key: cord-0725105-lcm62k65
authors: Sarteau, Angelica Cristello; Souris, Katherine Janine; Wang, Jessica; Ramadan, Amira A.; Addala, Ananta; Bowlby, Deborah; Corathers, Sarah; Forsander, Gun; King, Bruce; Law, Jennifer R.; Liu, Wei; Malik, Faisal; Pihoker, Catherine; Seid, Michael; Smart, Carmel; Sundberg, Frida; Tandon, Nikhil; Yao, Michael; Headley, Terry; Mayer‐Davis, Elizabeth
title: Changes to care delivery at nine international pediatric diabetes clinics in response to the COVID‐19 global pandemic
date: 2021-02-16
journal: Pediatr Diabetes
DOI: 10.1111/pedi.13180
sha: 6679d22393cecbb151e5af790ce27e02d1f18deb
doc_id: 725105
cord_uid: lcm62k65

BACKGROUND: Pediatric diabetes clinics around the world rapidly adapted care in response to COVID‐19. We explored provider perceptions of care delivery adaptations and challenges for providers and patients across nine international pediatric diabetes clinics. METHODS: Providers in a quality improvement collaborative completed a questionnaire about clinic adaptations, including roles, care delivery methods, and provider and patient concerns and challenges. We employed a rapid analysis to identify main themes. RESULTS: Providers described adaptations within multiple domains of care delivery, including provider roles and workload, clinical encounter and team meeting format, care delivery platforms, self‐management technology education, and patient‐provider data sharing. Providers reported concerns about potential negative impacts on patients from COVID‐19 and the clinical adaptations it required, including fears related to telemedicine efficacy, blood glucose and insulin pump/pen data sharing, and delayed care‐seeking. Particular concern was expressed about already vulnerable patients. Simultaneously, providers reported 'silver linings' of adaptations that they perceived as having potential to inform care and self‐management recommendations going forward, including time‐saving clinic processes, telemedicine, lifestyle changes compelled by COVID‐19, and improvements to family and clinic staff literacy around data sharing. CONCLUSIONS: Providers across diverse clinical settings reported care delivery adaptations in response to COVID‐19—particularly telemedicine processes—created challenges and opportunities to improve care quality and patient health. To develop quality care during COVID‐19, providers emphasized the importance of generating evidence about which in‐person or telemedicine processes were most beneficial for specific care scenarios, and incorporating the unique care needs of the most vulnerable patients.

care delivery platforms, self-management technology education, and patient-provider data sharing. Providers reported concerns about potential negative impacts on patients from COVID-19 and the clinical adaptations it required, including fears related to telemedicine efficacy, blood glucose and insulin pump/pen data sharing, and delayed care-seeking. Particular concern was expressed about already vulnerable patients. Simultaneously, providers reported 'silver linings' of adaptations that they perceived as having potential to inform care and self-management recommendations going forward, including time-saving clinic processes, telemedicine, lifestyle changes compelled by COVID-19, and improvements to family and clinic staff literacy around data sharing.

Conclusions: Providers across diverse clinical settings reported care delivery adaptations in response to COVID-19-particularly telemedicine processes-created challenges and opportunities to improve care quality and patient health. To develop quality care during COVID-19, providers emphasized the importance of generating evidence about which in-person or telemedicine processes were most beneficial for specific care scenarios, and incorporating the unique care needs of the most vulnerable patients. 

Like other health care centers, pediatric diabetes clinics around the world have rapidly shifted operations in response to COVID-19 in an effort to minimize deleterious patient health consequences caused by disruption in essential ongoing care. 1 We, an existing international quality improvement collaborative of researchers and clinicians from nine pediatric diabetes clinics, developed a questionnaire to (a) ascertain changes to clinical responsibilities, care delivery, team communication, and attempts to minimize patient visits from diabetes complications;

(b) document patient and provider concerns during the early months of COVID-19. Our main aim was to describe adaptations across centers and the perceived impacts of these changes on patients and providers. To expediently understand care delivery adaptations in the rapidly evolving context of COVID-19, while also ensuring a systematic, comprehensive analysis, we used a rapid qualitative analysis approach designed to deliver findings with methodological rigor in time and resource constrained contexts. This method has yielded results consistent (i.e., no significant information differences) with those of indepth analyses. [2] [3] [4] [5] Table 1 describes the method.

When providers were queried, all clinics were complying with local social distancing orders. Features of in-person care included sitting 1.5 m apart, face masks, daily temperature checks of staff and visitors, and limited waiting room occupancy.

Key themes that emerged included adaptive changes in care delivery due to COVID-19 (see Table 2 ), and their associated challenges and unanticipated 'silver linings.' 

Providers described remote sharing of diabetes-related data between providers and patients as a steep learning curve for both parties that required extra time investments from the entire care team. Providers reported difficulties coaching families to share data remotely and challenges retrieving information from data management platforms, as they were accustomed to reviewing data in printed form. As with telemedicine, unstable or no internet connectivity and lack of electronic devices in patient homes presented a barrier to data sharing.

Most centers were reluctant to make claims about increases in frequency or severity of diabetic ketoacidosis (DKA) in newonset or established patients; however, a few centers perceived that DKA presentation in new-onset patients was more severe, with one speculating that there was an increase in later presentation due to, "fear on the part of families or discouragement on T A B L E 1 Rapid analysis using the matrix method

Step 1: Deductively coding free response answers by clinic and refining codebook

• Creation of a standard summary table ("matrix") for each clinic to aggregate free response data (i.e., questions and corresponding answers were placed in adjacent columns) • Independent review of summary tables for all clinics ("immersion") by each analyst (Angelica Cristello Sarteau, Katherine Janine Souris, Jessica Wang) • To calibrate theme identification, all analysts independently coded responses from one randomly selected clinic using deductive codes developed a priori from themes anticipated based on the survey aims and questions. These codes included: changes in clinical care delivery methods that were adopted in response to the pandemic, challenges in delivering diabetes care during the pandemic, opportunities (i.e., unanticipated positives), major concerns of clinicians, patients, and families, provider perceptions of the effect of the pandemic on health outcomes, and perceived sustainability of clinic adaptations • Working session to discuss discrepancies in coding, to ensure consensus regarding code definitions and consistency in code application, and to revise, collapse, and add codes • Calibration and working session process repeated, after which analysts randomly distributed the summary tables among themselves to apply the revised codebook and identify salient quotations from survey responses

Step 2: Aggregating quotes and themes by question and developing summary responses

• Consolidation of the quotes and codes from the clinic-specific summary tables developed in step 1 into a new set of question-specific summary tables (i.e., one table per survey question in which the quotes and codes in the responses across clinics could be examined simultaneously). This step facilitated comparison across clinic responses to each question and theme identification • To ensure consistent methodology, all analysts independently examined the same table and listed the most relevant codes, highlighted illustrative quotes, and produced a short 2-3 sentence summary of the main insights • Working session to discuss any discrepancies in their individual coding and achieved consensus on themes and quotes • Calibration and working session process repeated twice before the matrices were randomly assigned and the analysts independently coded the data in the remaining tables

Step 3: Consolidating summaries, key themes and quotes from each question into one matrix 

Providers in settings without universal health care expressed greatest concern over patients with challenging home lives, food insecurity, and other social and economic difficulties who would be least likely to receive appropriate care in the context of COVID-19. They reported observing widening disparities in care within their clinics during COVID-19, which they attributed to differential access to internet and, in turn, health support. Other factors potentially exacerbating disparities included shifts in clinical responsibilities that prevented social workers from following up with hard-to-reach patients and the loss of supervision from school staff that had previously ensured at least minimal consistency in insulin dosing for the most poorly managed children.

Just as providers expressed concerns over the efficacy and sustainability of telemedicine, they also described the pandemic as an opportunity to refine telemedicine processes, and most described it as a tool that may prove valuable and effective for ongoing care for certain families and clinical care needs.

Providers perceived the opportunity to better educate families on accessing, analyzing, and sharing diabetes-related data as a positive result of adaptations. Across the board, providers and families were described as becoming markedly more familiar accessing or sending diabetes related data remotely, a fundamental step towards improving families' ability to use that data to inform self-management.

Providers devised new strategies to reduce physical contact with patients, which were described as having the added benefit of making T A B L E 2 Summary of clinical care delivery adaptations

Provider roles and workload • Providers shifted work hours, particularly research responsibilities, to evening hours to accommodate childcare needs • Increased non-physician (i.e., CDE, nurse, social worker) hours to provide logistical telemedicine support and manage new COVID-related responsibilities (i.e., staffing COVID screening checkpoints)

Provider meeting format • Shifted to teleconference, however almost all clinics maintained the frequency of team meetings Clinical encounter format • 90-100% of visits occurred remotely post-outbreak (vs. a reported 0-5% before COVID-19). Most visits occurred via videoconference, with phone visits for a subset without videoconference capabilities • All clinics described parents and patients attending remote visits together • In-person visits limited to "urgent patients," newly diagnosed patients, patients with "more complex social situations," patients needing an interpreter, or patients without necessary technology for remote visits • Two clinics described developing a mitigation approach to keep patients out of the emergency department, which involved intensifying communication with families via phone (e.g., disseminating contact numbers of multiple providers) or social media platforms (e.g. managing a Facebook page with self-management tips and reminders)

Care delivery platforms • Doximity and existing proprietary platforms built for the clinic pre-COVID were most frequently reported, although Skype, WhatsApp, Zoom, Jabber, and Cisco were also being utilized

Starting patients on selfmanagement technology

• All clinics that were starting patients on continuous glucose monitors (CGMs) before COVID-19 reported starting patients on CGM via videoconference after the outbreak; in contrast, of clinics that started patients on insulin pumps before COVID-19, approximately half were starting patients on pumps remotely • Most patients began their pump or CGM education via telehealth, either with a clinic provider or a company representative, followed by a subsequent telehealth or in-person visit with the provider team for more advanced skill building • In-person visits for CGM and/or insulin pump starts were arranged if preferred by some clinics Patient-provider sharing of selfmanagement data

• A minority of clinics reported patients sending reports from their own uploads or providers obtaining remote downloads • Providers described using remote downloads more frequently ( and adults have shown improvements in HbA1c and time in range. 9 As suggested by some providers in our study, other researchers attributed improvements in glycemic control during COVID-19 to more parental presence, meals at home, and a more consistent eating pattern. [9] [10] [11] Providers in our study noted that adaptations were more likely to negatively impact patients who were already 'high-risk' due to poor glycemic control and family contexts burdened by economic, social, and behavioral obstacles to diabetes management. These patients are also most likely to be missing from studies examining effects of adaptions on patient health. 12 Factors like low socioeconomic status, health literacy, language proficiency, and access to reliable internet and cellular service are barriers to telemedicine accessibility for some families. 13 Patients with cognitive and sensory impairments face additional barriers to effective virtual communication. 14 Elizabeth Mayer-Davis https://orcid.org/0000-0003-3858-0517

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Changes to care delivery at nine international pediatric diabetes clinics in response to the COVID-19 global pandemic