Mobile phone health apps for diabetes management: current evidence and future developments

User-Centered Design of a Diabetes Self-Management Tool for Underserved Populations

BACKGROUND

User-centered design (UCD) or user experience design (UXD) methods have gained recent popularity for the design of mobile health (mHealth) interventions. However, there is a gap in application of these methods for diabetes self-management. This study aims to document the UCD process for a self-management mobile application aimed for patients with diabetes in underserved communities.

METHODS

A UCD mixed-methods approach including interviews with patients and providers, a review of literature, and a technology landscape analysis were used to define the app functional information requirements that informed the user experience/user interface design process. Usability studies with the app designers and developers, intended users, and a focus group of nurse educators and dieticians were used to test and improve the design.

RESULTS

An mHealth app was developed with health-tracking features for stress, blood sugar, food, exercise, medications, weight, and blood pressure. We tackled a range of usability and user experience challenges, which encompassed addressing issues like low health literacy by employing a combination of user interface design principles, intuitive visualizations, customizable icons, seamless database integration, and automated data input features. Special attention was given to the design of educational content accounting for the intended users' cultural background and literacy levels.

CONCLUSIONS

User-centered design approach contributed to a better understanding of the intended users' needs, limitations, mental models, and expectations, facilitating the design of a comprehensive mobile app for patients with diabetes in underserved communities that includes essential features for self-management while providing a strong educational component, addressing an important gap in the literature.

An Evidence-Based Framework for Creating Inclusive and Personalized mHealth Solutions-Designing a Solution for Medicaid-Eligible Pregnant Individuals With Uncontrolled Type 2 Diabetes

Mobile health (mHealth) apps can be an evidence-based approach to improve health behavior and outcomes. Prior literature has highlighted the need for more research on mHealth personalization, including in diabetes and pregnancy. Critical gaps exist on the impact of personalization of mHealth apps on patient engagement, and in turn, health behaviors and outcomes. Evidence regarding how personalization, engagement, and health outcomes could be aligned when designing mHealth for underserved populations is much needed, given the historical oversights with mHealth design in these populations. This viewpoint is motivated by our experience from designing a personalized mHealth solution focused on Medicaid-enrolled pregnant individuals with uncontrolled type 2 diabetes, many of whom also experience a high burden of social needs. We describe fundamental components of designing mHealth solutions that are both inclusive and personalized, forming the basis of an evidence-based framework for future mHealth design in other disease states with similar contexts.

Current Status and Trends in mHealth-Based Research for Treatment and Intervention in Tinnitus: Bibliometric and Comparative Product Analysis

BACKGROUND

As a global medical problem, tinnitus can seriously harm human health and is difficult to alleviate, ranking among the top 3 complex diseases in the otolaryngology field. Traditional cognitive behavioral therapy and sound therapy require offline face-to-face treatment with medical staff and have limited effectiveness. Mobile health (mHealth), which, in recent decades, has been greatly applied in the field of rehabilitation health care, improving access to health care resources and the quality of services, has potential research value in the adjunctive treatment of tinnitus.

OBJECTIVE

This study aimed to understand the research trends, product characteristics, problems, and research transformation of tinnitus treatment software by analyzing the research progress of mHealth for tinnitus treatment based on the literature and related marketed apps.

METHODS

Bibliometric methods were used to describe the characteristics of the relevant literature in terms of the number and topics of publications, authors, and institutions. We further compared the features and limitations of the currently available tinnitus treatment software.

RESULTS

Data published until February 28, 2022, were collected. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standardized screening process, 75 papers were included. The country with the highest number of publications was Germany, followed by the United Kingdom and the United States, whereas China had only a single relevant study. The most frequently found journals were the American Journal of Audiology and the Journal of the American Academy of Audiology (18/75, 24%). With regard to publication topics, cognitive behavioral therapy started to become a hot topic in 2017, and research on mHealth apps has increased. In this study, 28 tinnitus treatment apps were obtained (n=24, 86% from product data and n=4, 14% from literature data); these apps were developed mainly in the United States (10/28, 36%) or China (9/28, 32%). The main treatment methods were sound therapy (10/28, 36%) and cognitive behavioral therapy (2/28, 7%). Of the 75 publications, 7 (9%) described apps in the market stage. Of the 28 apps, 22 (79%) lacked literature studies or evidence from professional bodies.

CONCLUSIONS

We found that, as a whole, the use of mHealth for treatment and intervention in tinnitus was showing a rapid development, in which good progress had been made in studies around sound therapy and cognitive behavioral therapy, although most of the studies (50/75, 67%) focused on treatment effects. However, the field is poorly accepted in top medical journals, and the majority are in the research design phase, with a lack of translation of the literature results and clinical validation of the marketed apps. Furthermore, in the future, novel artificial intelligence techniques should be used to address the issue of staged monitoring of tinnitus.

Automatic user sentiments extraction from diabetes mobile apps - An evaluation of reviews with machine learning

Using diabetes mobile apps for self-management of diabetes is one of the emerging strategies for controlling blood sugar levels and maintaining the wellness of patients with diabetes. This study aims to develop a strategy for thematically extracting user comments from diabetes mobile apps to understand the concern of patients with diabetes. Hence, 2678 user comments obtained from the Google Play Store are thematically analyzed with Non-negative Matrix Factorization (NMF) to identify the themes for describing positive, neutral, and negative sentiments. These themes are used as the ground truth for developing a 10-fold cross-validation ensemble Multilayer Artificial Neural Network (ANN) model following the Bag of Word (BOW) analysis of lemmatized user comments. The result shows that a total of 41.24% of positive sentimental users identified the diabetes mobile apps as Effective for Blood Sugar Monitoring (EBSM), 32.36% with neutral sentiments are mostly impressed by the Information Quality (IQ), whereas 40.81% of unhappy users are worried about the Poor Information Quality (PIQ). The prediction accuracy of the ANN model is 89%-97%, which is 5%-48% better than other predominant algorithms. It can be concluded from this study that diabetes mobile apps with a simple user interface, effective data storage and security, medication adherence, and doctor appointment scheduling are preferred by patients with diabetes.

Effectiveness of mHealth/eHealth interventions on obesity treatment: a protocol for umbrella review of meta-analyses

INTRODUCTION

Mobile health (mHealth)/electronic health (eHealth) have the effect of facilitating weight loss in overweight and obese populations. However, studies have shown varied results and relatively high heterogeneity in the efficacy of mHealth/eHealth interventions. The aim of the paper was to systematically summarise published studies about the weight loss efficacy of mHealth/eHealth.

METHODS AND ANALYSIS

A comprehensive review of PubMed, Embase and Cochrane Library databases published from inception to 21 March 2021 will be conducted. The selected articles are meta-analyses that integrated the studies, which evaluated efficacy of mHealth/eHealth. Two people will select eligible articles and extract data independently. Any disputes will be resolved by discussion or the arbitration of a third person. The methodological quality of the included meta-analyses will be assessed with AMSTAR V.2 and the quality of evidence will be obtained with Grade of Recommendations Assessment, Development and Evaluation (GRADE). The study selection process will be presented using a flowchart. We will reanalyse each outcome with random effect methods. If possible, we will use funnel plot and Egger's test to evaluate if publication bias existed.

ETHICS AND DISSEMINATION

Ethical approval is not required for the study, as we collected data only from available published materials. This umbrella review will also be submitted to a peer-reviewed journal for publication after completion.

PROSPERO REGISTRATION NUMBER

CRD42021247006.

Development of an information system and mobile application for the care of type 2 diabetes patients at the primary care level for the health sector in Mexico: study protocol for a randomized controlled, open-label trial

Background

Providing optimal care for type 2 diabetes (DM2) patients remains a challenge for all healthcare systems. Patients often encounter various barriers in adhering to self-management programs due to lack of knowledge and understanding of self-care activities, lack of individualized and coordinated care, inconvenient and costly education sessions, and poor patient-provider communication. Mobile technologies such as cell phones/smartphones, handheld tablets, and other wireless devices offer new and exciting opportunities for addressing some of these challenges. The purpose of this study is to compare a diabetes management strategy using an information board and a mobile application versus standard care in patients with uncontrolled DM2.

Method

The SANENT (Sistema de Análisis de Enfermedades No Transmisibles) trial is a primary care-based, prospective, two-arm, randomized controlled, open-label, blinded-endpoint study. We aim to recruit 1440 DM2 patients during a period of 6 months until the requested number of participants has been achieved. The total length of the intervention will be 1 year. Both men and women treated for DM2 with an HbA1c > 8.5% and ≥ 20 years of age are eligible to participate in the study. The primary outcome of the study is improved diabetes control measured by changes in HbA1c in the study participants. HbA1c will be measured at baseline, 3-month, 6-month, 9-month, and 12-month follow-up visits in all participants. The main analysis will be based on the intention-to-treat principle. The primary endpoint of the study will be the change in HbA1C within the groups and the differences between the groups. This will be assessed by a repeated measurement approach based on mixed models which contain both fixed effects and random effects.

Discussion

The overall goal of this project is to contribute to the evidence for the use of mobile technology to improve the treatment and regulation of poorly controlled DM2 patients living in Mexico. Our proposed project will show how mobile health technology tools can be used in the treatment of patients with uncontrolled DM2 in primary health care in a Latin American population, and particularly how they could help diabetes patients take better care of themselves.

Trial registration

ClinicalTrials.gov, US National Institutes of Health NCT04974333. Prospectively registered on July 13, 2021. Protocol version number 1, dated August 15th, 2021.

Obesity, preoperative weight loss, and telemedicine before total joint arthroplasty: a review

The preoperative period prior to elective total joint arthroplasty (TJA) is a critical time for lifestyle interventions since a scheduled surgery may help motivate patients to lose weight. Weight loss may reduce complications associated with obesity following TJA and enable patients with severe obesity (body mass index [BMI] > 40 kg/m²) to become eligible for TJA, as many institutions use a 40 kg/m² cut-off for offering surgery. A comprehensive review was conducted to (1) provide background on complications associated with obesity following TJA, (2) synthesize prior research on the success rate of patients losing weight after being denied TJA for severe obesity, (3) discuss bariatric surgery before TJA, and (4) propose mobile health telemedicine weight loss interventions as potential weight loss methods for patients preoperatively. It is well established that obesity increases complications associated with TJA. In total knee arthroplasty (TKA), obesity increases operative time, length of stay, and hospitalization costs as well as the risk of deep infection, revision, and component malpositioning. Obesity may have an even larger impact on complications associated with total hip arthroplasty (THA), including wound complications and deep infection. Obesity also increases the risk of hip dislocation, aseptic loosening, and venous thromboembolism after THA. Synthesis of the only two studies (n = 417), to our knowledge, that followed patients denied TJA for severe obesity demonstrated that only 7% successfully reduced their BMI below 40 kg/m² via lifestyle modifications and ultimately underwent TJA. Unfortunately, bariatric surgery may only increase certain post-TKA complications including death, pneumonia, and implant failure, and there is limited research on preoperative weight loss via lifestyle modification. A review of short-term mobile health weight loss interventions that combined personalized counseling with self-monitoring via a smartphone app found about 5 kg of weight loss over 3-6 months. Patients with severe obesity have more weight to lose and may have additional motivation to do so before TJA, so weight loss results may differ by patient population. Research is needed to determine whether preoperative mobile health interventions can help patients become eligible for TJA and produce clinically significant weight loss sufficient to improve postoperative outcomes.

Smartphone application-based follow-up care of patients after bariatric surgery: A mixed-method study of usability

OBJECTIVE

Due to potential short-term and long-term complications, adequate lifelong follow-up is crucial for patients after bariatric surgery. However, compliance with postoperative follow-up is poor despite clear national and international guidelines. This feasibility trial aimed to evaluate the usability of a smartphone application-based follow-up program in patients after bariatric surgery.

METHODS

Patients were included after having undergone a primary bariatric surgery. Instead of attending meetings in our outpatient clinic, they were followed up using a smartphone application. After 6 months, the System Usability Scale (SUS) was used to measure participant perception. Additional interviews were performed to gain more insight into the usability of the app.

RESULTS

Between August 2020 and February 2021, 52 patients met the inclusion criteria and agreed to participate in the study, of whom 5 (9.6%) dropped out of the study. At the time of analysis, 31 patients have been followed up for 6 months, among whom 26 patients completed the SUS questionnaire. The mean overall score of SUS is 82.1 ± 19.8. In the qualitative analysis, participants were generally positive about the follow-up care and found it easy to use, despite some minor technical problems.

CONCLUSION

Our smartphone app-based follow-up program was proven to be effective in the aftercare succeeding bariatric surgery. Our data indicates that the satisfaction, efficiency, learnability, and ease of use of the smartphone application were coherent in the acceptance and use of mobile technology by patients.

Eliciting Requirements for a Diabetes Self-Management Application for Underserved Populations: A Multi-Stakeholder Analysis

Medically underserved communities have limited access to effective disease management resources in the U.S. Mobile health applications (mHealth apps) offer patients a cost-effective way to monitor and self-manage their condition and to communicate with providers; however, current diabetes self-management apps have rarely included end-users from underserved communities in the design process. This research documents key stakeholder-driven design requirements for a diabetes self-management app for medically underserved patients. Semi-structured survey interviews were carried out on 97 patients with diabetes and 11 healthcare providers from medically underserved counties in South Texas, to elicit perspectives and preferences regarding a diabetes self-management app, and their beliefs regarding such an app's usage and utility. Patients emphasized the need for accessible educational content and for quick access to guidance on regulating blood sugar, diet, and exercise and physical activity using multimedia rather than textual forms. Healthcare providers indicated that glucose monitoring, educational content, and the graphical visualization of diabetes data were among the top-rated app features. These findings suggest that specific design requirements for the underserved can improve the adoption, usability, and sustainability of such interventions. Designers should consider health literacy and numeracy, linguistic barriers, data visualization, data entry complexity, and information exchange capabilities.

Pilot trial of remote monitoring to prevent malnutrition after hepatopancreatobiliary surgery

Background

Patients undergoing hepatopancreatobiliary (HPB) surgery, such patients with pancreatic, periampullary, and liver cancer, are at high risk for malnutrition. Malnutrition increases surgical complications and reduces overall survival. Despite its severity, there are limited interventions addressing malnutrition after HPB surgery. The aim of this pilot trial was to examine feasibility, acceptability, usability, and preliminary efficacy of a remote nutrition monitoring intervention after HPB surgery.

Methods

Participants received tailored nutritional counseling before and after surgery at 2 and 4 weeks after hospital discharge. Participants also recorded nutritional intake daily for 30 days, and these data were reviewed remotely by registered dietitians before nutritional counseling visits. Descriptive statistics were used to describe study outcomes.

Results

All 26 patients approached to participate consented to the trial before HPB surgery. Seven were excluded after consent for failing to meet eligibility criteria (e.g., did not receive surgery). Nineteen participants (52.6% female, median age = 65 years) remained eligible for remote monitoring post-surgery. Nineteen used the mobile app food diary, 79% of participants recorded food intake for greater than 80% of study days, 95% met with the dietitian for all visits, and 89% were highly satisfied with the intervention. Among participants with complete data, the average percent caloric goal obtained was 82.4% (IQR: 21.7).

Conclusions

This intervention was feasible and acceptable to patients undergoing HPB surgery. Preliminary efficacy data showed most participants were able to meet calorie intake goals. Future studies should examine intervention efficacy in a larger, randomized controlled trial.

Trial registration

Clinicaltrials.gov. Registered 16 September 2019, https://clinicaltrials.gov/ct2/show/NCT04091165.

Preoperative Nonsurgical Weight Loss Interventions Before Total Hip and Knee Arthroplasty: A Systematic Review

BACKGROUND

An upcoming total joint arthroplasty (TJA) may motivate patients with severe obesity (body mass index [BMI] > 40 kg/m²) to lose weight. Weight loss can optimize outcomes following TJA, and many surgeons use a 40 kg/m² cut-off for undergoing TJA to reduce the risk of complications. However, few patients who are denied TJA for severe obesity successfully lose weight. This is the first systematic review of nonsurgical weight loss interventions before TJA.

METHODS

Five electronic databases were searched for articles on January 11, 2021. Studies that utilized preoperative nonsurgical weight loss interventions for patients with obesity (BMI ≥ 30 kg/m²) scheduled for or awaiting TJA of the hip or knee were included. Two reviewers independently screened articles, assessed methodological quality, and extracted data.

RESULTS

We retrieved 1943 unique records, of which 7 met inclusion criteria including 2 randomized clinical trials and 5 single-arm case series. Overall, weight loss ranged from 5.0 to 32.5 kg. Four interventions reduced BMI by 3 kg/m² at 3-5 months, while 1 reduced BMI by 12.7 kg/m². Other weight outcomes and those related to pain, function, complications, and adverse events were inconsistently reported.

CONCLUSION

Although larger trials are needed, particularly randomized controlled trials that measure preoperative weight loss in a control group, nutritional status, and postoperative complications, the available evidence indicates that short-term, nonsurgical, preoperative weight loss interventions before TJA produce both statistically significant weight loss and reduced BMI before surgery. It remains unknown if the amount of weight loss from these interventions is clinically significant and sufficient to improve outcomes after TJA.

Health information technology foresight for Iran: A Delphi study of experts' views to inform future policymaking

BACKGROUND

Policymakers require a systematic approach when planning for information technology needs in healthcare.

OBJECTIVE

The aim of this study was to obtain experts' predictions of future health information technology (HIT) needs until 2025 for Iran in relation to the relative importance of key technologies, expected timeframe of realisation, areas that may be impacted upon and obstacles to achieving these goals.

METHOD

This article presents results from the third phase (a Delphi study) of a larger mixed-method study. Policymakers from the Iranian Ministry of Health and faculty members from different medical universities across the country who were expert in the field of HIT were invited to participate (n = 61).

RESULTS

Participants (39) completed the first-round questionnaire and 24 completed the second. The development of personal health records (n = 32, 82.0%), the development of clinical decision-making systems (n = 30, 76.9%) and the use of business intelligence for collecting and analysing clinical and financial data (n = 32, 82.0%) were predicted to occur after 2025. The healthcare areas predicted to experience the greatest impact from most HITs were facilitating patient-provider communication and improving healthcare quality. Key barriers to achieving HITs were related to weaknesses in planning and limited financial resources for most technologies.

CONCLUSION

By identifying the areas of impact and the barriers to achieving the HIT goals, more accurate planning is possible and resources can be allocated according to priorities.

Going digital: a narrative overview of the effects, quality and utility of mobile apps in chronic disease self-management

Objective Smartphone health applications (apps) are being increasingly used to assist patients in chronic disease self-management. The effects of such apps on patient outcomes are uncertain, as are design features that maximise usability and efficacy, and the best methods for evaluating app quality and utility. Methods In assessing efficacy, PubMed, Cochrane Library and EMBASE were searched for systematic reviews (and single studies if no systematic review was available) published between January 2007 and January 2018 using search terms (and synonyms) of 'smartphone' and 'mobile applications', and terms for each of 11 chronic diseases: asthma, chronic obstructive lung disease (COPD), diabetes, chronic pain, serious mental health disorders, alcohol and substance addiction, heart failure, ischaemic heart disease, cancer, cognitive impairment, chronic kidney disease (CKD). With regard to design features and evaluation methods, additional reviews were sought using search terms 'design', 'quality,' 'usability', 'functionality,' 'adherence', 'evaluation' and related synonyms. Results Of 13 reviews and six single studies assessing efficacy, consistent evidence of benefit was seen only with apps for diabetes, as measured by decreased glycosylated haemoglobin levels (HbA1c). Some, but not all, studies showed benefit in asthma, low back pain, alcohol addiction, heart failure, ischaemic heart disease and cancer. There was no evidence of benefit in COPD, cognitive impairment or CKD. In all studies, benefits were clinically marginal and none related to morbid events or hospitalisation. Twelve design features were identified as enhancing usability. An evaluation framework comprising 32 items was formulated. Conclusion Evidence of clinical benefit of most available apps is very limited. Design features that enhance usability and maximise efficacy were identified. A provisional 'first-pass' evaluation framework is proposed that can help decide which apps should be endorsed by government agencies following more detailed technical assessments and which could then be recommended with confidence by clinicians to their patients. What is known about the topic? Smartphone health apps have attracted considerable interest from patients and health managers as a means of promoting more effective self-management of chronic diseases, which leads to better health outcomes. However, most commercially available apps have never been evaluated for benefits or harms in clinical trials, and there are currently no agreed quality criteria, standards or regulations to ensure health apps are user-friendly, accurate in content, evidence based or efficacious. What does this paper add? This paper presents a comprehensive review of evidence relating to the efficacy, usability and evaluation of apps for 11 common diseases aimed at assisting patients in self-management. Consistent evidence of benefit was only seen for diabetes apps; there was absent or conflicting evidence of benefit for apps for the remaining 10 diseases. Benefits that were detected were of marginal clinical importance, with no reporting of hard clinical end-points, such as mortality or hospitalisations. Only a minority of studies explicitly reported using behaviour change theories to underpin the app intervention. Many apps lacked design features that the literature identified as enhancing usability and potential to confer benefit. Despite a plethora of published evaluation tools, there is no universal framework that covers all relevant clinical and technical attributes. An inclusive list of evaluation criteria is proposed that may overcome this shortcoming. What are the implications for practitioners? The number of smartphone apps will continue to grow, as will the appetite for patients and clinicians to use them in chronic disease self-management. However, the evidence to date of clinical benefit of most apps already available is very limited. Design features that enhance usability and clinical efficacy need to be considered. In making decisions about which apps should be endorsed by government agencies and recommended with confidence by clinicians to their patients, a comprehensive but workable evaluation framework needs to be used by bodies assuming the roles of setting and applying standards.

Exploring Suicidal Ideation Using an Innovative Mobile App-Strength Within Me: The Usability and Acceptability of Setting up a Trial Involving Mobile Technology and Mental Health Service Users

BACKGROUND

Suicide is a growing global public health problem that has resulted in an increase in the demand for psychological services to address mental health issues. It is expected that 1 in 6 people on a waiting list for mental health services will attempt suicide. Although suicidal ideation has been shown to be linked to a higher risk of death by suicide, not everybody openly discloses their suicidal thoughts or plans to friends and family or seeks professional help before suicide. Therefore, new methods are needed to track suicide risk in real time together with a better understanding of the ways in which people communicate or express their suicidality. Considering the dynamic nature and challenges in understanding suicide ideation and suicide risk, mobile apps could be better suited to prevent suicide as they have the ability to collect real-time data.

OBJECTIVE

This study aims to report the practicalities and acceptability of setting up and trialing digital technologies within an inpatient mental health setting in the United Kingdom and highlight their implications for future studies.

METHODS

Service users were recruited from 6 inpatient wards in the north west of England. Service users who were eligible to participate and provided consent were given an iPhone and Fitbit for 7 days and were asked to interact with a novel phone app, Strength Within Me (SWiM). Interaction with the app involved journaling (recording daily activities, how this made them feel, and rating their mood) and the option to create safety plans for emotions causing difficulties (identifying strategies that helped with these emotions). Participants also had the option to allow the study to access their personal Facebook account to monitor their social media use and activity. In addition, clinical data (ie, assessments conducted by trained researchers targeting suicidality, depression, and sleep) were also collected.

RESULTS

Overall, 43.0% (80/186 response rate) of eligible participants were recruited for the study. Of the total sample, 67 participants engaged in journaling, with the average number of entries per user being 8.2 (SD 8.7). Overall, only 24 participants created safety plans and the most common difficult emotion to be selected was feeling sad (n=21). This study reports on the engagement with the SWiM app, the technical difficulties the research team faced, the importance of building key relationships, and the implications of using Facebook as a source to detect suicidality.

CONCLUSIONS

To develop interventions that can be delivered in a timely manner, prediction of suicidality must be given priority. This paper has raised important issues and highlighted lessons learned from implementing a novel mobile app to detect the risk of suicidality for service users in an inpatient setting.

Assessing Digital Health Implementation for a Pediatric Chronic Pain Intervention: Comparing the RE-AIM and BIT Frameworks Against Real-World Trial Data and Recommendations for Future Studies

Background

Digital health interventions have demonstrated efficacy for several conditions including for pediatric chronic pain. However, the process of making interventions available to end users in an efficient and sustained way is challenging and remains a new area of research. To advance this field, comprehensive frameworks have been created.

Objective

The aim of this study is to compare the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) and Behavior Interventions using Technology (BIT) frameworks with data collected from the web-based management of adolescent pain (WebMAP Mobile; WMM) randomized controlled trial (RCT).

Methods

We conducted a hybrid effectiveness-implementation cluster RCT with a stepped wedge design in which the intervention was sequentially implemented in 8 clinics, following a usual care period. Participants were 143 youths (mean age 14.5 years, SD 1.9; 117/143, 81.8% female) with chronic pain, from which 73 were randomized to receive the active intervention. Implementation outcomes were assessed using the RE-AIM and BIT frameworks.

Results

According to the RE-AIM framework, the WMM showed excellent reach, recruiting a sample 19% larger than the size originally planned and consenting 79.0% (143/181) of eligible referred adolescents. Effectiveness was limited, with only global impression of change showing significantly greater improvements in the treatment group; however, greater treatment engagement was associated with greater reductions in pain and disability. Adoption was excellent (all the invited clinics participated and referred patients). Implementation was acceptable, showing good user engagement and moderate adherence and positive attitudes of providers. Costs were similar to planned, with a 7% increase in funds needed to make the WMM publicly available. Maintenance was evidenced by 56 new patients downloading the app during the maintenance period and by all clinics agreeing to continue making referrals and all, but one, making new referrals. According to the BIT, 82% (60/73) of adolescents considered the treatment acceptable. In terms of adoption, 93% (68/73) downloaded the app, and all of them used it after their first log-in. In terms of appropriateness at the user level, 2 participants were unable to download the app. Perceptions of the appearance, navigation, and theme were positive. Providers perceived the WMM as a good fit for their clinic, beneficial, helpful, and resource efficient. In terms of feasibility, no technical issues were reported. In terms of fidelity, 40% (29/73) completed the treatment. Implementation costs were 7% above the budget. With regard to penetration, 56 new users accessed the app during the maintenance period. In terms of sustainability, 88% (7/8) of clinics continued recommending the WMM after the end of the study.

Conclusions

For the first time, a real-world digital health intervention was used as a proof of concept to test all the domains in the RE-AIM and BIT frameworks, allowing for comparisons.

International Registered Report Identifier (IRRID)

RR2-10.1016/j.cct.2018.10.003

Effectiveness of Mobile App-Assisted Self-Care Interventions for Improving Patient Outcomes in Type 2 Diabetes and/or Hypertension: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Mobile app-assisted self-care interventions are emerging promising tools to support self-care of patients with chronic diseases such as type 2 diabetes and hypertension. The effectiveness of such interventions requires further exploration for more supporting evidence.

Objective

A systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted to examine the effectiveness of mobile app-assisted self-care interventions developed for type 2 diabetes and/or hypertension in improving patient outcomes.

Methods

We followed the Cochrane Collaboration guidelines and searched MEDLINE, Cochrane Library, EMBASE, and CINAHL Plus for relevant studies published between January 2007 and January 2019. Primary outcomes included changes in hemoglobin A_1c (HbA_1c) levels, systolic blood pressure (SBP), and diastolic blood pressure (DBP). Changes in other clinical-, behavioral-, knowledge-, and psychosocial-related outcomes were included as secondary outcomes. Primary outcomes and objective secondary outcomes that were reported in at least two trials were meta-analyzed; otherwise, a narrative synthesis was used for data analysis.

Results

A total of 27 trials were identified and analyzed. For primary outcomes, the use of mobile app-assisted self-care interventions was associated with significant reductions in HbA_1c levels (standardized mean difference [SMD] −0.44, 95% CI −0.59 to −0.29; P<.001), SBP (SMD −0.17, 95% CI −0.31 to −0.03, P=.02), and DBP (SMD −0.17, 95% CI −0.30 to −0.03, P=.02). Subgroup analyses for primary outcomes showed that several intervention features were supportive of self-management, including blood glucose, blood pressure, and medication monitoring, communication with health care providers, automated feedback, personalized goal setting, reminders, education materials, and data visualization. In addition, 8 objective secondary outcomes were meta-analyzed, which showed that the interventions had significant lowering effects on fasting blood glucose levels and waist circumference. A total of 42 secondary outcomes were narratively synthesized, and mixed results were found.

Conclusions

Mobile app-assisted self-care interventions can be effective tools for managing blood glucose and blood pressure, likely because their use facilitates remote management of health issues and data, provision of personalized self-care recommendations, patient–care provider communication, and decision making. More studies are required to further determine which combinations of intervention features are most effective in improving the control of the diseases. Moreover, evidence regarding the effects of these interventions on the behavioral, knowledge, and psychosocial outcomes of patients is still scarce, which warrants further examination.

e-Health Interventions for Community-Dwelling Type 2 Diabetes: A Scoping Review

Background: Because type 2 diabetes mellitus is a critical health problem with increasing incidence, prevalence, and complications worldwide, e-health has been widely utilized for management in type 2 diabetes. Introduction: This scoping review of meta-analyses and systematic reviews on e-health interventions aimed to examine service platforms, program types, outcomes, current status of research activities, research gaps, and the effectiveness of type 2 diabetes self-care management among community-dwelling adults. Materials and Methods: Arksey and O'Malley's method was adopted for this review. The Ovid MEDLINE and Ovid EMBASE databases were searched from inception until April 2018. Two reviewers independently screened, selected, and charted studies using a piloted charting form. Discrepancies were resolved by consensus, and results were collated, summarized, and thematically analyzed. Results: The final studies (N = 81) related to e-health interventions included systematic reviews/meta-analyses on clinical effectiveness (n = 64), usability (n = 14), and behavioral outcomes (n = 47). The commonest e-health intervention subtypes for type 2 diabetes care were patient monitoring (53/163, 32.5%), treatment adherence (50/163, 30.7%), and diabetes-related advice/education (34/163, 20.9%). Mobile devices were most often used to provide e-health services (57/142, 40.1%), followed by the internet (41/142, 28.9%). The e-health strategy that was effective in controlling blood glucose in type 2 diabetes patients was a multimodal intervention comprising treatment advice or education, treatment adherence or reminder methods, and patient monitoring. Treatment adherence or reminder methods and/or patient monitoring showed behavioral effects, but the usability of e-health interventions was controversial. Conclusions: We suggest that e-health intervention should be complex intervention including treatment advice/education, patient monitoring, and treatment adherence or reminder methods.

Effectiveness of Mobile Health Interventions on Diabetes and Obesity Treatment and Management: Systematic Review of Systematic Reviews

BACKGROUND

Diabetes and obesity have become epidemics and costly chronic diseases. The impact of mobile health (mHealth) interventions on diabetes and obesity management is promising; however, studies showed varied results in the efficacy of mHealth interventions.

OBJECTIVE

This review aimed to evaluate the effectiveness of mHealth interventions for diabetes and obesity treatment and management on the basis of evidence reported in reviews and meta-analyses and to provide recommendations for future interventions and research.

METHODS

We systematically searched the PubMed, IEEE Xplore Digital Library, and Cochrane databases for systematic reviews published between January 1, 2005, and October 1, 2019. We analyzed 17 reviews, which assessed 55,604 original intervention studies, that met the inclusion criteria. Of those, 6 reviews were included in our meta-analysis.

RESULTS

The reviews primarily focused on the use of mobile apps and text messaging and the self-monitoring and management function of mHealth programs in patients with diabetes and obesity. All reviews examined changes in biomarkers, and some reviews assessed treatment adherence (n=7) and health behaviors (n=9). Although the effectiveness of mHealth interventions varied widely by study, all reviews concluded that mHealth was a feasible option and had the potential for improving patient health when compared with standard care, especially for glycemic control (-0.3% to -0.5% greater reduction in hemoglobin A1c) and weight reduction (-1.0 kg to -2.4 kg body weight). Overall, the existing 6 meta-analysis studies showed pooled favorable effects of these mHealth interventions (-0.79, 95% CI -1.17 to -0.42; I2=90.5).

CONCLUSIONS

mHealth interventions are promising, but there is limited evidence about their effectiveness in glycemic control and weight reduction. Future research to develop evidence-based mHealth strategies should use valid measures and rigorous study designs. To enhance the effectiveness of mHealth interventions, future studies are warranted for the optimal formats and the frequency of contacting patients, better tailoring of messages, and enhancing usability, which places a greater emphasis on maintaining effectiveness over time.

Video-based smartphone app ('VIDEA bewegt') for physical activity support in German adults: a study protocol for a single-armed observational study

INTRODUCTION

Insufficient physical activity is one of the most important risk factors for non-communicable diseases. Physical activity should therefore be intensively promoted in all age groups. Several trials suggest that it can be effectively increased through smartphone interventions.However, few of the smartphone-interventions available on the market have been scientifically evaluated. Therefore, the described study aims to assess the short-term and long-term effects of the smartphone intervention 'VIDEA bewegt' to increase physical activity. The trial is designed as a single-armed observational trial to assess effects under real-life conditions.

METHODS AND ANALYSIS

The intervention consists of the smartphone-application 'VIDEA bewegt', which is a video-based preventative programme to improve physical activity in everyday life. The application contains several features and components including educational videos, documentation of activity and motivational exercises. A sample size of at least 106 participants is aimed for.The primary objective of this study is to determine the effect of the application on physical activity in German adults. Secondary objectives are to evaluate the self-efficacy, health-related quality of life and usability of 'VIDEA bewegt'.Data collection is based on online questionnaires, as well as system-internal recorded data.Changes of outcomes from baseline to programme completion and follow-up will be calculated.

ETHICS AND DISSEMINATION

The Ethics Committee of the Technical University Dresden approved the study on 25 May 2019 (EK 272062019). All data are processed anonymously and stored on servers only accessible by authorised personnel. The results of the study and the results of the usability test are aimed to be published in a scientific journal.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00017392).

Evaluation of mobile apps for treatment of patients at risk of developing gestational diabetes

This study evaluates mobile apps using a theory-based evaluation framework to discover their applicability for patients at risk of gestational diabetes. This study assessed how well the existing mobile apps on the market meet the information and tracking needs of patients with gestational diabetes and evaluated the feasibility of how to integrate these apps into patient care. A search was conducted in the Apple iTunes and Google Play store for mobile apps that contained keywords related to the following concepts of nutrition: diet, tracking, diabetes, and pregnancy. Evaluation criteria were developed to assess the mobile apps on five dimensions. Overall, the apps scored well on education and information functions and scored poorly on engagement functions. There are few apps that provide comprehensive evidence-based educational content, tracking tools, and integration with electronic health records. This study demonstrates the need to develop apps that have comprehensive content, tracking tools, and ability to bidirectionally share data.

Criteria for assessing the quality of mHealth apps: a systematic review

Objective

Review the existing studies including an assessment tool/method to assess the quality of mHealth apps; extract their criteria; and provide a classification of the collected criteria.

Methods

In accordance with the PRISMA statement, a literature search was conducted in MEDLINE, EMBase, ISI and Scopus for English language citations published from January 1, 2008 to December 22, 2016 for studies including tools or methods for quality assessment of mHealth apps. Two researchers screened the titles and abstracts of all retrieved citations against the inclusion and exclusion criteria. The full text of relevant papers was then individually examined by the same researchers. A senior researcher resolved eventual disagreements and confirmed the relevance of all included papers. The authors, date of publication, subject fields of target mHealth apps, development method, and assessment criteria were extracted from each paper. The extracted assessment criteria were then reviewed, compared, and classified by an expert panel of two medical informatics specialists and two health information management specialists.

Results

Twenty-three papers were included in the review. Thirty-eight main classes of assessment criteria were identified. These were reorganized by expert panel into 7 main classes (Design, Information/Content, Usability, Functionality, Ethical Issues, Security and Privacy, and User-perceived value) with 37 sub-classes of criteria.

Conclusions

There is a wide heterogeneity in assessment criteria for mHealth apps. It is necessary to define the exact meanings and degree of distinctness of each criterion. This will help to improve the existing tools and may lead to achieve a better comprehensive mHealth app assessment tool.

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

BACKGROUND

Mobile health interventions are widely used for self-management of diabetes, which is one of the most burdensome noncommunicable chronic diseases worldwide. However, little is known about the distribution of characteristics and functions of in-store mobile apps for diabetes.

OBJECTIVE

This study aimed to investigate the distribution of characteristics and functions of the in-store mobile apps for self-management of diabetes in the United States and China using a predefined functional taxonomy, which was developed and published in our previous study.

METHODS

We identified apps by searching diabetes in English or Chinese in the Apple iTunes Store and Android Markets (both in the United States and China) and included apps for diabetes self-management. We examined the validity and reliability of the predefined functional taxonomy with 3 dimensions: clinical module, functional module, and potential risk. We then classified all functions in the included apps according to the predefined taxonomy and compared the differences in the features of these apps between the United States and China.

RESULTS

We included 171 mobile diabetes apps, with 133 from the United States and 38 from China. Apps from both countries faced the challenges of evidence-based information, proper risk assessment, and declaration, especially Chinese apps. More Chinese apps provide app-based communication functions (general communication: Chinese vs US apps, 39%, 15/38 vs 18.0%, 24/133; P=.006 and patient-clinician communication: Chinese vs US apps, 68%, 26/38 vs 6.0%, 8/133; P<.001), whereas more US apps provide the decision-making module (Chinese vs US apps, 0%, 0/38 vs 23.3%, 31/133; P=.001), which is a high-risk module. Both complication prevention (Chinese vs US apps, 8%, 3/38 vs 3.8%, 5/133; P=.50) and psychological care (Chinese vs US apps, 0%, 0/38 vs 0.8%, 1/133; P>.99) are neglected by the 2 countries.

CONCLUSIONS

The distribution of characteristics and functions of in-store mobile apps for diabetes self-management in the United States was different from China. The design of in-store diabetes apps needs to be monitored closely.

Mobile application intervention to promote self-management in insulin-requiring type 1 and type 2 diabetes individuals: protocol for a mixed methods study and non-blinded randomized controlled trial

Background: Mobile applications (apps) have proven to be useful in supporting diabetes self-care, but non-consideration of users' needs and non-inclusion of educational features are reasons for low continual use. Well-designed mobile apps that meet the needs of diabetes patients and provide ongoing self-management education and support are required. It was hypothesized that apps designed with such features can improve a range of measures including clinical outcomes, knowledge of diabetes, medication adherence, perceived ability for self-management, and quality-of-life. This may eventually facilitate a more robust and cost-effective approach for improving skills and motivation for the management of diabetes. Methods: This project will be conducted in two phases. It will initially employ a mixed methods study design to investigate the self-management needs and perceptions of diabetes patients on the use of mobile apps to support diabetes self-management. Results of the mixed methods study will inform the content and design of an app which will be employed as an intervention tool in a 12-month parallel randomized controlled trial (RCT). The RCT will compare outcomes in relation to standard-of-care alone with standard-of-care plus a mobile phone diabetes app among 150 insulin-requiring types 1 and 2 diabetes patients. The primary outcome measures are clinical parameters such as hemoglobin A1c (HbA1c), lipids, urine albumin-to-creatinine ratio, blood pressure, frequency in events of emergency hyperglycemia and hypoglycemia. Secondary outcomes include knowledge of diabetes, medication intake and adherence, perception of self-care, and quality-of-life. Discussion: Results from this study will provide empirical evidence on the usefulness of a mobile app developed based on self-management needs analysis of diabetic patients. The long-term goal is to harness knowledge gained from this study to provide evidenced-based data, which promote the scale-up or adoption of mobile applications that provide regular, ongoing education and self-management support to people living with diabetes. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12618000065291, Registered on 17 January, 2018 (prospectively registered).

A validation study of questionnaire towards mobile based health applications in uncontrolled diabetic population of India (South)

BACKGROUND

Mobile applications have the potential to provide needed support for older adults with diabetes. The field of medical application is currently one of the most dynamic in application development and medicine.

OBJECTIVE

This study was designed to develop and validate a questionnaire to assess knowledge, attitude and practice of uncontrolled diabetic patients towards mobile based health applications.

METHODS

A Cross Sectional study was designed and enrolled 78 adult uncontrolled diabetic (≥18 years old DM type 2)patients and clinically validated questionnaire was examined for internal consistency, reproducibility, convergent and discriminant validity using Cronbach's alpha, intra class correlation and CITC scores respectively.

RESULTS

Cronbach's alpha coefficient was 0.97 for Assessment of Knowledge, 0.93 for Assessment of Attitude, and 0.90 for Assessment of Practice in uncontrolled diabetic population.

CONCLUSION

The final version of questionnaire was found to be statistically internally consistent, reproducible and reliable and could be used to assess the awareness and attitude of patients towards self-management of diabetes mellitus.

IDF Europe's position on mobile applications in diabetes

Over the last decade, advances in technology and connectivity have led to the boom of Internet-based and mobile applications (Apps) which have rendered access to information easier and faster and have changed our daily lives. With 60 million people living with diabetes (PWD) in Europe and 32 million more at risk, diabetes has been a major target for software companies, with the aim to help people manage their chronic condition, and to prevent diabetes in people at risk. IDF Europe is the voice of 70 national associations, representing PWD and health professionals in 47 European countries, and a strong supporter of innovation in healthcare. Witnessing the emergence of Apps in the field of diabetes, given the general uptake of a connected lifestyle, and recognising the potential in the ability of these Apps to make an impact on the lives of PWD, IDF Europe reflected on Mobile Applications in Diabetes, examining Diabetes and new technology through psychology, motivation and behavioral change in diabetes management; the healthcare professional perspective; potential roles of diabetes-related Apps, pointing to existing evidence and important ethical issues; and finally offering recommendations on four levels: individual, healthcare professional, political and App developers.

Requirements of an Application to Monitor Diet, Physical Activity and Glucose Values in Patients with Type 2 Diabetes: The Diameter

Adherence to a healthy diet and regular physical activity are two important factors in sufficient type 2 diabetes mellitus management. It is recognized that the traditional treatment of outpatients does not meet the requirements for sufficient lifestyle management. It is hypothesised that a personalized diabetes management mHealth application can help. Such an application ideally measures food intake, physical activity, glucose values, and medication use, and then integrates this to provide patients and healthcare professionals insight in these factors, as well as the effect of lifestyle on glucose values in daily life. The lifestyle data can be used to give tailored coaching to improve adherence to lifestyle recommendations and medication use. This study describes the requirements for such an application: the Diameter. An iterative mixed method design approach is used that consists of a cohort study, pilot studies, literature search, and expert meetings. The requirements are defined according to the Function and events, Interactions and usability, Content and structure and Style and aesthetics (FICS) framework. This resulted in 81 requirements for the dietary (n = 37), activity and sedentary (n = 15), glycaemic (n = 12), and general (n = 17) parts. Although many applications are currently available, many of these requirements are not implemented. This stresses the need for the Diameter as a new personalized diabetes application.

Mobile health in the management of type 1 diabetes: a systematic review and meta-analysis

BACKGROUND

As an insulin-dependent disease, type 1 diabetes requires paying close attention to the glycemic control. Studies have shown that mobile health (mHealth) can improve the management of chronic diseases. However, the effectiveness of mHealth in controlling the glycemic control remains uncertain. The objective of this study was to carry out a systematic review and meta-analysis using the available literature reporting findings on mHealth interventions, which may improve the management of type 1 diabetes.

METHODS

We performed a systematic literature review of all studies in the PubMed, Web of Science, and EMbase databases that used mHealth (including mobile phones) in diabetes care and reported glycated hemoglobin (HbA1c) values as a measure of glycemic control. The fixed effects model was used for this meta-analysis.

RESULTS

This study analyzed eight studies, which involved a total of 602 participants. In the meta-analysis, the fixed effects model showed a statistically significant decrease in the mean of HbA1c in the intervention group: - 0.25 (95% confidence interval: - 0.41, - 0.09; P = 0.003, I² = 12%). Subgroup analyses indicated that the patient's age, the type of intervention, and the duration of the intervention influenced blood glucose control. Funnel plots showed no publication bias.

CONCLUSIONS

Mobile health interventions may be effective among patients with type 1 diabetes. A significant reduction in HbA1c levels was associated with adult age, the use of a mobile application, and the long-term duration of the intervention.

Development of the mHealth App Trustworthiness checklist

BACKGROUND

Mobile health applications (mHealth apps) currently lack a consensus on substantial quality and safety standards. As such, the number of individuals engaging with untrustworthy mHealth apps continues to grow at a steady pace.

OBJECTIVE

The purpose of this study was to investigate end-users' opinions on the features or actions necessary for trustworthy mHealth apps; and to convey this information to app developers via a succinct but informative checklist: the mHealth app trustworthiness checklist.

METHODS

The checklist was formulated in three stages: (a) a literature review of studies identified the desirable features of the most prolific mHealth apps (health and fitness apps); (b) four focus group sessions with past or current users of these apps (n = 20); and (c) expert feedback on whether the checklist items are conceivable in a real-life setting (n = 6).

RESULTS

Five major themes emerged from the focus group discussions: informational content, organizational attributes, societal influence, technology-related features, and user control factors. The mHealth app trustworthiness checklist was developed to incorporate these five themes and subsequently modified following expert consultation. In addition to the trustworthiness themes, we identified features that lie between trust and mistrust (limited digital literacy and indifference) as well as 10 features and actions that cause end-users to mistrust mHealth apps.

CONCLUSION

This study contributes to the evidence base on the attributes of trustworthy mHealth apps. The mHealth app trustworthiness checklist is a useful tool in advancing continued efforts to ensure that health technologies are trustworthy.

Use of apps for physical activity in type 1 diabetes: current status and requirements for future development

Smartphone technologies, and the applications (apps) that they host, are developing rapidly mainly with regard to communication, information processing, design, features and connectivity with other devices. Technologies used in modern treatment modalities and monitoring of type 1 diabetes are also rapidly evolving and can communicate with smartphones and apps. Therefore, numerous web-based and smartphone apps aim to provide information and various patient data metrics (e.g. caloric intake, activity levels, glucose monitoring) that can be accessed and processed for decision support by smartphone apps. In this narrative review, we highlight current information about the effectiveness of interventions through smartphone apps with a focus on apps designed to give guidance to patients with type 1 diabetes on physical activity monitoring and glucose control during and after structured exercise sessions, as these patients are experiencing huge therapeutic challenges during exercise. Furthermore, we propose a number of critical elements for future apps designed for people with type 1 diabetes.

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

Background

Mobile phone applications (apps) offer motivation and support for self-management of diabetes mellitus (DM), but their use is limited by high attrition due to insufficient consideration of end-users perspectives and usability requirements. This study aimed to examine app usage and feature preferences among people with DM, and explore their recommendations for future inclusions to foster engagement with diabetes apps.

Methods

The study was conducted internationally on adults with type 1 or type 2 DM using online questionnaire (quantitative) to investigate usage and preferences for app features that support diabetes self-management and semi structured telephone interview (qualitative) to explore suggestions on fostering engagement and specific educational information for inclusion into diabetes apps. Survey and interview data were analysed using descriptive/ inferential statistics and inductive thematic analysis respectively.

Results

A total of 217 respondents with type 1 DM (38.25%) or type 2 DM (61.8%), from 4 continents (Australia, Europe, Asia and America) participated in the survey. About half of the respondents (48%) use apps, mainly with features for tracking blood glucose (56.6%), blood pressure (51.9%) and food calories (48.1%). Preferred features in future apps include nutrient values of foods (56.7%), blood glucose (54.8%), physical exercise tracker (47%), health data analytics (42.9%) and education on diabetes self-management (40.6%). Irrespective of the type of DM, participants proposed future apps that are user friendly, support healthy eating, provide actionable reminders and consolidate data across peripheral health devices. Participants with type 1 DM recommended customised features with news update on developments in the field of diabetes. Nominated specific educational topics included tips on problem solving, use of insulin pump therapy, signs of diabetes complication and transitioning from paediatric into adult care.

Conclusions

The study has highlighted patients’ perspectives on essential components for inclusion in diabetes apps to promote engagement and foster better health outcomes.

Use of a Mobile App to Facilitate Blood Glucose Monitoring in Adolescents With Type 1 Diabetes: Single-Subject Nonrandomized Clinical Trial

Background

Cloud-based glucose monitoring programs allow users with diabetes to wirelessly synchronize their glucometers to their mobile phones. They also provide visualization and remote access of their data through its mobile app. There have been very few studies evaluating their effectiveness in managing diabetes among adolescents with type 1 diabetes (T1D).

Objective

The purpose of this study was to assess the feasibility of using a mobile app to improve daily average blood glucose (BG) levels and increase BG monitoring frequency.

Methods

We used an ABA single-subject prospective study design. We recruited five participants aged 13 to 17 years with uncontrolled T1D, glycated hemoglobin A1c 9.0%-10.7%, self-monitoring behavior of ≤5 checks/day, and on multiple daily insulin injections. The study consisted of 4-week intervals of three phases: (1) phase A: usual glucose monitoring log (fax); (2) phase B: mobile app; and (3) phase A': second phase A. A certified diabetes educator and endocrinologist reviewed logs and provided recommendations weekly. Data were analyzed using a quasi-Poisson model to adjust for overdispersion among individual participants, and a generalized estimating equation model for overall intervention effect in aggregate.

Results

For mean daily BG (mg/dL) levels, participant 1 had decreased values on the mobile app (298 to 281, P=.03) and maintained in phase A'. Participant 4 had an increase in mean daily BG in phase A' (175 to 185, P=.01), whereas participant 5 had a decrease in mean daily BG in phase A' (314 to 211, P=.04). For daily monitoring (checks/day), participant 3 increased in phase B (4.6 to 8.3, P=.01) and maintained in phase A'. Participant 5 also had increased daily monitoring at each phase (2.1 to 2.4, P=.01; 2.4 to 3.4, P=.02). For the five participants combined, the overall mean BG and BG checks per day in phase A were mean 254.8 (SD 99.2) and mean 3.6 (SD 2.0), respectively, mean 223.1 (SD 95.7) and mean 4.5 (SD 3.0) in phase B, and mean 197.5 (SD 81.3) and mean 3.7 (SD 2.1) in phase A'. Compared to phase A, mean glucose levels declined during phase B and remained lower during phase A' (P=.002). There was no overall change in BG checks by phase (P=.25). However, mean BG levels negatively correlated with daily BG checks (r=–.47, P<.001). Although all participants had positive opinions about the app, its utilization was highly variable.

Conclusions

We demonstrated modest feasibility of adolescents with uncontrolled T1D utilizing a glucose monitoring mobile app. Further study is needed to better determine its effects on BG level and monitoring frequency. Psychosocial factors and motivational barriers likely influence adoption and continuous use of technology for diabetes management.

Development and Evaluation of a Mobile Personalized Blood Glucose Prediction System for Patients With Gestational Diabetes Mellitus

BACKGROUND

Personalized blood glucose (BG) prediction for diabetes patients is an important goal that is pursued by many researchers worldwide. Despite many proposals, only a few projects are dedicated to the development of complete recommender system infrastructures that incorporate BG prediction algorithms for diabetes patients. The development and implementation of such a system aided by mobile technology is of particular interest to patients with gestational diabetes mellitus (GDM), especially considering the significant importance of quickly achieving adequate BG control for these patients in a short period (ie, during pregnancy) and a typically higher acceptance rate for mobile health (mHealth) solutions for short- to midterm usage.

OBJECTIVE

This study was conducted with the objective of developing infrastructure comprising data processing algorithms, BG prediction models, and an appropriate mobile app for patients' electronic record management to guide BG prediction-based personalized recommendations for patients with GDM.

METHODS

A mobile app for electronic diary management was developed along with data exchange and continuous BG signal processing software. Both components were coupled to obtain the necessary data for use in the personalized BG prediction system. Necessary data on meals, BG measurements, and other events were collected via the implemented mobile app and continuous glucose monitoring (CGM) system processing software. These data were used to tune and evaluate the BG prediction model, which included an algorithm for dynamic coefficients tuning. In the clinical study, 62 participants (GDM: n=49; control: n=13) took part in a 1-week monitoring trial during which they used the mobile app to track their meals and self-measurements of BG and CGM system for continuous BG monitoring. The data on 909 food intakes and corresponding postprandial BG curves as well as the set of patients' characteristics (eg, glycated hemoglobin, body mass index [BMI], age, and lifestyle parameters) were selected as inputs for the BG prediction models.

RESULTS

The prediction results by the models for BG levels 1 hour after food intake were root mean square error=0.87 mmol/L, mean absolute error=0.69 mmol/L, and mean absolute percentage error=12.8%, which correspond to an adequate prediction accuracy for BG control decisions.

CONCLUSIONS

The mobile app for the collection and processing of relevant data, appropriate software for CGM system signals processing, and BG prediction models were developed for a recommender system. The developed system may help improve BG control in patients with GDM; this will be the subject of evaluation in a subsequent study.

A Smartphone Application to Reduce Time-to-Notification of Sexually Transmitted Infections

OBJECTIVES

To measure whether the implementation of Healthvana-an online patient engagement platform and smartphone application-reduced the number of days between sexually transmitted infection (STI) testing, notification, and treatment at AIDS Healthcare Foundation (AHF) Wellness Centers.

METHODS

We analyzed the retrospective data for 917 male clients who tested positive and received treatment for chlamydia, gonorrhea, or syphilis between January 1, 2014, and December 31, 2015. We included 8 AHF Wellness Centers from California and Florida in the study. We used regression models to evaluate the relationship between Healthvana implementation (pre-Healthvana vs post-Healthvana) and the number of days between the STI test, notification, and treatment.

RESULTS

Following Healthvana implementation at the AHF Wellness Centers, the mean number of days decreased between the STI test and notification, from 8 to 6 days. The mean number of days between the overall STI test and treatment decreased from 12 to 10 days. Regression models found the reduction in the number of days from STI test to notification to be statistically significant.

CONCLUSIONS

Smartphone applications like Healthvana are promising technologies to ensure clients are successfully and immediately notified of their STI test results.

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

BACKGROUND

The prevalence of diabetes is increasing and with the requirements for self-management and risk of late complications, it remains a challenge for the individual and society. Patients can benefit from support from health care personnel in their self-management, and the traditional communication between patients and health care personnel is changing. Smartphones and apps offer a unique platform for communication, but apps with integrated health care personnel communication based on patient data are yet to be investigated to provide evidence of possible effects.

OBJECTIVE

Our goal was to systematically review studies that aimed to evaluate integrated communication within mobile apps for tailored feedback between patients with diabetes and health care personnel in terms of (1) study characteristics, (2) functions, (3) study outcomes, (4) effects, and (5) methodological quality.

METHODS

A systematic literature search was conducted following our International Prospective Register of Systematic Reviews (PROSPERO) protocol, searching for apps with integrated communication for persons with diabetes tested in a controlled trial in the period 2008 to 2016. We searched the databases PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central, Excerpta Medica database (EMBASE), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. The search was closed in September 2016. Reference lists of primary articles and review papers were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and we applied the Cochrane risk of bias tool to assess methodological quality.

RESULTS

We identified 2822 citations and after duplicate removal, we assessed 1128 citations. A total of 6 papers were included in this systematic review, reporting on data from 431 persons participating in small trials of short duration. The integrated communication features were mostly individualized as written non-real-time feedback. The number of functions varied from 2 to 9, and blood glucose tracking was the most common. HbA_1c was the most common primary outcome, but the remaining reported outcomes were not standardized and comparable. Because of both the heterogeneity of the included trials and the poor methodological quality of the studies, a meta-analysis was not possible. A statistically significant improvement in the primary measure of outcome was found in 3 of the 6 included studies, of which 2 were HbA_1c and 1 was mean daytime ambulatory blood pressure. Participants in the included trials reported positive usability or feasibility postintervention in 5 out of 6 trials. The overall methodological quality of the trials was, however, scored as an uncertain risk of bias.

CONCLUSIONS

This systematic review highlights the need for more trials of higher methodological quality. Few studies offer an integrated function for communication and feedback from health care personnel, and the research field represents an area of heterogeneity with few studies of highly rigorous methodological quality. This, in combination with a low number of participants and a short follow-up, is making it difficult to provide reliable evidence of effects for stakeholders.

Assessing the Medication Adherence App Marketplace From the Health Professional and Consumer Vantage Points

Background

Nonadherence produces considerable health consequences and economic burden to patients and payers. One approach to improve medication nonadherence that has gained interest in recent years is the use of smartphone adherence apps. The development of smartphone adherence apps has increased rapidly since 2012; however, literature evaluating the clinical app and effectiveness of smartphone adherence apps to improve medication adherence is generally lacking.

Objective

The aims of this study were to (1) provide an updated evaluation and comparison of medication adherence apps in the marketplace by assessing the features, functionality, and health literacy (HL) of the highest-ranking adherence apps and (2) indirectly measure the validity of our rating methodology by determining the relationship between our app evaluations and Web-based consumer ratings.

Methods

Two independent reviewers assessed the features and functionality using a 4-domain rating tool of all adherence apps identified based on developer claims. The same reviewers downloaded and tested the 100 highest-ranking apps including an additional domain for assessment of HL. Pearson product correlations were estimated between the consumer ratings and our domain and total scores.

Results

A total of 824 adherence apps were identified; of these, 645 unique apps were evaluated after applying exclusion criteria. The median initial score based on descriptions was 14 (max of 68; range 0-60). As a result, 100 of the highest-scoring unique apps underwent user testing. The median overall user-tested score was 31.5 (max of 73; range 0-60). The majority of the user tested the adherence apps that underwent user testing reported a consumer rating score in their respective online marketplace. The mean consumer rating was 3.93 (SD 0.84). The total user-tested score was positively correlated with consumer ratings (r=.1969, P=.04).

Conclusions

More adherence apps are available in the Web-based marketplace, and the quality of these apps varies considerably. Consumer ratings are positively but weakly correlated with user-testing scores suggesting that our rating tool has some validity but that consumers and clinicians may assess adherence app quality differently.

Effectiveness of mHealth interventions for patients with diabetes: An overview of systematic reviews

Background

Diabetes is a common chronic disease that places an unprecedented strain on health care systems worldwide. Mobile health technologies such as smartphones, mobile applications, and wearable devices, known as mHealth, offer significant and innovative opportunities for improving patient to provider communication and self-management of diabetes.

Objective

The purpose of this overview is to critically appraise and consolidate evidence from multiple systematic reviews on the effectiveness of mHealth interventions for patients with diabetes to inform policy makers, practitioners, and researchers.

Methods

A comprehensive search on multiple databases was performed to identify relevant systematic reviews published between January 1996 and December 2015. Two authors independently selected reviews, extracted data, and assessed the methodological quality of included reviews using AMSTAR.

Results

Fifteen systematic reviews published between 2008 and 2014 were eligible for inclusion. The quality of the reviews varied considerably and most of them had important methodological limitations. Focusing on systematic reviews that offered the most direct evidence, this overview demonstrates that on average, mHealth interventions improve glycemic control (HbA1c) compared to standard care or other non-mHealth approaches by as much as 0.8% for patients with type 2 diabetes and 0.3% for patients with type 1 diabetes, at least in the short-term (≤12 months). However, limitations in the overall quality of evidence suggest that further research will likely have an important impact in these estimates of effect.

Conclusions

Findings are consistent with clinically relevant improvements, particularly with respect to patients with type 2 diabetes. Similar to home telemonitoring, mHealth interventions represent a promising approach for self-management of diabetes.

Content Analysis of Mobile Health Applications on Diabetes Mellitus

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

If you build it, they will come: unintended future uses of organised health data collections

BACKGROUND

Health research increasingly relies on organized collections of health data and biological samples. There are many types of sample and data collections that are used for health research, though these are collected for many purposes, not all of which are health-related. These collections exist under different jurisdictional and regulatory arrangements and include: 1) Population biobanks, cohort studies, and genome databases 2) Clinical and public health data 3) Direct-to-consumer genetic testing 4) Social media 5) Fitness trackers, health apps, and biometric data sensors Ethical, legal, and social challenges of such collections are well recognized, but there has been limited attention to the broader societal implications of the existence of these collections.

DISCUSSION

Although health research conducted using these collections is broadly recognized as beneficent, secondary uses of these data and samples may be controversial. We examine both documented and hypothetical scenarios of secondary uses of health data and samples. In particular, we focus on the use of health data for purposes of: Forensic investigations Civil lawsuits Identification of victims of mass casualty events Denial of entry for border security and immigration Making health resource rationing decisions Facilitating human rights abuses in autocratic regimes

CONCLUSIONS

Current safeguards relating to the use of health data and samples include research ethics oversight and privacy laws. These safeguards have a strong focus on informed consent and anonymization, which are aimed at the protection of the individual research subject. They are not intended to address broader societal implications of health data and sample collections. As such, existing arrangements are insufficient to protect against subversion of health databases for non-sanctioned secondary uses, or to provide guidance for reasonable but controversial secondary uses. We are concerned that existing debate in the scholarly literature and beyond has not sufficiently recognized the secondary data uses we outline in this paper. Our main purpose, therefore, is to raise awareness of the potential for unforeseen and unintended consequences, in particular negative consequences, of the increased availability and development of health data collections for research, by providing a comprehensive review of documented and hypothetical non-health research uses of such data.

Mobile Applications for Control and Self Management of Diabetes: A Systematic Review

Mobile applications (apps) can be very useful software on smartphones for all aspects of people's lives. Chronic diseases, such as diabetes, can be made manageable with the support of mobile apps. Applications on smartphones can also help people with diabetes to control their fitness and health. A systematic review of free apps in the English language for smartphones in three of the most popular mobile app stores: Google Play (Android), App Store (iOS) and Windows Phone Store, was performed from November to December 2015. The review of freely available mobile apps for self-management of diabetes was conducted based on the criteria for promoting diabetes self-management as defined by Goyal and Cafazzo (monitoring blood glucose level and medication, nutrition, physical exercise and body weight). The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) was followed. Three independent experts in the field of healthcare-related mobile apps were included in the assessment for eligibility and testing phase. We tested and evaluated 65 apps (21 from Google Play Store, 31 from App Store and 13 from Windows Phone Store). Fifty-six of these apps did not meet even minimal requirements or did not work properly. While a wide selection of mobile applications is available for self-management of diabetes, current results show that there are only nine (5 from Google Play Store, 3 from App Store and 1 from Windows Phone Store) out of 65 reviewed mobile apps that can be versatile and useful for successful self-management of diabetes based on selection criteria. The levels of inclusion of features based on selection criteria in selected mobile apps can be very different. The results of the study can be used as a basis to prvide app developers with certain recommendations. There is a need for mobile apps for self-management of diabetes with more features in order to increase the number of long-term users and thus influence better self-management of the disease.

Fibroline: A mobile app for improving the quality of life of young people with fibromyalgia

Fibroline is a mobile application with a self-administered cognitive behavioral treatment for young people with fibromyalgia or chronic widespread pain, designed to reduce pain and other common negative symptoms and improve quality of life. Our aims are to report on the usability and feasibility protocols used to assess the app. Two usability cycles were implemented. A group of patients followed the cognitive behavioral treatment intervention to test its feasibility. Qualitative data were collected and content analyses were conducted. The results demonstrated that the app is error-free, easy to use, liked by the users, and acceptable.

Conceptualizing type 2 diabetes and its management

Type 2 diabetes is growing worldwide due to population growth, increased rates of obesity, unhealthy diet, and physical inactivity. Risk assessment methods can effectively evaluate the risk of diabetes, and a healthy lifestyle can significantly reduce risk or prevent complications of type 2 diabetes. However, risk assessment alone has not significantly improved poor adherence to recommended medical interventions and lifestyle changes. This paper focuses on the challenge of nonadherence and posits that improving adherence requires tailoring interventions that explicitly consider the social determinants of health.

Mobile Phone Apps for Inflammatory Bowel Disease Self-Management: A Systematic Assessment of Content and Tools

Background

The rising incidence of inflammatory bowel disease (IBD) over the past decade has resulted in increased health care utilization and longer IBD outpatient waiting lists. Self-management is recognized as an important aspect of chronic disease management but its application to IBD has been limited. The age of IBD onset in a majority of patients is in their 20s to 30s. Mobile phone apps are a technology familiar to young adults and represent an opportunity to explore self-management as a new model of health care delivery for IBD.

Objective

The aim of this study was to explore the content and tools of existing IBD apps to identify functionalities that may facilitate patient self-management.

Methods

We systematically assessed apps targeted at IBD patients via searches of Google (Android devices) and Apple (iOS devices) app stores with pre-defined inclusion and exclusion criteria. Apps were assessed for specific functionalities; presence of professional medical involvement; consistency with international IBD guidelines based on “complete,” “partial,” or “absent” coverage of consensus statements derived from the European Crohn’s and Colitis Organisation, American College of Gastroenterology, and the Gastroenterology Society of Australia; comprehensiveness of data that could be entered; and average pricing.

Results

Of the 238 apps screened, 26 apps were assessed, including 10 available on Android platforms, 8 on iOS platforms, and 8 on both. Over half (14/26, 54%) of the apps had diary functionalities; over a third (10/26, 39%) provided health information about IBD. None of the apps offered decision support to facilitate the self-initiation of medical therapy. Five of 26 (19%) had professional medical involvement in their design. Apps demonstrated “complete” coverage of only 38% of the international consensus statements explored. The average price of the apps was AUD$1.37.

Conclusions

Apps may provide a useful adjunct to the management of IBD patients. However, a majority of current apps suffer from a lack of professional medical involvement and limited coverage of international consensus guidelines. Future studies and app design for IBD should include professional medical involvement, evidence-based guidelines, and functionalities with decision support that are specifically tailored to patient self-management.

Role of Emerging Insulin Technologies in the Initiation and Intensification of Insulin Therapy for Diabetes in Primary Care

In Brief This article explores some of the reasons for the delay in insulin initiation in primary care and evaluates new approaches to insulin therapy that may address these barriers and, therefore, improve insulin use by primary care providers.

A Digital Ecosystem of Diabetes Data and Technology: Services, Systems, and Tools Enabled by Wearables, Sensors, and Apps

The management of type 1 diabetes (T1D) ideally involves regimented measurement of various health signals; constant interpretation of diverse kinds of data; and consistent cohesion between patients, caregivers, and health care professionals (HCPs). In the context of myriad factors that influence blood glucose dynamics for each individual patient (eg, medication, activity, diet, stress, sleep quality, hormones, environment), such coordination of self-management and clinical care is a great challenge, amplified by the routine unavailability of many types of data thought to be useful in diabetes decision-making. While much remains to be understood about the physiology of diabetes and blood glucose dynamics at the level of the individual, recent and emerging medical and consumer technologies are helping the diabetes community to take great strides toward truly personalized, real-time, data-driven management of this chronic disease. This review describes "connected" technologies--such as smartphone apps, and wearable devices and sensors--which comprise part of a new digital ecosystem of data-driven tools that can link patients and their care teams for precision management of diabetes. These connected technologies are rich sources of physiologic, behavioral, and contextual data that can be integrated and analyzed in "the cloud" for research into personal models of glycemic dynamics, and employed in a multitude of applications for mobile health (mHealth) and telemedicine in diabetes care.

The Use of an Adapted Health IT Usability Evaluation Model (Health-ITUEM) for Evaluating Consumer Reported Ratings of Diabetes mHealth Applications: Implications for Diabetes Care and Management

Background:

The aim of this paper is to present a usability analysis of the consumer ratings of key diabetes mHealth applications using an adapted Health IT Usability Evaluation Model (Health-ITUEM).

Methods:

A qualitative content analysis method was used to analyze publicly available consumer reported data posted on the Android Market and Google Play for four leading diabetes mHealth applications. Health-ITUEM concepts including information needs, flexibility/customizability, learnability, performance speed, and competency guided the categorization and analysis of the data. Health impact was an additional category that was included in the study. A total of 405 consumers’ ratings collected from January 9, 2014 to February 17, 2014 were included in the study.

Results:

Overall, the consumers’ ratings of the leading diabetes mHealth applications for both usability and health impacts were positive. The performance speed of the mHealth application and the information needs of the consumers were the primary usability factors impacting the use of the diabetes mHealth applications. There was also evidence on the positive health impacts of such applications.

Conclusions:

Consumers are more likely to use diabetes related mHealth applications that perform well and meet their information needs. Furthermore, there is preliminary evidence that diabetes mHealth applications can have positive impact on the health of patients.

Data-Driven Personalized Feedback to Patients with Type 1 Diabetes: A Randomized Trial

BACKGROUND

A mobile phone-based application can be useful for patients with type 1 diabetes in managing their disease. This results in large datasets accumulated on the patient's devices, which can be used for individualized feedback. The effect of such feedback is investigated in this article.

MATERIALS AND METHODS

We developed an application that included a data-driven feedback module known as Diastat for patients on self-measured blood glucose regimens. Using a stepped-wedge design, both groups initially received an application without Diastat. Group 1 activated Diastat after 4 weeks, whereas Group 2 activated Diastat 12 weeks after startup (T1). End points were glycated hemoglobin (HbA1c) level and number of out-of-range (OOR) measurements (i.e., outside the range 72-270 mg/dL).

RESULTS

Thirty patients were recruited to the study, and 15 were assigned to each group after the initial meeting. There were no significant differences between groups at T1 in HbA1c or OOR events. Overall, all patients had a decrease of 0.6 percentage points in mean HbA1c (P < 0.001) and 14.5 in median OOR events over 2 weeks (P < 0.001).

CONCLUSIONS

The study does not provide evidence that data-driven feedback improves glycemic control. The decrease in HbA1c was sizeable and significant, even though the study was not powered to detect this. The overall improvement in glycemic control suggests that, in general, mobile phone-based interventions can be useful in diabetes self-management.

Linking community resources in diabetes care: a role for technology?

Designing and implementing effective lifestyle modification strategies remains one of the great challenges in diabetes care. Historically, programs have focused on individual behavior change with little or no attempt to integrate change within the broader social framework or community context. However, these contextual factors have been shown to be associated with poor diabetes outcomes, particularly in low-income minority populations. Recent evidence suggests that one way to address these disparities is to match patient needs to existing community resources. Not only does this position patients to more quickly adapt behavior in a practical way, but this also refers patients back to their local communities where a support mechanism is in place to sustain healthy behavior. Technology offers a new and promising platform for connecting patients to meaningful resources (also referred to as "assets"). This paper summarizes several noteworthy innovations that use technology as a practical bridge between healthcare and community-based resources that promote diabetes self-care.

Ethical issues when using social media for health outside professional relationships

Social media have the potential to revolutionize health and healthcare, but fulfilling this potential requires attention to the ethical issues social media may raise. This article reviews the major ethical issues arising when social media are used for research, public health, mobile health applications, and global health. It focuses on social media use outside fiduciary relationships between healthcare professionals and patients. Emphasis is given to the potential of social media in these contexts, the ethical issues relatively unique to each, and where possible how existing ethical principles and frameworks could help navigate these issues. In some cases social media create the circumstance for particular ethical issues but also facilitate managing them, such as in informed consent for research. In other cases, disagreement exists about whether social media - despite their potential - should be used for certain purposes, such as in public health surveillance (where confidentiality represents a significant ethical concern). In still others, ethical uncertainty exists about how social media will affect ethical issues, such as inequality in global health. As social media technologies continue to develop, identifying and managing the ethical issues they raise will be critical to their success in improving health while preserving fundamental ethical values.