Diabetes Self-management Apps Research Articles

157 Diabetes Self-Management Training with a Mobile APP among Older Adults in Taiwan: Comparative and Longitudinal Program Effectiveness

Abstract Diabetes is a prevalent chronic disease and a major medical disability worldwide. It affects 1 in 5 older people in Taiwan. Use of mobile computing technology has become increasingly prevalent among older adults but its potential to improve diabetes self-management and social integration is only begun to be realized. This presentation will introduce the Intergenerational Mobile Technology Opportunities Program (IMTOP) designed to motivate and train older adults with diabetes to use mobile technology for diabetes self-management. The IMTOP curriculum taught participants about diabetes self-management combined with tablet and Internet skill training. Patients were taught a diabetes self-management app to activate self-monitoring and behavior change. College students participated as volunteer tutors to provide intergenerational and technological support. The program was delivered in 8 weekly sessions of 2-hour long small group classes. To understand the program effects, a wait-list control trial with 350 age 55+ adults with diabetes was conducted in 2 Taiwanese hospital outpatient settings. Patients were assessed at baseline and every 4 months for up to 12 months post intervention. After participating in the intervention, the pre-post changes for the intervention group were significantly better than the waitlist group at 4-month in terms of physical health status, diabetes self-care, use of mobile technology, and overall quality of life. In addition, the intervention group was less depressed compared to its counterpart. The longitudinal effects were evaluated using linear mixed-effects models including contrasts compared mean estimates at each follow-up to the baseline. The results indicate a stable overtime improvement in overall diabetes self-care (p<.0001). Specifically, patients reported more blood-glucose testing, foot-care, and risk reduction (all with p<.0001), specific diet (p=.04), and reduced frequency of smoking (p=.03). Both the WHO-QOL physical health (p=.03) and self-rated general health (p=.001) were enhanced. The findings support the effectiveness of IMTOP intervention for older adults with diabetes.

Implications for GP endorsement of a diabetes app with patients from culturally diverse backgrounds: a qualitative study.

Although many diabetes self-management apps exist, these are not tailored for people from culturally and linguistically diverse (CALD) backgrounds. This study aimed to explore GP perceptions of how diabetes app features could help GPs better support their patients from CALD backgrounds. Twenty-five semi-structured interviews with GPs in Western Sydney explored attitudes towards a proposed app's suitability for CALD patients. Interviews were audio-recorded, transcribed and coded using Framework Analysis. Theme 1 explored the implications of perceptions that patients' health literacy is dependent on the language used. Theme 2 explored the influence of messaging from sources that share the patient's language and culture (including misinformation from community sources). Theme 3 described the suitability of the app platform for CALD patients, and its potential challenges in this group. GPs perceived that a diabetes app could be useful for providing support to patients from CALD backgrounds. Findings suggest app features should be optimised to address existing challenges that GPs face and carefully consider strategies for recruiting CALD patients. It is important that GPs feel comfortable promoting an app to their CALD patients to help increase participation rates by people in the CALD community.

ENGAGEMENT AND EFFECTIVENESS OF USING MOBILE APP FOR DIABETES SELF-MANAGEMENT AMONG OLDER ADULTS

Mobile health applications (app) have shown to be beneficial for chronic disease management. However, few studies assessed older adults’ engagement in tracking self-management activities with app functions and effectiveness on improving their diabetes outcomes. This study investigated tracking patterns of each app function (blood sugar, blood pressure, diet, exercise, medication adherence etc.) in a graphic-based aging-friendly diabetes self-management app (IMTOP app) and associated the patterns with changes in HbA1c, self-care behavior, diabetes empowerment, and health promotion. The sample included 334 community-dwelling older adults with type 2 diabetes in Taiwan (mean age 64.57 ± 6.64 years) participated in the IMTOP training course that designed to motivate and train older adults with diabetes to use mobile tablets and apps. We performed trajectory analyses using SAS TRAJ procedure to identify distinct classes of individuals following similar longitudinal patterns on absence or presence of weekly app use for each individual app function. The relationships between the app engagement class memberships and 4- and 8-month diabetes health outcomes were assessed using an econometric regression analysis approach. The results showed the degree of app engagement on any single function was significantly and positively correlated with diabetes self-care scale scores (all p < .05). Only the engagement on the blood sugar function had statistically significant association with HbA1c improvements (p < .05). The app use was not associated with diabetes empowerment or health promotion. The study findings suggest any app function engagement significantly improved older adults’ overall self-management but blood sugar tracking is critical to improve HbA1c.

A Comparison of Functional Features in Chinese and US Mobile Apps for Diabetes Self-Management: A Systematic Search in App Stores and Content Analysis.

BackgroundMobile health interventions are widely used for self-management of diabetes, which is one of the most burdensome noncommunicable chronic diseases worldwide. However, little is known about the distribution of characteristics and functions of in-store mobile apps for diabetes.ObjectiveThis study aimed to investigate the distribution of characteristics and functions of the in-store mobile apps for self-management of diabetes in the United States and China using a predefined functional taxonomy, which was developed and published in our previous study.MethodsWe identified apps by searching diabetes in English or Chinese in the Apple iTunes Store and Android Markets (both in the United States and China) and included apps for diabetes self-management. We examined the validity and reliability of the predefined functional taxonomy with 3 dimensions: clinical module, functional module, and potential risk. We then classified all functions in the included apps according to the predefined taxonomy and compared the differences in the features of these apps between the United States and China.ResultsWe included 171 mobile diabetes apps, with 133 from the United States and 38 from China. Apps from both countries faced the challenges of evidence-based information, proper risk assessment, and declaration, especially Chinese apps. More Chinese apps provide app-based communication functions (general communication: Chinese vs US apps, 39%, 15/38 vs 18.0%, 24/133; P=.006 and patient-clinician communication: Chinese vs US apps, 68%, 26/38 vs 6.0%, 8/133; P<.001), whereas more US apps provide the decision-making module (Chinese vs US apps, 0%, 0/38 vs 23.3%, 31/133; P=.001), which is a high-risk module. Both complication prevention (Chinese vs US apps, 8%, 3/38 vs 3.8%, 5/133; P=.50) and psychological care (Chinese vs US apps, 0%, 0/38 vs 0.8%, 1/133; P>.99) are neglected by the 2 countries.ConclusionsThe distribution of characteristics and functions of in-store mobile apps for diabetes self-management in the United States was different from China. The design of in-store diabetes apps needs to be monitored closely.

Small Data and Its Visualization for Diabetes Self-Management: Qualitative Study.

BackgroundAs digital healthcare expands to include the use of mobile devices, there are opportunities to integrate these technologies into the self-management of chronic disease. Purpose built apps for diabetes self-management are plentiful and vary in functionality; they offer capability for individuals to record, manage, display, and interpret their own data. The optimal incorporation of mobile tablets into diabetes self-care is little explored in research, and guidelines for use are scant.ObjectiveThe purpose of this study was to examine an individual’s use of mobile devices and apps in the self-management of type 2 diabetes to establish the potential and value of this ubiquitous technology for chronic healthcare.MethodsIn a 9-month intervention, 28 patients at a large multidisciplinary healthcare center were gifted internet connected Apple iPads with preinstalled apps and given digital support to use them. They were invited to take up predefined activities, which included recording their own biometrics, monitoring their diet, and traditional online information seeking. Four online surveys captured the participants’ perceptions and health outcomes throughout the study. This article reports on the qualitative analysis of the open-ended responses in all four surveys.ResultsUsing apps, participants self-curated small data sets that included their blood glucose level, blood pressure, weight, and dietary intake. The dynamic visualizations of the data in the form of charts and diagrams were created using apps and participants were able to interpret the impact of their choices and behaviors from the diagrammatic form of their small personal data sets. Findings are presented in four themes: (1) recording personal data; (2) modelling and visualizing the data; (3) interpreting the data; and (4) empowering and improving health.ConclusionsThe modelling capability of apps using small personal data sets, collected and curated by individuals, and the resultant graphical information that can be displayed on tablet screens proves a valuable asset for diabetes self-care. Informed by their own data, individuals are well-positioned to make changes in their daily lives that will improve their health.

Medication management support in diabetes: a systematic assessment of diabetes self-management apps

BackgroundSmartphone apps are becoming increasingly popular for supporting diabetes self-management. A key aspect of diabetes self-management is appropriate medication-taking. This study aims to systematically assess and characterise the medication management features in diabetes self-management apps and their congruence with best-practice evidence-based criteria.MethodsThe Google Play and Apple app stores were searched in June 2018 using diabetes-related terms in the English language. Apps with both medication and blood glucose management features were downloaded and evaluated against assessment criteria derived from international medication management and diabetes guidelines.ResultsOur search yielded 3369 Android and 1799 iOS potentially relevant apps; of which, 143 apps (81 Android, 62 iOS) met inclusion criteria and were downloaded and assessed. Over half 58.0% (83/143) of the apps had a medication reminder feature; 16.8% (24/143) had a feature to review medication adherence; 39.9% (57/143) allowed entry of medication-taking instructions; 5.6% (8/143) provided information about medication; and 4.2% (6/143) displayed motivational messages to encourage medication-taking. Only two apps prompted users on the use of complementary medicine. Issues such as limited medication logging capacity, faulty reminder features, unclear medication adherence assessment, and visually distracting excessive advertising were observed during app assessments.ConclusionsA large proportion of diabetes self-management apps lacked features for enhancing medication adherence and safety. More emphasis should be given to the design of medication management features in diabetes apps to improve their alignment to evidence-based best practice.

Gamification and Behavior Change Techniques in Diabetes Self-Management Apps.

Diabetes management apps may have positive effects on diabetes self-management. It remains unclear, however, which app features are particularly effective and encourage sustained app usage. Behavior change techniques (BCTs) and gamification are promising approaches to improve user engagement. However, little is known about the frequency BCTs and gamification techniques (GTs) are actually used. This app review aims to provide an overview of BCTs and GTs in current diabetes management apps. Google's Play Store was searched for applications using a broad search strategy (keyword: "diabetes"). We limited our research to freely available apps. A total of 56 apps matched the inclusion criteria and were reviewed in terms of the features they offer to support self-management. We used a taxonomy comprising 29 BCTs and 17 GTs to evaluate the applications. Two independent raters tested and evaluated each app. Interrater agreement was high (ICC = .75 for BCTs; ICC = .90 for GTs). An average of 7.4 BCTs (SD = 3.1) and an average of 1.4 out of 17 GTs (SD = 1.6) were implemented in each app. Five out of 29 BCTs accounted for 55.8% of the BCTs identified in total. The GT most often identified was "feedback" and accounted for 50% of the GTs. The potential of BCTs and GTs in diabetes management apps has not been fully exploited yet. Only very restricted sets of BCTs and gamification features were implemented. Systematic research on the efficacy of specific BCTs and GTs is needed to provide further guidance for app design.

How Do Smart Device Apps for Diabetes Self-Management Correspond with Theoretical Indicators of Empowerment? An Analysis of App Features.

Smart device apps for diabetes have the potential to support patients in their daily disease management. However, uncertainty exists regarding their suitability for empowering patients to improve self-management behaviors. This paper addresses a general research gap regarding theoretically based examinations of empowerment in diabetes research, by examining how diabetes app features correspond with conceptual indicators of empowerment. We examined features of 121 apps for diabetes self-management available in Singapore, with the second highest proportion of diabetes among developed nations, for psychological empowerment (feeling of empowerment) and for behavioral empowerment (social support). Diabetes apps studied offered a narrow range of features, with limited feature-sets corresponding to indicators of empowerment. Customization as a strategy to improve perceived relevance of diabetes self-management as an indicator of psychological empowerment was especially limited. Moreover, there was a lack of features supporting patients' communication with healthcare professionals and within their private social networks. Mobile apps for diabetes self-management failed to provide relevant features for empowering patients. Specific practical recommendations target improved adoption, sustained usage, and effectiveness of diabetes self-management apps.

How do Smart Device Apps for Diabetes Self-Management correspond with Theoretical Indicators of Empowerment? An Analysis of App Features-CORRIGENDUM.

How do Smart Device Apps for Diabetes Self-Management correspond with Theoretical Indicators of Empowerment? An Analysis of App Features-CORRIGENDUM.

Users' preferences and design recommendations to promote engagements with mobile apps for diabetes self-management: Multi-national perspectives.

BackgroundMobile phone applications (apps) offer motivation and support for self-management of diabetes mellitus (DM), but their use is limited by high attrition due to insufficient consideration of end-users perspectives and usability requirements. This study aimed to examine app usage and feature preferences among people with DM, and explore their recommendations for future inclusions to foster engagement with diabetes apps.MethodsThe study was conducted internationally on adults with type 1 or type 2 DM using online questionnaire (quantitative) to investigate usage and preferences for app features that support diabetes self-management and semi structured telephone interview (qualitative) to explore suggestions on fostering engagement and specific educational information for inclusion into diabetes apps. Survey and interview data were analysed using descriptive/ inferential statistics and inductive thematic analysis respectively.ResultsA total of 217 respondents with type 1 DM (38.25%) or type 2 DM (61.8%), from 4 continents (Australia, Europe, Asia and America) participated in the survey. About half of the respondents (48%) use apps, mainly with features for tracking blood glucose (56.6%), blood pressure (51.9%) and food calories (48.1%). Preferred features in future apps include nutrient values of foods (56.7%), blood glucose (54.8%), physical exercise tracker (47%), health data analytics (42.9%) and education on diabetes self-management (40.6%). Irrespective of the type of DM, participants proposed future apps that are user friendly, support healthy eating, provide actionable reminders and consolidate data across peripheral health devices. Participants with type 1 DM recommended customised features with news update on developments in the field of diabetes. Nominated specific educational topics included tips on problem solving, use of insulin pump therapy, signs of diabetes complication and transitioning from paediatric into adult care.ConclusionsThe study has highlighted patients’ perspectives on essential components for inclusion in diabetes apps to promote engagement and foster better health outcomes.

A Framework to Assist School Psychologists and Counsellors in Recommending Quality Apps for Supporting Diabetes Self-Management: An Illustrative Assessment Using Content Analysis

A framework was examined to assist school psychologists and counsellors in recommending quality apps for supporting diabetes self-management. A content analysis was undertaken to assess behaviour change strategies in Apple and Android smartphone apps for the self-management of type 2 diabetes. The Behaviour Change Technique Taxonomy was used to assess the presence of behaviour change strategies, while the Mobile App Rating Scale was used to assess overall app quality. Raters found, on average, 7.13 behaviour change techniques out of a possible 93, indicating few behaviour change techniques in apps for the self-management of Type 2 diabetes. Analysis indicated that apps of a higher overall quality tended to incorporate more behaviour change strategies. It was concluded that mental-health professionals are advantaged if they are able to assess and refine selection tools for matching apps with the needs of students with diabetes.

Free Diabetes Smartphone Apps—Downloads and Rankings 2016 vs. 2017

Purpose: Do the frequency of downloads of free diabetes smartphone droid apps change from year to year? Methods: Using Google playstore, we found the most popular apps in 2017. For 2016 apps, we used our 2016 data 1 from the Google playstore. The 11 most popular free apps in 2016 and 2017 were compared. Results: The change in app ranking were associated with "pay for premium features (PPF)" in 2017. The app, mySugr remains no. 1 in terms of number of downloads, due to fewest changes in PPF. Diabetes M went from no. 5 in 2016 to no. 8 in 2017, due to PPF. Glucose Buddy remained at no. 4 in the two years. Blood Glucose Tracker went from 2 to 11 in two years due to high cost PPF. Of the most popular apps in 2017, Diabetes Plus is only free on android. In 2016, only 2 are for children:Carb Counting with Lenny and mySugr Junior. As of 2017, mySugr Junior no longer exists. None of the 2017 or 2016 apps have glycemic index. All apps in 2017 require email login. 4/11 apps record height and weight in 2017. 3/11 apps do not record blood pressure in 2017. 5/6 apps were journal based vs. 12/12 apps in 2017. Conclusion: The popularity of apps change greatly in 24 months. Patients and MDs have a common goal in seeking useful mobile apps for diabetes self-management. Disclosure G. Wu: None. V. Ngo: None.

Clinical relevance of smartphone apps for diabetes management: A global overview.

We assessed the number, proportion, and clinical relevance of diabetes self-management apps in major languages spoken by 10 countries with the highest number of people with diabetes. China, India, USA, Brazil, Russian Federation, Mexico, Indonesia, Egypt, Japan, and Pakistan were identified as the 10 countries with the largest number of people with diabetes based on the latest NCD-RisC survey. Android and iOS apps in the 10 national languages were extracted with a search strategy. App titles and descriptions were systematically screened by trained reviewers, including apps specific for diabetes self-management and excluding apps for health care providers, general well-being, health and product promotion, and traditional cure. Eighteen apps in the above languages were then downloaded based on availability and popularity and assessed for clinical relevance to diabetes self-management with reference to current clinical guidelines. The diabetes-related search terms identified 3374 Android and 4477 iOS apps, where 1019 Android and 1303 iOS apps were screened as being relevant for diabetes self-management. Chinese and English language apps constitute above 80% of the diabetes apps, have more downloads, and more comprehensive clinically relevant functions compared with other languages. None of the apps assessed met all criteria for information provision and app functionalities nor provided information cited from accredited sources. Our study showed that apps could play an important role in complementing multifaceted diabetes care, but should preferably be regulated, context specific, and more tailored to users' needs with clear guidance for patients and clinicians about the choices.

An Analysis of Diabetes Mobile Applications Features Compared to AADE7™: Addressing Self-Management Behaviors in People With Diabetes.

Diabetes self-management (DSM) applications (apps) have been designed to improve knowledge of diabetes and self-management behaviors. However, few studies have systematically examined if diabetes apps followed the American Association of Diabetes Educators (AADE) Self-Care Behaviors™ guidelines. The purpose of this study was to compare the features of current DSM apps to the AADE7™ guidelines. In two major app stores (iTunes and Google Play), we used three search terms "diabetes," "blood sugar," and "glucose" to capture a wide range of diabetes apps. Apps were excluded based on five exclusion criteria. A multidisciplinary team analyzed and classified the features of each app based on the AADE7™. We conducted interviews with six diabetes physicians and educators for their opinions on the distribution of the features of DSM apps. Out of 1050 apps retrieved, 173 apps were identified as eligible during November 2015 and 137 apps during December 2017. We found an unbalanced DSM app development trend based on AADE7™ guidelines. Many apps were designed to support the behaviors of Healthy Eating (77%), Monitoring (76%), Taking Medication (58%), and Being Active (45%). On the other hand, few apps explored the behaviors of Problem Solving (31%), Healthy Coping (10%), and Reducing Risks (5%). From interviews, we identified the main reasons why only a few apps support the features related to Problem Solving, Healthy Coping, and Reducing Risks. Future diabetes apps should attempt to incorporate features under evidence-based guidelines such as AADE7™ to better support the self-management behavior changes of people with diabetes.

Correction: Mobile App-Based Interventions to Support Diabetes Self-Management: A Systematic Review of Randomized Controlled Trials to Identify Functions Associated with Glycemic Efficacy.

Background: Mobile health apps for diabetes self-management have different functions. However, the efficacy and safety of each function are not well studied, and no classification is available for these functions. Objective: The aims of this study were to (1) develop and validate a taxonomy of apps for diabetes self-management, (2) investigate the glycemic efficacy of mobile app-based interventions among adults with diabetes in a systematic review of randomized controlled trials (RCTs), and (3) explore the contribution of different function to the effectiveness of entire app-based interventions using the taxonomy. Methods: We developed a 3-axis taxonomy with columns of clinical modules, rows of functional modules and cells of functions with risk assessments. This taxonomy was validated by reviewing and classifying commercially available diabetes apps. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Chinese Biomedical Literature Database, and ClinicalTrials.gov from January 2007 to May 2016. We included RCTs of adult outpatients with diabetes that compared using mobile app-based interventions with usual care alone. The mean differences (MDs) in hemoglobin A1c (HbA1c) concentrations and risk ratios of adverse events were pooled using a random-effects meta-analysis. After taxonomic classification, we performed exploratory subgroup analyses of the presence or absence of each module across the included app-based interventions. Results: Across 12 included trials involving 974 participants, using app-based interventions was associated with a clinically significant reduction of HbA1c (MD 0.48%, 95% CI 0.19%-0.77%) without excess adverse events. Larger HbA1c reductions were noted among patients with type 2 diabetes than those with type 1 diabetes (MD 0.67%, 95% CI 0.30%-1.03% vs MD 0.36%, 95% CI 0.08%-0.81%). Having a complication prevention module in app-based interventions was associated with a greater HbA1c reduction (with complication prevention: MD 1.31%, 95% CI 0.66%-1.96% vs without: MD 0.38%, 95% CI 0.09%-0.67%; intersubgroup P=.01), as was having a structured display (with structured display: MD 0.69%, 95% CI 0.32%-1.06% vs without: MD 0.16%, 95% CI 0.16%-0.48%; intersubgroup P=.03). However, having a clinical decision-making function was not associated with a larger HbA1c reduction (with clinical decision making: MD 0.18%, 95% CI 0.21%-0.56% vs without: MD 0.61%, 95% CI 0.27%-0.95%; intersubgroup P=.10). Conclusions: The use of mobile app-based interventions yields a clinically significant HbA1c reduction among adult outpatients with diabetes, especially among those with type 2 diabetes. Our study suggests that the clinical decision-making function needs further improvement and evaluation before being added to apps. [JMIR Mhealth Uhealth 2017;5(3):e35]

Development of the IMB Model and an Evidence-Based Diabetes Self-management Mobile Application.

ObjectivesThis study developed a diabetes self-management mobile application based on the information-motivation-behavioral skills (IMB) model, evidence extracted from clinical practice guidelines, and requirements identified through focus group interviews (FGIs) with diabetes patients.MethodsWe developed a diabetes self-management (DSM) app in accordance with the following four stages of the system development life cycle. The functional and knowledge requirements of the users were extracted through FGIs with 19 diabetes patients. A system diagram, data models, a database, an algorithm, screens, and menus were designed. An Android app and server with an SSL protocol were developed. The DSM app algorithm and heuristics, as well as the usability of the DSM app were evaluated, and then the DSM app was modified based on heuristics and usability evaluation.ResultsA total of 11 requirement themes were identified through the FGIs. Sixteen functions and 49 knowledge rules were extracted. The system diagram consisted of a client part and server part, 78 data models, a database with 10 tables, an algorithm, and a menu structure with 6 main menus, and 40 user screens were developed. The DSM app was Android version 4.4 or higher for Bluetooth connectivity. The proficiency and efficiency scores of the algorithm were 90.96% and 92.39%, respectively. Fifteen issues were revealed through the heuristic evaluation, and the app was modified to address three of these issues. It was also modified to address five comments received by the researchers through the usability evaluation.ConclusionsThe DSM app was developed based on behavioral change theory through IMB models. It was designed to be evidence-based, user-centered, and effective. It remains necessary to fully evaluate the effect of the DSM app on the DSM behavior changes of diabetes patients.

Content Analysis of Mobile Health Applications on Diabetes Mellitus.

Diabetes self-management offers an opportunity to patients to be actively involved in managing their conditions and modifying lifestyle behaviors to attain positive health outcomes. With the unprecedented growth of mobile technology, smartphone plays a role in supporting diabetes self-management. Nonetheless, selecting appropriate mobile applications (apps) is challenging for patients. Thus, this study aimed to evaluate and compare the contents and features of mobile medical apps for diabetes self-management. Of 346 commercial apps, 16 (16%) and 19 (7.72%) of the diabetes apps found in Apple and Google Play stores, respectively, were included based on the selection criteria and individually scored for the availability of 8 main features of diabetes self-management. The apps supported self-management by offering features such as free installation, less than 50 MB space used, offline use, automated data entry, data export and sharing, educational tool, and advice. Of the 8 evaluated features, only 11 (31.4%) apps had a score of 5 whereas 7 (20%) apps scored the lowest, with a score of 3. The majority of apps were free, required no Internet connectivity to use and were less than 50 MB in size. Our findings showed that the design of diabetes mobile apps focused on reporting and setting reminders, rather than providing personalized education or therapeutic support. In the future, the design of apps could be improved to integrate patients’ needs, usability for disease management, and lifestyle modifications.

Use of and Beliefs About Mobile Phone Apps for Diabetes Self-Management: Surveys of People in a Hospital Diabetes Clinic and Diabetes Health Professionals in New Zealand.

BackgroundPeople with diabetes mellitus (DM) are using mobile phone apps to support self-management. The numerous apps available to assist with diabetes management have a variety of functions. Some functions, like insulin dose calculators, have significant potential for harm.ObjectivesThe study aimed to establish (1) whether people with DM in Wellington, New Zealand, use apps for DM self-management and evaluate desirable features of apps and (2) whether health professionals (HPs) in New Zealand treating people with DM recommend apps to patients, the features HPs regard as important, and their confidence with recommending apps.MethodsA survey of patients seen at a hospital diabetes clinic over 12 months (N=539) assessed current app use and desirable features. A second survey of HPs attending a diabetes conference (n=286) assessed their confidence with app recommendations and perceived usefulness.ResultsOf the 189 responders (35.0% response rate) to the patient survey, 19.6% (37/189) had used a diabetes app. App users were younger and in comparison to other forms of diabetes mellitus, users prominently had type 1 DM. The most favored feature of the app users was a glucose diary (87%, 32/37), and an insulin calculator was the most desirable function for a future app (46%, 17/37). In non-app users, the most desirable feature for a future app was a glucose diary (64.4%, 98/152). Of the 115 responders (40.2% response rate) to the HPs survey, 60.1% (68/113) had recommended a diabetes app. Diaries for blood glucose levels and carbohydrate counting were considered the most useful app features and the features HPs felt most confident to recommend. HPs were least confident in recommending insulin calculation apps.ConclusionsThe use of apps to record blood glucose was the most favored function in apps used by people with diabetes, with interest in insulin dose calculating function. HPs do not feel confident in recommending insulin dose calculators. There is an urgent need for an app assessment process to give confidence in the quality and safety of diabetes management apps to people with diabetes (potential app users) and HPs (potential app prescribers).

Tailored Communication Within Mobile Apps for Diabetes Self-Management: A Systematic Review.

BackgroundThe prevalence of diabetes is increasing and with the requirements for self-management and risk of late complications, it remains a challenge for the individual and society. Patients can benefit from support from health care personnel in their self-management, and the traditional communication between patients and health care personnel is changing. Smartphones and apps offer a unique platform for communication, but apps with integrated health care personnel communication based on patient data are yet to be investigated to provide evidence of possible effects.ObjectiveOur goal was to systematically review studies that aimed to evaluate integrated communication within mobile apps for tailored feedback between patients with diabetes and health care personnel in terms of (1) study characteristics, (2) functions, (3) study outcomes, (4) effects, and (5) methodological quality.MethodsA systematic literature search was conducted following our International Prospective Register of Systematic Reviews (PROSPERO) protocol, searching for apps with integrated communication for persons with diabetes tested in a controlled trial in the period 2008 to 2016. We searched the databases PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central, Excerpta Medica database (EMBASE), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. The search was closed in September 2016. Reference lists of primary articles and review papers were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and we applied the Cochrane risk of bias tool to assess methodological quality.ResultsWe identified 2822 citations and after duplicate removal, we assessed 1128 citations. A total of 6 papers were included in this systematic review, reporting on data from 431 persons participating in small trials of short duration. The integrated communication features were mostly individualized as written non–real-time feedback. The number of functions varied from 2 to 9, and blood glucose tracking was the most common. HbA1c was the most common primary outcome, but the remaining reported outcomes were not standardized and comparable. Because of both the heterogeneity of the included trials and the poor methodological quality of the studies, a meta-analysis was not possible. A statistically significant improvement in the primary measure of outcome was found in 3 of the 6 included studies, of which 2 were HbA1c and 1 was mean daytime ambulatory blood pressure. Participants in the included trials reported positive usability or feasibility postintervention in 5 out of 6 trials. The overall methodological quality of the trials was, however, scored as an uncertain risk of bias.ConclusionsThis systematic review highlights the need for more trials of higher methodological quality. Few studies offer an integrated function for communication and feedback from health care personnel, and the research field represents an area of heterogeneity with few studies of highly rigorous methodological quality. This, in combination with a low number of participants and a short follow-up, is making it difficult to provide reliable evidence of effects for stakeholders.

A Mobile App for the Self-Management of Type 1 Diabetes Among Adolescents: A Randomized Controlled Trial.

BackgroundWhile optimal blood glucose control is known to reduce the long-term complications associated with type 1 diabetes mellitus, adolescents often struggle to achieve their blood glucose targets. However, their strong propensity toward technology presents a unique opportunity for the delivery of novel self-management interventions. To support type 1 diabetes self-management in this population, we developed the diabetes self-management app bant, which included wireless blood glucose reading transfer, out-of-range blood glucose trend alerts, coaching around out-of-range trend causes and fixes, and a point-based incentive system.ObjectiveThe primary objective was to evaluate bant ’s effect on hemoglobin A1c (HbA1c) through a randomized controlled trial (RCT). Secondary measures (eg, self-monitoring of blood glucose [SMBG]) were also collected to assess bant ’s impact on the self-management behaviors of adolescents with type 1 diabetes.MethodsWe enrolled 92 adolescents into a 12-month RCT, with 46 receiving usual care and 46 receiving usual care plus bant. Clinical outcome data were collected at quarterly research visits via validated tools, electronic chart review, glucometer downloads, and semistructured interviews. App satisfaction was assessed at 6 and 12 months, and at trial end, users ranked bant components based on perceived usefulness. Mobile analytics captured frequency of blood glucose uploads, which were used to categorize participants into high, moderate, low, or very low engagement levels.ResultsLinear mixed models showed no changes in primary and secondary clinical outcomes. However, exploratory regression analysis demonstrated a statistically significant association between increased SMBG and improved HbA1c in the intervention group. For a subgroup of bant users taking SMBG ≥5 daily, there was a significant improvement in HbA1c of 0.58% (P=.02), while the parallel subgroup in the control arm experienced no significant change in HbA1c (decrease of 0.06%, P=.84). Although app usage did diminish over the trial, on average, 35% (16/46 participants) were classified as moderately or highly engaged (uploaded SMBG ≥3 days a week) over the 12 months.ConclusionAlthough primary analysis of clinical outcomes did not demonstrate differences between the bant and control groups, exploratory analysis suggested that bant may positively impact the use of SMBG data and glycemic control among youth. The next generation of bant will aim to remove barriers to use, such as deploying the app directly to personal devices instead of secondary research phones, and to explore the utility of integrating bant into routine clinical care to facilitate more frequent feedback. Future evaluations of mHealth apps should consider more robust research tools (eg, ResearchKit) and alternative RCT study designs to enable more rapid and iterative evaluations, better suited to the nature of rapidly evolving consumer technology.Trial RegistrationClinicalTrials.gov NCT01899274; https://clinicaltrials.gov/ct2/show/NCT01899274 (Archived by WebCite at http://www.webcitation.org/6qWrqF1yw)