What’s App? Challenges and Opportunities in Diabetes Mobile Technologies
Addie L. Fortmann, PhD
Scripps Whittier Diabetes Institute, Scripps Health
San Diego, CA
Disclosure Information
I have no conflicts of interest to disclose.
Everybody’s doing it Overview
mHealth defined
Why mHealth?
Opportunities
Challenges
Wrap-Up
I want to hear from you!
Mini-
Discussions
Overview
mHealth defined
Why mHealth?
Opportunities
Challenges
Wrap-Up
mHealth defined
“The use of mobile and wireless devices to improve health outcomes, healthcare services,
and health research.” NIH Consensus Group (2012)
https://www.networkworld.com/article/2286628/data-center/75802-10-Examples-of-Mobile-Health-Around-the-World.html
Overview
mHealth defined
Why mHealth?
Opportunities
Challenges
Wrap-Up
Why mHealth?
Haven’t we come so far in diabetes???
Increased number and efficacy of diabetes medications.
Improved medication delivery systems.
Evolving technology for glucose monitoring.
Ann Int Med (2017)
Why mHealth?
Haven’t we come so far in diabetes???
Yes.
Only 18.8% met all targets for HbA1c, lipids, and BP.
47.5% with HbA1c > 7%
15.6% with HbA1c > 9%
. .but!
Many PWD do not achieve optimal clinical control.
Casagrande et al. Diabetes Care, 2013; CDC, National Diabetes Statistics Report, 2017.
Why mHealth?
Check BG
Take orals
Wear a CGM?
Check BG Check BG Check BG
Take orals Inject insulin Inject insulin
Inject insulin Inject insulin
Track BG levels!
Carry/monitor supplies, pick-up refills!
Meal plan Count carbs Portion size Avoid SSBs
Limit alcohol intake Track what you eat & drink!
Be activeCheck BGCheck your feet
Wear an insulin pump?
Refrigerate Use a sharps container
Carry a snack
Physician appointmentsLab draws
DSME
Carry a list of your current medications! Be aware of signs of hyper/hypoglycemia!
Meal plan Count carbs
Portion size Avoid SSBs Meal plan Count carbs Portion size Avoid SSBs
Carry quick-acting sugar Warm-up/Cool-down
An illustration. . .
What do we ask of PWD?
Why mHealth?
Diabetes Self-Management Education (DSME):
It works. . .
Improves adherence, clinical, QOL, and financial outcomes.
DSME reduced HbA1c by an average of 0.74% in a meta-analysis of 118 RCTs.
. . . IF PWD can access it.
Utilization is 5-7%.
Chrvala et al. Patient Educ Couns, 2015; Strawbridge et al. Health Educ Behav, 2015; Li et al. MMWR, 2014
MINI-DISCUSSION #1
Might mHealth be a way to extend the reach of DSME?
Why or why not?
Why mHealth?
Food for thought!
Project Dulce:
RN-led team of MAs and RDs: clinical management
Promotoras: DSME
Good, but significant barriers to attendance, and attrition was high.
Food for thought!
Study Objective: Examine the effect of Dulce Digital on HbA1c.
. . .Dulce Digital
Can mobile text messaging be used to overcome
barriers and deliver DSME to individuals with poorly controlled diabetes?
Funded by McKesson Foundation
N=126 Hispanics w/ HbA1c ≥ 7.5% received Dulce Digital or UC.
Outcome assessments at baseline, 3 and 6 months.
Dulce Digital (n=63) received 3 types of text messages:
Educational/motivational
Medication reminders
BGM prompts
2-3 messages/day, with frequency tapering over 6 mos.
Food for thought!
Dulce Digital
7.8
8
8.2
8.4
8.6
8.8
9
9.2
9.4
9.6
Baseline Month-3 Month-6
Dulce
Digital
Control
Hb
A1
c (
%)
Dulce Digital showed
significantly greater
improvements over
time compared to
the control group
(p < .05)
Fortmann et al. Diabetes Care, 2017
Food for thought!
Dulce Digital
Check BG
Take orals
Wear a CGM?
Check BG Check BG Check BG
Take orals Inject insulin Inject insulin
Inject insulin Inject insulin
Track BG levels!
Carry/monitor supplies, pick-up refills!
Meal plan Count carbs Portion size Avoid SSBs
Limit alcohol intake Track what you eat & drink!
Be activeCheck BGCheck your feet
Wear an insulin pump?
Refrigerate Use a sharps container
Carry a snack
Physician appointmentsLab draws
DSME
Carry a list of your current medications! Be aware of signs of hyper/hypoglycemia!
Meal plan Count carbs
Portion size Avoid SSBs Meal plan Count carbs Portion size Avoid SSBs
Carry quick-acting sugar Warm-up/Cool-down
DSMS
DSMS
DS
MS
DS
MS
Why mHealth?
Diabetes Self-Management Support (DSMS):
Support for implementing and sustaining behaviors needed to self-manage on an ongoing basis.
Behavioral, educational, psychosocial, clinical.
Especially important in the context of new challenges
and/or advances in treatment.
Evidence for the role of CHWs, peers, lay persons.
ADA, Diabetes Care, 2017; Powers et al. Diabetes Educ, 2015
Why mHealth?
Hey wait! You
forgot your meter! MINI-DISCUSSION #2
How do you provide DSMS to your patients?
How might mHealth play a role?
So . . .
If there is potential for mHealth to provide, or to augment DSME/S. . .
. . . Where do we start?
No shortage of options!
325,000 mHealth apps
+ 78,000 in 1 year
Winner’s Circle:
Android is #1
Diabetes is #1
Million dollar question
What is the BEST diabetes app?
It’s complicated.
Million dollar answer
Overview
mHealth defined
Why mHealth?
Opportunities
Challenges
Wrap-Up
Opportunities: Functionality
Track
Blood sugar
Medication
Dietary intake
Physical activity
Emotional well-being
Graph
Report + share
Educate
Connect
Support children & families
What can’t these apps do? What can these apps do?
Hood et al. J Behav Med, 2016
Opportunities: Low Cost
Pricing:
Majority are free
Other payment plans:
$9.99 one-time fee
$3.99/month
$60/year
This is fairly low cost relative to. . .
Other healthcare expenses (PWD)
Traditional DSME/S interventions (healthcare)
Opportunities: Clinical Benefit
2016 – 2018 systematic reviews & meta-analyses:
HbA1c was the most common primary outcome.
∆ = - 0.15 to -1.9%.
Function analysis:
HCP feedback
Complications prevention focus
Structured display of data
Cui et al. PLOS ONE, 2016; Holmen et al. J Med Internet Res, 2017; Hood et al. J Behav Med, 2016; Hou et al. Diabetes Care, 2016;
Kitsiou et al. PLOS ONE, 2017; Wu et al. Obes Rev, 2018
MINI-DISCUSSION #3
What benefits have you seen through your patients’ use of apps?
Opportunities Overview
mHealth defined
Why mHealth?
Opportunities
Challenges
Wrap-Up
. . . “Considerations”
Hmm…….
MINI-DISCUSSION #4
What challenges have you seen with diabetes app use?
Considerations Considerations: The sheer number!
How does a PWD choose?
How does a HCP keep up?
How does the research keep up?
It doesn’t. . .
Considerations: Evidence-based?
“Rapid proliferation of app development is significantly outpacing
research on app use and related outcomes…”
Most apps in the marketplace have not been rigorously tested.
“Newness” of apps
Study limitations
Small n
Short intervention and/or follow-up periods
Bottom line: More rigorous testing is needed.
Holmen et al. J Med Internet Res, 2017; Hood et al. J Behav Med, 2016; Wang et al. Adv Nutr, 2017
An illustration: Insulin dose calculation
Considerations: Accuracy
http://www.voluntis.com/en/our-vision; https://www.glooko.com/resource/glooko-mobile-app-4-0-webinar/
An illustration: Insulin dose calculation
Considerations: Accuracy
• 30% documented the formula
• 59% allowed calculation when 1 or more missing values
• 48% used ambiguous terminology
• 37% did not update in response to a changing user input
46 calculators were identified that performed simple mathematical calculations using carb intake and BG:
Huckvale et al. BMC Medicine, 2015
67% carried a risk of dose recommendations that violated basic clinical assumptions.
Considerations: Appropriateness
Are the recommendations appropriate?
Is the feedback appropriate?
Encourage your PWD to be informed and discriminating app consumers.
Considerations: Is it for everyone?
MINI-DISCUSSION #5
Might some PWD benefit from app
use more (or less?) than others?
Considerations: Is it for everyone?
Subgroup analyses show greater benefit among:
T2D vs. T1D
HbA1c ∆ = - 0.8% vs. - 0.3%
“Younger” (Mean age ≤ 55 years) versus “older” samples
HbA1c ∆ = -1.0% vs. - 0.4%
Shorter (<8.5 years) duration of disease
HbA1c ∆ = - 0.8% vs. - 0.2%
Hou et al. Diabetes Care, 2016; Kitsiou et al. PLOS ONE, 2017; Wu et al. JMIR mHealth and uHealth, 2017; Wu et al. Obes Rev, 2018
Considerations: Is it for everyone?
79% wanted FF involvement
A text message intervention with the option to engage friends/family (FF).
Just because apps can network with FF ≠ all patients (or FFs) will engage.
In the end, 35% engaged FF
21% did not
29% did not have FF to invite
15% had FF who declined to participate
Mayberry et al. ADA Scientific Sessions, 2016.
Considerations: Is it for everyone?
Pew Research Center statistics on cell phone ownership:
Any cellphone SmartphoneCellphone, but
not smartphone
Men 96% 78% 18%
Women 94% 75% 19%
Any cellphone SmartphoneCellphone, but
not smartphone
White 94% 77% 17%
Black 94% 72% 23%
Hispanic 98% 75% 23%
Any cellphone SmartphoneCellphone, but
not smartphone
18-29 100% 92% 8%
30-49 99% 88% 11%
50-64 97% 74% 23%
65+ 80% 42% 38%
Any cellphone SmartphoneCellphone, but
not smartphone
< HS graduate 92% 54% 39%
HS graduate 92% 69% 23%
Some college 96% 80% 16%
College graduate 97% 89% 8%
Any cellphone SmartphoneCellphone, but
not smartphone
< $30,000 92% 64% 29%
$30,000-$49,999 95% 74% 21%
$50,000-$74,999 96% 83% 13%
≥ $75,000 99% 93% 6%
Any cellphone SmartphoneCellphone, but
not smartphone
Urban 95% 77% 17%
Suburban 96% 79% 16%
Rural 94% 67% 27%
http://www.pewinternet.org/fact-sheet/mobile/2017
Considerations: Engagement
Medicaid & Medicare patients w/ T2D used app for 4 months.
All were asked to monitor BG; non-BG features were optional:
“Modest” engagement with non-BG app features over 4 months.
Feature % who used % high frequency use
Exercise 100%
Med adherence 77%
Weight 73%
Blood pressure 41%
23%
41%
55%
33%
Katz et al. ADA Scientific Sessions, 2016.
Considerations: Engagement
MINI-DISCUSSION #6
Why?
Considerations: Engagement Considerations: Engagement
“The gap between recording information and changing behavior is substantial…little evidence suggests that (devices) are bridging that gap.”
Data must be presented back to the user in a manner that motivates and sustains action.
Few apps incorporate behavior change theory.
Recommendations:
Goal-setting and problem-solving
Personalized feedback
Tailored reminder features
More food for thought!
Dulce Digital-Me!
Standard MessagingDietPA
Stress
Tailored feedback& goal-setting
1
2
3
Cyberinfrastructure
Tailored feedback& goal-setting
Funded by NIH/NIDDK 5R01DK112322-02 (Philis-Tsimikas/Gallo)
Overview
mHealth defined
Why mHealth?
Opportunities
Challenges
Wrap-Up
Wrap-Up
Opportunities Considerations
Functionality Number
Low cost Evidence
Clinical benefit Accuracy
Appropriate
Is it for everyone?
Engagement
Apps are not magic wands . . . but can be useful tools.
Not all PWD are created equal.
Not all apps are created equal.
Do your research!
Wrap-Up
Thank you