Memorandum

Joslin Diabetes Center’s Dr. Bob Gabbay on COVID-19 and diabetes – an Interview with Close Concerns - April 2, 2020

Executive Highlights

  • Our team recently sat down (virtually, and actually some of us were standing) with Joslin Diabetes Center’s CMO Dr. Bob Gabbay to discuss how COVID-19 is impacting people with diabetes. Topics spanned from why people with diabetes may be at greater risk of COVID-19, to misinformation regarding the virus, to how Joslin Diabetes Center is ramping up its own telehealth efforts to adapt to new healthcare realities amidst a pandemic.  

  • Throughout the interview, Dr. Gabbay emphasized the importance of connectedness between patients and HCPs through this crisis. He commented, “What we undervalue is the power of a conversation… The feeling of connection, reassurance, touching base, having a conversation about the blood sugars as opposed to honing in on that as the focus of everything, which it has a tendency to do when you have all that data in front of you. [The situation] has reinforced for all of us how important that conversation and relationship is.”

  • In terms of challenges to remote diabetes care, Dr. Gabbay pointed to (i) the lack of a universal system to aggregate data from CGMs, pumps, glucose meters, etc.; and (ii) the difficulties surrounding prior authorizations. On the latter point, he noted, “Where we found a real pain point is the issue around devices and prior authorizations. That's been one of our big challenges in figuring out the workflow … Under normal times, that's an annoyance of the paperwork, but adding that level of uncertainty, I think that should be eliminated as well.” We’d love to see this happen but feel it is unlikely.

  • Dr. Gabbay ended the interview on a hopeful note, stating, “I tend to be an optimistic person. The silver linings here are (i) the rapidity to which we're moving to virtual care, which is what everybody wants; and (ii) to date, there are more than 200,000 people that have recovered from COVID-19. Yes, it's dangerous. It's bad. It's all of that. But by far, the vast majority of people are doing well with it. And so, we want people to be careful and take the right precautions. But it's not all doom and gloom.”

Interview Discussion and Highlights

On Diabetes and COVID-19

Martin Kurian: Could you expand upon why people with diabetes and related chronic conditions are more susceptible to COVID-19? Are there any differences in susceptibility between those with type 1 diabetes and type 2 diabetes that you want to discuss?

Dr. Bob Gabbay: I think the challenge with a lot of this is that we don't know all the answers, but we've taken various pieces of information and extrapolated from there. A piece of information that we do have comes from influenza, which is somewhat related but obviously different. In that case, we know that people with diabetes have a greater risk of developing the disease and probably more importantly, do worse or have the potential to do worse in terms of outcomes. The other piece of information we have is data from China that looked at mortality rates and severe illness rates and demonstrated that people with diabetes, again, tended to do worse than people without diabetes. Hence that idea of high risk.

There's really not any data comparing type 1 and type 2, and so that makes it tricky to be able to extrapolate.

Then, the other piece that is hard to know the answer to is – what about people with diabetes whose blood sugars are well controlled? Do they have an increased risk? Well, certainly not as much as people that have an A1c of 12 or 14. They obviously have a much higher risk. So, what that incremental risk is for people with a reasonably good A1c control is even a bigger question.

When we're advising individuals, I think we sort of say, “Look, consider yourself high risk. You may not be, which would be wonderful, but there's no harm in treating yourself as higher risk, in a sense.”

Rhea Teng: Got it. Thank you. What is some of the unproven and potentially dangerous misinformation that's come out on COVID-19 that could possibly impact people with diabetes?

Dr. Gabbay: Well, one that really has been quite troubling that circulated recently, that we've gotten a lot of questions about, has been about the use of ACE inhibitors and ARBs – blood pressure medications that are also protective to the kidneys. There was a paper that came out suggesting, not so much that there was evidence that those drugs were bad or problematic, but really based on a very theoretical framework, that the receptors for COVID-19 might be similar. And therefore, if you're upregulating those receptors, you might be more likely to have the disease.

That was just all conjectures, in essence. But, hypothesis generating, in other words, gets you thinking. Studies should be done to compare or not compare. But nobody, certainly in the medical community and this includes statements from American Heart Association and the American College of Cardiology, nobody believes that people with diabetes should be stopping these potentially very valuable and important medications in the midst of all of this. So, that's probably the diabetes-specific biggest misinformation piece that I've seen out there.

And then, there are just a ridiculous number of wacky things that people hear that, again, we get repeated to us. For example, “I'm going to drink water every five minutes or 10 minutes because it’s going to wash out the virus from my mouth.” Or just all sorts of wacky things like, “I'm going to gargle with isopropyl alcohol to help prevent the disease and a whole host of things.”

I think this is where, more than ever, it's important that people look to trusted sources, like you folks at Close Concerns, like the Joslin website where we catalog a lot of this information, and other reputable sources and not listen to some of the “wackiness” that can be out there.

On Telehealth

Ursula Biba: How is Joslin ramping up its telehealth capabilities now that the need (and interest) has exponentially increased in such a short period of time? Getting Medicare coverage for telehealth is quite exceptional, given previous expectations on how long it would take.

Dr. Gabbay: It's really been remarkable. I would have to say, we did at Joslin in a week what would normally take a year to do. And it was an incredible effort by an entire team that was highly focused. In a sense, there's nothing like a crisis to do a couple of things. One, to identify the things that you really need to work on, and also, to galvanize focus on what needs to be done.

We internally have been meeting every day, senior leadership and across the organization, to make this pivot. We have largely gone, with the exception of a small number of urgent cases –primarily ophthalmology care, where procedures and things like that need to be done to maintain eyesight – most everything else is remote.

That's not to say it's not a little clunky. It's taking some getting used to as clinicians and individuals with diabetes, but I do think that if there's some silver lining in all of this, it is that we're all making that pivot to virtual care far more rapidly than we ever would. And I think some of that will undoubtedly continue even after this crisis is over.

Ani Gururaj: Dr. Irl Hirsch recently wrote an editorial referring to learning how to manage diabetes during COVID-19 as “baptism by fire.” Can you speak to what some of the unforeseen challenges that COVID-19 has uncovered about telehealth, specifically?

Dr. Gabbay: Well, I think there are a number. It probably starts with both clinicians and individuals with diabetes that had been dipping their toe into this, now, having to jump into the deep end quickly. And so, with that there have been challenges around information sharing. The fact is that we still have to go through a variety of different tools to get all the data we want from different pumps and CGMs and glucose meters. There are some aggregators out there, but there isn't a uniform and universal system. So, we're all having to go to different places for different things. I think that has made things more challenging.

On the other hand, as clinicians, we're often thinking, “Well, we want to have all the data and look at everything and have it all in front of us for the visit,” but what we undervalue is the power of a conversation. Even in phone visits, which we've been doing, we're ramping up more virtual visits. The feeling of connection, reassurance, touching base, having a conversation about the blood sugars as opposed to honing in on that as the focus of everything, which it has a tendency to do when you have all that data in front of you. I think, it's reinforced for all of us how important that conversation and relationship is. And that, I think, is a good thing.

On Patient Reaction to Telehealth

Albert Cai: Can you talk a little bit about what the patient reaction to tele-visits have been, especially, maybe some of your older patients or less technically inclined patients?

Dr. Gabby: That's where we've sort of varied our approach. So, we, as I mentioned, we're doing a good number of telephone visits as well. And so for that patient population, it's just easier to adapt to a telephone visit. Virtually, everyone knows how to use a telephone. And so that's worked really well.

We have and we had been doing virtual visits for a while in the form of a pilot with one of the vendors, American Well. With another provider of virtual visits for some routine care (VSee), that has been more for people that were at a distance. We have people that come literally from all over the world to Joslin. So, we were able to use those approaches. Where we're looking to spread is into those different populations.

The other groups that I would say has been really important to do these kind of visits with have been around behavioral health. Where, number one, that reassurance is really important and that feeling of connectedness. Phone works well, but video is even more important because of the social connectedness.

On Joslin Diabetes Center

Bradley Fox: What is Joslin’s role in communicating with patients and who's in charge of developing these communications?

Dr. Gabbay: Yeah, that's a great question. So, we take a big responsibility here for our patients because we connect to so many health professionals through educational programs and really have a very global footprint. One of the ways that we were fortunate, in a sense, is that we revamped our website a few months ago, so it a lot more nimble and able to change quickly. Our old website was a bit antiquated and difficult to make edits. So now we can do that in virtually real time. So that's been a great source for us to do that.

We have a task force that I sit on along with a number of the other key leaders at Joslin, and we've been meeting literally every day, because every day there's something going on. Every day, we’ve been updating communications, internally and externally, based on that information. It's more than any health situation I've seen in my career. This is so fast moving that the plans are for today, and tomorrow, we'll have to relook at those plans.

On Potential Diabetes and COVID-19 Legislation

Rhea: ADA CEO Tracy Brown recently called on Congress to enact three specific measures to protect people with diabetes. The first was limiting co-pays for insulin for the duration of the emergency. The second was eliminating Medicare requirements that say that CGM patients must see their doctors in person every six months. And third, waiving in-person requirements for telehealth. We’re curious about your thoughts on these requirements.

Dr. Gabbay: I think all three of those are super important, and I agree with all of them. I think Tracy is a great leader in pushing that. Because she, also like many of us, has a chance to really shape the debate.

I think those are all important. I might add some other things. Again, when you're making an appeal to Congress, giving a list of ten things is probably less effective than three things. But where we found a real pain point is the issue around devices and prior authorizations. That's been one of our big challenges in figuring out the workflow, with how to go all virtual, is those prior authorizations and then the inevitable, “I was on this drug, but now that's not on formulary and I have to switch to that drug.” Under normal times, that's an annoyance of the paperwork. But adding that level of uncertainty, I think that should be eliminated as well, even if it’s just a temporary thing that the payers agree on. Medicare helps to set the standard on much of this, particularly for Medicaid. But really, we'd like to see health plans in general sort of move away from that, at a minimum, during this crisis period.

 

--by Rhea Teng, Martin Kurian, Bradley Fox, and Kelly Close