKDiabet Med 2022;39: e14755IntroductionIn response to the COVID-19 pandemic, remote care methods have been quickly implemented for patients with type 1 diabetes in the United Kingdom. We studied current modes of care delivery, experiences of health-care professionals, and impact on insulin-pump training in type 1 diabetes care in the United Kingdom.Materials and MethodsThe UK Diabetes Technology Network designed a 48-question survey aimed at health-care professionals providing care in type 1 diabetes.ResultsA total of 143 health-care professionals (48% diabetes physicians, 52% diabetes educators, and 88% working in adult services) from approximately 75 UK centers (52% university hospitals, 46% general and community hospitals) responded to the survey. Care was delivered mainly via telephone calls. Video consultations took longer than telephone calls (P<.001). Common barriers to remote consultations were patient familiarity with technology (72%) and access to patient device data (67%). Effects were also seen on insulin pump training. Reduction in total new pump starts (73%) and renewals (61%) were highlighted. Common barriers to insulin training included patient digital literacy (61%), limited health-care professional experience (46%), and time required per patient (44%). Pump starts and renewals in larger insulin-pump services were less impacted by the pandemic than were those of smaller services.ConclusionThis survey highlights UK health-care professional experiences of remote care delivery. Although the results support the use of virtual care, several of the highlighted factors, especially patient digital literacy, need to be addressed to improve virtual care delivery and device training.Telemonitoring, Telemedicine and Time in Range During the Pandemic: Paradigm Change for Diabetes Risk Management in the Post-COVID FutureDanne T1, Limbert C2,3, Domingo MP4, Del Prato S5, Renard E6,7, Choudhary P8,9, Seibold A101Diabetes Center for Children and Adolescents, Kinder- und Jugendkrankenhaus AUF DER BULT, Hannover, Germany; Wiesbaden, Germany2Unit for Paediatric Endocrinology and Diabetes, CHULC, Hospital Dona Estefania, Lisbon, Portugal; Wiesbaden, Germany3NOVA Medical School, Lisbon, Portugal; Wiesbaden, Germany4Endocrinology and Nutrition Service, Department of Medicine, Germans Trias I Pujol Research Institute and Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain; Wiesbaden, Germany5Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy; Wiesbaden, Germany6Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France; Wiesbaden, Germany7Department of Physiology, Institute of Functional Genomics, CNRS, INSERM, University of Montpellier, Montpellier, France; Wiesbaden, Germany8Department of Diabetes and Nutritional Sciences, Kin's College London, London, UK; Wiesbaden, Germany9Diabetes Research Centre, University of Leicester, Leicester, UK; Wiesbaden, Germany10Abbott Diabetes Care, Wiesbaden, GermanyDiabetes Ther 2021;12: 2289–2310IntroductionPeople with diabetes are at greater risk for negative outcomes from COVID-19. Though this risk is multifactorial, poor glycemic control before and during admission to hospital for COVID-19 is likely to contribute to the increased risk. The COVID-19 pandemic and restrictions on mobility and interaction can also be expected to impact daily glucose management of people with diabetes. During the pandemic, glucose levels have been telemonitored for many people with diabetes, including adults and children with type 1 diabetes (T1D), allowing the effects of COVID-19 on glycemic control to be examined inside and outside the hospital setting. Periodic virtual visits allow people with diabetes to receive care while limiting the need for in-person attendance at diabetes clinics. Reports that sustained hyperglycemia and early-stage diabetic ketoacidosis may go untreated because of the lockdown and concerns about the risk of exposure argue for wider access to glucose telemonitoring. Therefore, in this paper we have critically reviewed reports concerning use of telemonitoring in the acute hospitalized setting as well as during daily diabetes management. Furthermore, we discuss the indications and implications of adopting telemonitoring and telemedicine in the present challenging time, as well as their potential for the future.Materials and MethodsTo date, 27 studies including 69,294 individuals with T1D have reported the effect of glycemic control during the COVID-19 pandemic.ResultsDespite restricted access to diabetes clinics, glycemic control did not worsen for 25/27 cohorts and improved in 23/27 study groups. Significantly, time in range (TIR; 70–180 mg/dL [3.9–10 mmol/L]) increased across 19/27 cohorts with a median 3.3% (−6.0% to 11.2%) change. Thirty percent of the cohorts with TIR data reported an average clinically significant TIR improvement of 5% or more, possibly as a consequence of more accurate glucose monitoring and improved connectivity through telemedicine.ConclusionPeriodic virtual visits allow people with diabetes to receive care without having to visit diabetes clinics as often. Because the lockdown may prevent sustained hyperglycemia and early-stage diabetic ketoacidosis from being treated and because in-person visits can increase the risk of infection, glucose telemonitoring should be more widely accessible. Therefore, in this paper we have critically reviewed reports concerning use of telemonitoring in the acute hospitalized setting as well as during daily diabetes management. Furthermore, we discuss the indications and implications of adopting telemonitoring and telemedicine in the present challenging time as well as the future potential of these care modes.Telemedicine and COVID-19 Pandemic: The Perfect Storm to Mark a Change in Diabetes Care. Results from a World-Wide Cross-Sectional Web-Based SurveyGiani E1, Dovc K2, Dos Santos TJ3,4, Chobot A5,6, Braune K7, Cardona-Hernandez R8, De Beaufort C9, Scaramuzza AE10; ISPAD Jenious Group1Department of Biomedical Sciences, Humanitas University, Milan, Italy; Pediatric Diabetes, Endocrinology and Nutrition, ASST Cremona, Cremona, Italy2Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, Ljubljana, Slovenia, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Pediatric Diabetes, Endocrinology and Nutrition, ASST Cremona, Cremona, Italy3Pediatric Unit, Vithas Almería, Instituto Hispalense de Pediatría, Almería, Spain; Pediatric Diabetes, Endocrinology and Nutrition, ASST Cremona, Cremona, Italy4Department of Public Health, and Epidemiology, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; Pediatric Diabetes, Endocrinology and Nutrition, ASST Cremona, Cremona, Italy5Department of Pediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland; Pediatric Diabetes, Endocrinology and Nutrition, ASST Cremona, Cremona, Italy6Department of Pediatrics, University Clinical Hospital, Opole, Poland; Pediatric Diabetes, Endocrinology and Nutrition, ASST Cremona, Cremona, Italy7Department of Pediatric Endocrinology and Diabetes, Charité - Universitätsmedizin Berlin, Berlin, Germany; Pediatric Diabetes, Endocrinology and Nutrition, ASST Cremona, Cremona, Italy8Division of Pediatric Endocrinology, Hospital Sant Joan de Déu, Barcelona, Spain; Pediatric Diabetes, Endocrinology and Nutrition, ASST Cremona, Cremona, Italy9DECCP, Clinique Pédiatrique/CH de Luxembourg, Luxembourg, GD de, Luxembourg; Pediatric Diabetes, Endocrinology and Nutrition, ASST Cremona, Cremona, Italy10Division of Paediatrics, Pediatric Diabetes, Endocrinology and Nutrition, ASST Cremona, Cremona, ItalyPediatr Diabetes 2021;22: 1115–1119IntroductionDuring the COVID-19 pandemic, many of the usual barriers to care for people with diabetes (PwD) were circumvented by using telemedicine. During this time, the proportion of PwD receiving care via telemedicine grew quickly in many countries. The goals of this study were to learn about health-care professionals' (HCPs) experiences with using telemedicine for diabetes care and about the changes and challenges with doing so.Materials and MethodsA cross-sectional electronic survey was distributed through the global network of Juniors in Educational Networking and International Research Opportunities United States (JENIOUS) members of the International Society for Pediatric and Adolescent Diabetes (ISPAD). Respondents' professional and practice profiles, clinic sizes, their country of practice, and data regarding local telemedicine practices during COVID-19 pandemic were investigated.ResultsAnswers from 209 HCPs from 33 countries were analyzed. During the pandemic, the proportion of PwD receiving telemedicine visits increased from <10% (65.1% of responders) to >50% (66.5%). There was an increase in specific privacy requirements for remote visits (37.3% to 75.6%), data protection policies (42.6% to 74.2%), and reimbursement for remote care (from 41.1% to 76.6%). Overall, 83.3% HCPs reported to be satisfied with the use of telemedicine. Some concerns (17.5%) about the complexity and heterogeneity of the digital platforms to be managed in everyday practice remain, feeding the need for unifying and making the tools for remote care interoperable. Also, 45.5% of professionals reported feeling stressed by the need for extra time for telemedicine consultations.ConclusionTelemedicine was rapidly and broadly adopted during the pandemic globally. Some issues related to its use were promptly addressed by local institutions. Challenges with the use of different platforms and for the need of extra time still need to be solved.CommentsThe five abstracts listed above highlight the rapid and broad adoption of telehealth and virtual clinics during the COVID-19 pandemic globally. Many manuscripts also reveal the challenges facing virtual clinics. The abstract from the United Kingdom surveying UK health-care professionals' experiences of remote care delivery highlighted the issues related to patient digital literacy; these issues need to be addressed for effective virtual care delivery and device training. The abstract from the study in Germany went further than many other abstracts in making telemedicine and telemonitoring an aspiration goal for diabetes management during the COVID-19 pandemic and beyond. Telemedicine clearly is an option for a subset of patients who are digitally literate and have access to technology. However, many patients with diabetes may have difficulty with this format. Thus, implementation for all patients with diabetes may not be possible. The authors highlighted that receiving care through virtual clinics was easier for the patients who were more experienced and confident in working with diabetes health-care technologies and creating their own diabetes health ecosystems. Many of those patients happened to be in the pediatric age groups.The abstract from Israel highlighted that virtual care cannot fully replace conventional in-person visits for patients with T1D, especially those in the older age groups. Only about 60% of the adult patients were confident of their ability to download data from their personal medical devices. Although technologies for patients with diabetes have come a long way, manufacturers need to make every attempt to make the data available in a much easier platform for all age groups.An abstract reported that hospitalization frequency, glycemic control, and depression screening were unchanged in a large urban pediatric hospital in the United States during the COVID-19 pandemic. The researchers recognized that increased use of continuous glucose monitoring (CGM) and rapid adoption of telemedicine may have ameliorated the impact of the pandemic on disease management, especially on individuals who had noncommercial insurance, were underinsured, or were Black or Hispanic. Due to increased authorization of diabetes-related technology during the COVID-19 pandemic, CGM use increased. This allowed digital data to be better managed through virtual clinics.The future of virtual care for people for T1D will depend on reimbursement challenges and wider adoption of such care. As indicated previously, this may need to be individualized based on the patients' needs. It is clear that the use of virtual clinics does break many ethnic and socioeconomic barriers, but the reimbursement and cost challenges will need to be addressed.VIRTUAL CLINICS: TYPE 2 DIABETESType 2 Diabetes Management, Control and Outcomes During the COVID-19 Pandemic in Older US Veterans: An Observational StudyAubert CE1,2,3,4, Henderson JB3,5, Kerr EA3,4,6, Holleman R3, Klamerus ML3, Hofer TP3,4,61Department of General Internal Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland; University of Michigan, Ann Arbor, MI2Institute of Primary Health Care, University of Bern, Bern, Switzerland; University of Michigan, Ann Arbor, MI3Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; University of Michigan, Ann Arbor, MI4Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; University of Michigan, Ann Arbor, MI5Consulting for Statistics, Computing & Analytics Research, University of Michigan, Ann Arbor, MI; University of Michigan, Ann Arbor, MI6Department of Internal Medicine, University of Michigan, Ann Arbor, MIJ Gen Intern Med 2022;3: 870–877IntroductionThe medical care of vulnerable patients may have adversely been affected by the COVID-19–related change from in-person to virtual visits. The aim of this study was to examine changes in management, control, and outcomes in older people with type 2 diabetes (T2D) that were associated with the shift from in-person to virtual visits.Materials and MethodsIn veterans aged ≥65 years with T2D, we assessed the rates of visits (in person, virtual), A1c measurements, antidiabetic deintensification/intensification, emergency room visits and hospitalizations (for hypoglycemia, hyperglycemia, other causes), and A1c level, in March 2020 and from April 2020 to November 2020 (pandemic period). We used negative binomial regression to assess change over time (reference: prepandemic period, July 2018 to February 2020), with respect to baseline Charlson Comorbidity Index (CCI; >2 vs ≤2) and A1c level.ResultsAmong 740,602 veterans (mean age 74.2 [SD 6.6] years), there were 55% (95% CI, 52%–58%) fewer in-person visits, 821% (95% CI, 793%–856%) more virtual visits, 6% (95% CI, 1%–11%) fewer A1c measurements, and 14% (95% CI, 10%–17%) more treatment intensification relative to baseline during the pandemic. Patients with CCI >2 had a 14% (95% CI 12%–16%) smaller relative increase in virtual visits than those with CCI ≤2. We observed a seasonality of A1c level and treatment modification, but no association of either with the pandemic. After a decrease at the beginning of the pandemic, there was a rebound in other-cause (but not hypoglycemia- or hyperglycemia-related) emergency room visits and hospitaliz