Digital health technology and mobile devices for the management of diabetes mellitus: state of the art

Research status and hotspots of patient engagement: A bibliometric analysis

OBJECTIVE

This analysis aimed to examine current global trends in patient engagement research and identify critical focus areas.

METHODS

We searched the Web of Science Core Collection database for pertinent literature from January 1, 2000 to December 31, 2022. CiteSpace and VOSviewer were used for information analysis.

RESULTS

The bibliometric analysis covered 11,386 documents from 140 countries/regions, featuring contributions from 12,731 organizations and 45,489 authors. The United States and The University of Toronto were the most prolific country and institution. Leading researchers in publications and citations included Hibbard JH, Elwyn G, Legare F, and Street RL. Patient Education and Counseling led among journals.

CONCLUSION

Patient engagement research has experienced significant growth over the past two decades. The core of patient engagement research includes concepts, content, practical frameworks, impact assessment, and barriers. The current research focal points revolve around interventions for chronic disease patients, integrating digital health technologies to improve engagement, and incorporating patient-reported outcomes (PROs) into healthcare delivery.

PRACTICE IMPLICATIONS

This study unveils key trends and emphasizes global collaboration, strategic focus on chronic disease interventions, integration of digital health technologies, and the pivotal role of PROs. Embracing these insights promises to optimize healthcare practices and empower patients on a global scale.

Efficacy of using telecare services for community-dwelling people with diabetes: A systematic review and meta-analysis

OBJECTIVE

To evaluate the glycated hemoglobin (HbA1c), blood pressure, self-efficacy, and quality of life efficacy of using telecare services for community-dwelling people with diabetes.

METHODS

Cochrane Library, Web of Science, PsycINFO, PubMed, EMBASE, CINAHL, and Scopus databases were systematically searched from their inception dates to June 22, 2023. Two evaluators independently selected and evaluated eligible studies. A protocol was registered in PROSPERO.

RESULTS

An analysis of 17 studies that included 3586 subjects showed that telecare significantly improved the management of patients with diabetes. Compared to controls, intervention care had significant benefits regarding HbA1c (MD = -0.30, 95 % CI = -0.44 - -0.17, 16 studies), systolic blood pressure (MD = -2.45, 95 % CI = -4.53 - -0.36, P = 0.02), self-efficacy (MD = 0.36, 95 % CI = 0.04 - 0.67, P = 0.03) and quality of life (MD = 0.37, 95 % CI = 0.05 - 0.70, P = 0.02). However, diastolic blood pressure (MD = -1.37, 95 % CI = -3.34 - -0.61, P = 0.17) was not found to be significantly affected.

CONCLUSIONS

Telecare is effective in improving self-management among community-dwelling people with diabetes, suggesting an effective means for them to achieve self-management.

N-of-1 health optimization: Digital monitoring of biomarker dynamics to gamify adherence to metabolic switching

The digital health field is experiencing substantial growth due to its potential for sustained and longitudinal deployment. In turn, this may drive improved monitoring and intervention as catalysts for behavioral change compared to traditional point-of-care practices. In particular, the increase in incidence of population health challenges such as diabetes, heart disease, fatty liver disease, and other disorders coupled with rising healthcare costs have emphasized the importance of exploring technical, economics, and implementation considerations, among others in the decentralization of health and healthcare innovations. Both healthy individuals and patients stand to benefit from continued technical advances and studies in these domains. To address these points, this study reports a N-of-1 study comprised of sustained regimens of intermittent fasting, fitness (strength and cardiovascular training), and high protein, low carbohydrate diet and parallel monitoring. These regimens were paired with serial blood ketone, blood glucose (wearable and finger stick) and blood pressure readings, as well as body weight measurements using a collection of devices. Collectively this suite of platforms and approaches were used to monitor metabolic switching from glucose to ketones as energy sources-a process associated with potential cardio- and neuroprotective functions. In addition to longitudinal biomarker dynamics, this work discusses user perspectives on the potential role of harnessing digital devices to these dynamics as potential gamification factors, as well as considerations for the role of biomarker monitoring in health regimen development, user stratification, and potentially informing downstream population-scale studies to address metabolic disease, healthy aging and longevity, among other indications.

Efficacy of telemedicine intervention in the self-management of patients with type 2 diabetes: a systematic review and meta-analysis

Purpose

We aimed to report the latest and largest pooled analyses and evidence updates to assess the effectiveness of telemedicine interventions for self-management (DSM) in patients with type 2 diabetes mellitus (T2DM).

Methods

A systematic literature search was conducted using PubMed, Cochrane, Embase, and Web of Science in December 2023. We included randomized controlled trials (RCTs) of adults (≥18 years of age) diagnosed with T2DM where the intervention was the application of telemedicine. The Cochrane Risk of Bias Assessment was used to evaluate quality. The study's main outcome indicators were glycosylated hemoglobin (HbA1c) and diabetes self-management (DSM) capacity.

Results

A total of 17 eligible articles, comprising 20 studies and 1,456 patients (734 in the intervention group and 722 in the control group), were included in the evidence synthesis. The baseline characteristics of both groups were similar in all outcomes. Comprehensive analyses showed post-intervention decreases in HbA1c, 2-h postprandial glucose, systolic and diastolic blood pressure, increases in Diabetes Self- Care activities, DSM competencies based on dietary and medication adherence, and improvements in overall DSM scores, all of which were statistically significant. While no statistically significant differences were observed in body mass index, lipids, and other DSM dimensions. Based on subgroup analyses, app-based experimental interventions targeting under 60 years old populations in Asia and North America were found to be more effective and less heterogeneity in the short term (<6 months of intervention).

Conclusion

Telemedicine interventions may assist patients with T2DM in enhancing their DSM and improving their HbA1c levels. Clinician can use various telemedicine interventions to enhance DSM in T2DM patients, considering local circumstances.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, CRD42024508522.

Exploring the Role of Complexity in Health Care Technology Bottom-Up Innovations: Multiple-Case Study Using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability Complexity Assessment Tool

BACKGROUND

New digital technology presents new challenges to health care on multiple levels. There are calls for further research that considers the complex factors related to digital innovations in complex health care settings to bridge the gap when moving from linear, logistic research to embracing and testing the concept of complexity. The nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework was developed to help study complexity in digital innovations.

OBJECTIVE

This study aims to investigate the role of complexity in the development and deployment of innovations by retrospectively assessing challenges to 4 digital health care innovations initiated from the bottom up.

METHODS

A multicase retrospective, deductive, and explorative analysis using the NASSS complexity assessment tool LONG was conducted. In total, 4 bottom-up innovations developed in Region Västra Götaland in Sweden were explored and compared to identify unique and shared complexity-related challenges.

RESULTS

The analysis resulted in joint insights and individual learning. Overall, the complexity was mostly found outside the actual innovation; more specifically, it related to the organization's readiness to integrate new innovations, how to manage and maintain innovations, and how to finance them. The NASSS framework sheds light on various perspectives that can either facilitate or hinder the adoption, scale-up, and spread of technological innovations. In the domain of condition or diagnosis, a well-informed understanding of the complexity related to the condition or illness (diabetes, cancer, bipolar disorders, and schizophrenia disorders) is of great importance for the innovation. The value proposition needs to be clearly described early to enable an understanding of costs and outcomes. The questions in the NASSS complexity assessment tool LONG were sometimes difficult to comprehend, not only from a language perspective but also due to a lack of understanding of the surrounding organization's system and its setting.

CONCLUSIONS

Even when bottom-up innovations arise within the same support organization, the complexity can vary based on the developmental phase and the unique characteristics of each project. Identifying, defining, and understanding complexity may not solve the issues but substantially improves the prospects for successful deployment. Successful innovation within complex organizations necessitates an adaptive leadership and structures to surmount cultural resistance and organizational impediments. A rigid, linear, and stepwise approach risks disregarding interconnected variables and dependencies, leading to suboptimal outcomes. Success lies in embracing the complexity with its uncertainty, nurturing creativity, and adopting a nonlinear methodology that accommodates the iterative nature of innovation processes within complex organizations.

A novel questionnaire for evaluating digital tool use (DTUQ-D) among individuals with type 2 diabetes: exploring the digital landscape

Introduction

Effective healthcare currently incorporates a patient-centric system and accessible technology for patient self-management. This study aimed to develop and validate a novel questionnaire titled the Digital Tool Use Questionnaire for Diabetes (DTUQ-D) - a screening tool identifying the type, number, and frequency of digital tools used by Type 2 Diabetes Mellitus (T2DM) patients with within HMOs, online, and via applications.

Methods

The questionnaire was administered to two ethnic groups and both genders. A mixed-methods approach was used. In the qualitative phase, the questionnaire was developed through phone surveys of 29 T2DM patients, two endocrinologists and two technology experts. In the quantitative phase, involving 367 participants, convergent validity, construct validity, and reliability were examined.

Results

Findings indicated that the DTUQ-D is valid and reliable, successfully identifying digital tools utilized by T2DM patients, notwithstanding variations in factor structures between ethnic groups. This questionnaire provides a foundation for future research, offering a standardized approach to evaluating digital tool usage.

Discussion

The study enhances understanding of the role of digital tools in healthcare, especially for T2DM self-management. It also can be easily adapted to assess digital tool use for other illnesses by adjusting instructions and the wording of certain items.

Which behaviour change techniques work best for diabetes self-management mobile apps? Results from a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Self-management is pivotal in addressing noncommunicable diseases, such as diabetes. The increased availability of digital behaviour change interventions (DBCIs) delivered through mobile health apps offers unprecedented opportunities to enhance self-management and improve health outcomes. However, little is known about the characteristics of DBCIs for diabetes that significantly impact glycaemic control. Therefore, our systematic review with meta-analysis aimed to summarize characteristics and behaviour change components in DBCIs for diabetes self-management and explore potential associations with metabolic outcomes.

METHODS

A systematic search was conducted in PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Scopus to identify randomized controlled trials published until November 2023. The main outcome variable was the change in the mean difference of HbA1c levels between baseline and follow-up across intervention and control groups. Random-effects meta-regression was used to explore variation in glycaemic control as a function of prespecified characteristics of study designs and app interventions.

FINDINGS

A total of 57 studies was included in the analysis, showing a statistically significant percentage point reduction in HbA1c for the intervention group compared to the control arm (-0.36, 95% CI = -0.46 to -0.26, p < 0.001). The inclusion of "self-monitoring of behaviour" as a behaviour change technique (β = -0.22, p = 0.04) and "taking medication" as a target behaviour (β = -0.20, p = 0.05) was associated with improved metabolic outcomes.

INTERPRETATION

Our analyses endorse the use of diabetes self-management apps, highlighting characteristics statistically associated with intervention effectiveness and guiding the design of more effective DBCIs.

FUNDING

This project received funding from the European Union's Horizon 2020 programme.

The Impact of Digital Self-Monitoring of Weight on Improving Diabetes Clinical Outcomes: Quasi-Randomized Study

BACKGROUND

The management of type 2 diabetes (T2D) and obesity, particularly in the context of self-monitoring, remains a critical challenge in health care. As nearly 80% to 90% of patients with T2D have overweight or obesity, there is a compelling need for interventions that can effectively manage both conditions simultaneously. One of the goals in managing chronic conditions is to increase awareness and generate behavioral change to improve outcomes in diabetes and related comorbidities, such as overweight or obesity. There is a lack of real-life evidence to test the impact of self-monitoring of weight on glycemic outcomes and its underlying mechanisms.

OBJECTIVE

This study aims to assess the efficacy of digital self-monitoring of weight on blood glucose (BG) levels during diabetes management, investigating whether the weight changes may drive glucose fluctuations.

METHODS

In this retrospective, real-world quasi-randomized study, 50% of the individuals who regularly used the weight monitoring (WM) feature were propensity score matched with 50% of the users who did not use the weight monitoring feature (NWM) based on demographic and clinical characteristics. All the patients were diagnosed with T2D and tracked their BG levels. We analyzed monthly aggregated data 6 months before and after starting their weight monitoring. A piecewise mixed model was used for analyzing the time trajectories of BG and weight as well as exploring the disaggregation effect of between- and within-patient lagged effects of weight on BG.

RESULTS

The WM group exhibited a significant reduction in BG levels post intervention (P<.001), whereas the nonmonitoring group showed no significant changes (P=.59), and both groups showed no differences in BG pattern before the intervention (P=.59). Furthermore, the WM group achieved a meaningful decrease in BMI (P<.001). Finally, both within-patient (P<.001) and between-patient (P=.008) weight variability was positively associated with BG levels. However, 1-month lagged back BMI was not associated with BG levels (P=.36).

CONCLUSIONS

This study highlights the substantial benefits of self-monitoring of weight in managing BG levels in patients with diabetes, facilitated by a digital health platform, and advocates for the integration of digital self-monitoring tools in chronic disease management. We also provide initial evidence of testing the underlying mechanisms associated with BG management, underscoring the potential role of patient empowerment.

Telehealth for Chronic Disease Management Among Vulnerable Populations

Chronic diseases disproportionately affect patients in low-income minority groups who traditionally use in-person healthcare services. COVID-19 disrupted their routines and limited options for people to receive care; this could exacerbate health inequities. The study examined telehealth chronic disease management among low-income minority groups. We used Florida Medicaid claims data from March to December 2020 and the American Consumer Survey to examine the study objectives. Data were analyzed using Linear and Logistic Regression. We retrieved claim records of 52,904 unique patients; 31,999 were female and 49% of the sample had at least one telehealth visit. Medicaid patients were 8% less likely to use telehealth and 21% more likely to have audio visits when compared to Medicare patients. The analyses suggest that Non-Hispanic Black patients and individuals with a lack of education experience significant health inequities. People with chronic obstructive pulmonary disease (5%) and heart failure (14%) were less likely to use telehealth than patients with diabetes. Telehealth will continue to be a health delivery option; thus we recommend that strategies are enacted to educate, and resources are provided to promote equity among Non-Hispanic Black patients. Without priority attention to people among low-income minority populations, health inequities will continue to plague this community.

Efficacy of a Digital Diabetes Logbook for People With Type 1, Type 2, and Gestational Diabetes: Results From a Multicenter, Open-Label, Parallel-Group, Randomized Controlled Trial

BACKGROUND

In a randomized controlled trial, the efficacy of a digital diabetes diary regarding a reduction of diabetes distress was evaluated.

METHODS

A randomized controlled trial with a 12-week follow-up was conducted in 41 study sites across Germany. Key eligibility criteria were a diagnosis of type 1, type 2, or gestational diabetes and regular self-monitoring of blood glucose. Participants were randomly assigned (2:1 ratio) to either use the digital diabetes logbook (mySugr PRO), or to the control group without app use. The primary outcome was the reduction in diabetes distress at the 12-week follow-up. All analyses were based on the intention-to-treat population with all randomized participants. The trial was registered at the German Register for Clinical Studies (DRKS00022923).

RESULTS

Between February 11, 2021, and June 24, 2022, 424 participants (50% female, 50% male) were included, with 282 being randomized to the intervention group (66.5%) and 142 to the control group (33.5%). A total of 397 participants completed the trial (drop-out rate: 6.4%). The median reduction in diabetes distress was 2.41 (interquartile range [IQR]: -2.50 to 8.11) in the intervention group and 1.25 (IQR: -5.00 to 7.50) in the control group. The model-based adjusted between-group difference was significant (-2.20, IQR: -4.02 to -0.38, P = .0182) favoring the intervention group. There were 27 adverse events, 17 (6.0%) in the intervention group, and 10 (7.0%) in the control group.

CONCLUSIONS

The efficacy of the digital diabetes logbook was demonstrated regarding improvements in mental health in people with type 1, type 2, and gestational diabetes.

Identifying Main Themes in Diabetes Management Interviews Using Natural Language Processing-Based Text Mining

This study aimed to identify the main themes from exit interviews of adult patients with type 2 diabetes after completion of a diabetes education program. Eighteen participants with type 2 diabetes completed an exit interview regarding their program experience and satisfaction. Semistructured interview questions were used, and the interviews were auto-recorded. The interview transcripts were preprocessed and analyzed using four natural language processing-based text-mining techniques. The top 30 words from the term frequency and term frequency-inverse document frequency each were derived. In the N-gram analysis, the connection strength of "diabetes" and "education" was the highest, and the simultaneous connectivity of word chains ranged from a maximum of seven words to a minimum of two words. Based on the CONvergence of iteration CORrelation (CONCOR) analysis, three clusters were generated, and each cluster was named as follows: participation in a diabetes education program to control blood glucose, exercise, and use of digital devices. This study using text mining proposes a new and useful approach to visualize data to develop patient-centered diabetes education.

Assessment of the impact of a personalised nutrition intervention in impaired glucose regulation over 26 weeks: a randomised controlled trial

Dietary interventions can reduce progression to type 2 diabetes mellitus (T2DM) in people with non-diabetic hyperglycaemia. In this study we aimed to determine the impact of a DNA-personalised nutrition intervention in people with non-diabetic hyperglycaemia over 26 weeks. ASPIRE-DNA was a pilot study. Participants were randomised into three arms to receive either (i) Control arm: standard care (NICE guidelines) (n = 51), (ii) Intervention arm: DNA-personalised dietary advice (n = 50), or (iii) Exploratory arm: DNA-personalised dietary advice via a self-guided app and wearable device (n = 46). The primary outcome was the difference in fasting plasma glucose (FPG) between the Control and Intervention arms after 6 weeks. 180 people were recruited, of whom 148 people were randomised, mean age of 59 years (SD = 11), 69% of whom were female. There was no significant difference in the FPG change between the Control and Intervention arms at 6 weeks (- 0.13 mmol/L (95% CI [- 0.37, 0.11]), p = 0.29), however, we found that a DNA-personalised dietary intervention led to a significant reduction of FPG at 26 weeks in the Intervention arm when compared to standard care (- 0.019 (SD = 0.008), p = 0.01), as did the Exploratory arm (- 0.021 (SD = 0.008), p = 0.006). HbA1c at 26 weeks was significantly reduced in the Intervention arm when compared to standard care (- 0.038 (SD = 0.018), p = 0.04). There was some evidence suggesting prevention of progression to T2DM across the groups that received a DNA-based intervention (p = 0.06). Personalisation of dietary advice based on DNA did not result in glucose changes within the first 6 weeks but was associated with significant reduction of FPG and HbA1c at 26 weeks when compared to standard care. The DNA-based diet was effective regardless of intervention type, though results should be interpreted with caution due to the low sample size. These findings suggest that DNA-based dietary guidance is an effective intervention compared to standard care, but there is still a minimum timeframe of adherence to the intervention before changes in clinical outcomes become apparent.Trial Registration: www.clinicaltrials.gov.uk Ref: NCT03702465.

Identifying Unmet Needs in Major Depressive Disorder Using a Computer-Assisted Alternative to Conventional Thematic Analysis: Qualitative Interview Study With Psychiatrists

BACKGROUND

The development of digital health tools that are clinically relevant requires a deep understanding of the unmet needs of stakeholders, such as clinicians and patients. One way to reveal unforeseen stakeholder needs is through qualitative research, including stakeholder interviews. However, conventional qualitative data analytical approaches are time-consuming and resource-intensive, rendering them untenable in many industry settings where digital tools are conceived of and developed. Thus, a more time-efficient process for identifying clinically relevant target needs for digital tool development is needed.

OBJECTIVE

The objective of this study was to address the need for an accessible, simple, and time-efficient alternative to conventional thematic analysis of qualitative research data through text analysis of semistructured interview transcripts. In addition, we sought to identify important themes across expert psychiatrist advisor interview transcripts to efficiently reveal areas for the development of digital tools that target unmet clinical needs.

METHODS

We conducted 10 (1-hour-long) semistructured interviews with US-based psychiatrists treating major depressive disorder. The interviews were conducted using an interview guide that comprised open-ended questions predesigned to (1) understand the clinicians' experience of the care management process and (2) understand the clinicians' perceptions of the patients' experience of the care management process. We then implemented a hybrid analytical approach that combines computer-assisted text analyses with deductive analyses as an alternative to conventional qualitative thematic analysis to identify word combination frequencies, content categories, and broad themes characterizing unmet needs in the care management process.

RESULTS

Using this hybrid computer-assisted analytical approach, we were able to identify several key areas that are of interest to clinicians in the context of major depressive disorder and would be appropriate targets for digital tool development.

CONCLUSIONS

A hybrid approach to qualitative research combining computer-assisted techniques with deductive techniques provides a time-efficient approach to identifying unmet needs, targets, and relevant themes to inform digital tool development. This can increase the likelihood that useful and practical tools are built and implemented to ultimately improve health outcomes for patients.

Digital health integration for noncommunicable diseases: Comprehensive process mapping for full-life-cycle management

AIM

To create a systematic digital health process mapping framework for full-life-cycle noncommunicable disease management grounded in key stakeholder engagement.

METHODS

A triphasic, qualitative methodology was employed to construct a process mapping framework for digital noncommunicable disease management in Shanghai, China. The first phase involved desk research to examine current guidance and practices. In the second phase, pivotal stakeholders participated in focus group discussions to identify prevalent digital touchpoints across lifetime noncommunicable disease management. In the final phase, the Delphi technique was used to refine the framework based on expert insights and obtain consensus.

RESULTS

We identified 60 digital touchpoints across five essential stages of full-life-cycle noncommunicable disease management. Most experts acknowledged the rationality and feasibility of these touchpoints.

CONCLUSIONS

This study led to the creation of a comprehensive digital health process mapping framework that encompasses the entire life cycle of noncommunicable disease management. The insights gained emphasize the importance of a systemic strategic, person-centered approach over a fragmented, purely technocentric approach. We recommend that healthcare professionals use this framework as a linchpin for efficient disease management and seamless technology incorporation in clinical practice.

Adolescents with type 1 diabetes' perspectives on digital health interventions to enhance health literacy: a qualitative study

Introduction

Digital health intervention offers the potential to enhance health literacy, which is crucial for effective diabetes management, especially among adolescents. Diabetes is a major global public health issue, leading to devastating complications and increasing mortality rates. The incidence of type 1 diabetes mellitus (T1DM) is also on the rise, particularly among adolescents, necessitating multisectoral strategies to combat this disease. This study explores the perceptions of adolescents with T1DM in Germany regarding digital health interventions, with the aim of improving healthcare by addressing specific needs and guiding future research.

Methodology

This study employed a qualitative approach using semi-structured individual interviews with adolescents with T1DM (n = 20) aged 14 to 18 years old in Germany to explore their perspectives on digital interventions for health literacy promotion. The study adopted content analysis according to Kuckartz et al. and the research followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Ethical considerations were paramount and data were rigorously analyzed using coding and iterative processes to ensure data quality and reliability.

Results

The findings indicate that within three prominent domains, namely the utilization of digital health intervention for accessing and comprehending information, facilitating peer-to-peer interactions, and enhancing physician-patient communication and interaction, digital health interventions are either underutilized or insufficiently deployed. In addition, a notable observation is the apparent lack of patient-centered approaches for adolescents with T1DM in relation to digital health interventions and health literacy.

Conclusion

In order to enhance the utilization of digital health interventions and enhance health literacy it is essential to focus on capacity building through a patient-centered approach, to promote digital health literacy, and foster the cultivation of a participatory culture. The outcomes of this study offer valuable insights that can inform practical applications, further research endeavors, and influence policymaking.

Applications of digital health approaches for cardiometabolic diseases prevention and management in the Western Pacific region

Cardiometabolic diseases (CMDs) are the major types of non-communicable diseases, contributing to huge disease burdens in the Western Pacific region (WPR). The use of digital health (dHealth) technologies, such as wearable gadgets, mobile apps, and artificial intelligence (AI), facilitates interventions for CMDs prevention and treatment. Currently, most studies on dHealth and CMDs in WPR were conducted in a few high- and middle-income countries like Australia, China, Japan, the Republic of Korea, and New Zealand. Evidence indicated that dHealth services promoted early prevention by behavior interventions, and AI-based innovation brought automated diagnosis and clinical decision-support. dHealth brought facilitators for the doctor-patient interplay in the effectiveness, experience, and communication skills during healthcare services, with rapidly development during the pandemic of coronavirus disease 2019. In the future, the improvement of dHealth services in WPR needs to gain more policy support, enhance technology innovation and privacy protection, and perform cost-effectiveness research.

Evaluation of Mobile Applications for Patients with Diabetes Mellitus: A Scoping Review

There has been increasing interest in mobile healthcare for diabetes management. However, there remains limited evidence regarding the effectiveness of these mobile applications (apps). This scoping review aimed to evaluate the clinical effectiveness of mobile diabetes management apps. We used the following search terms: "mobile app", "mobile application", and "diabetes". We included only articles written in English and published between January 2016 and August 2021. We identified two, six, and four articles focused on type 1 diabetes, type 2 diabetes, and both diabetes types, respectively. Five, four, and three of these studies reported on the apps' functionality, usability, and both, respectively. Our findings indicated that diabetes mobile apps allowed for convenient user experience and improved blood sugar levels in patients with diabetes. Considering these findings, usability must be comprehensively evaluated by using definitions such as the ISO9241-11 usability definition or the mobile application rating scale (MARS) when developing diabetes-related apps. For the feasibility of diabetes mobile apps, we recommend that HbA1C and self-management be included as evaluation variables. Given the increasing importance of continuous management for patients with diabetes, interventions using mobile apps are bound to become effective tools for patient-led self-management.

Effects of Digitization of Self-Monitoring of Blood Glucose Records Using a Mobile App and the Cloud System on Outpatient Management of Diabetes: Single-Armed Prospective Study

BACKGROUND

In recent years, technologies promoting the digitization of self-monitoring of blood glucose (SMBG) records including app-cloud cooperation systems have emerged. Studies combining these technological interventions with support from remote health care professionals have reported improvements in glycemic control.

OBJECTIVE

To assess the use of an app-cloud cooperation system linked with SMBG devices in clinical settings, we evaluated its effects on outpatient management of diabetes without remote health care professional support.

METHODS

In this multicenter, open-label, and single-armed prospective study, 48 patients with diabetes (including type 1 and type 2) at 3 hospitals in Japan treated with insulin or glucagon-like peptide 1 receptor agonists and performing SMBG used the app-cloud cooperation system for 24 weeks. The SMBG data were automatically uploaded to the cloud via the app. The patients could check their data, and their attending physicians reviewed the data through the cloud prior to the patients' regular visits. The primary outcome was changes in glycated hemoglobin (HbA1c) levels.

RESULTS

Although HbA1c levels did not significantly change in all patients, the frequency of daily SMBG following applying the system was significantly increased before induction at 12 (0.60 per day, 95% CI 0.19-1.00; P=.002) and 24 weeks (0.43 per day, 95% CI 0.02-0.84; P=.04). In the subset of 21 patients whose antidiabetic medication had not been adjusted during the intervention period, a decrease in HbA1c level was observed at 12 weeks (P=.02); however, this significant change disappeared at 24 weeks (P=.49). The Diabetes Treatment Satisfaction Questionnaire total score and "Q4: convenience" and "Q5: flexibility" scores significantly improved after using the system (all P<.05), and 72% (33/46) patients and 76% (35/46) physicians reported that the app-cloud cooperation system helped them adjust insulin doses.

CONCLUSIONS

The digitization of SMBG records and sharing of the data by patients and attending physicians during face-to-face visits improved self-management in patients with diabetes.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCT) jRCTs042190057; https://jrct.niph.go.jp/en-latest-detail/jRCTs042190057.

The Goldilocks Dilemma on Balancing User Response and Reflection in mHealth Interventions: Observational Study

Background

Mobile health (mHealth) has the potential to radically improve health behaviors and quality of life; however, there are still key gaps in understanding how to optimize mHealth engagement. Most engagement research reports only on system use without consideration of whether the user is reflecting on the content cognitively. Although interactions with mHealth are critical, cognitive investment may also be important for meaningful behavior change. Notably, content that is designed to request too much reflection could result in users' disengagement. Understanding how to strike the balance between response burden and reflection burden has critical implications for achieving effective engagement to impact intended outcomes.

Objective

In this observational study, we sought to understand the interplay between response burden and reflection burden and how they impact mHealth engagement. Specifically, we explored how varying the response and reflection burdens of mHealth content would impact users' text message response rates in an mHealth intervention.

Methods

We recruited support persons of people with diabetes for a randomized controlled trial that evaluated an mHealth intervention for diabetes management. Support person participants assigned to the intervention (n=148) completed a survey and received text messages for 9 months. During the 2-year randomized controlled trial, we sent 4 versions of a weekly, two-way text message that varied in both reflection burden (level of cognitive reflection requested relative to that of other messages) and response burden (level of information requested for the response relative to that of other messages). We quantified engagement by using participant-level response rates. We compared the odds of responding to each text and used Poisson regression to estimate associations between participant characteristics and response rates.

Results

The texts requesting the most reflection had the lowest response rates regardless of response burden (high reflection and low response burdens: median 10%, IQR 0%-40%; high reflection and high response burdens: median 23%, IQR 0%-51%). The response rate was highest for the text requesting the least reflection (low reflection and low response burdens: median 90%, IQR 61%-100%) yet still relatively high for the text requesting medium reflection (medium reflection and low response burdens: median 75%, IQR 38%-96%). Lower odds of responding were associated with higher reflection burden (P<.001). Younger participants and participants who had a lower socioeconomic status had lower response rates to texts with more reflection burden, relative to those of their counterparts (all P values were <.05).

Conclusions

As reflection burden increased, engagement decreased, and we found more disparities in engagement across participants' characteristics. Content encouraging moderate levels of reflection may be ideal for achieving both cognitive investment and system use. Our findings provide insights into mHealth design and the optimization of both engagement and effectiveness.

The Sukaribit Smartphone App for Better Self-Management of Type 2 Diabetes: Randomized Controlled Feasibility Study

BACKGROUND

A new app, Sukaribit, was designed to enable contact between the caregiver and the patient with the intent to improve self-care and glycemic control (hemoglobin A1c [HbA1c]).

OBJECTIVE

This study investigated the feasibility of the study methodology and the intervention in preparation for a larger effectiveness study.

METHODS

Adults with type 2 diabetes were recruited in this randomized controlled feasibility study with a mixed methods design. The intervention group (n=28) tried Sukaribit for 2 months. They were encouraged to report blood glucose levels and medications, and they received feedback from a physician. The control group (n=31) received standard care. Both groups were evaluated with pre and postmeasurements of glycemic control (HbA1c), diabetes distress, physical activity, and self-care. Feasibility was evaluated against 5 progression criteria regarding recruitment, study methods, and active participation.

RESULTS

Of the 5 progression criteria, only 2 were met or partially met. The recruitment process exceeded expectations, and data collection worked well for self-reported data but not for HbA1c measured with a home testing kit. The participants were less active than anticipated, and the effect sizes were small. Only the number of blood glucose tests per day was positively affected by the intervention, with 0.6 more tests per day in the intervention group.

CONCLUSIONS

Recruitment of participants to a future fully powered study may work with minor adjustments. The collection of HbA1c using home testing constituted a major problem, and an alternative strategy is warranted. Finally, the app was not used as intended. In order to proceed with a larger study, the app and study procedures need improvement.

Barriers and Enablers to the Adoption of a Healthier Diet Using an App: Qualitative Interview Study With Patients With Type 2 Diabetes Mellitus

BACKGROUND

Adopting a healthy diet is one of the cornerstones of type 2 diabetes (T2D) management. Apps are increasingly used in diabetes self-management, but most studies to date have focused on assessing their impact in terms of weight loss or glycemic control, with limited evidence on the behavioral factors that influence app use to change dietary habits.

OBJECTIVE

The main objectives of this study were to assess the enablers and barriers to adopting a healthier diet using the Gro Health app in 2 patient groups with T2D (patients with recently diagnosed and long-standing T2D) and to identify behavior change techniques (BCTs) to enhance enablers and overcome barriers.

METHODS

Two semistructured qualitative interview studies were conducted; the first study took place between June and July 2021, with a sample of 8 patients with recently diagnosed (<12 mo) T2D, whereas the second study was conducted between May and June 2022 and included 15 patients with long-standing (>18 mo) T2D. In both studies, topic guides were informed by the Capability, Opportunity, Motivation, and Behavior model and the Theoretical Domains Framework. Transcripts were analyzed using a combined deductive framework and inductive thematic analysis approach. The Behavior Change Wheel framework was applied to identify appropriate BCTs that could be used in future iterations of apps for patients with diabetes. Themes were compared between the patient groups.

RESULTS

This study identified similarities and differences between patient groups in terms of enablers and barriers to adopting a healthier diet using the app. The main enablers for recently diagnosed patients included the acquired knowledge about T2D diets and skills to implement these, whereas the main barriers were the difficulty in deciding which app features to use and limited cooking skills. By contrast, for patients with long-standing T2D, the main enablers included knowledge validation provided by the app, along with app elements to help self-regulate food intake; the main barriers were the limited interest paid to the content provided or limited skills engaging with apps in general. Both groups reported more enablers than barriers to performing the target behavior when using the app. Consequently, BCTs were selected to address key barriers in both groups, such as simplifying the information hierarchy in the app interface, including tutorials demonstrating how to use the app features, and redesigning the landing page of the app to guide users toward these tutorials.

CONCLUSIONS

Patients with recently diagnosed and long-standing T2D encountered similar enablers but slightly different barriers when using an app to adopting a healthier diet. Consequently, the development of app-based approaches to adopt a healthier diet should account for these similarities and differences within patient segments to reduce barriers to performing the target behavior.

Addressing Insulin Injection Technique: A Follow-up Study of Canadian Patients with Diabetes

INTRODUCTION

Proper insulin injection technique is important for optimal glycaemic control, yet patients with diabetes often inject insulin incorrectly. Previous studies identified common errors in insulin injection in Canada, and this article seeks to evaluate the current insulin injection technique practices among patients and explore the effectiveness of feedback and education in improving their technique.

METHODS

The study recruited 147 patients and 16 physicians across Canada to gather insights into current insulin injection practices and education gaps. Eligible patients were people living with diabetes who inject insulin using an insulin pen and pen needles. Eligible physicians, who were unsupported by diabetes educators, completed a practice assessment survey and selected 10 eligible patients to complete a baseline assessment survey. During the patient visit, if an error in the patient's technique was identified, a pop-up knowledge transfer (KT) prompt would appear, providing feedback and information on best practices at the point of care. Follow-up surveys were completed 1-3 months later.

RESULTS

Physicians reported facing barriers to providing education and feedback, including lack of time and personnel, and lack of effective educational material. Patients demonstrated modest improvements in some injection technique domains at their follow-up visit, including injection force factors, time the needle was held in the skin, pen needle reuse, injection area size, and injection angle. The most common initial mistakes by patients were selecting an area smaller than recommended and not paying attention to the injection force. At the second visit, patients reduced an average of one error in their injection technique.

CONCLUSION

Results showed that basic feedback by their physician during one visit could exert moderate improvements on patients' injection technique. Proper injection technique is critical for diabetes management, and incorporating targeted ongoing education and support can significantly enhance physician practices, ultimately reducing risks and improving outcomes.

Comparing the effects of home visits and telenursing on blood glucose control: A systematic review of randomized controlled trials

BACKGROUND

Home visits have often been performed for diabetes management, but with the increased use of the internet and smartphones, people are opting for telenursing as the main method for monitoring and controlling diabetes.

OBJECTIVE

This study compares the effects of home visits and telenursing on diabetes management.

METHODS

Four electronic databases (MEDLINE, Embase, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature) were used as data sources. Glycated hemoglobin (HbA1c), fasting blood sugar, and two-hour post-prandial glucose levels were used as outcome measures. A subgroup analysis was performed based on the type of diabetes and follow-up.

RESULTS

Of 1890 studies, 24 (2801 participants) were selected and meta-analyzed. The nursing interventions provided during nursing visits or telenursing mainly included education on diabetes and blood sugar control. It was seen that HbA1c decreased with a weighted mean difference of -0.66 (95 % confidence interval -0.82 to -0.51, p < .001) % in home visits and -0.56 (95 % confidence interval -0.81 to -0.31, p < .001) % in telenursing. The fasting blood sugar reported only in telenursing was reduced by a weighted mean difference of -14.23 (95 % confidence interval 27.59 to -0.88, p = .04) mg/dL and two-hour post-prandial glucose was reduced with a mean difference of -15.84 (95 % confidence interval -24.45 to -7.24, p = .003) mg/dL. Furthermore, low heterogeneity was found among the studies. In a subgroup analysis of diabetes type, HbA1c in home visits was reduced by -0.86 % in type 1 diabetes and -0.62 % in type 2 diabetes, while in telenursing, the reductions were -0.65 % and -0.53 %, respectively. Fasting blood glucose was reduced by -6.08 mg/dL and -18.50 mg/dL, respectively, whereas two-hour postprandial blood sugar was reduced by -14.49 mg/dL and -30.30 mg/dL, respectively, in telenursing. In the subgroup analysis of the follow-up period, HbA1c during home visits decreased by -0.63 % at 10 to 16 weeks, -0.73 % at 24 to 36 weeks, and -0.64 % at 52 weeks or more, while in telenursing, the reductions were -0.80 %, -0.44 %, and -0.07 %, respectively. Home visits were not statistically significant between 10 and 16 weeks, whereas telenursing was not significant at 52 weeks or more.

CONCLUSIONS

Despite telenursing reducing HbA1c slightly less than home visits, evidence from this systematic review suggests that telenursing is a similarly effective approach for controlling blood glucose levels in patients with diabetes. Telenursing is a nursing intervention that can be used as an alternative to home visits for patients requiring diabetes management.

Psycho-social factors associated with type two diabetes remission through lifestyle intervention: A scoping review

OBJECTIVES

There is growing evidence that type 2 diabetes (T2D) can be put into remission through lifestyle intervention. Current focus on remission in terms of physiological considerations and biomedical scales, means there is limited understanding of the role psycho-social factors play in moderating the efficacy of lifestyle interventions for T2D remission. In the current review we aimed to synthesise the emerging literature on psycho-social factors associated with T2D remission, specifically from lifestyle interventions.

METHODS

Five databases (EMBASE, MEDLINE, CINAHL ultimate, PsychINFO and PsycArticles) were searched to identify studies from 2009 onwards that reported remission outcomes from lifestyle interventions in participants ≥ 18years old, with a clinical diagnosis of T2D. Studies included were of an interventional or observational design and restricted to English language. Screening and data extraction was performed independently by two reviewers using prespecified criteria.

RESULTS

In total 6106 studies were screened, 36 studies meeting the inclusion criteria were included. Studies were globally diverse, with 30 (83%) being published ≥ 2017. Psycho-social scales were under-utilised with 22 (67%) of studies failing to include any psycho-social measures. Single arm, prospective studies were most frequently utilised, however study quality was perceived to be heterogeneous. Further disparity in the quality, content and delineation of the psycho-social interventions was also identified. Education and self-monitoring interventions were the most frequently incorporated. Self-monitoring was also identified as an important facilitator to remission, in addition to social support.

CONCLUSIONS

Our findings indicate that psycho-social factors in T2D remission are under-explored. We have identified a number of methodological issues (comparability, conflicting remission criteria and poorly defined psycho-social interventions) suggesting knowledge gaps which could inform the methodology of future research design. There is significant opportunity for future research to incorporate the social model of disease, conceptualise remission more holistically, and build a more comprehensive evidence base to guide clinical practice.

An AI Dietitian for Type 2 Diabetes Mellitus Management Based on Large Language and Image Recognition Models: Preclinical Concept Validation Study

BACKGROUND

Nutritional management for patients with diabetes in China is a significant challenge due to the low supply of registered clinical dietitians. To address this, an artificial intelligence (AI)-based nutritionist program that uses advanced language and image recognition models was created. This program can identify ingredients from images of a patient's meal and offer nutritional guidance and dietary recommendations.

OBJECTIVE

The primary objective of this study is to evaluate the competence of the models that support this program.

METHODS

The potential of an AI nutritionist program for patients with type 2 diabetes mellitus (T2DM) was evaluated through a multistep process. First, a survey was conducted among patients with T2DM and endocrinologists to identify knowledge gaps in dietary practices. ChatGPT and GPT 4.0 were then tested through the Chinese Registered Dietitian Examination to assess their proficiency in providing evidence-based dietary advice. ChatGPT's responses to common questions about medical nutrition therapy were compared with expert responses by professional dietitians to evaluate its proficiency. The model's food recommendations were scrutinized for consistency with expert advice. A deep learning-based image recognition model was developed for food identification at the ingredient level, and its performance was compared with existing models. Finally, a user-friendly app was developed, integrating the capabilities of language and image recognition models to potentially improve care for patients with T2DM.

RESULTS

Most patients (182/206, 88.4%) demanded more immediate and comprehensive nutritional management and education. Both ChatGPT and GPT 4.0 passed the Chinese Registered Dietitian examination. ChatGPT's food recommendations were mainly in line with best practices, except for certain foods like root vegetables and dry beans. Professional dietitians' reviews of ChatGPT's responses to common questions were largely positive, with 162 out of 168 providing favorable reviews. The multilabel image recognition model evaluation showed that the Dino V2 model achieved an average F1 score of 0.825, indicating high accuracy in recognizing ingredients.

CONCLUSIONS

The model evaluations were promising. The AI-based nutritionist program is now ready for a supervised pilot study.

Next-generation cognitive assessment: Combining functional brain imaging, system perturbations and novel equipment interfaces

Conventional cognitive assessment is widely used in clinical and research settings, in educational institutions, and in the corporate world for personnel selection. Such approaches involve having a client, a patient, or a research participant complete a series of standardized cognitive tasks in order to challenge specific and global cognitive abilities, and then quantify performance for the desired end purpose. The latter may include a diagnostic confirmation of a disease, description of a state or ability, or matching cognitive characteristics to a particular occupational role requirement. Metrics derived from cognitive assessments are putatively informative about important features of the brain and its function. For this reason, the research sector also makes use of cognitive assessments, most frequently as a stimulus for cognitive activity from which to extract functional neuroimaging data. Such "task-related activations" form the core of the most widely used neuroimaging technologies, such as fMRI. Much of what we know about the brain has been drawn from the interleaving of cognitive assessments of various types with functional brain imaging technologies. Despite innovation in neuroimaging (i.e., quantifying the neural response), relatively little innovation has occurred on task presentation and volitional response measurement; yet these together comprise the core of cognitive performance. Moreover, even when cognitive assessment is interleaved with functional neuroimaging, this is most often undertaken in the research domain, rather than the primary applications of cognitive assessment in diagnosis and monitoring, education and personnel selection. There are new ways in which brain imaging-and even more importantly, brain modulation-technologies can be combined with automation and artificial intelligence to deliver next-generation cognitive assessment methods. In this review paper, we describe some prototypes for how this can be done and identify important areas for progress (technological and otherwise) to enable it to happen. We will argue that the future of cognitive assessment will include semi- and fully-automated assessments involving neuroimaging, standardized perturbations via neuromodulation technologies, and artificial intelligence. Furthermore, the fact that cognitive assessments take place in a social/interpersonal context-normally between the patient and clinician-makes the human-machine interface consequential, and this will also be discussed.

Mobile Application for Adhering to Diabetic Foot Self-care: Randomized Controlled Clinical Trial

This study aimed to analyze the effectiveness of a mobile application for adherence to foot self-care in people with type 2 diabetes at risk for diabetic foot ulcer. A double-blind randomized controlled clinical trial was conducted with people with type 2 diabetes in a secondary healthcare unit. A total of 42 patients were recruited, matched, and allocated into two groups: one (intervention group) undergoing standard nursing consultations and application use and the other (control group) receiving only standard nursing consultations. The outcome variable was the adherence to foot self-care, measured by completing questionnaires on diabetes self-care activities and adherence to foot self-care. Measures of central tendency and dispersion were calculated, in addition to bivariate associations, considering a significance level of P ≤ .05. The intragroup and intergroup analyses regarding diabetes self-care did not show statistical significance; however, the intervention group showed a considerable increase in the frequency of daily assessments ( P = .048) and adherence to foot self-care ( P = .046). The use of the app, combined with the nursing consultation, increased adherence to foot self-care of people with type 2 diabetes. Brazilian Registry of Clinical Trials: U1111-1202-6318.

Digital lifestyle treatment improves long-term metabolic control in type 2 diabetes with different effects in pathophysiological and genetic subgroups

To address the unmet need for scalable solutions for lifestyle treatment, we developed a new digital method to promote behavioral change. Here we report that patients with type-2 diabetes in Sweden (n = 331) exposed to the intervention have significantly improved HbA1c during a median follow-up of 1038 days (4 mmol/mol compared with matched controls; P = 0.009). This is paralleled by reduced body weight, ameliorated insulin secretion, increased physical activity, and cognitive eating restraints. Participants with high BMI and insulin resistance have an even larger response, as have non-risk allele carriers for the FTO gene. The findings open a new avenue for scalable lifestyle management with sustained efficacy and highlight a previously unrecognized opportunity for digital precision treatment based on genetics and individual pathophysiology. ClinicalTrials.gov NCT04624321.

Factors affecting the willingness of patients with type 2 diabetes to use digital disease management applications: a cross-sectional study

Background

The global burden of type 2 diabetes has significantly increased, leading to a considerable impact on healthcare systems worldwide. While the advent of mobile healthcare has provided some relief by addressing the shortage of certain medical resources, its adoption among the Chinese population remains relatively low. To extend the benefits of mHealth to a greater number of Chinese diabetic patients, it is essential to investigate the factors that influence their willingness to utilize it and implement targeted interventions based on these influencing factors. The Technology Acceptance Model (TAM) is widely employed to examine users' ultimate usage behaviors, and previous studies have indicated the potential relevance of the Perceived Risk (PR) theory and the eHealth Literacy Theory to users' usage behaviors.

Objective

Our objective was to investigate the determinants that affect the willingness of Chinese patients diagnosed with type 2 diabetes patients to utilize digital disease management applications (DDMAs).

Methods

We conducted a cross-sectional study of patients with type 2 diabetes in three tertiary general hospitals in Chengdu using questionnaires designed by the investigators. Participants were sampled using a convenience sampling method. The questionnaire comprised three sections: socio-demographic profile and medical history; current awareness and willingness to use digital disease management applications; and the current level of e-health literacy. Structural equation modeling was employed to assess the impact of patient awareness of DDMAs and e-health literacy on the willingness to use such DDMAs.

Results

(1) Patients' attitudes toward using DDMAs were significantly influenced by perceived ease of use (β = 0.380, P < 0.001) and perceived usefulness (β = 0.546, P < 0.001); (2) Electronic health literacy exerted a significant impact on patients' perceived usefulness (β = 0.115, P = 0.018) and perceived ease of use (β = 0.659, P < 0.001); (3) Patients' willingness to use was significantly influenced by perceived usefulness (β = 0.137, P < 0.001) and use attitude (β = 0.825, P < 0.001).

Conclusions

The present research findings hold both theoretical and practical significance, and can serve as a guide for healthcare practitioners and researchers to gain a deeper comprehension of the acceptance of digital disease management applications (DDMAs) among type 2 diabetes patients.

How to evaluate over 60 million blood glucose data - The design of the MÉRY Diabetes Database

AIMS

The aim of the article is to describe the method for creating a close to ideal diabetes database. The MÉRY Diabetes Database (MDD) consists of a large quantity of reliable, well-maintained, precise and up-to-date data suited for clinical research with the intention to improve diabetes care in terms of maintaining targeted blood glucose levels, avoiding hypoglycemic episodes and complications and improving patient compliance and quality of life.

METHODS

Based on the analysis of the databases found in the literature and the experience of our research team, nine important characteristics were identified as critical to an ideal diabetes database. The data for our database is collected using MÉRYkék glucometers, a device that meets all requirements of international regulations and measures blood glucose levels within the normal range with appropriate precision (10 %).

RESULTS

Using the key characteristics defined, we were able to create a database suitable for the analysis of a large amount of data regarding diabetes care and outcomes.

CONCLUSIONS

The MDD is a reliable and ever growing database which provides stable and expansive foundation for extensive clinical investigations that hold the potential to significantly influence the trajectory of diabetes care and enhance patient outcomes.

Understanding Whether and How a Digital Health Intervention Improves Transition Care for Emerging Adults Living With Type 1 Diabetes: Protocol for a Mixed Methods Realist Evaluation

BACKGROUND

Emerging adults living with type 1 diabetes (T1D) face a series of challenges with self-management and decreased health system engagement, leading to an increased risk of acute complications and hospital admissions. Effective and scalable strategies are needed to support this population to transfer seamlessly from pediatric to adult care with sufficient self-management capability. While digital health interventions for T1D self-management are a promising strategy, it remains unclear which elements work, how, and for which groups of individuals.

OBJECTIVE

This study aims to evaluate the design and implementation of a multicomponent SMS text message-based digital health intervention to support emerging adults living with T1D in real-world settings. The objectives are to identify the intervention components and associated mechanisms that support user engagement and T1D health care transition experiences and determine the individual characteristics that influence the implementation process.

METHODS

We used a realist evaluation embedded alongside a randomized controlled trial, which uses a sequential mixed methods design to analyze data from multiple sources, including intervention usage data, patient-reported outcomes, and realist interviews. In step 1, we conducted a document analysis to develop a program theory that outlines the hypothesized relationships among "individual-level contextual factors, intervention components and features, mechanisms, and outcomes," with special attention paid to user engagement. Among them, intervention components and features depict 10 core characteristics such as transition support information, problem-solving information, and real-time interactivity. The proximal outcomes of interest include user engagement, self-efficacy, and negative emotions, whereas the distal outcomes of interest include transition readiness, self-blood glucose monitoring behaviors, and blood glucose. In step 2, we plan to conduct semistructured realist interviews with the randomized controlled trial's intervention-arm participants to test the hypothesized "context-intervention-mechanism-outcome" configurations. In step 3, we plan to triangulate all sources of data using a coincidence analysis to identify the necessary combinations of factors that determine whether and how the desired outcomes are achieved and use these insights to consolidate the program theory.

RESULTS

For step 1 analysis, we have developed the initial program theory and the corresponding data collection plan. For step 2 analysis, participant enrollment for the randomized controlled trial started in January 2023. Participant enrollment for this realist evaluation was anticipated to start in July 2023 and continue until we reached thematic saturation or achieved informational power.

CONCLUSIONS

Beyond contributing to knowledge on the multiple pathways that lead to successful engagement with a digital health intervention as well as target outcomes in T1D care transitions, embedding the realist evaluation alongside the trial may inform real-time intervention refinement to improve user engagement and transition experiences. The knowledge gained from this study may inform the design, implementation, and evaluation of future digital health interventions that aim to improve transition experiences.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46115.

eHealth profile of patients with diabetes

Background

Digital health technology can be useful to improve the health of patients with diabetes and to support patient-centered care and self-management. In this cross-sectional study, we described the eHealth profile of patients with diabetes, based on their use of digital health technology, and its association with sociodemographic characteristics.

Methods

We used data from the "Qualité Diabète Valais" cohort study, conducted in one region of Switzerland (Canton Valais) since 2019. Participants with type 1 or type 2 diabetes completed questionnaires on sociodemographic characteristics and on the use of digital health technology. We defined eHealth profiles based on three features, i.e., ownership or use of (1) internet-connected devices (smartphone, tablet, or computer), (2) mHealth applications, and (3) connected health tools (activity sensor, smart weight scale, or connected blood glucose meter). We assessed the association between sociodemographic characteristics and participants' eHealth profiles using stratified analyses and logistic regression models.

Results

Some 398 participants (38% women) with a mean age of 65 years (min: 25, max: 92) were included. The vast majority (94%) were Swiss citizens or bi-national and 68% were economically inactive; 14% had a primary level education, 51% a secondary level, and 32% a tertiary level. Some 75% of participants had type 2 diabetes. Some 90% of the participants owned internet-connected devices, 43% used mHealth applications, and 44% owned a connected health tool. Older age and a lower educational level were associated with lower odds of all features of the eHealth profile. To a lesser extent, having type 2 diabetes or not being a Swiss citizen were also associated with a lower use of digital health technology. There was no association with sex.

Conclusion

While most participants owned internet-connected devices, only about half of them used mHealth applications or owned connected health tools. Older participants and those with a lower educational level were less likely to use digital health technology. eHealth implementation strategies need to consider these sociodemographic patterns among patients with diabetes.

Patent analysis of digital sensors for continuous glucose monitoring

The high need for optimal diabetes management among an ever-increasing number of patients dictates the development and implementation of new digital sensors for continuous glucose monitoring. The purpose of this work is to systematize the global patenting trends of digital sensors for continuous glucose monitoring and analyze their effectiveness in controlling the treatment of diabetes patients of different ages and risk groups. The Lens database was used to build the patent landscape of sensors for continuous glucose monitoring. Retrospective analysis showed that the patenting of sensors for continuous glucose monitoring had positive trend over the analyzed period (2000-2022). Leading development companies are Dexcom Inc., Abbott Diabetes Care Inc., Medtronic Minimed Inc., Roche Diabetes Care Inc., Roche Diagnostics Operations Inc., Roche Diabetes Care Gmbh, and Ascensia Diabetes Care Holdings Ag, among others. Since 2006, a new approach has emerged where digital sensors are used for continuous glucose monitoring, and smartphones act as receivers for the data. Additionally, telemedicine communication is employed to facilitate this process. This opens up new opportunities for assessing the glycemic profile (glycemic curve information, quantitative assessment of the duration and amplitude of glucose fluctuations, and so on), which may contribute to improved diabetes management. A number of digital sensors for minimally invasive glucose monitoring are patented, have received FDA approval, and have been on the market for over 10 years. Their effectiveness in the clinic has been proven, and advantages and disadvantages have been clarified. Digital sensors offer a non-invasive option for monitoring blood glucose levels, providing an alternative to traditional invasive methods. This is particularly useful for patients with diabetes who require frequent monitoring, including before and after meals, during and after exercise, and in other scenarios where glucose levels can fluctuate. However, non-invasive glucose measurements can also benefit patients without diabetes, such as those following a dietary treatment plan, pregnant women, and individuals during fasting periods like Ramadan. The availability of non-invasive monitoring is especially valuable for patients in high-risk groups and across different age ranges. New world trends have been identified in the patenting of digital sensors for non-invasive glucose monitoring in interstitial skin fluid, saliva, sweat, tear fluid, and exhaled air. A number of non-invasive devices have received the CE mark approval, which confirms that the items meet European health, safety, and environmental protection standards (TensorTip Combo-Glucometer, Cnoga Medical Ltd.; SugarBEAT, Nemaura Medical; GlucoTrack, GlucoTrack Inc.), but are not FDA-approved yet. The above-mentioned sensors have characteristics that make them popular in the treatment of diabetes: they do not require implantation, do not cause an organism reaction to a foreign body, and are convenient to use. In the EU, in order to increase clinical safety and the level of transparency about medical devices, manufacturers must obtain certificates in accordance with Regulation (EU) 2017/745, taking into account the transition period. The development of systems, which include digital sensors for continuous glucose monitoring, mobile applications, and web platforms for professional analysis of glycemic control and implementation of unified glycemic assessment principles in mobile healthcare, represent promising approaches for controlling glycaemia in patients.

Persuasive features for patient engagement through mHealth applications in managing chronic conditions: A systematic literature review and meta-analysis

Patient engagement is currently considered the cornerstone of a revolution in healthcare for its positive impact on health outcomes, health behaviors and healthcare costs. Patient engagement is focused on personalized care to consumers through providing knowledge, skills and confidence. Mobile health (mHealth) applications are an innovative means to facilitate patient engagement. Nevertheless, the extent to which the current mHealth applications are designed to engage patients in managing their chronic diseases is unclear. This paper aims to identify the Persuasive System Design (PSD) features present in current mHealth applications that increased the engagement of patients with chronic diseases. This review also aims to identify patient engagement-related outcomes of these features. This paper conducted a systematic literature review and meta-analysis to find relevant studies published from all years up to 2020 through six databases: PubMed, Scopus, Web of Science, Cinahl plus with full text, MEDLINE with full text, and Cochrane Library (Central register of controlled trials). The database search returned 4939 articles; after applying the inclusion and exclusion criteria, the number of included articles for the final review was 13. A qualitative content analysis was performed to identify PSD model features and their patient engagement-related outcomes. The quality assessment has been done through the Cochrane Risk of Bias tool for RCTs. The systematic literature review and meta-analysis identified eleven PSD features that can increase patient engagement through using mHealth applications. The identified PSD features have been shown to have various patient engagement-related outcomes. Behavior Change Techniques (BCTs) were combined with the identified PSD features. This paper identified persuasive features of mHealth application design that influence the engagement of patients with chronic diseases toward changing their behavior. The impact of these features is also analyzed in this review. The results show that an mHealth technology-mediated patient engagement model is needed.

Precision Medicine 2.0: How Digital Health and AI Are Changing the Game

In the era of rapid IT developments, the health domain is undergoing a considerable transformation [...].

Evaluation of feasibility and acceptability of a web-based diabetes prevention program (DPP) for diabetes risk reduction in Chinese Americans in New York City

Introduction

Intensive lifestyle intervention remains an effective modality to reduce diabetes incidence and delay the progression to type 2 diabetes. The primary aim of this study was to pilot-test the feasibility and acceptability of a culturally and linguistically tailored web-based DPP intervention among Chinese Americans with prediabetes living in New York City.

Methods

Thirteen Chinese American participants with prediabetes were recruited to complete a 1-year web-based Diabetes Prevention Program (DPP) lifestyle intervention. Quantitative and qualitative measures such as retention rate and data collected from web-based questionnaires and focus groups were collected and analyzed to assess study feasibility and acceptability.

Results and Discussion

Participants were receptive to the program through high engagement, retention and satisfaction. Retention rate was 85%. 92% of participants completed at least 16 sessions out of 22 sessions. Post-trial surveys indicated high satisfaction of 27.2/32 based on Client Satisfaction Questionnaire (CSQ-8) score. Participants expressed the program increased their knowledge and methods to prevent onset of type 2 diabetes such as incorporating healthy eating habits and increasing physical activities. Although not a primary outcome, there was a significant weight reduction of 2.3% at the end of month 8 of the program (p < 0.05). The culturally and linguistically adapted DPP via online platform successfully demonstrated feasibility and acceptability among Chinese Americans with prediabetes. Further evaluation of the web-based Chinese Diabetes Prevention Program in a larger trial is warranted.

Effects of E-health-based interventions on glycemic control for patients with type 2 diabetes: a Bayesian network meta-analysis

The high disease burden of type 2 diabetes seriously affects the quality of life of patients, and with the deep integration of the Internet and healthcare, the application of electronic tools and information technology to has become a trend for disease management. The aim of this study was to evaluate the effectiveness of different forms and durations of E-health interventions in achieving glycemic control in type 2 diabetes patients. PubMed, Embase, Cochrane, and Clinical Trials.gov were searched for randomized controlled trials reporting different forms of E-health intervention for glycemic control in type 2 diabetes patients, including comprehensive measures (CM), smartphone applications (SA), phone calls (PC), short message service (SMS), websites (W), wearable devices (WD), and usual care. The inclusion criteria were as follows: (1) adults (age≥18) with type 2 diabetes mellitus; (2) intervention period ≥1 month; (3) outcome HbA1c (%); and (4) randomized control of E-health based approaches. Cochrane tools were used to assess the risk of bias. R 4.1.2 was used to conduct the Bayesian network meta-analysis. A total of 88 studies with 13,972 type 2 diabetes patients were included. Compared to the usual care group, the SMS-based intervention was superior in reducing HbA1c levels (mean difference (MD)-0.56, 95% confidence interval (CI): -0.82 to -0.31), followed by SA (MD-0.45, 95% CI: -0.61 to -0.30), CM (MD-0.41, 95% CI: -0.57 to -0.25), W (MD-0.39, 95% CI: -0.60 to -0.18) and PC (MD-0.32, 95% CI: -0.50 to -0.14) (p < 0.05). Subgroup analysis revealed that intervention durations of ≤6 months were most effective. All type of E-health based approaches can improve glycemic control in patients with type 2 diabetes. SMS is a high-frequency, low-barrier technology that achieves the best effect in lowering HbA1c, with ≤6 months being the optimal intervention duration.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42022299896.

Clinical, Economic, and Patient-Reported Benefits of Connected Insulin Pen Systems: A Systematic Literature Review

INTRODUCTION

The objective of this systematic literature review was to evaluate the available literature concerning the clinical, economic, and patient-reported benefits of insulin pen platforms, including connected insulin pens/caps/sleeves and insulin platforms, as well as mobile apps capable of receiving near real-time insulin dosing information.

METHODS

Medline and Embase databases and the Cochrane Library were searched for published literature between January 2015 and May 2021, and manual searches for conference abstracts from 2018 to May 2021 were performed. These searches were supplemented by internet searches for relevant literature and clinical trials. Study selection involved the population, intervention, comparator, outcomes, time frame, and study design outline. Included studies investigated connected insulin systems or connected caps/sleeves enabling pens to be connected, or apps able to connect to these systems, in individuals of all ages with type 1 or type 2 diabetes mellitus.

RESULTS

Searches identified a total of 26 publications (mostly observational studies and conference abstracts) for inclusion, representing ten unique, predominantly small studies. Evidence in this field is still in its early stages, and only two randomized controlled trials met our inclusion criteria. Available results showed that connected insulin pens and their systems potentially helped reduce suboptimal insulin use and may therefore improve glycemic control. Satisfaction of people with diabetes with the technologies used was high, and economic benefits were noted. Features of effective connected insulin pen devices include simplicity of use and data upload/sharing, useful "point-of-care" alerts, and simple and understandable data presentation to facilitate more effective consultations.

CONCLUSIONS

Connected insulin pen systems could be increasingly considered as part of routine clinical care for insulin-treated persons with diabetes who must manage the complexity of their daily insulin routine. Future research focusing on the way data obtained from these devices can be most effectively used alongside other information is urgently needed.

Effectiveness of the Lilly Connected Care Program in Improving Glycemic Management Among Patients With Type 2 Diabetes in China: Retrospective Real-world Study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a worldwide public health concern. Mobile health management platforms could be a potential way to achieve effective glycemic control.

OBJECTIVE

This study aimed to evaluate the real-world effectiveness of the Lilly Connected Care Program (LCCP) platform in glycemic control among patients with T2DM in China.

METHODS

This retrospective study included Chinese patients with T2DM (aged ≥18 years) from April 1, 2017, to January 31, 2020, for the LCCP group and from January 1, 2015, to January 31, 2020, for the non-LCCP group. Propensity score matching was used to match the LCCP and non-LCCP groups to reduce confounding, with covariates including age, sex, the duration of diabetes, baseline hemoglobin A_1c (HbA_1c), and the number of oral antidiabetic medication classes. HbA_1c reduction over 4 months, the proportions of patients achieving an HbA_1c reduction of ≥0.5% or ≥1%, and the proportions of patients reaching to target HbA_1c level of ≤6.5% or <7% were compared between the LCCP and non-LCCP groups. Multivariate linear regression was used to assess factors associated with HbA_1c reduction.

RESULTS

A total of 923 patients were included, among whom 303 pairs of patients were well matched after propensity score matching. HbA_1c reduction during the 4-month follow-up was significantly larger in the LCCP group than the non-LCCP group (mean 2.21%, SD 2.37% vs mean 1.65%, SD 2.29%; P=.003). The LCCP group had a higher proportion of patients with an HbA_1c reduction of ≥1% (209/303, 69% vs 174/303, 57.4%; P=.003) and ≥0.5% (229/303, 75.6% vs 206/303, 68%; P=.04). The proportions of patients reaching the target HbA_1c level of ≤6.5% were significantly different between the LCCP and non-LCCP groups (88/303, 29% vs 61/303, 20.1%; P=.01), whereas the difference in the proportions of patients reaching the target HbA_1c level of <7% was not statistically significant (LCCP vs non-LCCP: 128/303, 42.2% vs 109/303, 36%; P=.11). LCCP participation and higher baseline HbA_1c were associated with a larger HbA_1c reduction, whereas older age, longer diabetes duration, and higher baseline dose of premixed insulin analogue were associated with a smaller HbA_1c reduction.

CONCLUSIONS

The LCCP mobile platform was effective in glycemic control among patients with T2DM in China in the real world.

A Randomised Control Trial to Explore the Impact and Efficacy of the Healum Collaborative Care Planning Software and App on Condition Management in the Type 2 Diabetes Mellitus Population in NHS Primary Care

INTRODUCTION

Effective and scalable solutions to support management of Type 2 Diabetes (T2D) at a distance are a priority for health systems worldwide. The use of personalised care planning has been shown to be effective at improving the health outcomes and the experience of care amongst people with T2D and other long-term health conditions. Here we describe a specific example of such an intervention.

METHODS

The sample comprised 197 participants with T2D randomised to either the active intervention group with digital health planning (App + usual care), with 115 participants, or the control group (usual care), with 82 participants. We analysed data in relation to changes in body mass index (BMI) and glycated haemoglobin (HbA1c) over a 6-month follow-up period. We also analysed responses to questionnaires sent out and held interviews with participants that were in the active treatment group and therefore had a care plan created and access to an app.

RESULTS

The active treatment group had significant reductions in HbA1c (p < 0.01) and BMI (p < 0.037) vs the control group (no significant change). The average percentage change in HbA1c for the treatment group over 6 months was - 7.4% (± SE 1.4%), compared with 1.8% (± SE 2.1%) for the control group. The average percentage change in BMI for the treatment group was - 0.7% (± SE 0.4%) and it was - 0.2% (± SE 0.5%) for the control group. A higher percentage of the active treatment group reduced their HbA1c and BMI than the control group. For HbA1c, 72.4% of the active treatment group reduced their HbA1c, compared to 41.5% of the control group. For BMI, 52.7% of the active treatment group experienced a reduction, compared to 42.9% for the control group. Self-measured quality of life (QoL) improved for patients in the active treatment group, shown by an increase in their pre-trial to post-trial EQ-5D-5L rating by an average of 0.0464 (± SE 0.0625), compared to a decrease of 0.0086 (± SE 0.0530) for the control group. The average EQ VAS score also increased pre- to post-trial for the active treatment group, on average by 8.2%, whereas it decreased by an  average of - 2.8% for the control group.

CONCLUSION

These findings point to how the provision of personalised plans of care, support and education linked to a mobile app, can result in HbA1c and BMI reduction for many individuals with T2D. The use of a patient management app as well as a personalised care plan also led to an improvement in patient self-rated QoL and engagement.

Impact of digital health interventions for adolescents with type 1 diabetes mellitus on health literacy: a systematic review

BACKGROUND

Evidence shows that living with diabetes mellitus type 1 (T1DM) in adolescent age is particularly challenging and difficult to manage. A high level of health literacy is important to prevent and avoid debilitating complications. Despite the increasing prevalence and incidence of T1DM by adolescent and the large use of digital health interventions, little is known about the association between this use and health literacy. This systematic review provides an overview on the impact of digital health interventions for adolescents with type 1 diabetes on health literacy and derive recommendations for further research.

METHODS

Electronic searches were performed in five databases in Medline (Medline, PubMed + via PubMed), The Cochrane Library, EMBASE (via Ovid), Web of Science and PsycINFO from 2011 to 2021. In addition, grey literature searches were conducted in Google Scholar, OAlster and Trip. Relevant studies that have been missed by electronic and hand-searching strategies were searched in the reference lists of all included studies. The review followed PRISMA guidelines. Two researchers independently screened abstracts for initial eligibility and applied the inclusion and exclusion criteria to the relevant full-text articles. Quality was assessed using the tools RoB2 Cochrane, ROBINS I, NOS (Newcastle-Ottawa Scale), CASP (Critical Appraisal Skills Programme) for primary studies and Amstar-2 for secondary studies.

RESULTS

Out of 981 studies, 22 were included in the final review. Most primary studies included in this review were judged as moderate overall risk of bias or with some concerns and most of the secondary studies as critically low quality reviews. Our findings suggest that the interplay of health care providers (HCP) and patients through social media helps the management of the disease. This corroborates Bröder et al.' (2017) dimension of 'communication and interactions' in their concept of health literacy.

CONCLUSIONS

For adolescents with T1DM, social media may be a specific and beneficial intervention for an improved communication and interaction with their HCP. Further research should investigate what specific form of social media suits best for which adolescents.

TRIAL REGISTRATION

The study protocol was registered on the 15th of November 2021 on Prospero (reg. NR: CRD42021282199).

Evaluation of overweight control applications with cognitive‐behavioral therapy approach: A systematic review

Background and Aims

Overweight and obesity lead to the development of physical diseases. Cognitive factors play a vital role in controlling one's weight. Currently, cognitive‐behavioral therapy (CBT) interventions are recognized as a subcategory of lifestyle modification programs that can be implemented to control weight and modify eating patterns as well as physical activity. Nowadays, smartphone‐based applications are utilized to implement behavioral interventions. The main purpose of this study is to evaluate the quality of CBT‐based smartphone applications available on Google Play and the App Store in the field of overweight control.

Methods

Smartphone‐based utility applications available on Google Play and App Store were identified in March 2021. Weight control smartphone applications were obtained based on inclusion and exclusion criteria. The app name, platform, version, number of downloads, password protection, affiliations, and features of retrieved apps were tabulated. The Mobile Application Rating Scale was utilized to evaluate the quality of the identified apps.

Results

Seventeen CBT‐based weight control smartphone apps were retrieved. The average engagement, functionality, aesthetics, and information quality scores were 3.65, 3.92, 3.80, and 3.91, respectively. Also, the average score in an aspect containing the usefulness of the app, frequency of using the application, cost, and user satisfaction was 3.5.

Conclusion

Future applications related to this field can be improved by providing a personalization program according to the needs of users and the possibility of online chatting with the therapist. Further improvements can be achieved by improving the areas of engagement, aesthetics, and subjective quality as well as having appropriate privacy policies.

Patients' Preferences for Connected Insulin Pens: A Discrete Choice Experiment Among Patients with Type 1 and Type 2 Diabetes

BACKGROUND

This study quantified how people with diabetes value the unique features of connected insulin pens and related mobile apps, and the underlying reasons for preferring connected versus non-connected insulin pens.

METHODS

A discrete choice experiment (DCE) was conducted in the USA and UK to elicit preferences of adults (≥ 18 years) with type 1 or 2 diabetes for attributes of insulin pens. Attributes included device type, dosing support, glucose monitoring, additional app features, and data sharing. Relative attribute importance (RAI) scores were calculated to capture the relative importance of an attribute. Predicted choice probabilities were obtained to compare different profiles for connected and non-connected insulin pens.

RESULTS

The DCE was completed by 540 participants (58.9% male; 90.7% Caucasian; mean age, 58.3 years; 69.4% type 2 diabetes). Participants most valued the possibility of using a connected insulin pen with dosing support and automated dose logging (RAI = 39.9%), followed by automatic transfer of glucose levels (RAI = 29.0%), additional features of tracking diet and physical activity (RAI = 14.6%), data sharing (RAI = 13.6%), and device type (RAI = 2.9%). All profiles of connected insulin pens were preferred over a non-connected pen (p < 0.001), and pen profiles with advanced features were preferred over those without (p < 0.001). Preferences differed by age but not diabetes type, country of residence, or insulin regimen.

CONCLUSION

People with diabetes in the USA and UK prefer connected over non-connected insulin pens due largely to the availability of automated logging of dose and glucose levels.

Getting Connected to M-Health Technologies through a Meta-Analysis

The demand for mobile e-health technologies (m-health) continues with constant growth, stimulating the technological advancement of such devices. However, the customer needs to perceive the utility of these devices to incorporate them into their daily lives. Hence, this study aims to identify users' perceptions regarding the acceptance of m-health technologies based on a synthesis of meta-analysis studies on the subject in the literature. Using the relations and constructs proposed in the UTAUT2 (Unified Theory of Acceptance and Use of Technology 2) technology acceptance model, the methodological approach utilized a meta-analysis to raise the effect of the main factors on the Behavioral Intention to Use m-health technologies. Furthermore, the model proposed also estimated the moderation effect of gender, age, and timeline variables on the UTAUT2 relations. In total, the meta-analysis utilized 84 different articles, which presented 376 estimations based on a sample of 31,609 respondents. The results indicate an overall compilation of the relations, as well as the primary factors and moderating variables that determine users' acceptance of the studied m-health systems.

Digital technology and its effects on knowledge improvement for diabetes management: An integrative review

AIM

To evaluate the effectiveness of educational digital technology in improving patients' and health professionals' knowledge about diabetes management.

BACKGROUND

The use of digital technologies has been expanding in recent years in several areas of healthcare and education.

DESIGN

Integrative literature review.

DATA SOURCES

The following databases were searched: PubMed, Lilacs, BDENF, Web of Science and SciELO (1 January 2016 and 31 December 2020).

REVIEW METHODS

Titles and abstracts were screened and selected by independent reviewers based on eligibility criteria. A consensus was drawn on which articles should be included. Data were extracted using an instrument created by the authors, and the synthesis of knowledge was made by compiling the results in a table and identifying thematic axes.

RESULTS

Seventy-one articles were retrieved, and after the final analysis, a total of 11 were included. Most studies have pointed out benefits from the use of digital technologies in diabetes education, with two thematic categories emerging: 'Digital technologies in the education of patients with diabetes' and 'Digital technologies in continuing professional education in diabetes'.

CONCLUSION

The use of digital technologies is beneficial and effective both for continuing professional education and educating patients about diabetes management.

Endocrinologists' Experiences With Telehealth: A Qualitative Study With Implications for Promoting Sustained Use

OBJECTIVE

Endocrinology is well-suited to telehealth, with high rates of use and known benefits. Clinician attitudes toward telehealth will be critical to ensuring sustained use after the pandemic. We examined endocrinologists' experiences with synchronous telehealth to identify factors affecting experiences with and acceptance of the technology.

METHODS

We conducted qualitative interviews and directed-content analysis with a purposive sample of 26 U.S. endocrinologists. Factors affecting clinicians' experiences were mapped to the human-organization-technology fit (HOT-fit) framework.

RESULTS

We found that clinicians' experiences with synchronous telehealth were influenced by: (1) Clinician factors: Clinicians welcomed telehealth but expressed concerns about patient interest, rapport building, and clinical appropriateness, desiring more data to support its use. Many clinicians feared missing clinical findings on virtual examination, despite no such personal experiences. Effects on professional and personal life contributed to satisfaction, through increased flexibility but also increased workload. (2) Organizational factors: Departmental meetings and trainings supported clinicians' technical, logistical, and clinical needs, reducing resistance to telehealth use. Shifting staff responsibilities in clinical workflows improved clinicians' experiences and supported telehealth use, while mixed telehealth and in-person schedules impeded workflow. (3) Technology factors: Most clinicians preferred video visits to telephone. Usability and reliability of telehealth platforms, integration of patient self-monitoring data, and availability of IT support were crucial to a positive experience.

CONCLUSION

Clinician acceptance of telehealth is influenced by clinician, organizational, and technology factors that can be leveraged to improve buy-in. Organizational leaders' attention to addressing these factors will be critical to support endocrinologists' continued provision of telehealth for their patients.

Application and prospect of artificial intellingence in diabetes care

Diabetes is one of the fastest-growing non-communicable diseases, becoming an important public health concern worldwide as well as in China. Currently, China has the largest population living with diabetes. Artificial intelligence (AI) is a fast-growing field and its applications to diabetes could enable the delivery of better management services for people with diabetes. This perspective summarized the latest findings of digital technologies and AI use in the following areas of diabetes care, mainly including screening and risk predictions of diabetes and diabetic complications, precise monitoring and intervention combined with new technologies, and mobile health application in self-management support for people with diabetes. Challenges to promote further use of AI in diabetes care included data standardization and integration, performance of AI-based medical devices, motivation of patients, and sensitivity to privacy. In summary, although the AI applications in clinical practice is still at an early stage, we are moving toward a new paradigm for diabetes care with the rapid development and emerging application of AI.

A three step protocol for the development of an innovative footwear (shoe and sensor based insole) to prevent diabetic foot ulceration

Background

The incidence of diabetic foot ulceration (DFU) is increasing worldwide. Therapeutic footwear is usually recommended in clinical practice for preventing foot ulcers in persons with diabetes. The project Science DiabetICC Footwear aims to develop innovative footwear to prevent DFU, specifically a shoe and sensor-based insole, which will allow for monitoring pressure, temperature, and humidity parameters.

Method

This study presents a three-step protocol for the development and evaluation of this therapeutic footwear, specifically: (i) a first observational study will specify the user requirements and contexts of use; (ii) after the design solutions were developed for shoe and insole, the semi-functional prototypes will be evaluated against the initial requirements; (iii) and a pre-clinical study protocol will enable the evaluation of the final functional prototype. The eligible diabetic participants will be involved in each stage of product development. The data will be collected using interviews, clinical evaluation of the foot, 3D foot parameters and plantar pressure evaluation. This three-step protocol was defined according to the national and international legal requirements, ISO norms for medical devices development, and was also reviewed and approved by the Ethics Committee of the Health Sciences Research Unit: Nursing (UICISA: E) of the Nursing School of Coimbra (ESEnfC).

Results

The involvement of end-users (diabetic patients) will enable the definition of user requirements and contexts of use to develop design solutions for the footwear. Those design solutions will be prototyped and evaluated by end-users to achieve the final design for therapeutic footwear. The final functional prototype will be evaluated in pre-clinical studies to ensure that the footwear meets all the requirements to move forward to clinical studies.

Discussion

The three-step study outlined in this protocol will provide the necessary insights during the product development, ensuring this new therapeutic footwear's main functional and ergonomic features for DFU prevention.

(St)aging in place: Information and communication technologies for a health-centered agile dwelling unit

As the number of older adults is growing rapidly in the U.S., the need for personalized, innovative, and sustainable Information and Communication Technologies (ICTs) solutions is critical to support individuals' social, emotional, and physical health. Such technology can significantly help older adults' ability to live independently in their homes despite the challenges the aging process may present, referred to as aging or staging in place. In this study, we explored ways to integrate ICTs into Agile Dwelling Units (AgDUs) through affordable, innovative, technology-enabled tools and practices that can be adapted to respond to individual's needs while supporting independent, secure, and engaged healthy living. The technology-enabled and human-centered AgDUs organically transform in response to users' needs. This approach offers a viable solution for older adults at different stages throughout their lifespan to transition into an intimate, technologically-enhanced living environment while allowing for (1) customization to user's needs; (2) cost optimization and maintenance; and (3) accessibility that minimizes gaps in compliance from a provider and user perspectives. Integrating ICTs in AgDUs to support health monitoring and management could reduce forthcoming pressure on the healthcare system and care providers to accommodate the needs of older adults. This approach is described through a collaborative multidisciplinary lens that highlights a partnership between academia, industry experts, and key stakeholders to advance healthy living and extend lifespan through design-build and technology integration. The main goal of this approach is to increase access to health services and optimize healthcare costs.

Development of the Support self-guided, web application for adults living with type 1 diabetes in Canada by a multi-disciplinary team using a people-oriented approach based on the Behaviour Change Wheel

Background

Diabetes self-management education and support (DSME/S) are central in type 1 diabetes (T1D) where individuals are responsible for 95% of care. In-person DSME/S programs have been proven clinically effective (e.g. optimizing glycemic management, improving diabetes-related behaviors) but are limited by a lack of accessibility and long-term follow-up. Self-guided digital tools such as web applications (web apps) can be an alternative for delivering DSME/S.

Objective

This article describes the development of Support, a behavioral theory-based, self-guided, web application for adults living with T1D in the province of Quebec, Canada.

Methods

A multi-disciplinary team developed Support. Patient partners first proposed its focus, learning topics, and expressed barriers to using digital tools for DSME/S. These barriers were analyzed based on the Behaviour Change Wheel. A group of healthcare professionals (HCPs) drafted the evidence-based learning content which was reviewed by external HCPs and by patient partners.

Results

Support is a bilingual (English and French) web app accessible at any time via the Internet. It has four learning paths focusing on hypoglycemia and based on the user's method of diabetes treatment. Learning modules are divided into six categories with a maximum of three learning levels. It contains features such as a discussion forum, videos, and quizzes to ensure interactivity, provide social support, and maintain the motivation and long-term engagement of users.

Conclusions

To the best of the authors' knowledge, Support is the first self-guided evidence-based web app for adults living with T1D. It is currently under study to evaluate its feasibility and clinical impacts.