Participation in a Virtual Diabetes Clinic Improves Glycemic Control in Adults with Type 2 Diabetes
Authors: Dixon Ronald , Zisser Howard , Barleen Nathan , Layne Jennifer , Moloney Daniel , Majithia Amit , Riff Josh 
Published: October 2019

Background
Telemedicine for people with type 2 diabetes (T2D) has the potential to positively impact self-management behaviors and improve health outcomes. The Onduo Virtual Diabetes Clinic (VDC) is a comprehensive telehealth program for people with T2D that combines mobile app technology, remote personalized lifestyle coaching from certified diabetes educators and health coaches, connected devices including blood glucose meters and continuous glucose monitoring systems, and clinical support from board certified endocrinologists.

Objective
To describe the VDC care delivery model and present preliminary data on change in glycemic control in program participants with up to 6 months of follow-up.

Methods
Adults ≥18 years of age with T2D and who were members of sponsoring health plans and employers throughout the US were eligible to participate. Those who elected to enroll downloaded the VDC app to their smartphone, provided demographic and clinical information, completed an onboarding survey, and were mailed a self-management kit that included a connected blood glucose meter, test strips and a home glycosylated hemoglobin (HbA1c) testing kit. Participants interacted with their care team primarily through the VDC app, with occasional phone calls, and by synchronous video consultations with endocrinologists, as clinically appropriate. Change in glycemic control in participants who completed a baseline survey from February 2018 through December 31, 2018, with an initial HbA1c measurement within 30 days of enrollment and a follow-up measurement between 90 and 180 days after baseline was analyzed.

Results
Participants (n=740) were (mean ± SD): 53.8 ± 8.8 years of age, 62% female, BMI 35.6 ± 8.5, initial HbA1c 7.7% ± 1.8, 31.0% were on insulin and 25.9% were on sulfonylureas at baseline, and 30.0% lived in a rural area. HbA1c decreased significantly by 2.3% ± 1.9, 0.7% ± 1.0 and 0.2% ± 0.8 across the baseline categories of >9.0%, 8.0% to 9.0% and 7.0% to <8.0%, respectively (all P<.001). Within these categories, HbA1c improved in 91.9%, 77.3% and 63.5% of participants. For the group with an initial HbA1c >9.0%, HbA1c decreased from 10.7% ± 1.4 to 8.3% ± 1.5, and when stratified by HbA1c ≥8.0% the mean decrease in HbA1c was 1.5%, from 9.5% ± 1.5 to 8.0% ± 1.3, with 84.5% of participants demonstrating improvement. Participants with an initial HbA1c <7.0% who were meeting treatment targets at baseline, HbA1c 6.3% ± 0.4, continued to maintain this level of glycemic control at follow-up, HbA1c 6.4% ± 0.6 (ns).

Conclusions
Participation in the VDC was associated with a significant improvement in HbA1c in adults with T2D who were not meeting treatment targets, with the greatest improvement observed in those with an initial HbA1c >9.0%. Importantly, the majority of program participants experienced an improvement in glycemic control. Our findings suggest that the VDC program is an effective approach to support individuals with T2D and their clinicians in diabetes management between office visits.