‘Pace of change is dizzying’: Joslin Diabetes Center navigates shifts in care brought on by COVID-19
The COVID-19 pandemic has forced health care institutions around the country and around the globe to change the way they practice medicine. Clinicians at Joslin Diabetes Center — the world’s largest diabetes research center, diabetes clinic and provider of diabetes education —ramped up the organization’s telehealth capabilities within a week’s time to provide remote care for routine and nonurgent appointments, while fielding questions from anxious patients about access to medications and risks for worse coronavirus complications that can come with poorly controlled diabetes.
Healio spoke with Robert Gabbay, MD, PhD, FACP, chief medical officer and senior vice president at Joslin Diabetes Center in Boston, about the organization’s rapid shift to telemedicine, patient concerns about access to insulin during a pandemic, and the importance of addressing potentially dangerous misinformation related to medications and COVID-19.
How are you, and how has this situation changed your day-to-day routine?
Gabbay: We have been trying to accomplish things that would normally take us a year in a matter of a week or two. The pace of change is dizzying, but in some ways, there is a silver lining to all of this. From the care delivery side, we will have made some changes that, hopefully, will continue, and we will be better for it. I would have preferred not to do it so quickly and intensely, but that is the way it is.
How is Joslin adapting to the telehealth transition?
Gabbay: I just did a series of virtual visits today. There are adjustments on both ends — among patients and providers — to interact in this different way. What we have been doing at Joslin is very quickly moving to telephone, and then gradually moving to video. With the telephone, there is no instruction needed, so it was easier to move to that right away. Now, obtaining glucose data and other information, like insulin pump settings, has been a work in progress. The unfortunate issue we have all struggled with is there are not any universal sources; there are only a few data aggregators that pull some of what we need for a visit, so there is a lot of time and effort on the workflow side of things on our end. Also on our end, we are contacting patients a day or two before an appointment to walk them through the transition process, because education is often needed. We do that advance work so we don’t use that time during the visit. When that works optimally, we have the necessary data stored, and then the provider can look at that data during the visit. Everything works pretty smoothly when that happens.
What questions are Joslin clinicians hearing the most from patients, and how are they responding?
Gabbay: There are a lot. Predominantly supply chain questions — will I be able to get my insulins? Will I be able to get my diabetes medicines? What we are saying is, so far, yes, but be prepared and make sure you are not running low on anything. Many payors are allowing people to renew sooner so that people can have extra medication on hand. We tell people to plan ahead.
Supplies for devices are another issue. Diabetes, as you know, is driven by that. So far, that supply chain has also been good, but, again, you don’t know what may happen later. One of the challenges there has been managing the paperwork issues associated with continuous glucose monitors and insulin pumps, such as prior authorizations. Our understanding is many payors, including Medicare, are now relaxing visit frequency requirements or allowing a virtual visit to be acceptable. This is accelerating changes that should have happened a long time ago.
There have been some unproven claims published recently, stating that people may want to consider stopping certain medications because they increase the risks for serious complications from COVID-19. What is important for people with diabetes, particularly those with comorbid conditions, to know?
Gabbay: There are some big misconceptions. To summarize the background, a paper was recently published — that was largely theoretical — suggesting an association between treatment with renin-angiotensin-aldosterone system antagonists, such as ACE inhibitors and angiotensin receptor blockers, and increased risk for COVID-19 and increased severity of the disease for those who have contracted COVID-19. These are commonly prescribed treatments for people with hypertension, heart failure and/or ischemic heart disease, all of which can be complications of diabetes. The concern was that the COVID-19 virus binds to a specific enzyme called ACE2 to infect cells, and ACE2 levels are increased after treatment with ACE inhibitors and angiotensin receptor blockers. The paper is conjecture and not based on any study; rather, it is something that was presented to spur further research. Yet it was extrapolated to the crazy talk of people stopping these medications, which are clearly important and beneficial for people with diabetes to protect their kidneys, their heart. We are not recommending stopping any of those medicines due to COVID-19. We are trying to clear up that misconception, because that is a dangerous one.
What message are you stressing for people with diabetes right now?
Gabbay: The data out there that suggests that people with diabetes fare worse if they contract COVID-19 does not divide out people who have well-controlled diabetes vs. people who do not. Our assumption is most things are worse when your diabetes control is poor, and when you are at goal, your risks for complications go way down with any illness. It may or may not be true that well-controlled people have a higher risk for coronavirus complications.
For people who are just not sick, but stuck at home, be creative about how to get exercise. Make sure you have healthy foods on hand, such as whole grains and foods that are low in sodium, if possible. If you do become ill, standard “sick day” rules apply for testing glucose and managing insulin dosing. Have those sick-day supplies at home — something for fever, a cough suppressant — so you don’t have to figure out how to get those things when you are ill.
The big thing I would emphasize is there is good news. It is not all doom and gloom. Many people have had COVID-19 and have recovered. The vast majority of people will do fine. Too much fear is unhelpful. That said, we do need to take all of the recommended precautions and be mobilized to do the right thing. – by Regina Schaffer
Disclosure: Gabbay is chief medical officer of Joslin Diabetes Center.