We were interested to follow implementation of telemedicine care in children and adolescents with T1D in Germany and particularly focused on whether telemedicine worked as ad hoc uptake during the strict COVID-19-lockdown period, as it has been strongly demonstrated by the T1DX-QI register . The DPV registry prospectively surveys more than 90% of all individuals with T1D younger than 18 years in Germany. Here we give a detailed picture of first, patients that had a chance to use telemedicine in 2020 with special focus on the strict lockdown weeks in Germany, and second, on those diabetes centers that established some level of telemedicine compared to centers who provided in-person visits only.
In Germany, most children and adolescents with T1D receive continuous outpatient care in specialized pediatric diabetes centers providing both inpatient and outpatient care. The “COVID-19-lockdown” was imposed all over Germany and within days decisions were made on what kind of in-person visits needed to be classified as “urgent” or had to be cancelled. Any type of telemedicine was immediately used to contact families and assure that prescriptions for devices, supplies and insulin were sufficient. All routine contacts should be postponed or switched to telemedicine contacts, if accepted by the families. Interestingly, even under this conditions, the majority of outpatient contacts were postponed over the two-month-period or still continued as in-person visits, while telemedicine visits rose to 12.8.%. This was remarkably higher than 0.5% in the same period of 2019 but far from the 95% rise in telemedicine visits found in the T1DX-QI for the US . Our evaluation revealed that only 61 centers used telemedicine in more than 5 of their patients and their mode of telemedicine ranged from almost exclusively using video consultation to primarily using telephone calls. Telephone calls were also the major strategy for telemedicine contacts with families and patients during the lockdown weeks. As reported above, the majority of the 61 centers started documenting telemedicine visits during lockdown until May 13th, so that COVID-lockdown clearly fueled onset of telemedicine in most of those centers.
Remarkably, in-person contacts were significantly reduced during the lockdown phase, compared to identical calendar weeks in 2019. But the decrease to 78.6% compared to 88.5% in 2019 was moderate and obviously, the majority of pediatric diabetes appointments had been classified as “urgent medical”, not allowing to be postponed along with local lockdown regulations. Hospital admissions dropped and were also restricted to acute diabetes complications. Telemedicine contacts increased, but their absolute numbers were not sufficient to compensate for all of the postponed in-person appointments. Also only a minority of pediatric diabetes centers in Germany were prepared and could provide any of the telemedicine options as the lockdown suddenly impacted on diabetes care.
The COVID-19-pandemic and in particular lockdown regulations should catalyze telemedicine care of children and adolescents with T1D and some authors even emphasized a paradigm change in pediatric diabetes care by the pandemic . The majority of children and adolescents treated in pediatric centers in Germany use a CGMS and insulin pump  and thus already had technical prerequisites to upload and share their glucose values and insulin-treatment data. We also found that longer travelling distance to diabetes centers favored but migration background of families restricted the use of telemedicine. This second aspect points to language and other socioeconomic factors that could impair any nondiscriminatory and fair expansion of telemedicine use.
We found no deterioration of metabolic control over the lockdown weeks, at least in terms of HbA1c and time-in-range, irrespective of whether contacts were switched to telemedicine or kept in-person. In Sweden, the results during the first 7 months (Jan–July 2020) of the pandemic showed no deterioration of HbA1c, blood lipids and time-in-range, compared to corresponding periods within previous years. These medical data give us some relief, but we should interpret with care, how the Corona pandemic and in particular what adaptations of treatment policies may have impacted on T1D care. Telemedicine usability might only be one of many changes resulting from the pandemic .
Centers’ perspective (Fig. 1) gave a heterogeneous picture of individual centers in Germany, even if a similar number of patients were followed by telemedicine. Some centers used video consultations, others telephone calls in almost identical frequencies, but only a minority of 11 centers managed to follow more than 50 patients per year via telemedicine. Looking at all German patients in DPV and their caretakers, less than 10% experienced any telemedicine contact in 2020 and as mentioned above only few centers provided telemedicine on a regular base. Thus, telemedicine in 2020 was already a light at the end of the tunnel but not a load-bearing infrastructure for pediatric diabetes care in Germany.
Looking ahead, some barriers to scale up telemedicine in Germany are identified so far. First, the European Union enacted the General Data Protection Regulation (GDPR) and up to now, some manufacturers’ software solutions are still not completely GDPR compliant and local hospital data protection regulations blocked active upload of patient data into these data-sharing cloud software systems. Second, implementation of video consultations into hospital ecosystems is a long process for health care professionals and requires investments into hardware, software and upload devices. However, a qualitative assessment of diabetes educators and pediatric diabetologists who were familiar with telemedicine found that video consultation offered several benefits in the ongoing care of children with T1D .
In conclusion, we experienced an impressive dynamics of telemedicine within the COVID-lockdown phase in the US but also in Germany, and finally use of telemedicine established at a much higher rate thereafter. This reflects very good acceptance once telemedicine was established - not only under emergency conditions. However, the overall use of telemedicine in Germany was unable to compensate any reduction of in-person visits and has not been established in the majority of our pediatric diabetes centers. Additional key factors to scale up telemedicine for children with diabetes in Germany were (i) GDPR compliant telehealth or video consultation programs and associated health data platforms, (ii) addressing specific socioeconomic demands and (iii) securing equal financing of telemedicine compared to in-person visits.