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.

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 ...

Metformin is the most prescribed oral medication for type 2 diabetes in the US due to its low cost, efficacy in reducing insulin resistance, and overall safety profile. However, literature shows that metformin can cause a rare but serious side effect of lactic acidosis (LA) with an incidence of 0.03-0.06 per 1000 patients. Persons requiring continuous oxygen therapy (COT) may be at risk for LA associated with hypoxia and decreased tissue perfusion, but the risk of metformin associated lactic acidosis (MALA) in persons requiring COT is unclear. Due to lack of evidence, some clinicians may empirically discontinue metformin in patients on COT, compromising glycemic stability. The objective of this drug utilization evaluation was to determine the frequency of metformin use and incidence of MALA in patients receiving COT. A retrospective review was conducted at a large regional Veterans Affairs Medical Center for patients with active prescriptions of metformin and supplemental oxygen therapy from 4/2017-4/2020. Of 578 unique patients identified, manual medical-record review was conducted for 6 patients who had serum lactate levels &gt;4 mmol/L while using concomitant metformin and COT. All were white males with mean: age of 71, pH of 7.35, and eGFR of 56. No cases of LA or DKA were identified. In all cases, elevated lactate levels were attributed to advanced medical conditions including: COPD, sepsis, CHF, CKD, and liver disease. None had serum metformin levels drawn. In conclusion, the association of elevated serum lactate among persons using concomitant metformin and COT was low and occurred in persons with advanced medical conditions. It could not be determined if metformin use was a contributing factor without metformin levels. These findings confirm the importance of clinical judgement when prescribing and continuing metformin for persons with advanced underlying medical conditions. Further study with serum metformin levels may help to better characterize the risk of MALA for persons on COT. Disclosure S. J. Lutz-mccain: None. B. E. Desanzo: None. B. Herk: None. M. Mclinden: None. M. M. Dinardo: None. R. Codario: None.

Clinical inertia is the failure to initiate or intensify treatment in a timely manner in people with type-2 diabetes mellitus (T2DM) in primary care (PC) where collaborative care can be an approach to overcome inertia. Diabetes care network (DCN) is a telehealth based collaborative care model to address clinical inertia in the PC environment. In DCN, initial care was delivered via E-Consult by hub diabetes team for Veterans with A1c of 9% or higher and the longitudinal collaborative care delivered by PC liaison with weekly team huddle. To study the difference in the clinical outcomes with DCN vs. PC practices, we compared the DCN cohort (97.7% male, 90.8% white, with a mean age 67.2 (8.9), with a PC cohort (100% male, 94.9% white, mean age: 68 year (10.5), with A1C &gt;9%). Methods: Means (SD), frequencies and percentages were presented. The DCN cohort had a significant decline in the baseline A1C of 10.2% (1.4), to 8.1% (0.99), 7.6% (0.96), 7.5 % (0.86) at 3, 6, and 12 months while A1c in PC cohort stayed poor with baseline A1C of 10.1% (0.89), to 10.2% (1.69), 9.7% (1.74) and, 9.5% (1.83) at 3, 6, and 12 months. Patients who achieved A1c less than 8% in DCN cohort were 38 (43.6%), 56 (64%), and 56 (64%) at 3, 6, and 12 months and were 1(1.7%), 5(8.5%), and 6(10.2%) at 3, 6, and 12 months in PC cohort. An A1c of less than 7% was achieved in DCN cohort in 10 (11.4%), 21 (24.1%), and 23 (26.4%) patients at 3, 6, and 12 months and only 1(1.7%), 0(0%), and 0(0%) patients achieved A1c less than 7% at 3, 6, and 12 months in PC cohort. Our study shows participation in the DCN telehealth program for 1 year was associated with significant improvement in A1c. This improvement was not seen within the PC with traditional care practices. Thus, addressing clinical inertia in PC will need a paradigm shift in current practices. The proposed collaborative approach of DCN can overcome clinical inertia in PC and improve care for people with T2D by supporting PC access to specialty care expertise, decreasing the burden of diabetes care for patients and PC providers. Disclosure K. Clark: None. M. J. Larson: None. S. J. Lutz-McCain: None. A. Bandi: None.

Purpose: The purpose of the study was to examine the impact of a novel approach to provide diabetes specialty team care to rural patients with type 2 diabetes (T2DM) on clinical outcomes and processes of care. Methods: Diabetes Care Network (DCN) provides Veterans with T2DM and elevated A1C an initial 6-week period of remote self-management education and support and medication management by a centrally located team of diabetes specialists. Participants are then comanaged by remote liaisons embedded in rural primary care facilities for the remainder of the 12-month intervention. In this pre-post intervention study, 87 Veterans enrolled in DCN from 2 different clinical sites had baseline and 12-month postenrollment A1C, systolic blood pressure, weight, and LDL cholesterol levels collected and compared using paired t tests. Results: Participants were mostly male and White with elevated baseline A1C. Participants from both sites had significant improvement in A1C over the 12-month intervention period compared to an increase in the 12 months prior to enrollment. There were also significant improvements in LDL and systolic blood pressure at 1 site, with no significant change in weight at either site. Conclusions: DCN participants had significant improvement in A1C after not meeting similar goals previously in a robust primary care setting. A technology-enabled collaborative partnership between centrally located diabetes care teams and local liaisons is a feasible approach to enhance access to diabetes specialty care for rural populations.