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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

What’s App? Challenges and Opportunities in Diabetes ... · What’s App? Challenges and Opportunities in Diabetes Mobile Technologies Addie L. Fortmann, PhD Scripps Whittier Diabetes

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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