Leptin has potent lipid-lowering effects in peripheral tissues and plasma that are proposed to be important for the prevention of cellular lipotoxicity and insulin resistance. The current study addressed in vivo the effects of acute leptin delivery on liver triglyceride (TG) metabolism, the consequence of hepatic leptin action on whole-body TG homeostasis, and the mechanisms of leptin action. A 120-min iv leptin infusion (plasma leptin, approximately 14 ng/ml) decreased liver TG levels (53 +/- 3%; P = 0.001), but not skeletal muscle TG levels, and increased liver phosphatidylinositol 3-kinase activity (341 +/- 95%; P = 0.01) in lean rats. Leptin had no effect on liver TG levels or phosphatidylinositol 3-kinase activity in diet-induced obese rats. In lean animals, leptin decreased the plasma TG concentration (20 +/- 7%; P = 0.017), the rate of TG accumulation in plasma after tyloxapol administration (26 +/- 6%; P = 0.003), and TG secretion from isolated liver (51 +/- 8%; P = 0.004). To determine possible metabolic fates of depleted hepatic TG, we assessed leptin effects on liver oxidative metabolism. Leptin increased hepatic acetyl-coenzyme A carboxylase phosphorylation (85 +/- 13%; P = 0.006), fatty acid oxidation (49 +/- 7%; P = 0.001) and ketogenesis (69 +/- 15%; P = 0.004). Finally, intracerebroventricular delivery of leptin for 120 min had no effect on liver TG levels, but did increase signal transducer and activator of transcription 3 phosphorylation (162 +/- 40%; P = 0.02). These data present in vivo evidence for a role for leptin in the acute regulation of hepatic TG metabolism, and whole body TG homeostasis. A likely contributing mechanism for these effects is leptin-induced partitioning of TG into oxidative pathways.

Electronic Consults (EC) offer enhanced access to endocrinologists for patients with type 2 diabetes mellitus (T2DM). The effects of EC on costs of care and glycemic control compared to Face-to-Face (F2F) visits are unknown. A retrospective chart review was conducted for Veterans who received EC (n=440) or F2F (n=397) care for T2DM through the VA Pittsburgh Healthcare System (VAPHS) from 2010 to 2015. Data on demographics, rurality, days to consult completion, and percent (%) A1C at baseline and post-consult at 3-6, and 12 months were collected. A web-based tool calculated the average round-trip distance in miles and travel time in hours from patient’s residential zip code to VAPHS. Annual travel costs for recommended 3 visits per year were estimated at a reimbursement rate of $0.415 per mile. Continuous measures (mean ± standard deviation) were compared using Wilcoxon rank-sum tests. Categorical measures (sex, rurality) were presented as percentages and compared between groups by time point using chi-square tests. Veterans who received EC were predominantly male (98.4%), younger (64.2±8.5 years) and rural (15.8%) than those who received F2F care (95.3% male, p=0.01; 68.1±8.7 years, p<0.0001; 3.7% rural, p<0.0001). The EC cohort had shorter consult completion time than the F2F cohort (EC: 10±10 days, F2F: 37±33; p<0.0001). Mean annual travel-related savings per Veteran in the EC cohort were 431±297 miles, 9.4±7 hours, and $179±123. Mean annual travel burden per Veteran in the F2F cohort were 159±171 miles, 3.5±4 hours and $66±71. EC and F2F cohorts had similar baseline A1C values (10%±1.6). Both cohorts had decline in baseline percent A1C to 3- 6 months (EC: 8.98%±1.54, F2F: 8.75%±1.77, p=0.03) and from baseline percent A1C to 12 months (EC: 8.80%±1.61, F2F: 8.57%±1.72, p=0.002). Electronic consults deliver effective and expedient care by saving money and travel time, and offer long-term, sustainable glycemic control comparable to F2F care for patients in remote areas with T2DM. Disclosure N. Karajgikar: None. K.B. Detoya: None. J.N. Beattie: None. S.J. Lutz-McCain: None. M.Y. Boudreaux-Kelly: None. A. Bandi: None.

The high prevalence of diabetes mellitus (DM) and shortage of Diabetes Care and Education Specialists (DCES) in rural communities requires providers and patients to travel long distances to access care. This burden impedes optimal DM management and increases cost. Telemedicine for Reach, Education, Access, Treatment, and Ongoing Support (TREAT-ON) is a Diabetes Education and Support (DSMES) model, where a DCES provides DSMES to patients identified as high risk (A1c >9% or unplanned care). TREAT-ON was initiated in February 2020, where DSMES was provided via telemedicine (TM) visits, previously delivered face-to-face (F2F) to high-risk patients. In this retrospective study, the DCES overall costs (fuel, tolls, and postage), travel time for care delivery, and number of patients seen over a 6-month period (March-August 2019) was compared to (March-August 2020) after TM practices were adopted. From March to August 2019, 59 of 91 patient referrals were completed, compared to 110 of 167 referrals from March to August 2020. The percentage of successful referrals were similar in both groups (64.8% vs. 65.9%). However, the percent of referrals declined by patients were higher in 2019 (18.7%) vs. 2020 (9.0%). Of 59 referrals completed in 2019, 54 were F2F and five TM whereas in 2020 twelve were F2F and 98 TM. Lower average cost per patient was noted in 2020 ($38.85 vs. $6.20). A similar reduction in average travel time per patient was seen, 99 min vs. 16 min in 2020. TREAT-ON model translated to a direct cost savings of $1,606 and reduction of DCES travel time of 67.6 hours equating to a gain of 8.4 workdays opening care opportunities for an additional 67 new referrals. DSMES is a pillar of DM care and alternative methods to expand DSMES services remain imperative. Our early TREAT-ON data shows that telemedicine offers a time and cost-effective approach to DSMES with potential to reach a larger population when compared to traditional F2F visits, and helps to address a current DSCES shortage. Disclosure E. Gammoh: None. P. A. Johnson: None. J. S. Krall: Research Support; Self; Becton, Dickinson and Company, Sanofi. J. Ng: Research Support; Self; Sanofi-Aventis. L. M. Siminerio: Advisory Panel; Self; Abbott Diabetes, Bayer U. S., Research Support; Self; Becton, Dickinson and Company. A. Bandi: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (1R34DK123370-01)

Background: Diabetes Care Network (DCN) is a collaborative care pathway that uses a team approach via telehealth to modernize diabetes care delivery and scale the endocrine expertise for complex diabetic patients. Methods: We studied the efficacy and sustainability of our approach to improving diabetes care over 12 months among 101 Veterans with poorly controlled Type 2 Diabetes (T2DM) (A1c>9%) identified from the electronic database. Among all enrolled Veterans, 87 (86.1%) were followed for 12 months. We assessed consultation completion via E-consult and protocol-based continuity care collaboration with primary care liaisons. Means (SD), frequencies, and percentages are presented, and Spearman correlations were assessed. Statistical significance set at p<0.05. Results: The cohort (N=87) was 97.7% male, 90.8% white, had a mean age 67.2 (8.9), and an average of 3.3 comorbidities, 0.7 macro-, and 1.3 microvascular complications. Initial care delivered via E-consult within 2.6(1.7) days with weekly follow-up telephonic team meetings. Collaborative care in the study cohort (N=87) allowed for therapy optimization and/or escalation with the initiation of metformin in 9 (10.3%), SGLT-2-I in 6 (6.8%), DPP-4I in 8 (9.1%), insulin U500 in 8 (9.1%), GLP-1A agents in 25 (28.7%), any insulin in 12 (13.7%), discontinuation of metformin in 9 (10.3%) and oral sulfonylurea in 17 (19.5%) Veterans. Of the 24 (27%) non-insulin users at enrollment, 12 Veterans initiated insulin therapy by 12 months. A1C declined significantly from the baseline A1C of 10.2% (1.4), to 8.1% (0.99) at 3 months, 7.6% (0.96) at 6 months, and 7.5 % (0.86) at 12 months (all p<.0001). At 3, 6, 12 months, number of patients who achieved HBA1c <8 % were 38 (43.6%), 56 (64%), and 56 (64%), and number of patients who achieved HBA1c <7% were 10 (11.4%), 21 (24.1%), and 23 (26.4%), respectively. Non-statistically significant improvements were noted in Weight {229.3lbs (48.1) to 228.4lbs (46.9)}, LDL {89.0mg/dl (36.4) to 79.5mg/dl (32.5)}, systolic BP {130.5mmHg (16.1) to 123.9mmHg (17.5)}, and triglycerides {226.9 mg/dl (195.3) to 159.3 (97.4)}. Compared to the 12 months pre-enrollment period, no difference in healthcare utilization (ER visits or admissions) was noted in the post-enrollment period. From baseline to completion, only nonsignificant improvements were noted in secondary preventative therapy for the use of antiplatelet agents, ACE-I/ARB, moderate to high-intensity statins and, the frequency of urine microalbumin tests, and annual foot/ retinal exams. Conclusions : With the DCN approach, we show that using telehealth technologies and collaborative partnerships, endocrine expertise can successfully be scaled to address the shortage of endocrinologists and help attain improved diabetes control. Such pathways will alleviate the large burden on primary care and address primary care inertia with timely therapy optimizations. Unless otherwise noted, all ...

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