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Since December of 2019, the COVID-19 outbreak has affected more than 215 countries, translating to more than 125 million cases worldwide of COVID-19 at the time of this writing. More than 2.8 million people have died from COVID-19 across the globe; specifically, in the USA and South America, there have been more than 30 million cases reported, with a total of 560,000 deaths due to the virus. The exact prevalence of infection is currently unknown. However, it is commonly believed that ~70-80% of the population will need to be infected or vaccinated for herd immunity to be effective.

Many new-onset patients with type 1 diabetes delayed seeking medical advice during COVID-19 because of the risk of getting infected. Many hospitals noted a higher number of patients presenting with diabetic ketoacidosis because of the delay in diagnosing type 1 diabetes. Similar concerns were noted by many of the physicians managing diabetes during pregnancy. However, in many instances, most diabetes care including patients with DKA could be effectively managed remotely by using newer technologies like CGM, insulin pumps, and hybrid closed-loop systems. In several instances, even the pump and CGM initiation were initiated remotely with no adverse outcomes. The virtual care gave a similar or better Time in Range (TIR) for glucose levels with no increase in Time Below Range during the virtual care period, irrespective of how patients were treated (whether it was remotely or in-person).

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The covid-19 pandemic saw an urgent need for virtual diabetes clinics to ensure ongoing longitudinal care of young people living with type 1 diabetes. This urgent situation yielded substantial experience at multiple centers globally with need to implement telehealth, accompanied by reimbursement for such services. Previous to the pandemic, a number of centers had implemented virtual care, especially in areas where reimbursement was not based upon a fee-for-service model (like in the USA) or where there was need to deliver remote care due to deficient numbers of trained diabetes expert in more remote areas. Telehealth during the pandemic allowed for routine follow-up as needed, aided by availability of cloud-based data acquired from advanced diabetes technologies, including continuous glucose monitors and insulin pumps. Such easily accessible data made telehealth visits especially effective. Indeed, the emphasis on diabetes data collection for the care of people with diabetes is very well-suited to virtual care delivery. In the USA, reimbursement is available for monthly review of CGM data, again adding support to telehealth.
Virtual care is not new, as it was a mainstay of the Diabetes Control and Complications Trial (DCCT), in which weekly telephone visits, along with monthly face-to-face visits, followed attainment of target glucose levels for the duration of the study for those intensively treated. The frequent telephone calls during the DCCT would supplanted by video calls with today’s technologies. It remains critical to document the utility of telehealth in order to continue these efforts after the pandemic, given the ease with which data can be accessed and patients can receive care, thereby saving time and potentially costs of care delivery. Further, telehealth makes it easy to have more frequent visits for those in suboptimal control or for those at great distance from specialized diabetes centers who are unable to access needed diabetes expertise locally. Thus, it is important to demonstrate non-inferiority of care when delivered virtually compare with face-to-face.

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Introduction and Objectives: Project ECHO (Extension for Community Healthcare Outcomes) is a tele-education outreach model seeking to democratize specialty knowledge, reduce disparities, and improve outcomes. Limited access to endocrinologists forces many primary care providers (PCPs) to care for patients with T1D without specialty support. Accordingly, an ECHO T1D program was developed and piloted in Florida and California. Our goal was to demonstrate feasibility and improve PCPs’ abilities to manage patients with T1D.

Methods: Health centers (i.e. spokes) were recruited through an innovative approach, focusing on Federally Qualified Health Centers (FQHC) and through identification of high-need catchment areas using the Neighborhood Deprivation Index (NDI) and provider geocoding. Participating spokes received weekly tele-education provided by the University of Florida and Stanford University hub team, real-time support with T1D medical decision making, access to diabetes support coaches, and access to an online repository of resources. Participating PCPs completed pre/post-tests assessing diabetes knowledge and confidence and exit surveys.

Results: In Florida, 12 spoke sites enrolled with 67 clinics serving >1,000 patients with T1D. In California, 11 spoke sites enrolled with 37 clinics serving >900 patients with T1D. During the 6-month intervention, 27 tele-education clinics were offered and n=70 PCPs (22 from Florida, 48 from California) from participating spoke sites completed pre/post-test surveys assessing knowledge and confidence in diabetes care. There was statistically significant improvement in knowledge (p≤0.01) and diabetes confidence (p≤0.01).

Conclusions: ECHO T1D's pilot demonstrated proof of concept for a T1D-specific ECHO program and represents a viable model to reach medically underserved communities.