Disclosure Information What s App? Challenges and Opportunities in Diabetes Mobile Technologies I have no conflicts of interest to disclose. Addie L. Fortmann, PhD Scripps Whittier Diabetes Institute, Scripps Health San Diego, CA Everybody s doing it I want to hear from you! Mini- Discussions 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
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) Haven t we come so far in diabetes??? Yes...but! Only 18.8% met all targets for HbA1c, lipids, and BP. 47.5% with HbA1c > 7% 15.6% with HbA1c > 9% Many PWD do not achieve optimal clinical control. Casagrande et al. Diabetes Care, 2013; CDC, National Diabetes Statistics Report, 2017. What do we ask of PWD? An illustration... DSME Lab draws Physician appointments Check your feet Carry quick-acting sugar Check BG Warm-up/Cool-down Be active Carry a snack Limit alcohol intake Track what you eat & drink! Portion size Avoid SSBs Meal plan Count carbs Portion size Avoid SSBs Meal plan Count carbs Portion size Avoid SSBs Meal plan Count carbs Carry a list of your current medications! Be aware of signs of hyper/hypoglycemia! Wear an insulin pump? Carry/monitor supplies, pick-up refills! Inject insulin Inject insulin Refrigerate Use a sharps container Take orals Take orals Inject insulin Inject insulin Wear a CGM? Check BG Check BG Check BG Check BG Track BG levels! 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 metaanalysis of 118 RCTs.... IF PWD can access it. Utilization is 5-7%. MINI-DISCUSSION #1 Might mhealth be a way to extend the reach of DSME? Why or why not? Chrvala et al. Patient Educ Couns, 2015; Strawbridge et al. Health Educ Behav, 2015; Li et al. MMWR, 2014
DSMS HbA1c (%) Food for thought! Project Dulce: RN-led team of MAs and RDs: clinical management Promotoras: DSME Food for thought!...dulce Digital Can mobile text messaging be used to overcome barriers and deliver DSME to individuals with poorly controlled diabetes? Good, but significant barriers to attendance, and attrition was high. Study Objective: Examine the effect of Dulce Digital on HbA1c. Funded by McKesson Foundation Food for thought! Food for thought! Dulce Digital N=126 Hispanics w/ HbA1c 7.5% received Dulce Digital or UC. 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. Outcome assessments at baseline, 3 and 6 months. Dulce Digital Dulce Digital showed significantly greater improvements over time compared to the control group (p <.05) 9.6 9.4 9.2 9 8.8 8.6 8.4 8.2 8 7.8 Baseline Month-3 Month-6 Dulce Digital Control Fortmann et al. Diabetes Care, 2017 DSMS Diabetes Self-Management Support (DSMS): Support for implementing and sustaining behaviors needed to self-manage on an ongoing basis. DSME Lab draws Physician appointments Check your feet Carry quick-acting sugar Check BG Warm-up/Cool-down Be active Carry a snack Limit alcohol intake Track what you eat & drink! Portion size Avoid SSBs Meal plan Count carbs Portion size Avoid SSBs Meal plan Count carbs Portion size Avoid SSBs Meal plan Count carbs Carry a list of your current medications! Be aware of signs of hyper/hypoglycemia! Wear an insulin pump? Carry/monitor supplies, pick-up refills! Inject insulin Inject insulin Refrigerate Use a sharps container Take orals Take orals Inject insulin Inject insulin Wear a CGM? Check BG Check BG Check BG DSMS Check BG Track BG levels! DSMS 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
So... MINI-DISCUSSION Hey wait! You #2 forgot your meter! If there is potential for mhealth to provide, or to augment DSME/S... How do you provide DSMS to your patients? How might mhealth play a role?... 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? Million dollar answer It s complicated. Opportunities: Functionality What can these apps do? Track Blood sugar Medication Dietary intake Physical activity Emotional well-being Graph Report + share Educate Connect Support children & families 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 Opportunities MINI-DISCUSSION #3 What benefits have you seen through your patients use of apps?... Considerations Hmm. Considerations Considerations: The sheer number! MINI-DISCUSSION #4 How does a PWD choose? What challenges have you seen with diabetes app use? 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 Considerations: Accuracy An illustration: Insulin dose calculation 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 http://www.voluntis.com/en/our-vision; https://www.glooko.com/resource/glooko-mobile-app-4-0-webinar/ Considerations: Accuracy Considerations: Appropriateness An illustration: Insulin dose calculation 46 calculators were identified that performed simple mathematical calculations using carb intake and BG: 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 67% carried a risk of dose recommendations that violated basic clinical assumptions. Are the recommendations appropriate? Is the feedback appropriate? Encourage your PWD to be informed and discriminating app consumers. Huckvale et al. BMC Medicine, 2015 Considerations: Is it for everyone? Considerations: Is it for everyone? Subgroup analyses show greater benefit among: MINI-DISCUSSION #5 T2D vs. T1D HbA1c = - 0.8% vs. - 0.3% Might some PWD benefit from app use more (or less?) than others? 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? A text message intervention with the option to engage friends/family (FF). Considerations: Is it for everyone? Pew Research Center statistics on cell phone ownership: 29% did not have FF to invite 15% had FF who declined to participate 21% did not 79% In the wanted end, 35% FF involvement engaged FF Just because apps can network with FF all patients (or FFs) will engage. Cellphone, but Any cellphone Smartphone not smartphone < HS $30,000 graduate Men White 18-29 96% 92% 94% 100% 78% 54% 64% 77% 92% 18% 39% 29% 17% Urban HS graduate Women Black 30-49 94% 95% 92% 94% 99% 75% 77% 69% 72% 88% 19% 17% $30,000-$49,999 95% 74% 23% 21% 11% Some $50,000-$74,999 Suburban college Hispanic 50-64 96% 98% 97% 96% 80% 83% 79% 75% 74% 13% 16% 23% College Rural $75,000 65+ graduate 97% 99% 80% 94% 89% 93% 67% 42% 6% 27% 38% Mayberry et al. ADA Scientific Sessions, 2016. http://www.pewinternet.org/fact-sheet/mobile/2017 Considerations: Engagement Considerations: Engagement Medicaid & Medicare patients w/ T2D used app for 4 months. All were asked to monitor BG; non-bg features were optional: Feature % who used % high frequency use Exercise 100% 23% Med adherence 77% 55% Weight 73% 41% Blood pressure 41% 33% MINI-DISCUSSION #6 Why? Modest engagement with non-bg app features over 4 months. Katz et al. ADA Scientific Sessions, 2016. 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! Cyberinfrastructure Standard Messaging Diet PA Stress Tailored feedback & goal-setting Tailored feedback & goal-setting 1 2 3 Funded by NIH/NIDDK 5R01DK112322-02 (Philis-Tsimikas/Gallo) Wrap-Up Wrap-Up Opportunities Functionality Low cost Clinical benefit Considerations Number Evidence 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! Thank you