Early on in the pandemic, evidence emerged suggesting that people with “underlying conditions” such as diabetes were at increased risk of developing complications and potentially dying as a result of covid-19.1,2,3
As we were undertaking an index looking at digital diabetes provision in Europe at the time, we spoke to a number of experts in diabetes—people with diabetes and healthcare professionals—about the short and long term impact of covid-19 on diabetes care.
In particular we were interested in how to translate short-term workarounds and policies to a permanent change in service delivery.
Increased online and telephone consultations
The early days of the pandemic in Europe saw a huge rise in the number of teleconsultations, for example up from 40,000 a month to 486,369 in France, supported by temporary full reimbursement.4,5 This switch was especially important for people with diabetes who require regular monitoring and were highlighted as a group that was at an increased risk for worse outcomes from covid-19. Continuity of care has been achieved in the main thanks to increased use of teleconsultations.6 This serves as a stark reminder that digital technology is not just a luxury, but a vital infrastructure to deliver and maintain services.
The experts we spoke to—people with diabetes and healthcare professionals alike—reported that the biggest increase was actually in telephone consultations. This was largely due to concerns around digital exclusion and not wanting to leave any people with diabetes behind because of a lack of access to technologies such as laptops and smartphones.
The role of glucose monitors
In countries where real-time and flash glucose monitors are widely adopted, healthcare professionals can monitor people’s condition with limited physical interaction. Under “normal” circumstances this is more convenient for people with diabetes and during covid-19 it has been important for reducing infection risks (in both directions).7 Automated tools to assess insulin requirements and administer dosing could improve disease management and ensure resilience to health system shocks in the future.8 In response to the covid-19 crisis, NHS England launched a digital education service that lets people manage their condition online, through online videos and training for children and adults.9
Professor Mathieu, Chair of the European Diabetes Forum, commented that “this happening now, versus five years ago is a different world” because of technological advances and the “game changing” effect of full reimbursement of flash and real-time monitors, enabling her to provide remote consultations that are almost as good as face-to-face. However, experts are also advocating for more involvement of people with diabetes as new digital platforms are developed and implemented, including user training. Where covid-19 has presented opportunities to reduce red tape, Ms Perraudin, Senior Policy Officer at Diabetes UK says that “what we’ve lost in that process is user involvement and co-production.”
Making a temporary change last
Covid-19 has created the necessity for increased use of digital tools across healthcare and diabetes is no exception. At present, it is unclear how much of these service changes will translate into permanent service provision.
The experts we spoke to were keen that the temporary changes to service delivery introduced in response to covid-19 be capitalised upon to achieve long-term shifts in how services are delivered. Experts we’ve spoken to agree that digital tools have been important in maintaining services to people with diabetes. In particular they would like to see the greater role of teleconsultations continue beyond the immediate covid-19 crisis to become an integrated part of the package of services offered. Finance is a key component in incentivising the continuation of digital diabetes care. Belgium was quick to respond to the changing demand brought about by covid-19 by introducing a consistent reimbursement fee for teleconsultations across specialties, but at around a third the value of a face-to-face consultation. In countries with a fee-for-service model, such discrepancies may prove a disincentive to continuing digital services. Reimbursement has been highlighted by experts as a key mechanism for improving access to and uptake of digital health tools because “everything is guided by reimbursement” and its ability to guide behaviour amongst health professionals and people with diabetes alike, according to Chantal Mathieu.
How covid-19 has highlighted existing fault lines in digital infrastructure
There is also a need to consider how the pandemic crisis has highlighted existing issues in digital health infrastructure, such as how the highly regionalised system in Italy experienced issues due to a lack of connectedness between systems.10 Similarly in Spain, experts have suggested that a more centralised approach to digital healthcare could support innovation, implementation and reduce variation. 11 In Slovenia, experts have pointed to an opportunity to update the eHealth strategy based on lessons learned during the covid-19 pandemic and increased digital health use.12
Decision-making on the most appropriate medium to use for individual appointments would be based on clinical considerations and the preferences of the person with diabetes. The voice of people with diabetes will play a key role in pushing for the continuation of digital diabetes care, but this depends on strong advocacy groups for people with diabetes, which are lacking in some countries says Mr Hauck.
Find out more about broad digital readiness and digital diabetes tool use in Europe by checking out our Digital Diabetes Index.
Thanks to the following experts for their time and insights: Chris Aldred, Patient Representative to multiple diabetes organisations and person living with Type 1 diabetes; Professor Nick Guldemond, Senior researcher at the Leiden University Medical Center and Visiting Professor at I.M. Sechenov First Moscow State Medical; Bastian Hauck, Board Member IDF Europe, Patient Advocate, CEO and person living with Type 1 diabetes; Dr Chantal Mathieu, President of the European Diabetes Forum (EUDF); Ms Liz Perraudin, Senior Policy Officer at Diabetes UK.
[1] Katulanda P, Dissanayake HA, Ranathunga I et al. Prevention and management of COVID-19 among patients with diabetes: an appraisal of the literature. Diabetologia. 2020;63:1440–52.
[2] First study of COVID-19 patients with diabetes shows that 10% die within seven days of hospital admission and two thirds are men. In the news. Diabetologia. 2020 May 29. Available from: https://diabetologia-journal.org/2020/05/29/first-study-of-covid-19-patients-with-diabetes-shows-that-10-die-within-seven-days-of-hospital-admission-and-two-thirds-are-men/
[3] Bornstein SR, Rubino F, Khunti K et al. Practical recommendations for the management of diabetes in patients with COVID-19. The Lancet Diabetes & Endocrinology. 2020;8(6):54–60.
[4] Access to medical technologies and services during the COVID-19 pandemic. Update from the diabetes medical technology sector - April 2020. MedTech Europe. Available from: https://www.medtecheurope.org/wp-content/uploads/2020/04/Joint-Industry-Statement-Diabetes-Sector-Group-COVID-19-23-April-2020.pdf.
[5] Télémédecine : baisse possible de 300.000 à 500.000 déplacements quotidiens en Ile-de-France. Internet: Paris Match; 2020. Available from: https://www.parismatch.com/Actu/Sante/Possible-baisse-de-300-000-a-500-000-deplacements-quotidiens-en-Ile-de-France-grace-a-la-telemedecine-1685387
[6] COVID-19 and diabetes: perspectives from Europe. Diabetes Voice. Brussels: International Diabetes Federation; 2020 May 11. Available from: https://diabetesvoice.org/en/news/covid-19-and-diabetes-perspectives-from-europe/.
[7] Katulanda P, Dissanayake HA, Ranathunga I et al. Prevention and management of COVID-19 among patients with diabetes: an appraisal of the literature. Diabetologia. 2020;63:1440–52.
[8] Iqvia. Innovation in diabetes care technology. Durham [NC]: Iqvia, 2020 May 6. Available from: https://www.iqvia.com/insights/the-iqvia-institute/reports/innovation-in-diabetes-care-technology.
[9] NHS England. News. NHS launches new online support for people with diabetes. London: NHS England, 2020 Jun 9. Available from: https://www.england.nhs.uk/2020/06/nhs-launches-new-online-support-for-people-with-diabetes/.
[10] Omboni S. Telemedicine During The COVID-19 in Italy: A Missed Opportunity? Telemedicine and e-Health; 202 Apr 22. Available from: https://www.liebertpub.com/doi/full/10.1089/TMJ.2020.0106
[11] Rouger M. COVID-19 pandemic expedites a cultural change in healthcare. Internet: Healthcare-in-Europe; 2020. Available from: https://healthcare-in-europe.com/en/news/covid-19-pandemic-expedites-a-cultural-change-in-healthcare.html
[12] Read Tomaž Gornik from Better talking about “eHealth is our unexploited opportunity”. Internet: ECHAlliance; 2020. Available from: https://echalliance.com/read-the-interesting-to-tomaz-gornik-from-better-on-ehealth-is-our-unexploited-opportunity/.
