Managing type 2 diabetes in primary care during COVID-19

Most care can be delivered virtually

In a virtual-first approach to diabetes care during COVID-19, virtual assessments (by telephone or video) should be done every 3 to 6 months and can address most aspects of care. More frequent virtual touchpoints might be needed for complex issues or if guiding the patient through change. In-person visits should still occur at least annually. In-person assessments should be more frequent if a patient’s risk factor control is suboptimal or his or her capacity to engage in virtual care is limited.

Support self-assessment

Where feasible, patients should be encouraged to assess their blood pressure, weight, and feet at home. Supporting patient self-assessment makes virtual visits more effective and in-person visits more efficient and thereby safer. Hypertension Canada provides a list of reputable home blood pressure monitors (https://hypertension.ca/bpdevices) and offers practical advice for patients on how to take their blood pressure at home (https://hypertension.ca/hypertension-and-you/managing-hypertension/measuring-blood-pressure). Blood pressure targets need to be adjusted for home monitoring (eg, an office target of < 130/80 mm Hg means a home target of < 125/75 mm Hg).³ Patients, together with a caregiver, can perform foot screening for neuropathy using the Touch the Toes Test, a method promoted by Diabetes UK (https://www.diabetes.org.uk/guide-to-diabetes/complications/feet/touch-the-toes).⁴ Additionally, clinicians can assess feet visually using video or photos and provide virtual counseling on foot care.

Some investigations can be deferred

Some investigations can be deferred during the COVID-19 pandemic based on individual patient characteristics and risk. For example, patients can have their cholesterol levels checked every 3 years rather than annually if they are taking a stable statin dose with low-density lipoprotein levels at target and have good medication adherence.⁵ If the last hemoglobin A_1c level measured within 3 months was less than 8%, testing can likely be extended to a 6- to 9-month interval, with self-monitoring of blood glucose used as a proxy in the interim. Retinopathy screening can be done at a 3-year interval for those with no previous eye disease and a hemoglobin A_1c level of less than 8%.⁶ Cardiac screening for asymptomatic individuals using electrocardiography can be deferred. Whenever possible, laboratory tests should be clustered to avoid repeat in-person visits.

In-person care should be focused and efficient

In-person care should focus on blood pressure measurement (and home machine calibration), foot assessment, immunizations, and review of a blood glucose log if relevant. Even with in-person visits, relevant information can be collected virtually before the appointment to minimize the time in clinic. For example, an electronic survey can be completed by patients and automatically populated into their electronic medical records (https://ocean.cognisantmd.com/questionnaires/preview/QuestionnairePreview.html?ref=diabetes is an example).

Self-management is more important than ever

Supporting self-management has always been a core tenet of good diabetes care and is even more critical during the COVID-19 pandemic. Patients can be referred to a free virtual diabetes educator through Diabetes Canada by calling 800 BANTING (800 226-8464). Providers can gauge medication adherence by asking, “How many doses have you missed in the past week?” Assessing adherence is particularly important because of a potential decrease in the frequency of “objective” measurement (eg, hemoglobin A_1c level, blood pressure, cholesterol level).

Digital health apps can be helpful for some patients, although most apps in Canada focus on glycemic control alone and require paid upgrades for data sharing with a primary care provider. Many glucometers have specific apps; other popular apps to support glycemic control include Health2Sync and mySugr. Additionally, popular exercise tracking apps (eg, MyFitnessPal) might support patients to maintain a healthy lifestyle during the pandemic.

Finally, it is important to recognize that people with diabetes might be experiencing increased socioeconomic challenges and worsening mental health and addictions because of COVID-19. We encourage proactive screening and referral to relevant supports. For example, Wellness Together Canada (https://ca.portal.gs) is a relatively new national hub providing free mental health and addiction support to patients. The recently developed COVID-19 Social Care Guidance tool⁷ provides tips on screening for social issues and practical resources to help patients.