A Digital-First Model of Diabetes Care

What is meant by 'integrated personalized diabetes management': A view into the future and what success should look like

Integrated personalized diabetes management (IPDM) has emerged as a promising approach to improving outcomes in patients with diabetes mellitus (DM). This care approach emphasizes the integration and coordination of different providers, including physicians, nurses, dietitians, social workers and pharmacists. The goal of IPDM is to provide patients with personalized care that is tailored to their needs. This review addresses the concept of integrated care and the use of technology (including data, software applications and artificial intelligence) as well as managerial, regulatory and financial aspects. The implementation and upscaling of digitally enabled IPDM are discussed, with elaboration of successful practices and related evidence. Finally, recommendations are made. It is concluded that the adoption of digitally enabled IPDM on a global level is inevitable, considering the challenges created by an increasing prevalence of patients with DM and the need for better outcomes and improvement of health system sustainability.

Digital Therapeutics for Improving Effectiveness of Pharmaceutical Drugs and Biological Products: Preclinical and Clinical Studies Supporting Development of Drug + Digital Combination Therapies for Chronic Diseases

Limitations of pharmaceutical drugs and biologics for chronic diseases (e.g., medication non-adherence, adverse effects, toxicity, or inadequate efficacy) can be mitigated by mobile medical apps, known as digital therapeutics (DTx). Authorization of adjunct DTx by the US Food and Drug Administration and draft guidelines on "prescription drug use-related software" illustrate opportunities to create drug + digital combination therapies, ultimately leading towards drug-device combination products (DTx has a status of medical devices). Digital interventions (mobile, web-based, virtual reality, and video game applications) demonstrate clinically meaningful benefits for people living with Alzheimer's disease, dementia, rheumatoid arthritis, cancer, chronic pain, epilepsy, depression, and anxiety. In the respective animal disease models, preclinical studies on environmental enrichment and other non-pharmacological modalities (physical activity, social interactions, learning, and music) as surrogates for DTx "active ingredients" also show improved outcomes. In this narrative review, we discuss how drug + digital combination therapies can impact translational research, drug discovery and development, generic drug repurposing, and gene therapies. Market-driven incentives to create drug-device combination products are illustrated by Humira® (adalimumab) facing a "patent-cliff" competition with cheaper and more effective biosimilars seamlessly integrated with DTx. In conclusion, pharma and biotech companies, patients, and healthcare professionals will benefit from accelerating integration of digital interventions with pharmacotherapies.

Smart Insulin Pens: Advancing Digital Transformation and a Connected Diabetes Care Ecosystem

With the first commercially available smart insulin pens, the predominant insulin delivery device for millions of people living with diabetes is now coming into the digital age. Smart insulin pens (SIPs) have the potential to reshape a connected diabetes care ecosystem for patients, providers, and health systems. Existing SIPs are enhanced with real-time wireless connectivity, digital dose capture, and integration with personalized dosing decision support. Automatic dose capture can promote effective retrospective review of insulin dose data, particularly when paired with glucose data. Patients, providers, and diabetes care teams will be able to make increasingly data-driven decisions and recommendations, in real time, during scheduled visits, and in a more continuous, asynchronous care model. As SIPs continue to progress along the path of digital transformation, we can expect additional benefits: iteratively improving software, machine learning, and advanced decision support. Both these technological advances, and future care delivery models with asynchronous interactions, will depend on easy, open, and continuous data exchange between the growing number of diabetes devices. SIPs have a key role in modernizing diabetes care for a large population of people living with diabetes.

Current provision and HCP experiences of remote care delivery and diabetes technology training for people with type 1 diabetes in the UK during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has led to the rapid implementation of remote care delivery in type 1 diabetes. We studied current modes of care delivery, healthcare professional experiences and impact on insulin pump training in type 1 diabetes care in the United Kingdom (UK).

METHODS

The UK Diabetes Technology Network designed a 48-question survey aimed at healthcare professionals providing care in type 1 diabetes.

RESULTS

One hundred and forty-three healthcare professionals (48% diabetes physicians, 52% diabetes educators and 88% working in adult services) from approximately 75 UK centres (52% university hospitals, 46% general and community hospitals), responded to the survey. Telephone consultations were the main modality of care delivery. There was a higher reported time taken for video consultations versus telephone (p < 0.001). Common barriers to remote consultations were patient familiarity with technology (72%) and access to patient device data (67%). We assessed the impact on insulin pump training. A reduction in total new pump starts (73%) and renewals (61%) was highlighted. Common barriers included patient digital literacy (61%), limited healthcare professional experience (46%) and time required per patient (44%). When grouped according to size of insulin pump service, pump starts and renewals in larger services were less impacted by the pandemic compared to smaller services.

CONCLUSION

This survey highlights UK healthcare professional experiences of remote care delivery. While supportive of virtual care models, a number of factors highlighted, especially patient digital literacy, need to be addressed to improve virtual care delivery and device training.

User-Centered Design of A Novel Risk Prediction Behavior Change Tool Augmented With an Artificial Intelligence Engine (MyDiabetesIQ): A Sociotechnical Systems Approach

Background

Diabetes and its complications account for 10% of annual health care spending in the United Kingdom. Digital health care interventions (DHIs) can provide scalable care, fostering diabetes self-management and reducing the risk of complications. Tailorability (providing personalized interventions) and usability are key to DHI engagement/effectiveness. User-centered design of DHIs (aligning features to end users’ needs) can generate more usable interventions, avoiding unintended consequences and improving user engagement.

Objective

MyDiabetesIQ (MDIQ) is an artificial intelligence engine intended to predict users’ diabetes complications risk. It will underpin a user interface in which users will alter lifestyle parameters to see the impact on their future risks. MDIQ will link to an existing DHI, My Diabetes My Way (MDMW). We describe the user-centered design of the user interface of MDIQ as informed by human factors engineering.

Methods

Current users of MDMW were invited to take part in focus groups to gather their insights about users being shown their likelihood of developing diabetes-related complications and any risks they perceived from using MDIQ. Findings from focus groups informed the development of a prototype MDIQ interface, which was then user-tested through the “think aloud” method, in which users speak aloud about their thoughts/impressions while performing prescribed tasks. Focus group and think aloud transcripts were analyzed thematically, using a combination of inductive and deductive analysis. For think aloud data, a sociotechnical model was used as a framework for thematic analysis.

Results

Focus group participants (n=8) felt that some users could become anxious when shown their future complications risks. They highlighted the importance of easy navigation, jargon avoidance, and the use of positive/encouraging language. User testing of the prototype site through think aloud sessions (n=7) highlighted several usability issues. Issues included confusing visual cues and confusion over whether user-updated information fed back to health care teams. Some issues could be compounded for users with limited digital skills. Results from the focus groups and think aloud workshops were used in the development of a live MDIQ platform.

Conclusions

Acting on the input of end users at each iterative stage of a digital tool’s development can help to prioritize users throughout the design process, ensuring the alignment of DHI features with user needs. The use of the sociotechnical framework encouraged the consideration of interactions between different sociotechnical dimensions in finding solutions to issues, for example, avoiding the exclusion of users with limited digital skills. Based on user feedback, the tool could scaffold good goal setting, allowing users to balance their palatable future complications risk against acceptable lifestyle changes. Optimal control of diabetes relies heavily on self-management. Tools such as MDMW/ MDIQ can offer personalized support for self-management alongside access to users’ electronic health records, potentially helping to delay or reduce long-term complications, thereby providing significant reductions in health care costs.

Efficacy of Digitally Supported and Real-Time Self-Monitoring of Blood Glucose-Driven Counseling in Patients with Type 2 Diabetes Mellitus: A Real-World, Retrospective Study in North India

PURPOSE

Poor glycemic control is prevalent in patients with type 2 diabetes mellitus (T2DM) in India. This study aims to understand the effectiveness of a smartphone-connected glucometer, real-time feedback, and contextualized counseling on glycemic control and hypoglycemic episodes in T2DM patients.

METHODS

This retrospective, multicenter study reviewed the medical records of T2DM patients belonging to several cities of north India, who were digitally engaged with a smartphone-connected glucometer and who had received at least one counseling session between September 2019 and July 2020. Intervention included self-monitoring of blood glucose (SMBG) using a smartphone-connected glucometer enabled with real-time transmission of information to certified diabetes educators (CDE) and their corresponding counseling based on SMBG findings.

RESULTS

Of 7111 adult T2DM patients included in this study, majority (75%) of the patients received a single session of counseling, and the remaining patients received 2 (16.7%), 3 (5%), 4 (2%), or ≥5 (1.3%) sessions. The mean age of the patients was 51.6 years, and the majority (77.9%) were males. Digital monitoring of BG and counseling with CDE significantly reduced the mean fasting (by 9.6%), pre-prandial (by 9.9%), and post-prandial (by 9.2%) BG values in 53%, 52%, and 54% of patients, respectively. The majority (81.4%) of patients showed no hypoglycemic episode (≤70 mg/dL) post-counseling. The hypoglycemia episodes observed with FBG, pre-prandial, and post-prandial BG values were reduced significantly by 58.5%, 48.1%, and 61.8%, respectively, post-counseling.

CONCLUSION

Digitally supported and real-time SMBG-driven counselling was effective in glycemic control and reduction of hypoglycemic episodes in T2DM patients in India. Moreover, reduction in hypoglycemia may be due to back end real-time support of CDE intervention.

Association of the Coronavirus Disease 2019 Outbreak on the Diabetes Self-Management in Chinese Patients: An Analytical Cross-Sectional Study

BACKGROUND

The coronavirus disease 2019 (COVID-19) outbreak has seriously affected people's lives, especially those with chronic diseases. Diabetes self-management, which plays an important role in glycaemic control and reducing the risk of acute and long-term complications, may be discouraged by social distancing.

PURPOSE

To evaluate the level of self-management activities in Chinese patients with type 2 diabetes mellitus (T2DM) during the COVID-19 pandemic.

PATIENTS AND METHODS

A survey of with 872 patients with T2DM in the inpatient and outpatient departments through face-to-face interviews was conducted from 1 July, 2020 to 30 September, 2020. The main outcome measures were glycaemic control status and level of self-management activities during the pandemic.

RESULTS

In terms of glycaemic control, the data showed that patients with fasting plasma glucose (FPG) < 7.0 mmol/L (36.4%), postprandial plasma glucose (PPG) < 10.0 mmol/L (26.3%), or glycosylated haemoglobin (HbA1c) < 7.0% (18.6%) in our investigation has well-controlled blood glucose level, and 11.9% of patients experienced blood glucose <3.9 mmol/L during the outbreak. The diabetes self-management of Chinese patients decreased and the final diabetes self-management score of the Chinese patients was 3.4 ± 1.45. Patients with higher education, diabetes education, comorbidities, and online consultations had higher diabetes self-management scores (P <0.05). Adherence to diabetes self-management in the normal glycaemic control group was higher than that in the substandard glycaemic control group (P<0.05). Among all participants, 72.1% of the patients reduced the frequency of hospital visits, and 44.8% considered that they had diabetes-related stress during the pandemic. The mean anxiety level score rated by 286 patients was 5.3±2.8.

CONCLUSION

The COVID-19 pandemic has affected diabetes self-management, including substandard glycemic control, increased diabetes-related stress, limited exercise range and medical visits. Therefore, future interventions should focus on the online management of chronic diseases and support online consultation' development and promotion, which can overcome physical distance and provide personalized services conveniently.

Analysis of "Accuracy of a 14-Day Factory Calibrated Continuous Glucose Monitoring System With Advanced Algorithm in Pediatric and Adult Population With Diabetes"

In this study by Alva et al, accuracy of a second-generation factory calibrated continuous glucose monitoring system is evaluated. Compared to the first-generation FreeStyle Libre 14-day system (FSL), accuracy was improved throughout the 14-day wear period, including improved accuracy in hypoglycemia for adults and youth. The addition of optional real-time alerts for hypoglycemia and hyperglycemia as well as an integrated continuous glucose monitor (iCGM) designation by the FDA may further enable users to benefit from using CGM in real time, including in future automated insulin delivery systems. As CGM accuracy, affordability, and accessibility improve, we anticipate increased uptake of CGM by people on intensive insulin therapy, and also potential benefits and expansion into a broader patient population. There are growing opportunities to leverage cloud-connected CGM devices in the increasingly virtual, continuous telehealth-driven diabetes care model, which will require more focus on development and use of data interoperability standards.

An International, Mixed-Methods Study of the Perceived Intrusiveness of Remote Digital Diabetes Monitoring

OBJECTIVE

To assess the relationship between remote digital monitoring (RDM) modalities for diabetes and intrusiveness in patients' lives.

PATIENTS AND METHODS

Online vignette-based survey (February 1 through July 1, 2019). Adults with diabetes (type 1, 2, or subtypes such as latent autoimmune diabetes of adulthood) assessed three randomly selected vignettes among 36 that combined different modalities for monitoring tools (three options: glucose- and physical activity [PA]-monitoring only, or glucose- and PA-monitoring with occasional or regular food monitoring), duration/feedback loops (six options: monitoring for a week before all vs before specific consultations with feedback given in consultation, vs monitoring permanently, with real-time feedback by one's physician vs by anoter caregiver, vs monitoring permanently, with real-time, artificial intelligence-generated treatment feedback vs treatment and lifestyle feedback), and data handling (two options: by the public vs private sector). We compared intrusiveness (assessed on a 5-point scale) across vignettes and used linear mixed models to identify intrusiveness determinants. We collected qualitative data to identify aspects that drove participants' perception of intrusiveness.

RESULTS

Overall, 1010 participants from 30 countries provided 2860 vignette-assessments (52% were type 1 diabetes). The monitoring modalities associated with increased intrusiveness were food monitoring compared with glucose- and PA-monitoring alone (β=0.34; 95% CI, 0.26 to 0.42; P<.001) and permanent monitoring with real-time physician-generated feedback compared with monitoring for a week with feedback in consultation (β=0.25; 95% CI, 0.16 to 0.34, P<.001). Public-sector data handling was associated with decreased intrusiveness as compared with private-sector (β=-0.15; 95% CI, -0.22 to -0.09; P<.001). Four drivers of intrusiveness emerged from the qualitative analysis: practical/psychosocial burden (eg, RDM attracting attention in public), control, data safety/misuse, and dehumanization of care.

CONCLUSION

RDM is intrusive when it includes food monitoring, real-time human feedback, and private-sector data handling.

Telehealth in type 1 diabetes

PURPOSE OF REVIEW

The role of telehealth in the care of people with type 1 diabetes (T1D) has expanded dramatically during the coronavirus pandemic, and is expected to remain a major care delivery modality going forward. This review explores the landscape of recent evidence for telehealth in T1D care.

RECENT FINDINGS

Telemedicine for routine T1D care has shown equivalence to standard in-person care, with respect to glycemic control, while also increasing access, convenience, and satisfaction. Telehealth use promotes increased engagement of adolescents with T1D. Telehealth platforms have successfully been used in the care of microvascular complications and to support mental health related to diabetes. Machine learning and advanced decision support will increasingly be used to augment T1D care, as recent evidence suggests increasing capabilities to improve glycemic control. A spectrum of digital connected care services are emerging to support people with diabetes with daily management of diabetes. Finally, policy and systems are required that promote data interoperability, telemedicine provision, and reimbursement to support the ongoing growth of telehealth in T1D.

SUMMARY

A developing field of evidence supports use of telehealth in T1D. As this care modality scales, it has the potential to increase access to high-quality diabetes care for many people with T1D.

The Digital/Virtual Diabetes Clinic: The Future Is Now-Recommendations from an International Panel on Diabetes Digital Technologies Introduction

The increasing prevalence of diabetes, combined with a growing global shortage of health care professionals (HCP), necessitates the need to develop new approaches to diabetes care delivery to expand access to care, lessen the burden on people with diabetes, improve efficiencies, and reduce the unsustainable financial liability on health systems and payers. Use of digital diabetes technologies and telehealth protocols within a digital/virtual diabetes clinic has the potential to address these challenges. However, several issues must be resolved to move forward. In February 2020, organizers of the Advanced Technologies & Treatments for Diabetes Annual Conference convened an international panel of HCP, researchers, patient advocates, and industry representatives to review the status of digital diabetes technologies, characterize deficits in current technologies, and identify issues for consideration. Since that meeting, the importance of using telehealth and digital diabetes technologies has been demonstrated amid the global coronavirus disease (COVID-19) pandemic. This article summarizes the panel's discussion of the opportunities, obstacles, and requisites for advancing the use of these technologies as a standard of care for the management of diabetes.

Evaluation of Patient Willingness to Adopt Remote Digital Monitoring for Diabetes Management

Importance

Patients will decide whether to adopt remote digital monitoring (RDM) for diabetes by weighing its health benefits against the inconvenience it may cause.

Objective

To identify the minimum effectiveness patients report they require to adopt 36 different RDM scenarios.

Design, Setting, and Participants

This survey study was conducted among adults with type 1 or type 2 diabetes living in 30 countries from February to July 2019.

Exposures

Survey participants assessed 3 randomly selected scenarios from a total of 36. Scenarios described different combinations of digital monitoring tools (glucose, physical activity, food monitoring), duration and feedback loops (feedback in consultation vs real-time telefeedback by a health care professional or by artificial intelligence), and data handling modalities (by a public vs private company), reflecting different degrees of RDM intrusiveness in patients' personal lives.

Main Outcomes and Measures

Participants assessed the minimum effectiveness for 2 diabetes-related outcomes (reducing hypoglycemic episodes and preventing ophthalmologic complications) for which they would adopt each RDM (from much less effective to much more effective than their current monitoring).

Results

Of 1577 individuals who consented to participate, 1010 (64%; 572 [57%] women, median [interquartile range] age, 51 [37-63] years, 524 [52%] with type 1 diabetes) assessed at least 1 vignette. Overall, 2860 vignette assessments were collected. In 1025 vignette assessments (36%), participants would adopt RDM only if it was much more effective at reducing hypoglycemic episodes compared with their current monitoring; in 1835 assessments (65%), participants would adopt RDM if was just as or somewhat more effective. The main factors associated with required effectiveness were food monitoring (β = 0.32; SE, 0.12; P = .009), real-time telefeedback by a health care professional (β = 0.49; SE, 0.15; P = .001), and perceived intrusiveness (β = 0.36; SE, 0.06; P < .001). Minimum required effectiveness varied among participants; 34 of 36 RDM scenarios (94%) were simultaneously required to be just as or less effective by at least 25% of participants and much more effective by at least 25% of participants. Results were similar for participant assessments of scenarios regarding the prevention of ophthalmologic complications.

Conclusions and Relevance

The findings of this study suggest that patients require greater health benefits to adopt more intrusive RDM modalities, food monitoring, and real-time feedback by a health care professional. Patient monitoring devices should be designed to be minimally intrusive. The variability in patients' requirements points to a need for shared decision-making.

Virtual care models for cancer survivorship

Virtual care models for cancer survivorship are needed to support patients living with the chronic effects of cancer treatment, while increasing health system capacity. Characteristics that may be critical to their success have not been adequately studied. This scoping review summarizes previous efforts to virtualize survivorship care to inform future innovations in the field. Four databases were searched for articles published before January 2020, and 24 articles that met selection criteria were included in this analysis. Rationale for pursuing virtual models of care shared two common objectives: (1) the need for sustainable survivorship care, and (2) the opportunity to improve survivorship outcomes. Breast cancer (N = 10) and prostate cancer (N = 4) were the most targeted cancers for virtual survivorship care. The implemented technologies included web platforms (N = 15), telephone calls (N = 12), and smartphone or tablet applications (N = 5). A variety of healthcare professionals were effectively involved in the provision of virtual care. Future virtual care models may benefit from integrating with existing health systems and services, repurposing common technologies, involving allied health professionals, and engaging patients and caregivers from diverse communities in the design of virtual services.

The Challenges of COVID-19 for People Living With Diabetes: Considerations for Digital Health

The coronavirus disease (COVID-19) is a global pandemic that significantly impacts people living with diabetes. Diabetes-related factors of glycemic control, medication pharmacodynamics, and insulin access can impact the severity of a COVID-19 infection. In this commentary, we explore how digital health can support the diabetes community through the pandemic. For those living with diabetes, digital health presents the opportunity to access care with greater convenience while not having to expose themselves to infection in an in-person clinic. Digital diabetes apps can increase agency in self-care and produce clinically significant improvement in glycemic control through facilitating the capture of diabetes device data. However, the ability to share these data back to the clinic to inform virtual care and enhance diabetes coaching and guidance remains a challenge. In the end, it requires an unnecessarily high level of technical sophistication on the clinic’s part and on those living with diabetes to routinely use their diabetes device data in clinic visits, virtual or otherwise. As the world comes together to fight the COVID-19 pandemic, close collaboration among the global diabetes community is critical to understand and manage the sustained impact of the pandemic on people living with diabetes.