Introduction The need to rapidly implement telehealth at large scale during the COVID-19 pandemic led to many patients using telehealth for the first time. We assessed the effect of structured pre-visit preparatory telephone calls on success of telehealth visits and examined risk factors for unsuccessful visits. Methods A retrospective cohort study was carried out of 45,803 adult patients scheduled for a total of 64,447 telehealth appointments between March and July 2020 at an academic medical center. A subset of patients received a structured pre-visit phone call. Demographic factors and inclusion of a pre-visit call were analysed by logistic regression. Primary outcomes were non-completion of any visit and completion of phone-only versus audio-visual telehealth visits. Results A pre-visit telephone call to a subset of patients significantly increased the likelihood of a successful telehealth visit (OR 0.54; 95% CI: 0.48–0.60). Patients aged 18–30 years, those with non-commercial insurance or those of Black race were more likely to have incomplete visits. Compared to age 18–30, increasing age increased likelihood of a failed video visit: 31–50 years (OR 1.31; 95% CI: 1.13–1.51), 51–70 years (OR 2.98; 2.60–3.42) and >70 years (OR 4.16; 3.58–4.82). Those with non-commercial insurance and those of Black race (OR 1.8; 95% CI 1.67–1.92) were more likely to have a failed video visit. Discussion A structured pre-call to patients improved the likelihood of a successful video visit during widespread adoption of telehealth. Structured pre-calls to patients may be an important tool to help reduce gaps in utilization among groups.

This cross-sectional study assesses whether health literacy and area deprivation index are associated with completion rates of telehealth video visits among adult patients in a large health care system.

BACKGROUND This study evaluated synchronous audiovisual telehealth and audio-only visits for patients with inflammatory bowel disease (IBD) to determine frequency of successful telehealth visits and determine what factors increase the likelihood of completion. METHODS Data were collected from March to July 2020 in a tertiary care adult IBD clinic that was transitioned to a fully telehealth model. A protocol for telehealth was implemented. A retrospective analysis was performed using electronic medical record (EMR) data. All patients were scheduled for video telehealth. If this failed, providers attempted to conduct the visit as audio only. RESULTS Between March and July 2020, 2571 telehealth visits were scheduled for adult patients with IBD. Of these, 2498 (99%) were successfully completed by video or phone. Sixty percent were female, and the median age was 41 years. Eighty six percent of the population was white, 8% black, 2% other, and 4% were missing. Seventy-five percent had commercial insurance, 15% had Medicare, 5% had Medicaid, and 5% had other insurance. No significant factors were found for an attempted but completely failed visit. Using a multivariate logistic regression model, increasing age (odds ratio, 1.80; 95% CI, 1.55-2.08; P < 0.05), noncommercial insurance status (odds ratio, 1.89; 95% CI, 1.61-2.21; P < 0.05), and black race (odds ratio, 2.07; 95% CI, 1.38-3.08; P < 0.05) increased the likelihood of a video encounter failure. CONCLUSIONS There is a high success rate for telehealth within an IBD population with defined clinic protocols. Certain patient characteristics such as age, race, and health insurance type increase the risk of failure of a video visit.

The published literature generally supports video visits as an effective method to provide care to persons with diabetes. Telehealth can be a key part of healthcare redesign, particularly in the care of diabetes. While the short-term clinical efficacy of diabetes care via telehealth is well established in the literature, less is known about outcomes of longitudinal care via telehealth. With recent increases in direct-to-patient telehealth, the available literature on telehealth interventions in diabetes care is growing. Advocates continue to seek policy change that will protect telehealth for the future. Current barriers to ongoing use of telehealth include uncertainty around policy and reimbursement, lack of universal internet access, interoperability limits, and disparities in use of diabetes technology. Attention to these inequalities will allow telehealth to achieve its full potential for medical and social benefits.

OBJECTIVE:Telehealth (TH) use in endocrinology was limited before the COVID-19 pandemic but will remain a major modality of care postpandemic. Reimbursement policies have been limited historically due to concerns of overutilization of visits and testing. Additionally, there is limited literature on endocrinology care delivered via TH for conditions other than diabetes. We assess real-world TH use for endocrinology in a prepandemic environment with the hypothesis that TH would not increase the utilization of total visits or related ancillary testing services compared with conventional (CVL) face-to-face office visits. METHODS:A single-institution retrospective cohort study assessing the prepandemic use of TH in endocrinology, consisting of 75 patients seen via TH and 225 patients seen in CVL visits. For most patients, TH was conducted via a clinic-to-clinic model. Outcomes measured were total endocrine visit frequency and frequency of related laboratory and radiology testing per patient, hemoglobin A1C, microalbumin, low-density lipoprotein, thyroid-stimulating hormone, thyroglobulin, and thyroid ultrasounds. RESULTS:For all endocrine visits, TH patients had a median of 0.24 (interquartile range, 0.015-0.36) visits per month. CVL patients had a median of 0.20 visits per month (interquartile range, 0.11-0.37). Total visits per month did not vary significantly between groups (P = .051). Hemoglobin A1C outcomes were equivalent and there was no increase in ancillary laboratory testing for the TH group. CONCLUSION:Our observations demonstrate that, in a prepandemic health care setting, TH visits can provide equivalent care for endocrinology patients, without increasing utilization of total visits or ancillary services.

The coronavirus disease pandemic has created opportunities for innovation in diabetes care that were not possible before. From the lens of this "new normal" state, we have an opportunity to rapidly implement, test, and iterate models of diabetes care to achieve the quadruple aim of improving medical outcomes, patient experience, provider satisfaction, and reducing costs. In this perspective, we discuss several innovative diabetes models of care which promote collaborative care models and improve access to high-quality specialty diabetes care. We discuss ongoing threats to diabetes care innovation, and offer practical solutions to foster evolution and sustain current strides made during the pandemic.

Abstract Telehealth (TH) usage increased exponentially with the COVID-19 pandemic, aided by more permissive policies. Prior to the pandemic, policy makers and payers expressed concern that telehealth might lead to over-utilization of services. This contributed to a limited reimbursement environment. To assess evidence for this concern, we studied real-world TH at an academic medical center and hypothesized that TH would not increase utilization. We compared pre-pandemic utilization in a retrospective cohort of adult endocrinology patients with either TH (synchronous audio-visual visits) or conventional visits (CV) between 11/1/2017 - 3/16/2020. We focused on a pre-pandemic cohort to reflect usual practice. TH patients (i.e., 1+ TH visit with endocrinology in the study period) were identified using billing modifiers in EHR-derived data. CV patients were matched for provider and primary diagnosis, then selected from EHR-derived data in a 1:3 ratio. A minority of providers were performing TH visits pre-pandemic. Matching was performed to eliminate confounding from individual practice variation and to assure ability to compare patients with similar diagnoses. The majority of TH encounters in our practice during the study were clinic-to-clinic, with patients at a TH-enabled remote clinic. 75 TH and 225 CV patients were identified. 77% (55) of TH and 72% (163) of CV patients were female. The mean age was 45.2 (SD 12.4) and 49.6 (SD 16.7) years, respectively. Among TH patients, 68% (51) were white and 12% (9) were black with no statistically significant demographic differences between groups. The most common TH primary diagnoses were DM (33 patients) and thyroid disease (33 patients). Other TH diagnoses included pituitary/adrenal conditions, hyperparathyroidism, PCOS, and hypogonadism. TH patients had median follow-up of 21 months (IQR 13-25) and CV patients 18 months (IQR 11-25), p=0.613. TH patients had a range of 1 to 9 TH encounters during this time (median 2, IQR 1-3). Median TH visits per month were 0.20 (IQR 0.11-0.3). Looking at all endocrine encounters, TH patients had a median of 0.24 (IQR 0.015-0.36) encounters per month. CV patients had median of 0.20 encounters per month (IQR 0.11-0.37). Total encounters per month did not vary significantly between groups (p=0.0512, Wilcoxon rank-sum test). Patients with primary thyroid diagnoses had similar frequencies of TSH testing with TH median 4 tests (IQR 2-7); CV median 3 tests (IQR 1-5), p=0.057. A1c testing frequency was similar in patients with primary diagnosis of DM. TH patients had median 2 tests (IQR 1-3.5); CV median 3 (IQR 1-5), p=0.8012. In conclusion, TH was not associated with higher utilization of visits or lab testing in a small study of a pre-pandemic telehealth program. Coupled with larger scale and replicative studies, these findings might inform policy making and support continuation of telehealth in the post-pandemic environment.

Abstract Context The potential for endocrine care via telemedicine has been recognized since the early 2000s when clinical outcome data demonstrated improvements in glycemic control with telemedicine. The widespread use of telemedicine during the COVID-19 pandemic has pushed telemedicine beyond diabetes care and into clinical areas with a paucity of published data. The evaluation and treatment of thyrotoxicosis heavily relies on laboratory assessment and imaging with physical exam playing a role to help differentiate the etiology and assess the severity of thyrotoxicosis. Case Description We describe a patient presenting for evaluation of new thyrotoxicosis via telemedicine, and describe modifications to consider for thorough, safe evaluation via telemedicine. Conclusion Telemedicine may be an ideal way to assess and treat patients with thyrotoxicosis who are not able to physically attend a visit with an endocrinologist but still have access to a laboratory for blood draws. Potential challenges include access to imaging and high-volume surgeons if needed. Clinical and economic outcomes of telemedicine care of thyrotoxicosis should be studied so that standards of care for endocrine telemedicine can be established.

The Vanderbilt Health Affiliated Network (VHAN) is a collaborative alliance of physicians, health systems, and employers driving a new level of clinical innovation and teamwork to enhance patient care, contain costs, and improve the health of communities in Tennessee and surrounding states. The network includes more than 5,000 clinicians, 60 hospitals, 12 health systems, and hundreds of physician practices and clinics who work together to strengthen communities and improve quality of life across the Southeast through better health. The statin outreach service was piloted in one VHAN practice, the Vanderbilt Medical Group, a large primary care group at Vanderbilt University Medical Center (VUMC). VUMC is a tertiary care academic center. VUMC primary care providers (PCPs) are located in several practice locations, and one location was chosen to pilot this intervention. The PCPs included internal medicine residents and attending physicians. Before this project, there was no clinical pharmacy presence in this practice.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes the design and implementation of a pharmacist-led program to improve rates of statin use among appropriate patients in high-risk populations.

A 70-year-old male truck driver with type II diabetes, treated with insulin, presented to the endocrinology clinic for evaluation of his commercial driver license waiver form.His glucose meter recorded an average daily glucose of 148 mg/dL, consistent with a hemoglobin A 1c (Hb A 1c ) value of 6.5% obtained by the Siemens DCA Vantage pointof-care immunoassay device; however, his Hb A 1c with the Bio-Rad Turbo 2.0 HPLC was 12.7% at 1 month earlier.(Fig. 1) His endocrinologist contacted the laboratory to inquire about this discrepancy. QUESTIONS1. What can cause discordant Hb A 1c results? 2. What methods can be used to identify the accurate result?3. Which method is more accurate for this patient?

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients frequently develop glucose intolerance and post-transplant diabetes mellitus (PTDM). The clinical importance of PTDM and its detrimental impact on HSCT outcomes are under-recognized. After allo-HSCT, various mechanisms can contribute to the development of PTDM. Here we review information about hyperglycemia and PTDM after allo-HSCT as well as PTDM after solid organ transplantation and describe ways to manage hyperglycemia/PTDM after allogeneic HSCT. Taking into consideration a lack of well-established evidence in the field of allo-HSCT, more studies should be conducted in the future, which will require closer multidisciplinary collaboration between hematologists, endocrinologists and nutritionists.

Telemedicine can connect specialist health care providers with patients in remote and underserved areas. It is especially relevant in diabetes care, where a proliferation of treatment options has added further complexity to the care of an already complex, highly prevalent disease. Recent developments in health reform encourage delivery systems to use team-based models and engage patients in shared decision-making (SDM), where patients and providers together make health care decisions that are tailored to the specific characteristics and values of the patient. The goal of this project was to design, integrate, and evaluate a team-based, SDM approach delivered to patients with diabetes in a rural community, building upon the previously established telemedicine for reach, education, access, and treatment (TREAT) model. Patients in this feasibility study demonstrated improvement in hemoglobin A1c values, and reported better understanding of diabetes. Providers reported the SDM aids increased cohesion among team members (including patients) and facilitated patient education and behavioral goal setting. This project demonstrated that SDM could be integrated into the workflow of a telemedicine team visit with good provider and patient satisfaction.

OBJECTIVE:We examined the effect of hospital admissions on the medical treatment of poorly controlled diabetes mellitus among Veterans Affairs (VA) patients.RESEARCH DESIGN AND METHODS:This retrospective cohort study included male patients admitted to one of three VA hospitals from July 1, 2002, to August 31, 2009, who were receiving medication therapy for diabetes with hemoglobin A1c (HgbA1c) greater than 8.0%. The primary outcome was a change in preadmission and outpatient prescriptions for diabetes at hospital discharge. Covariates for multivariable logistic regression analysis of the primary outcome were defined a priori and retrieved from the electronic health record.RESULTS:Of 2025 admissions for 1359 patients, 454 had some change in diabetes medications at discharge (rate of change 22.4%). In an adjusted analysis, higher preadmission HgbA1c [odds ratio (OR) 1.12 per 1.0 U increase; 95% confidence interval (CI) 1.12-1.05; P < 0.001], higher mean blood glucose during admission (OR 1.07 per 10 mg/dl increase; 95% CI 1.05-1.10; P < 0.0001), occurrence of inpatient hypoglycemia (blood glucose < 50 mg/dl; OR 1.82, 95% CI 1.32-2.51, P < 0.001), and inpatient basal insulin therapy (OR 1.71; 95% CI 1.25-2.35; P < 0.001) were associated with higher odds of change in therapy. A total of 656 admissions (32%) demonstrated aggregate clinical inertia with no change in therapy, no documentation of HgbA1c within 60 d of discharge, and no follow-up appointment within 30 d of discharge.CONCLUSIONS:In this multicenter, retrospective study of patients with poorly controlled diabetes and at least one hospitalization, less than a quarter received a change in outpatient diabetes therapy upon discharge, suggesting widespread clinical inertia. Nearly one third had no change in therapy or subsequent follow-up scheduled.

Chronic inflammation and decreased frequency of regulatory T cells (Tregs) in visceral adipose tissue contribute to the propagation of insulin resistance to diabetes mellitus. We tested the hypothesis that new-onset posttransplantation diabetes mellitus (PTDM) is associated with measurable changes in Treg subsets after allogeneic hematopoietic stem cell transplantation (HSCT). PTDM before day 100 and Treg phenotype at engraftment were determined in 36 HSCT recipients without preceding history of diabetes mellitus. Among patients with new-onset PTDM (N = 24), the frequency of circulating CLA(+) (skin-homing) Tregs was decreased (1.53% vs 3.99%; P = .002) and the percentage of α(4)β(7)(+) (gut-homing) Tregs was increased (17.9% vs 10.7%; P = .048). In multivariate analysis, patients with PTDM continued to demonstrate elevated ratios of α(4)β(7)(+) Tregs to CLA(+) Tregs (odds ratio, 18.1; P = .020). PTDM is associated with altered immune regulation after HSCT and could represent a target to modulate alloreactivity.

A Objective: The majority of clinical symptoms are stored as free text in the clinical record, and this information can inform clinical decision support and automated surveillance efforts if it can be accurately processed into computer interpretable data.Methods: We developed rule-based algorithms and evaluated a natural language processing (NLP) system for infectious symptom detection using clinical narratives. Training (60) and testing (444) documents were randomly selected from VA emergency department, urgent care, and primary care records. Each document was processed with NLP and independently manually reviewed by two clinicians with adjudication by referee. Infectious symptom detection rules were developed in the training set using keywords and SNOMED-CT concepts, and subsequently evaluated using the testing set.Results: Overall symptom detection performance was measured with a precision of 0.91, a recall of 0.84, and an F measure of 0.87. Overall symptom detection with assertion performance was measured with a precision of 0.67, a recall of 0.62, and an F measure of 0.64. Among those instances in which the automated system matched the reference set determination for symptom, the system correctly detected 84.7% of positive assertions, 75.1% of negative assertions, and 0.7% of uncertain assertions.Conclusion: This work demonstrates how processed text could enable detection of nonspecific symptom clusters for use in automated surveillance activities. (C) 2011 Published by Elsevier Ireland Ltd