by Raghu G. Mirmira, MD, PhD

The discipline of clinical endocrinology has seen enormous challenges in the past decade, and these have been heightened by the COVID-19 pandemic. The rising epidemic of obesity and diabetes and their associated complications has created a crisis for both patients and healthcare providers. With fewer than 50% of patients with diabetes achieve glycemic targets,¹ downstream complications of diabetes will compound the economic burden most countries are facing. Layered upon this crisis in the US, we are now facing a shortage of adult and pediatric endocrinologists^2,3 – the specialty providers asked to deliver solutions to the most challenging clinical situations.

There has been broad recognition for years that new models of diabetes care delivery must be considered and implemented to meet these challenges. These models include telemedicine, asynchronous electronic consults, team-based care, and pharmacist-led care, among others. Evidence that some of these approaches can be as effective – or more-so – in achieving glycemic goals has appeared in the literature over the years,^4-7 but systemic, cultural, and infrastructure challenges exist to the broader adoption of these innovative modes of care. The COVID-19 pandemic, because of need for physical distancing, has represented both a challenge and an opportunity to the implementation of new care models—particularly telehealth. Healthcare providers, institutions, and payors have embraced telehealth approaches at a remarkable pace to ensure ongoing healthcare delivery, but as the outcomes to these approaches are being evaluated, future sustainability remains uncertain.

In the perspective article by Agarwal et al., the authors present some innovative approaches that may represent the future of diabetes healthcare delivery to address both the rising number of patients and the limited number of endocrinologists. These include, first and foremost, the use of telehealth and eConsults – which together have the potential to reach more patients (particular those who are remote from the site of service) and address issues raised by primary-care providers in a timely fashion. In addition, the authors discuss Project ECHO,⁸ a global telementoring program that disseminates case-based learning through a “hub and spoke” model, in which a single endocrinologist (hub) addresses patient-specific issues brought forth by a geographically diverse group of primary-care providers (spokes). This model expands the reach of endocrinologists, such that specialized insight and approaches can be implemented and disseminated by primary-care clinicians. Additionally, models that involve active team-based participation by allied health professionals, such as nutritionists, educators, nurse practitioners, pharmacists, psychologists, and others serve to enhance 360-degree care of diabetes patients, and to reduce intervals between lifestyle and medication adjustments. Finally, models that promote warmer transitions between pediatric and adult care were discussed that include transition navigator programs and low-cost, short summaries of patient information. Although many of these models existed long before the COVID-19 pandemic, the implementation of many has occurred at a rapid pace over the past year – in some cases with great success. However, several barriers to long-term sustainability exist, including lack of clearly generalizable payment models, slow adoption of technologies, access to technologies in underserved regions, a dearth of outcomes data, and future workforce shortages, among others. Precisely how diabetes healthcare delivery will look 5 years from now still remains uncertain, but, as with many things during the pandemic, new models are here to stay in some hybrid format, and they will represent the “new normal.”

 

References

1. Ali MK, Bullard KM, Saaddine JB, et al. Achievement of goals in U.S. diabetes care, 1999-2010. N Engl J Med 2013;368(17):1613–24.
2. Romeo GR, Hirsch IB, Lash RW, Gabbay RA. Trends in the Endocrinology Fellowship Recruitment: Reasons for Concern and Possible Interventions. J Clin Endocrinol Metab 2020;105(6).
3. Vigersky RA, Fish L, Hogan P, et al. The Clinical Endocrinology Workforce: Current Status and Future Projections of Supply and Demand. J Clin Endocrinol Metab 2014;99(9):3112–21.
4. Moczygemba LR, Goode J-VR, Gatewood SBS, et al. Integration of collaborative medication therapy management in a safety net patient-centered medical home. J Am Pharm Assoc 2011;51(2):167–72.
5. Kwok J, Olayiwola JN, Knox M, et al. Electronic consultation system demonstrates educational benefit for primary care providers. J Telemed Telecare 2018;24(7):465–72.
6. Barnett ML, Yee HF, Mehrotra A, Giboney P. Los Angeles Safety-Net Program eConsult System Was Rapidly Adopted And Decreased Wait Times To See Specialists. Health Aff Proj Hope 2017;36(3):492–9.
7. Liu W, Saxon DR, McNair B, et al. Endocrinology Telehealth Consultation Improved Glycemic Control Similar to Face-to-Face Visits in Veterans. J Diabetes Sci Technol 2016;10(5):1079–86.
8. Bouchonville MF, Paul MM, Billings J, et al. Taking Telemedicine to the Next Level in Diabetes Population Management: a Review of the Endo ECHO Model. Curr Diab Rep 2016;16(10):96.