ENDOCRINOLOGY IN THE TIME OF COVID-19: Remodelling diabetes services and emerging innovation

Abstract

<jats:p>The COVID-19 pandemic is a major international emergency leading to unprecedented medical, economic and societal challenges. Countries around the globe are facing challenges with diabetes care and are similarly adapting care delivery, with local cultural nuances. People with diabetes suffer disproportionately from acute COVID-19 with higher rates of serious complications and death. In-patient services need specialist support to appropriately manage glycaemia in people with known and undiagnosed diabetes presenting with COVID-19. Due to the restrictions imposed by the pandemic, people with diabetes may suffer longer-term harm caused by inadequate clinical support and less frequent monitoring of their condition and diabetes-related complications. Outpatient services need reorganised to maintain advice and support, focusing on proactive care for the highest risk, making use of telehealth and digital services for consultations, self-management and remote monitoring, where appropriate. Stratification of patients for face-to-face or remote follow-up should be based on a balanced risk assessment. Public health and national organisations have generally responded rapidly with guidance on care management, but the pandemic has created a tension around prioritisation of communicable vs non-communicable disease. Resulting challenges in clinical decision making are compounded by a reduced clinical workforce. For many years, increasing diabetes mellitus incidence has been mirrored by rising preventable morbidity and mortality due to complications, yet innovation in service delivery has been slow. While the current focus is on limiting the terrible harm caused by the pandemic, it is possible that a positive lasting legacy of COVID-19 might include accelerated innovation in chronic disease management.</jats:p>

COVID-19 associated with diabetes and other noncommunicable diseases led to a global health crisis

“…Telemedicine was one of the key strategies to enable individuals to continue receiving medical attention while staying safe at home [16,38,44,47,48,49,50]. The lack of other options or the identification of telemedicine's potential led to its quick legal approval and reimbursement in several countries [33,45,46,49,51,52]. A variety of digital components were adopted in different places for diabetes care during the pandemic [41,53,54].…”

“…In Australia webchats, podcasts and a guide were developed [42]. The United Kingdom wisely developed a consensus document for treating PwD with COVID-19 and another for outpatients' appointment prioritization [49]. A guide for HCPs was also published in Bangladesh [70].…”

“…Not only were the satisfaction rates of measuring HbA1c this way above 90%, but it also represented a good alternative for healthcare teams to monitor PwD, especially those who do not use continuous glucose monitoring or uploadable glucometers. This strategy to obtain HbA1c results was also encouraged in the United Kingdom [49], where a group expanded the postal tactic to urinalysis dipsticks to continue measuring albumin-to-creatinine ratio of PwD supported [57].…”

“…Telemedicine and other digital strategies were among the most successful strategies during the pandemic and are seen as permanent [16,45,46,47,49,71]. They allowed continuity of diabetes care in a safe and flexible manner [53,55], reducing no-show rates -4% only in Bahrain [45] -and alleviating part of the pressure by optimizing health systems' resources.…”

Preparedness cycle to address transitions in diabetes care during the COVID-19 pandemic and future outbreaks

“…However, these changes are being implemented without clear plans or directives for managing other comorbidities often associated with diabetes, such as hypertension and established cardiovascular disease (CVD). There has also been a push toward more patient self-managed care via online structured educational resources, 13 yet the reach of such programs is not known. Prior to the COVID-19 pandemic, a meta-analysis including randomized controlled trials (RCTs) that compared telemedicine interventions with usual care found that systems allowing for medication adjustments with or without text messaging or a web portal improved glycated hemoglobin A1c (HbA1C) but not other clinically relevant outcomes in patients with diabetes.…”