Technology Use for Diabetes Problem Solving in Adolescents with Type 1 Diabetes: Relationship to Glycemic Control

Psychosocial Effects of the Loop Open-Source Automated Insulin Delivery System

AIMS

This study examined the psychosocial impact of Loop, an open-source automated insulin dosing system that has emerged from the diabetes technology "Do-It-Yourself" (DIY) movement.

METHODS

Subsamples of 239 adults, 115 children, and 243 parents completed data collection at the time of Loop initiation and 3 and 6 months later. Surveys collected demographic and clinical information, percent time-in-range, HbA1c, and validated psychosocial measures. Analyses included paired t tests and McNemar's tests to compare psychosocial functioning at 3 and 6 months and regression models to assess baseline predictors of psychosocial outcomes at 6 months.

RESULTS

Adults reported significant improvements in diabetes distress (t = -7.20 P < .001; t = -8.01, P < .001), sleep quality (t = 6.81, P < .001; t = 2.98, P = .003), fear of hypoglycemia (t = -4.42, P < .001; t = -4.97, P < .001), and hypoglycemia confidence (t = 8.68, P < .001; t = 7.96 P < .001) from baseline to 3 months and 6 months, respectively. Significant improvements in parents' and children's sleep quality and parents' fear of hypoglycemia were also observed. Several baseline characteristics were associated with psychosocial outcomes at 6 months.

CONCLUSIONS

The current findings support the broad and sustained benefits of Loop across multiple aspects of psychosocial well-being. Advancement and dissemination of such technologies has the potential to improve mental and physiological health among people living with type 1 diabetes.

Using Momentary Assessment and Machine Learning to Identify Barriers to Self-management in Type 1 Diabetes: Observational Study

Background

For adolescents living with type 1 diabetes (T1D), completion of multiple daily self-management tasks, such as monitoring blood glucose and administering insulin, can be challenging because of psychosocial and contextual barriers. These barriers are hard to assess accurately and specifically by using traditional retrospective recall. Ecological momentary assessment (EMA) uses mobile technologies to assess the contexts, subjective experiences, and psychosocial processes that surround self-management decision-making in daily life. However, the rich data generated via EMA have not been frequently examined in T1D or integrated with machine learning analytic approaches.

Objective

The goal of this study is to develop a machine learning algorithm to predict the risk of missed self-management in young adults with T1D. To achieve this goal, we train and compare a number of machine learning models through a learned filtering architecture to explore the extent to which EMA data were associated with the completion of two self-management behaviors: mealtime self-monitoring of blood glucose (SMBG) and insulin administration.

Methods

We analyzed data from a randomized controlled pilot study using machine learning–based filtering architecture to investigate whether novel information related to contextual, psychosocial, and time-related factors (ie, time of day) relate to self-management. We combined EMA-collected contextual and insulin variables via the MyDay mobile app with Bluetooth blood glucose data to construct machine learning classifiers that predicted the 2 self-management behaviors of interest.

Results

With 1231 day-level SMBG frequency counts for 45 participants, demographic variables and time-related variables were able to predict whether daily SMBG was below the clinical threshold of 4 times a day. Using the 1869 data points derived from app-based EMA data of 31 participants, our learned filtering architecture method was able to infer nonadherence events with high accuracy and precision. Although the recall score is low, there is high confidence that the nonadherence events identified by the model are truly nonadherent.

Conclusions

Combining EMA data with machine learning methods showed promise in the relationship with risk for nonadherence. The next steps include collecting larger data sets that would more effectively power a classifier that can be deployed to infer individual behavior. Improvements in individual self-management insights, behavioral risk predictions, enhanced clinical decision-making, and just-in-time patient support in diabetes could result from this type of approach.

A Text Messaging Intervention With Financial Incentive for Adolescents With Type 1 Diabetes

BACKGROUND

Adolescents with type 1 diabetes (T1D) have higher hemoglobin A1C (HbA1c) levels than others. In general, adolescents engage with text messaging (TM) and financial incentives, both associated with improved diabetes outcomes. This study aimed to assess the impact of a TM intervention with financial incentives on self-care behaviors and HbA1c.

METHODS

A six-month randomized controlled trial compared MyDiaText™, a TM education and support application, with standard care. The sample included 166 teens with T1D, 12-18 years old, attending a diabetes clinic. The intervention group received one daily TM and were instructed to respond. Participants who responded to TMs for the most consecutive days were eligible for a financial reward biweekly via lottery. All participants received prompts to complete the self-care inventory (SCI) at baseline, 90, and 180 days. HbA1c was collected at clinic visits. Changes in SCI and HbA1c were analyzed using a multilevel mixed-effects linear regression model. Intention-to-treat and per-protocol analyses were performed.

RESULTS

The median TM response rate was 59% (interquartile range 40.1%-85.2%) and decreased over time. After adjustment for baseline characteristics, in per-protocol analysis, there was a statistically significant difference in SCI score increase in those receiving one TM per day vs control (P = .035). HbA1c decreased overall, without significant difference between groups (P = .786).

CONCLUSIONS

A TM intervention with financial incentives for adolescents with T1D in suboptimal control was associated with increasing self-care report; however, glycemic control did not differ from controls. Further research is needed to develop digital health interventions that will impact glycemic control.

Before-Visit Questionnaire: A Tool to Augment Communication and Decrease Provider Documentation Burden in Pediatric Diabetes

OBJECTIVE

To develop and evaluate an electronic tool that collects interval history and incorporates it into a provider summary note.

METHODS

A parent-facing online before-visit questionnaire (BVQ) collected information from parents and caregivers of pediatric diabetes patients prior to a clinic encounter. This information was related to interval history and perceived self-management barriers. The BVQ generated a summary note that providers could paste in their own documentation. Parents also completed postvisit experience questionnaires. We assessed the BVQs perceived usefulness to parents and providers and compared provider documentation content and length pre- and post-BVQ rollout. We interviewed providers regarding their experiences with the system-generated note.

RESULTS

Seventy-three parents of diabetic children were recruited and completed the BVQ. A total of 79% of parents stated that the BVQ helped with visit preparation and 80% said it improved perceived quality of visits. All 16 participating providers reviewed BVQs prior to patient encounters and 100% considered the summary beneficial. Most providers (81%) desired summaries less than 1 week old. A total of 69% of providers preferred the prose version of the summary; however, 75% also viewed the bulleted version as preferable for provider review. Analysis of provider notes revealed that BVQs increased provider documentation of patients' adherence and barriers. We observed a 50% reduction in typing by providers to document interval histories. Providers not using summaries typed an average of 137 words (standard deviation [SD]: 74) to document interval history compared with 68 words [SD 47] typed with BVQ use.

DISCUSSION

Providers and parents of children with diabetes appreciated the use of previsit, parent-completed BVQs that automatically produced provider documentation. Despite the BVQ redistributing work from providers to parents, its use was acceptable to both groups.

CONCLUSION

Parent-completed questionnaires on the patient's behalf that generate provider documentation encourage communication between parents and providers regarding disease management and reduce provider workload.

A Community and Technology-Based Approach for Hypertension Self-Management (COACHMAN) to Improve Blood Pressure Control in African Americans: Results from a Pilot Study

PURPOSE

Adoption of technology has increased to support self-managing chronic diseases. However, behavioral interventions evaluating such technology have been understudied in African Americans with hypertension. The aim of this study was to explore a community and technology-based intervention for hypertension self-management (COACHMAN) intervention on blood pressure (BP) control and health-related quality of life (HRQoL) in African Americans with hypertension.

METHODS

Sixty African Americans (mean age 60; 75% females) who were prescribed antihypertensive medications and owning a smartphone were randomized to the COACHMAN (n = 30) or enhanced usual care (n = 30) group for 12 weeks. COACHMAN is comprised of four components: web-based education, home BP monitoring, medication management application, and nurse counseling. Hypertension knowledge, self-efficacy, technology adoption/use, medication adherence, BP, and HRQoL scores were assessed.

RESULTS

Mean systolic and diastolic BP at baseline was 150.49 (SD = 13.89) and 86.80 (SD = 13.39), respectively. After completing the 3-month intervention to improve hypertension self-management, the groups did not significantly differ in BP control and HRQoL. Clinically relevant BP reduction was observed in the intervention group. Paired t-test showed that mean medication-taking adherence scores significantly improved in the intervention group (P = 0.023) compared to the control group (P = 0.075).

CONCLUSION

Using technology may have a positive impact on supporting hypertension self-management, particularly in medication-taking adherence. Further research is warranted in a larger sample and should include standardization of medication management to isolate the effects of behavioral interventions on changes in BP.

CLINICALTRIALSGOV IDENTIFIER

NCT03722667.

Realizing a Closed-Loop (Artificial Pancreas) System for the Treatment of Type 1 Diabetes

Recent, rapid changes in the treatment of type 1 diabetes have allowed for commercialization of an "artificial pancreas" that is better described as a closed-loop controller of insulin delivery. This review presents the current state of closed-loop control systems and expected future developments with a discussion of the human factor issues in allowing automation of glucose control. The goal of these systems is to minimize or prevent both short-term and long-term complications from diabetes and to decrease the daily burden of managing diabetes. The closed-loop systems are generally very effective and safe at night, have allowed for improved sleep, and have decreased the burden of diabetes management overnight. However, there are still significant barriers to achieving excellent daytime glucose control while simultaneously decreasing the burden of daytime diabetes management. These systems use a subcutaneous continuous glucose sensor, an algorithm that accounts for the current glucose and rate of change of the glucose, and the amount of insulin that has already been delivered to safely deliver insulin to control hyperglycemia, while minimizing the risk of hypoglycemia. The future challenge will be to allow for full closed-loop control with minimal burden on the patient during the day, alleviating meal announcements, carbohydrate counting, alerts, and maintenance. The human factors involved with interfacing with a closed-loop system and allowing the system to take control of diabetes management are significant. It is important to find a balance between enthusiasm and realistic expectations and experiences with the closed-loop system.

Adherence to diabetes care: Knowledge of biochemical processes has a high impact on glycaemic control among adolescents with type 1 diabetes

AIM

To evaluate the impact of patients' understanding of biochemical processes involved in glucose regulation (causal-biochemical knowledge) and of diabetes self-management knowledge on adherence to treatment recommendations among adolescents with type 1 diabetes mellitus.

DESIGN

A cross-sectional study.

METHODS

Adolescents with type 1 diabetes mellitus, aged 12-18 years and able to read and write in Hebrew or in Arabic were eligible. Participants were recruited between August 2016 - January 2018 during routine visits to the Paediatric Diabetes Clinic; informed consent was obtained as customary. Patients completed sociodemographic, clinical and type 1 diabetes mellitus self-management and biochemical knowledge questionnaires. Adherence to treatment was assessed by patients' serum HbA1c levels, collected from medical records.

RESULTS

Ninety-seven patients participated in the study. Mean HbA1c levels were 9.2% (1.9%) and only 24 (24.7%) patients met the recommended HbA1c ≤ 7.5%. Lower HbA1c levels were strongly associated with higher family income, older age at diagnosis and with better type 1 diabetes mellitus self-management and causal-biochemical knowledge. A regression model showed that causal-biochemical knowledge contributed to the variance in HbA1c levels. Furthermore, causal-biochemical knowledge, but not self-management knowledge, was found to mediate the negative relationship between low family income and high HbA1c levels.

CONCLUSIONS

Causal-biochemical knowledge is a valuable component for the adherence to diabetes care and glycaemic control.

IMPACT

Our study suggests that causal knowledge is a valuable component that should be included in nursing and healthcare educational programmes for adolescents with type 1 diabetes mellitus.

Experiences of Adults With Type 1 Diabetes Using Glucose Sensor-Based Mobile Technology for Glycemic Variability: Qualitative Study

Background

Adults with type 1 diabetes (PWDs) face challenging self-management regimens including monitoring their glucose values multiple times a day to assist with achieving glycemic targets and reduce the risk of long-term diabetes complications. Recent advances in diabetes technology have reportedly improved glycemia, but little is known about how PWDs utilize mobile technology to make positive changes in their diabetes self-management.

Objective

The aim of this qualitative study was to explore PWDs’ experiences using Sugar Sleuth, a glucose sensor–based mobile app and Web-based reporting system, integrated with the FreeStyle Libre glucose monitor that provides feedback about glycemic variability.

Methods

We used a qualitative descriptive research design and conducted semistructured interviews with 10 PWDs (baseline mean glycated hemoglobin, HbA_1c) 8.0%, (SD 0.45); 6 males and 4 females, aged 52 years (SD 15), type 1 diabetes (T1D) duration 31 years (SD 13), 40% (4/10, insulin pump) following a 14-week intervention during which they received clinical support and used Sugar Sleuth to evaluate and understand their glucose data. Audio-recorded interviews were transcribed, coded, and analyzed using thematic analysis and NVivo 11 (QSR International Pty Ltd).

Results

A total of 4 main themes emerged from the data. Participants perceived Sugar Sleuth as an Empowering Tool that served to inform lifestyle choices and diabetes self-management tasks, promoted preemptive self-care actions, and improved discussions with clinicians. They also described Sugar Sleuth as providing a Source of Psychosocial Support and offering relief from worry, reducing glycemic uncertainty, and supporting positive feelings about everyday life with diabetes. Participants varied in their Approaches to Glycemic Data: 40% (4/10) described using Sugar Sleuth to review data, understand glycemic cause and effect, and plan for future self-care. On the contrary, 60% (6/10) were reluctant to review past data; they described receiving benefits from the immediate numbers and trend arrows, but the app still prompted them to enter in the suspected causes of glucose excursions within hours of their occurrence. Finally, only 2 participants voiced Concerns About Use of Sugar Sleuth; they perceived the app as sometimes too demanding of information or as not attuned to the socioeconomic backgrounds of PWDs from diverse populations.

Conclusions

Results suggest that Sugar Sleuth can be an effective educational tool to enhance both patient-clinician collaboration and diabetes self-management. Findings also highlight the importance of exploring psychosocial and socioeconomic factors that may advance the understanding of PWDs’ individual differences when using glycemic technology and may promote the development of customized mobile tools to improve diabetes self-management.

Development and Assessment of a Mobile Health Application for Monitoring the Linkage Among Treatment Factors of Type 1 Diabetes Mellitus

Background: In the daily routine of type 1 diabetes mellitus (T1DM), the patients deal with many data and consider many variables to perform actions, decisions, and regimen adjustments. There is a need to apply filtering techniques to extract relevant information and provide appropriate data visualization methods to assist in clinical tasks and decision making. Objective: To present Soins DM, a mobile health tool, for monitoring the linkage among treatment factors of T1DM with an interactive data visualization approach. Methods: First, we performed a literature review, a commercial search, and ideation. Next, we created a prototype and an online survey for its feedback, with participation of 76 individuals. Afterward, the mobile app and its website version were built. Eventually, we conducted a pilot experiment with 4 patients, an online experiment for satisfaction assessment with 97 patients, and an online assessment by 9 health professionals. Results: Prototyping and feedback facilitated the design refinement. Soins DM enables the recording of data from routines of glycemia, insulin applications, meals, and physical exercises. From these logs, the app builds two different ways of interactive data visualization, a timeline and an integrated chart, providing personalized feedback on bad glycemia with its possible causes. The assessments revealed overall satisfaction with the app's characteristics. Conclusions: Soins DM is a novel application with interactive visualization and personalized feedback for easy identification of the linkage among treatment factors of T1DM. The test scenario with patients and health professionals indicates Soins DM as a useful and reliable tool.

Aplicativos para adolescentes com diabetes mellitus tipo 1: revisão integrativa da literatura

Resumo Objetivo: Examinar os recursos de aplicativos para dispositivos móveis destinados ao autocuidado de adolescentes com diabetes mellitus tipo 1. Métodos: Revisão integrativa por meio da busca de artigos nos periódicos indexados nas bases de dados: Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Literatura Latino-Americana em Ciências da Saúde, PubMed (National Library of Medicine), Scopus, e Web of Science no período de 2012 a 2017, utilizando os seguintes descritores: aplicativos móveis, autocuidado e diabetes mellitus tipo 1, bem como respectivos descritores em inglês e espanhol. Resultados: A busca gerou um total de 248 artigos, dos quais 12 artigos atenderam os critérios de seleção. Os recursos dos aplicativos foram examinados a partir das funções de controle glicêmico, insulinoterapia, alimentação, atividade física, abordagem dos sentimentos e relações sociais. Observou-se que nenhum artigo descreveu um aplicativo que integrasse todos os recursos examinados. Conclusão: Os recursos de aplicativos para dispositivos móveis foram apontados como necessários para auxiliar no controle glicêmico de adolescentes com diabetes mellitus tipo 1.

The Use of Mobile Applications Among Adolescents with Type 1 Diabetes: Results from Diabetes MILES Youth-Australia

BACKGROUND

The use of mobile applications ("apps") for diabetes management is a rapidly developing area and has relevance to adolescents who tend to be early technology adopters. Apps may be useful for supporting self-management or connecting young people with type 1 diabetes (T1D) with their peers. However, outside controlled trials testing the effectiveness of apps, little is known about app usage in this population. Our aim was to explore app usage among adolescents with T1D.

METHODS

Diabetes MILES Youth-Australia is a national, online cross-sectional survey focused on behavioral and psychosocial aspects relevant to adolescents with T1D. Associations between app usage and demographic, clinical, and psychosocial variables were analyzed using logistic regression.

RESULTS

In total, 425 adolescents with T1D responded to the app questions (mean age, 16 ± 2 years; 62% female; diabetes duration 7 ± 4 years). Overall, 21% (n = 87) indicated that they used an app for diabetes management. Of these, 89% (n = 77) reported carbohydrate counting as the most common purpose. Of those not using apps, 44% (n = 149) indicated that this was due either to no awareness of suitable apps or a belief that apps could not help. App usage was associated significantly with shorter T1D duration, higher socioeconomic status, and at least seven daily blood glucose checks.

CONCLUSIONS

Only one in five respondents were using apps to support their diabetes management; most apps used were not diabetes specific. App users can be characterized as having a more recent T1D diagnosis, checking blood glucose more frequently, and being from a middle-to-high socioeconomic background.

Technology Use in Transition-Age Patients With Type 1 Diabetes: Reality and Promises

Youth with chronic illnesses have the greatest risk for a decline in their health management during transition-age. Because of this demonstrated and well-known issue, research has focused on how to improve the transition of care process. Despite the increasing number of technological devices on the market and the advances in telemedicine modalities available to patients with type 1 diabetes (T1D), the utilization of technology is still suboptimal among patients of transition-age (ages 13-25). This article reviews the available resources, patterns of use in transition-age youth, and explores opportunities to advance technology use in transitioning patients with T1D from pediatric to adult care.

Use of Commonly Available Technologies for Diabetes Information and Self-Management Among Adolescents With Type 1 Diabetes and Their Parents: A Web-Based Survey Study

BACKGROUND

For individuals with Type 1 diabetes (T1D), following a complicated daily medical regimen is critical to maintaining optimal health. Adolescents in particular struggle with regimen adherence. Commonly available technologies (eg, diabetes websites, apps) can provide diabetes-related support, yet little is known about how many adolescents with T1D use them, why they are used, or relationships between use and self-management.

OBJECTIVE

This study examined adolescent and parent use of 5 commonly available technologies for diabetes, including proportions who use each technology, frequency of use, and number of different technologies used for diabetes. Analyses also investigated the reasons adolescents reported for using or not using technologies for diabetes, and factors correlated with adolescents' technology use. Finally, this study examined relationships between the type and number of technologies adolescents use for diabetes and their self-management and glycemic control.

METHODS

Adolescents (12-17 years) and their parents (N=174 pairs), recruited from a pediatric diabetes clinic (n=134) and the Children with Diabetes community website (n=40), participated in this Web-based survey study. Glycosylated hemoglobin (A1C) values were obtained from medical records for pediatric clinic patients. Adolescents reported their use of 5 commonly available technologies for diabetes (ie, social networking, diabetes websites, mobile diabetes apps, text messaging, and glucometer/insulin pump software), reasons for use, and self-management behavior (Self-Care Inventory-Revised, SCI-R).

RESULTS

Most adolescents and parents used at least one of the 5 technologies for diabetes. Among adolescents, the most commonly used technology for diabetes was text messaging (53%), and the least commonly used was diabetes websites (25%). Most adolescents who used diabetes apps, text messaging, or pump/glucometer software did so more frequently (≥2 times per week), compared to social networking and website use (≤1 time per week). The demographic, clinical, and parent-technology use factors related to adolescents' technology use varied by technology. Adolescents who used social networking, websites, or pump/glucometer software for diabetes had better self-management behavior (SCI-R scores: beta=.18, P=.02; beta=.15, P=.046; beta=.15, P=.04, respectively), as did those who used several technologies for diabetes (beta=.23, P=.003). However, use of diabetes websites was related to poorer glycemic control (A1C: beta=.18, P=.01).

CONCLUSIONS

Adolescents with T1D may be drawn to different technologies for different purposes, as individual technologies likely offer differing forms of support for diabetes self-management (eg, tracking blood glucose or aiding problem solving). Findings suggest that technologies that are especially useful for adolescents' diabetes problem solving may be particularly beneficial for their self-management. Additional research should examine relationships between the nature of technology use and adolescents' T1D self-management over time.