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J Telemed Telecare OnlineFirst, published on June 1, 2015 as doi:10.1177/1357633X15583425
RESEARCH/Original article
Telemedicine in US Army soldiers with type 1 diabetes
Journal of Telemedicine and Telecare 0(0) 1–4 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X15583425 jtt.sagepub.com
Y Sammy Choi MD1,2, Jon Cucura MS, RD1, Ram Jain PhD2,3 and Cristobal Berry-Caban PhD2
Abstract A retrospective study of a telemedicine clinic for active duty US Army soldiers with type 1 diabetes was conducted. Fifty-one consecutive patients (mean age 33.9 years) were enrolled into the clinic. All soldiers with known or newly diagnosed type 1 diabetes received three weekly office visits for intensive diabetes education. After this, all communication occurred via a messaging system consisting of texting, web-based download, and/or email to a diabetes management team. For urgent matters, 24/7 direct paging or telephone access was provided. Routine adjustments in insulin dosing were accomplished via email. Soldiers were followed for a mean of 17.1 months. Baseline, three-month, and end of study glycated hemoglobin (A1C) values were 9.8, 7.3, and 6.9, respectively. There were no significant differences in end of study A1C levels between patients with known vs. newly diagnosed type 1 diabetes, nor were there any differences between those patients who received insulin via pump therapy vs. multiple daily injections. Telemedicine was safe and effective in lowering A1C levels in US Army soldiers with type 1 diabetes. Keywords Type 1 diabetes, telemedicine, military, soldiers Date received: 22 January 2015; accepted: 15 February 2015
Introduction Telemedicine has been well described in the literature for a multitude of medical conditions.1,2 Use of telemedicine may be of particular interest for conditions that may require frequent follow-up to ensure not only positive outcome but reduction of adverse events. The military in particular creates an extremely active and variable lifestyle where telemedicine support could be beneficial. By utilizing remote access, telemedicine could be a cost-effective means to provide medical care, thereby facilitating the ability for a soldier to remain on active duty status. Furthermore, service members often deploy for 3–12 months to locations that may not have specialty medical care. Telemedicine support could therefore allow not only for retention of highly trained soldiers, but safe deployment with established continuity of care.3 In the US Army, those with a pre-existing diagnosis of type 1 diabetes cannot enter military service, but those already in the military may be retained after the diagnosis of type 1 diabetes is made if they attain adequate control and can fulfil their duties.3 We have for many years taken care of active duty soldiers with type 1 diabetes and our approach has been to consider them as comparable to an elite athlete who develops type 1 diabetes. The athlete and soldier both require frequent monitoring and feedback to ensure optimal and safe performance.
Our experience with telemedicine in paediatric patients with type 1 diabetes has been previously reported.4 Using a similar model, we hypothesized that telemedicine could achieve adequate and safe control in soldiers with type 1 diabetes, thereby allowing them to perform a full range of duties, including intense and specialized physical training, airborne operations, and military deployments. This study reports the results of 51 consecutive soldiers with type 1 diabetes enrolled into our telemedicine clinic.
Methods Case managers and primary care providers at Womack Army Medical Centre (WAMC), Fort Bragg, North Carolina, were invited to enrol soldiers with type 1 diabetes into the active duty type 1 diabetes telemedicine clinic (hereafter ‘clinic’) comprised of a diabetes provider and a certified diabetes educator/pump trainer. All patients were seen at an initial intake visit by an 1
Department of Medicine, Fort Bragg, North Carolina, USA Department of Clinical Investigation, Fort Bragg, North Carolina, USA 3 EmpiriStat, Inc., Mount Airy, Maryland, USA 2
Corresponding author: Y Sammy Choi, Department of Clinical Investigation, Fort Bragg, North Carolina 28310, USA. Email: [email protected]
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educator/trainer who had extensive experience with type 1 diabetes. If eligibility was confirmed, patients were then seen by the diabetic provider for three onehour weekly intensive training sessions that focused on advanced tools of diabetes management. Topics of discussion were hypoglycaemia awareness and treatment, basal/ bolus strategy to include determination and verification, sick day management, and physical exercise to include endurance activities. Concurrently, all soldiers were offered insulin pump therapy and continuous glucose monitoring via any of the currently available commercial products. After the initial three-week train-up period, soldiers were managed almost exclusively through telemedicine. Those soldiers previously not on insulin pump therapy that opted for pump therapy were started on an intensive two-week insulin pump start-up protocol via telemedicine. Once user expertise and pump settings were verified, additional verification for appropriate glucose control was achieved through use of continuous glucose monitoring for special duties such as airborne operations that included static line and high altitude low opening parachute jumps. A typical soldier completed all training within eight weeks. The primary insulin pump used was the MiniMed Paradigm or 530 G (Medtronic, Northridge, CA). This system allows wireless download of data into a website that can be viewed instantly by the clinic. The data download provides information such as glucose values and continuous glucose sensor readings, quantity of carbohydrates counted, amount of meal and correction boluses given, insulin pump settings, and the exact time the data was collected. For those not on an insulin pump, a spreadsheet was provided that allowed patients to enter time, glucose values, amount of carbohydrates ingested and amount of basal or bolus insulin given. These values were transmitted to the clinic via the internet. Soldiers were encouraged to transmit data frequently to allow for near real-time assessment and adjustments. During intense field or athletic training on consecutive days, transmission of data could occur daily or more frequently to allow for remote adjustment of medical treatment. All were given 24/7 direct paging and telephone access. At least weekly transmittal of data was required for glycated hemoglobin (A1C) > 8.0. Our clinic allowed borderline control, i.e. A1C of 7.0–7.5, for those soldiers who were at risk of hypoglycaemia or had not developed the confidence to more aggressively manage their diabetes. Those with borderline or adequate control (A1C < 7.0) were not required to transmit weekly data. Baseline A1C was collected at enrolment and after three months; a subsequent follow-up visit was also recorded. Descriptive statistics were reported for baseline and follow-up A1C levels. This project received WAMC institutional approval.
Results A total of 51 patients (49 males, two females) participated in the study. The mean age of the patients was 33.9 years (SD ¼ 7.9 years). At entry into the clinic, the mean A1C was 9.8 (SD ¼ 2.9). The number of patients with A1C < 7.0, between 7.0 and 8.0, and >8.0 was 10, 6, and 35, respectively. Twenty-nine (57%) soldiers were newly diagnosed with type 1 diabetes. Thirty-seven (73%) soldiers were managed by insulin pump therapy, 13 by multiple daily injections (MDI) and one by a combination of both. At the first follow-up A1C at three months the mean A1C was 7.3 (SD ¼ 1.6). Forty patients had their A1C decrease from their initial values (mean ¼ 3.4, SD ¼ 2.9). Overall (N ¼ 51), the mean decrease in A1C between the baseline and first follow-up A1C was 2.5 (SD ¼ 3.1). At the first follow-up, there was no significant difference in mean A1C in those with newly vs. previously diagnosed type 1 diabetes (7.2 [SD ¼ 1.7] vs. 7.4 [SD ¼ 1.4], respectively; P ¼ 0.75). Also, at first follow-up, there was no significant difference in mean A1C in those receiving insulin pump therapy vs. MDI (7.1 [SD ¼ 1.1] vs. 7.8 [SD ¼ 2.4], respectively; P ¼ 0.30). Mean total time in the study was 17.1 months (SD ¼ 13.6 months) and mean A1C at the end of the study was 6.9 (SD ¼ 1.7); 34 patients achieved an A1C of 7.0 at the time of entry into the study, 33 reached an A1C level of 8 was 34, 11, and 6, respectively. At the conclusion of the study, there were no significant differences in mean A1C for those newly diagnosed vs. those with known diagnosis (6.6 [SD ¼ 1.9] vs. 7.2 [SD ¼ 1.5], respectively; P ¼ 0.21). Also, at the end of the study, there were no significant differences in mean A1C in those receiving insulin pump therapy vs. MDI (6.7 [SD ¼ 1.5] vs. 7.5 [SD ¼ 2.3], respectively; P ¼ 0.16). Three patients were determined to be non-compliant: one was separated from the military due to substance abuse; another opted to exit the military on a medical discharge; and the final soldier chose retirement. Their final A1Cs were 10.9, 13.6, and 10.1. If these three are excluded from the data analysis, the initial and final A1C values for the entire cohort were 9.6 and 6.6, respectively.
Discussion Several recent reviews have shown that telemedicine has some success in treating patients with type 1 diabetes.5–11 However, randomized controlled trials are not available to show the efficacy of using telemedicine to treat patients with diabetes who have a lifestyle comparable to a soldier. There are case reports of athletes with type 1 diabetes who have been monitored during endurance sports,12–15 some with continuous glucose monitoring.16 Various studies and reviews describe anticipated glucose response to
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exercise in patients with type 1 diabetes.17–25 Using available literature and our own experience with soldiers, we developed a programme that allows for soldiers participating in a full range of physical activities that are similar to published accounts of athletic competitions. To our knowledge, this is the largest reported case series describing the use of telemedicine in very physically active patients with type 1 diabetes. In our cohort of 51 active duty soldiers with type 1 diabetes, the use of telemedicine demonstrated that such soldiers could attain acceptable A1C targets without compromise of military duties. Furthermore, through advanced monitoring techniques, we were able to verify that participation in extreme forms of activity was safe. Examples of such activities are military deployments, airborne operations to include static line and high altitude low opening parachute jumps, specialized training such as airborne and jumpmaster school, 400 mile cycling events, and ultra-marathons. Several limitations to our study include the use of retrospective design and a lack of matched controls. From experience, it would be quite difficult to randomize any soldier to conventional office group simply because frequent visits to optimize control are very difficult due to the operational demands placed upon a service member, i.e. soldiers prefer telemedicine to conventional office care. Additionally, our approach is designed to provide unlimited access to our soldiers, which is not feasible in the current private payer reimbursement system.26 Though of limited generalizability, our study does offer some insight into the use of telemedicine in the military. When soldiers are given remote access to care, whether from home or another country, they develop the confidence to effectively and safely perform their duties. Such performance of duties at times includes work in extreme conditions. Additionally, they have the confidence to continue or begin a wide variety of recreational activities. We have piloted a programme that allows for longer term continuity of care via telemedicine. When our soldiers are re-assigned to another military base, continued telemedicine is offered through joint agreement with the local military primary care provider and soldier. This is of particular advantage when the nearest diabetes specialty care is over an hour away as non-military providers rarely offer the extensive telemedicine support that we do. Our team initiates all requests for scheduled laboratory and consultative visits, e.g. eye and dietetic appointments. A focused diabetic examination is conducted by the primary care provider. If complications occur or control is not adequate, we then recommend referral to local diabetes care. In summary, this study demonstrates the effectiveness of telemedicine in adequately controlling active duty US Army soldiers with type 1 diabetes via telemedicine. Such soldiers have some similarity to athletes engaged in a variety of training and competitive events. Further research into the long-term sustainability of acceptable control over multiple deployments and re-assignments would be beneficial.
Acknowledgements The views expressed here are those of the authors and do not reflect the official policy or position of the Department of Army, Department of Defence or the US Government. We wish to thank Ms. Brenda Lowery, Medical Library and Learning Resource Centre, for her invaluable assistance.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Roine R, Ohinmaa A and Hailey D. Assessing telemedicine: a systematic review of the literature. Can Med Assoc J 2001; 165: 765–771. 2. Wootton R. Twenty years of telemedicine in chronic disease management – an evidence synthesis. J Telemed Telecare 2012; 18: 211–220. 3. Army Regulation 40-501. Medical Services Standards of Medical Fitness. Table 5-1. Headquarters, Department of the Army, Washington, DC, 10 September 2008. 4. Choi YS, Berry-Caban C and Nance J. Telemedicine in paediatric patients with poorly controlled type 1 diabetes. J Telemed Telecare 2013; 19: 219–221. 5. Fitzner K and Moss G. Telehealth–an effective delivery method for diabetes self-management education? Popul Health Manag 2013; 16: 169–177. 6. Wojcicki JM, Ladyzynski P and Foltynski P. What we can really expect from telemedicine in intensive diabetes treatment: 10 years later. Diabetes Technol Ther 2013; 15: 260–268. 7. Siriwardena N, Wickramasinghe S, Perera D, et al. A review of telemedicine interventions in diabetes care. J Telemed Telecare 2012; 18: 164–168. 8. Franc S, Daoudi A, Mounier S, et al. Telemedicine and diabetes: achievements and prospects. Diabetes Metab 2011; 37: 463–476. 9. Verhoeven F, Tanja-Dijkstra K, Nijland N, et al. Asynchronous and synchronous teleconsultation for diabetes care: a systematic literature review. J Diabetes Sci Technol 2010; 4: 666–684. 10. Polisena J, Tran K, Cimon K, et al. Home telehealth for diabetes management: a systematic review and meta-analysis. Diabetes Obes Metabol 2009; 11: 913–930. 11. Azar M and Gabbay R. Web-based management of diabetes through glucose uploads: has the time come for telemedicine? Diabetes Res Clin Pract 2009; 83: 9–17. 12. Sane T, Helve E, Pelkonen R, et al. The adjustment of diet and insulin dose during long-term endurance exercise in type 1 (insulin-dependent) diabetic men. Diabetologia 1988; 31: 35–40. 13. Pavao V, Sinisˇ a C and Ivanka O. Sweet 452 km – a report on the first type 1 diabetes patient to finish Double Ironman, a 30-hour endurance triathlon race. Croat Med J 2013; 54: 306–307.
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14. Boehncke S, Poettgen K, Maser-Gluth C, et al. Endurance capabilities of triathlon competitors with type 1 diabetes mellitus. Dtsch Med Wochenschr 2009; 134: 677–682. 15. Murillo S, Brugnara L and Novials AJ. One year follow-up in a group of half-marathon runners with type-1 diabetes treated with insulin analogues. J Sports Med Phys Fitness 2010; 50: 506–510. 16. Cauza E, Hanusch-Enserer U, Strasser B, et al. Continuous glucose monitoring in diabetic long distance runners. Int J Sports Med 2005; 26: 774–780. 17. McMahon SK, Ferreira LD, Ratnam N, et al. Glucose requirements to maintain euglycemia after moderate-intensity afternoon exercise in adolescents with type 1 diabetes are increased in a biphasic manner. J Clin Endocrinol Metab 2007; 92: 963–968. 18. Guelfi KJ, Jones TW and Fournier PA. The decline in blood glucose levels is less with intermittent high-intensity compared with moderate exercise in individuals with type 1 diabetes. Diabetes Care 2005; 28: 1289–1294.
19. Gallen IW. Review: helping the athlete with type 1 diabetes. Br J Diabetes Vasc Dis 2004; 4: 87–92. 20. Elder CL, Pujol TJ and Barnes JT. Exercise considerations for individuals with type 1 diabetes. Strength Condit J 2004; 26: 16–18. 21. Macknight JM, Mistry DJ, Pastors JG, et al. The daily management of athletes with diabetes. Clin Sports Med 2009; 28: 479–495. 22. Lumb AN and Gallen IW. Diabetes management for intense exercise. Curr Opin Endocrinol Diabetes Obes 2009; 16: 150–155. 23. De Feo P, Di Loreto C, Ranchelli A, et al. Exercise and diabetes. Acta Biomed 2006; 77(S1): 14–17. 24. Toni S, Reali MF, Barni F, et al. Managing insulin therapy during exercise in type 1 diabetes mellitus. Acta Biomed 2006; 77(S1): 34–40. 25. Lisle DK and Trojian TH. Managing the athlete with type 1 diabetes. Curr Sports Med Rep 2006; 5: 93–98. 26. Whitten P and Buis L. Private payer reimbursement for telemedicine services in the United States. Telemed J E Health 2007; 13: 15–24.
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J Telemed Telecare OnlineFirst, published on June 1, 2015 as doi:10.1177/1357633X15583425
RESEARCH/Original article
Telemedicine in US Army soldiers with type 1 diabetes
Journal of Telemedicine and Telecare 0(0) 1–4 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X15583425 jtt.sagepub.com
Y Sammy Choi MD1,2, Jon Cucura MS, RD1, Ram Jain PhD2,3 and Cristobal Berry-Caban PhD2
Abstract A retrospective study of a telemedicine clinic for active duty US Army soldiers with type 1 diabetes was conducted. Fifty-one consecutive patients (mean age 33.9 years) were enrolled into the clinic. All soldiers with known or newly diagnosed type 1 diabetes received three weekly office visits for intensive diabetes education. After this, all communication occurred via a messaging system consisting of texting, web-based download, and/or email to a diabetes management team. For urgent matters, 24/7 direct paging or telephone access was provided. Routine adjustments in insulin dosing were accomplished via email. Soldiers were followed for a mean of 17.1 months. Baseline, three-month, and end of study glycated hemoglobin (A1C) values were 9.8, 7.3, and 6.9, respectively. There were no significant differences in end of study A1C levels between patients with known vs. newly diagnosed type 1 diabetes, nor were there any differences between those patients who received insulin via pump therapy vs. multiple daily injections. Telemedicine was safe and effective in lowering A1C levels in US Army soldiers with type 1 diabetes. Keywords Type 1 diabetes, telemedicine, military, soldiers Date received: 22 January 2015; accepted: 15 February 2015
Introduction Telemedicine has been well described in the literature for a multitude of medical conditions.1,2 Use of telemedicine may be of particular interest for conditions that may require frequent follow-up to ensure not only positive outcome but reduction of adverse events. The military in particular creates an extremely active and variable lifestyle where telemedicine support could be beneficial. By utilizing remote access, telemedicine could be a cost-effective means to provide medical care, thereby facilitating the ability for a soldier to remain on active duty status. Furthermore, service members often deploy for 3–12 months to locations that may not have specialty medical care. Telemedicine support could therefore allow not only for retention of highly trained soldiers, but safe deployment with established continuity of care.3 In the US Army, those with a pre-existing diagnosis of type 1 diabetes cannot enter military service, but those already in the military may be retained after the diagnosis of type 1 diabetes is made if they attain adequate control and can fulfil their duties.3 We have for many years taken care of active duty soldiers with type 1 diabetes and our approach has been to consider them as comparable to an elite athlete who develops type 1 diabetes. The athlete and soldier both require frequent monitoring and feedback to ensure optimal and safe performance.
Our experience with telemedicine in paediatric patients with type 1 diabetes has been previously reported.4 Using a similar model, we hypothesized that telemedicine could achieve adequate and safe control in soldiers with type 1 diabetes, thereby allowing them to perform a full range of duties, including intense and specialized physical training, airborne operations, and military deployments. This study reports the results of 51 consecutive soldiers with type 1 diabetes enrolled into our telemedicine clinic.
Methods Case managers and primary care providers at Womack Army Medical Centre (WAMC), Fort Bragg, North Carolina, were invited to enrol soldiers with type 1 diabetes into the active duty type 1 diabetes telemedicine clinic (hereafter ‘clinic’) comprised of a diabetes provider and a certified diabetes educator/pump trainer. All patients were seen at an initial intake visit by an 1
Department of Medicine, Fort Bragg, North Carolina, USA Department of Clinical Investigation, Fort Bragg, North Carolina, USA 3 EmpiriStat, Inc., Mount Airy, Maryland, USA 2
Corresponding author: Y Sammy Choi, Department of Clinical Investigation, Fort Bragg, North Carolina 28310, USA. Email: [email protected]
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educator/trainer who had extensive experience with type 1 diabetes. If eligibility was confirmed, patients were then seen by the diabetic provider for three onehour weekly intensive training sessions that focused on advanced tools of diabetes management. Topics of discussion were hypoglycaemia awareness and treatment, basal/ bolus strategy to include determination and verification, sick day management, and physical exercise to include endurance activities. Concurrently, all soldiers were offered insulin pump therapy and continuous glucose monitoring via any of the currently available commercial products. After the initial three-week train-up period, soldiers were managed almost exclusively through telemedicine. Those soldiers previously not on insulin pump therapy that opted for pump therapy were started on an intensive two-week insulin pump start-up protocol via telemedicine. Once user expertise and pump settings were verified, additional verification for appropriate glucose control was achieved through use of continuous glucose monitoring for special duties such as airborne operations that included static line and high altitude low opening parachute jumps. A typical soldier completed all training within eight weeks. The primary insulin pump used was the MiniMed Paradigm or 530 G (Medtronic, Northridge, CA). This system allows wireless download of data into a website that can be viewed instantly by the clinic. The data download provides information such as glucose values and continuous glucose sensor readings, quantity of carbohydrates counted, amount of meal and correction boluses given, insulin pump settings, and the exact time the data was collected. For those not on an insulin pump, a spreadsheet was provided that allowed patients to enter time, glucose values, amount of carbohydrates ingested and amount of basal or bolus insulin given. These values were transmitted to the clinic via the internet. Soldiers were encouraged to transmit data frequently to allow for near real-time assessment and adjustments. During intense field or athletic training on consecutive days, transmission of data could occur daily or more frequently to allow for remote adjustment of medical treatment. All were given 24/7 direct paging and telephone access. At least weekly transmittal of data was required for glycated hemoglobin (A1C) > 8.0. Our clinic allowed borderline control, i.e. A1C of 7.0–7.5, for those soldiers who were at risk of hypoglycaemia or had not developed the confidence to more aggressively manage their diabetes. Those with borderline or adequate control (A1C < 7.0) were not required to transmit weekly data. Baseline A1C was collected at enrolment and after three months; a subsequent follow-up visit was also recorded. Descriptive statistics were reported for baseline and follow-up A1C levels. This project received WAMC institutional approval.
Results A total of 51 patients (49 males, two females) participated in the study. The mean age of the patients was 33.9 years (SD ¼ 7.9 years). At entry into the clinic, the mean A1C was 9.8 (SD ¼ 2.9). The number of patients with A1C < 7.0, between 7.0 and 8.0, and >8.0 was 10, 6, and 35, respectively. Twenty-nine (57%) soldiers were newly diagnosed with type 1 diabetes. Thirty-seven (73%) soldiers were managed by insulin pump therapy, 13 by multiple daily injections (MDI) and one by a combination of both. At the first follow-up A1C at three months the mean A1C was 7.3 (SD ¼ 1.6). Forty patients had their A1C decrease from their initial values (mean ¼ 3.4, SD ¼ 2.9). Overall (N ¼ 51), the mean decrease in A1C between the baseline and first follow-up A1C was 2.5 (SD ¼ 3.1). At the first follow-up, there was no significant difference in mean A1C in those with newly vs. previously diagnosed type 1 diabetes (7.2 [SD ¼ 1.7] vs. 7.4 [SD ¼ 1.4], respectively; P ¼ 0.75). Also, at first follow-up, there was no significant difference in mean A1C in those receiving insulin pump therapy vs. MDI (7.1 [SD ¼ 1.1] vs. 7.8 [SD ¼ 2.4], respectively; P ¼ 0.30). Mean total time in the study was 17.1 months (SD ¼ 13.6 months) and mean A1C at the end of the study was 6.9 (SD ¼ 1.7); 34 patients achieved an A1C of 7.0 at the time of entry into the study, 33 reached an A1C level of 8 was 34, 11, and 6, respectively. At the conclusion of the study, there were no significant differences in mean A1C for those newly diagnosed vs. those with known diagnosis (6.6 [SD ¼ 1.9] vs. 7.2 [SD ¼ 1.5], respectively; P ¼ 0.21). Also, at the end of the study, there were no significant differences in mean A1C in those receiving insulin pump therapy vs. MDI (6.7 [SD ¼ 1.5] vs. 7.5 [SD ¼ 2.3], respectively; P ¼ 0.16). Three patients were determined to be non-compliant: one was separated from the military due to substance abuse; another opted to exit the military on a medical discharge; and the final soldier chose retirement. Their final A1Cs were 10.9, 13.6, and 10.1. If these three are excluded from the data analysis, the initial and final A1C values for the entire cohort were 9.6 and 6.6, respectively.
Discussion Several recent reviews have shown that telemedicine has some success in treating patients with type 1 diabetes.5–11 However, randomized controlled trials are not available to show the efficacy of using telemedicine to treat patients with diabetes who have a lifestyle comparable to a soldier. There are case reports of athletes with type 1 diabetes who have been monitored during endurance sports,12–15 some with continuous glucose monitoring.16 Various studies and reviews describe anticipated glucose response to
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exercise in patients with type 1 diabetes.17–25 Using available literature and our own experience with soldiers, we developed a programme that allows for soldiers participating in a full range of physical activities that are similar to published accounts of athletic competitions. To our knowledge, this is the largest reported case series describing the use of telemedicine in very physically active patients with type 1 diabetes. In our cohort of 51 active duty soldiers with type 1 diabetes, the use of telemedicine demonstrated that such soldiers could attain acceptable A1C targets without compromise of military duties. Furthermore, through advanced monitoring techniques, we were able to verify that participation in extreme forms of activity was safe. Examples of such activities are military deployments, airborne operations to include static line and high altitude low opening parachute jumps, specialized training such as airborne and jumpmaster school, 400 mile cycling events, and ultra-marathons. Several limitations to our study include the use of retrospective design and a lack of matched controls. From experience, it would be quite difficult to randomize any soldier to conventional office group simply because frequent visits to optimize control are very difficult due to the operational demands placed upon a service member, i.e. soldiers prefer telemedicine to conventional office care. Additionally, our approach is designed to provide unlimited access to our soldiers, which is not feasible in the current private payer reimbursement system.26 Though of limited generalizability, our study does offer some insight into the use of telemedicine in the military. When soldiers are given remote access to care, whether from home or another country, they develop the confidence to effectively and safely perform their duties. Such performance of duties at times includes work in extreme conditions. Additionally, they have the confidence to continue or begin a wide variety of recreational activities. We have piloted a programme that allows for longer term continuity of care via telemedicine. When our soldiers are re-assigned to another military base, continued telemedicine is offered through joint agreement with the local military primary care provider and soldier. This is of particular advantage when the nearest diabetes specialty care is over an hour away as non-military providers rarely offer the extensive telemedicine support that we do. Our team initiates all requests for scheduled laboratory and consultative visits, e.g. eye and dietetic appointments. A focused diabetic examination is conducted by the primary care provider. If complications occur or control is not adequate, we then recommend referral to local diabetes care. In summary, this study demonstrates the effectiveness of telemedicine in adequately controlling active duty US Army soldiers with type 1 diabetes via telemedicine. Such soldiers have some similarity to athletes engaged in a variety of training and competitive events. Further research into the long-term sustainability of acceptable control over multiple deployments and re-assignments would be beneficial.
Acknowledgements The views expressed here are those of the authors and do not reflect the official policy or position of the Department of Army, Department of Defence or the US Government. We wish to thank Ms. Brenda Lowery, Medical Library and Learning Resource Centre, for her invaluable assistance.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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