Impact and efficacy of mobile health intervention in the management of diabetes and hypertension: a systematic review and meta-analysis

Effects of group communication norms on daily steps in a team-based financial incentive mobile phone intervention in Shanghai, China

BACKGROUND

Mobile technology offers great potential for physical activity promotion, especially by facilitating online communication, however, the impact of group communication norms on intervention effectiveness remains unclear. This study aimed to evaluate the effect on daily steps of a team-based social norms-related intervention using a mobile application.

METHODS

The 13-week quasi-experimental study was conducted in Shanghai, China, from September to November 2019, involving 2,985 employees from 32 worksites. For the intervention group (n = 2,049), participants set a goal of 10,000 steps per day. The teams and individual members would receive points for meeting the daily goal, contributing to team-based rankings and financial rewards for the teams and their members. In addition, the intervention teams created dedicated WeChat groups to facilitate communication, which were also used to collect group chat messages. The communication type in these groups was classified into four types: (1) nudging - encouraging team members to be more active, (2) sharing - exchanging the completion of daily step goals, (3) feedback - providing responses or suggestions to team members, and (4) other -diverse topics that could not be classified otherwise. The control group only tracked their steps online.

RESULTS

The weekly average steps of the intervention group increased by 2,523 steps, while the control group increased by 470 steps. In the first 3 weeks of follow-up, the frequency of nudging of 7-18 times/week had a positive cumulative effect on the step counts. Sharing more than 3 times/week had a positive cumulative effect. Over 6 and 13 weeks of follow-up, nudging 19 times/week or more had a positive cumulative effect while sharing and feedback at any frequency negatively affected average weekly steps.

CONCLUSIONS

Communication types within a team affected team-based step counts in a financial incentive intervention. The team-level social norms related to communications might have different cumulative effects on team-level physical activity. 'nudging' messages had a significant association with the change in individual-level step counts in the medium or long term.

TRIAL REGISTRATION

Pilot Project of the application of walking incentive technology in occupational groups, 2019, ChiCTR1900023813. Registered 13 June 2019,  https://www.chictr.org.cn/showproj.html?proj=39858 .

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Pathways to usage intention of mobile health apps among hypertensive patients: A fuzzy-set qualitative comparative analysis

Background: The efficacy of mHealth apps in managing hypertension has been proven; however, low usage intention remains a significant challenge, warranting an in-depth exploration of the influencing factors. Objectives: This study aimed to examine the factors influencing hypertensive new users' intention to use mobile health applications through a cross-sectional survey. Methods: Fuzzy-set qualitative comparative analysis (fsQCA) was employed to investigate the combinations of various determinants, including technology acceptance, adoption factors, compliance behavior initiation factors, and time motivation factors for decision making. Results: A total of 100 middle-aged and elderly hypertensive individuals participated in the survey, with 98 responses included in the final statistical analysis. The analysis identified four distinct configurations that contribute to high usage intentions, with solution consistency and coverage values of 0.93 and 0.36, respectively. Conclusion: The findings suggest that intervention strategies should account for the various pathways leading to usage intentions.

Methodological Challenges in Randomized Controlled Trials of mHealth Interventions: Cross-Sectional Survey Study and Consensus-Based Recommendations

BACKGROUND

Mobile health (mHealth) refers to using mobile communication devices such as smartphones to support health, health care, and public health. mHealth interventions have their own nature and characteristics that distinguish them from traditional health care interventions, including drug interventions. Thus, randomized controlled trials (RCTs) of mHealth interventions present specific methodological challenges. Identifying and overcoming those challenges is essential to determine whether mHealth interventions improve health outcomes.

OBJECTIVE

We aimed to identify specific methodological challenges in RCTs testing mHealth interventions' effects and develop consensus-based recommendations to address selected challenges.

METHODS

A 2-phase participatory research project was conducted. First, we sent a web-based survey to authors of mHealth RCTs. Survey respondents rated on a 5-point scale how challenging they found 21 methodological aspects in mHealth RCTs compared to non-mHealth RCTs. Nonsystematic searches until June 2022 informed the selection of the methodological challenges listed in the survey. Second, a subset of survey respondents participated in an online workshop to discuss recommendations to address selected methodological aspects identified in the survey. Finally, consensus-based recommendations were developed based on the workshop discussion and email interaction.

RESULTS

We contacted 1535 authors of mHealth intervention RCTs, of whom 80 (5.21%) completed the survey. Most respondents (74/80, 92%) identified at least one methodological aspect as more or much more challenging in mHealth RCTs. The aspects most frequently reported as more or much more challenging were those related to mHealth intervention integrity, that is, the degree to which the study intervention was implemented as intended, in particular managing low adherence to the mHealth intervention (43/77, 56%), defining adherence (39/79, 49%), measuring adherence (33/78, 42%), and determining which mHealth intervention components are used or received by the participant (31/75, 41%). Other challenges were also frequent, such as analyzing passive data (eg, data collected from smartphone sensors; 24/58, 41%) and verifying the participants' identity during recruitment (28/68, 41%). In total, 11 survey respondents participated in the subsequent workshop (n=8, 73% had been involved in at least 2 mHealth RCTs). We developed 17 consensus-based recommendations related to the following four categories: (1) how to measure adherence to the mHealth intervention (7 recommendations), (2) defining adequate adherence (2 recommendations), (3) dealing with low adherence rates (3 recommendations), and (4) addressing mHealth intervention components (5 recommendations).

CONCLUSIONS

RCTs of mHealth interventions have specific methodological challenges compared to those of non-mHealth interventions, particularly those related to intervention integrity. Following our recommendations for addressing these challenges can lead to more reliable assessments of the effects of mHealth interventions on health outcomes.

Perspectives of Digital Health Innovations in Low- and Middle-Income Health Care Systems From South and Southeast Asia

Digital health innovations have emerged globally as a transformative force for addressing health system challenges, particularly in resource-constrained settings. The COVID-19 pandemic underscored the critical importance of these innovations for enhancing public health. In South and Southeast Asia, a region known for its cultural diversity and complex health care landscape, digital health innovations present a dynamic interplay of challenges and opportunities. We advocate for ongoing research built into system development and an evidence-based strategy focusing on designing and scaling national digital health infrastructures combined with a vibrant ecosystem or "marketplace" of local experiments generating shared experience about what works in which settings. As the global digital health revolution unfolds, the perspectives drawn from South and Southeast Asia-including the importance of local partnerships-may provide valuable insights for shaping future strategies and informing similar initiatives in low- and middle-income countries, contributing to effective digital health strategies across diverse global health contexts.

State of the art of mobile health technologies use in clinical arrhythmia care

The rapid growth in consumer-facing mobile and sensor technologies has created tremendous opportunities for patient-driven personalized health management. The diagnosis and management of cardiac arrhythmias are particularly well suited to benefit from these easily accessible consumer health technologies. In particular, smartphone-based and wrist-worn wearable electrocardiogram (ECG) and photoplethysmography (PPG) technology can facilitate relatively inexpensive, long-term rhythm monitoring. Here we review the practical utility of the currently available and emerging mobile health technologies relevant to cardiac arrhythmia care. We discuss the applications of these tools, which vary with respect to diagnostic performance, target populations, and indications. We also highlight that requirements for successful integration into clinical practice require adaptations to regulatory approval, data management, electronic medical record integration, quality oversight, and efforts to minimize the additional burden to health care professionals.

Information and Communications Technology-Based Monitoring Service for Tailored Chronic Disease Management in Primary Care: Cost-Effectiveness Analysis Based on ICT-CM Trial Results

BACKGROUND

Information and communications technology-based tailored management (TM) intervention is a novel automatic system in which a smartphone app for the management of patients with hypertension and diabetes, the provider web, and Bluetooth devices are linked. However, little evidence exists regarding the cost-effectiveness of the interventions using mobile apps.

OBJECTIVE

This study aimed to assess the cost-effectiveness of TM intervention for adult patients with hypertension or diabetes in primary care compared with usual care (UC).

METHODS

Cost-effectiveness analysis using a Markov model was conducted from the Korean health care system perspective. Based on 6-month outcome data from an information and communications technology-based tailored chronic disease management (ICT-CM) trial, effectiveness over a lifetime beyond the trial periods was extrapolated using a cardiovascular disease risk prediction model. Costs were estimated using ICT-CM trial data and national health insurance claims data. Health utility weights were obtained from the Korea National Health and Nutrition Examination Survey.

RESULTS

In the base-case analysis, compared with UC, TM was more costly (US $23,157 for TM vs US $22,391 for UC) and more effective (12.006 quality-adjusted life-years [QALYs] for TM vs 11.868 QALYs for UC). The incremental cost-effectiveness ratio was US $5556 per QALY gained. Probabilistic sensitivity analysis showed that the probability of TM being cost-effective compared with UC was approximately 97% at an incremental cost-effectiveness ratio threshold of US $26,515 (KRW 35 million) per QALY gained.

CONCLUSIONS

Compared with UC, TM intervention is a cost-effective option for patients with hypertension or diabetes in primary care settings. The study results can assist policy makers in making evidence-based decisions when implementing accessible chronic disease management services.

A mobile health application use among diabetes mellitus patients: a systematic review and meta-analysis

Background

Mobile health technologies are increasingly acknowledged as a cost-effective and convenient means of delivering top-notch healthcare services to patients in low- and middle-income countries. This research explores the utilization of mobile health applications in managing, monitoring, and self-care for adult diabetes mellitus (DM) patients. The objective is to gain insight into how diabetic patients currently utilize Mobile health applications for self-management and their inclination to use them in the future.

Methods

The authors conducted a systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. They included articles that reported on the use of mobile/smartphone applications for diabetic mellitus disorders, focusing on ownership, application use, future interest in use, and use patterns. The search was conducted in the PubMed, Web of Science, Embase, and SCOPUS electronic databases, with various published articles from January 2016 up to February 2024. The methodological quality was evaluated using the Joanna Briggs Institute critical appraisal tool. Statistical techniques were applied, including the heterogeneity test, publication bias assessment, Egger's test, and funnel plots. The pooled prevalence was calculated using meta-analysis proportion with a random-effects model.

Results

Thirteen studies were included, out of 4568 recognized articles. The pooled prevalence of mobile health application use for current diabetic management self-management, future interest in using the application for diabetic disorder self-management, and lack of belief in mobile health application users for self-management was 35%, 57%, and 39%, respectively. We observed significant heterogeneity (I2 = 97.7, p=<0.001), but no significant publication bias was detected on Egger's test.

Conclusions

Our meta-analysis results show that over one-third of individuals use mobile health applications for diabetic self-management, and more than half of individuals would like to manage their diabetes mellitus in the future by using mobile health applications. These mobile health apps may be promising in future diabetes mellitus self-management. However, we still need to study the effectiveness of these apps. In addition, adopting mobile health apps based on the cultural context makes this self-management more achievable, practical, and impactful for individuals with diabetes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier 42024537917.

Is a 12-week home-based functional teletraining for individuals with type 2 diabetes an alternative for blood glucose control?

BACKGROUND

Virtual or Tele-exercise programs have emerged due to safety concerns of COVID-19 contamination for at-risk groups. However, blood glucose (BG) comparisons concerning in-person and virtual exercise programs need to be scientifically researched. Understanding and monitoring home-based teletraining effects on glycemia is vital for safe management of people with type-2 diabetes (T2DM).

PURPOSE

To verify a 12-week functional teletraining on the capillary BG and compare it with in-person exercise before the COVID-19 pandemic in people with T2DM.

METHODS

T2DM participants underwent tele-exercise during the COVID-19 pandemic. It consisted of functional training (functional resistance training (FRT) for 12 weeks, 2 times a week, ∼60 min). Capillary BG was performed before and after (pre-post) each exercise session. The pre-post ΔBG for each session was considered for statistical analysis. Friedman's test with repetitive measures over time was performed to compare the ΔBG of the teletraining and the results of these participants before the pandemic. The minimum detectable difference was performed to verify clinical ΔBG for each session over the weeks.

RESULTS

Similar responses were seen over time without a statistical time effect after the programs (p = 0.177). A noticeable minimum difference of 24.5 mg/dL was observed in the in-person group post-session in all sessions. The virtual group showed a minimum detectable difference of 21.1 mg/dL post-session with clinical relevance over the 12 weeks.

CONCLUSION

Despite the teletraining being twice weekly and the in-person program thrice weekly, both exhibited similar outcomes over time, with the virtual program showing significant clinical improvements in BG after each session.

Design and rationale of the cardiometabolic health program linked with community health workers and mobile health telemonitoring to reduce health disparities (LINKED-HEARTS) program

BACKGROUND

Hypertension and diabetes are major risk factors for cardiovascular diseases, stroke, and chronic kidney disease (CKD). Disparities in hypertension control persist among Black and Hispanic adults and persons living in poverty in the United States. The "LINKED-HEARTS Program" (a Cardiometabolic Health Program LINKED with Community Health WorkErs and Mobile HeAlth TelemonitoRing To reduce Health DisparitieS"), is a multi-level intervention that includes home blood pressure (BP) monitoring (HBPM), blood glucose telemonitoring, and team-based care. This study aims to examine the effect of the LINKED-HEARTS Program intervention in improving BP control compared to enhanced usual care (EUC) and to evaluate the reach, adoption, sustainability, and cost-effectiveness of the program.

METHODS

Using a hybrid type I effectiveness-implementation design, 428 adults with uncontrolled hypertension (systolic BP ≥ 140 mm Hg) and diabetes or CKD will be recruited from 18 primary care practices, including community health centers, in Maryland. Using a cluster-randomized trial design, practices are randomly assigned to the LINKED-HEARTS intervention arm or EUC arm. Participants in the LINKED-HEARTS intervention arm receive training on HBPM, BP and glucose telemonitoring, and community health worker and pharmacist telehealth visits on lifestyle modification and medication management over 12 months. The primary outcome is the proportion of participants with controlled BP (<140/90 mm Hg) at 12 months.

CONCLUSIONS

The study tests a multi-level intervention to control multiple chronic diseases. Findings from the study may be leveraged to reduce disparities in the management and control of chronic diseases and make primary care more responsive to the needs of underserved populations.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT05321368.

Effect of m-Health-Based Interventions on Blood Pressure: An Updated Systematic Review with Meta-Analysis

Background: In recent years, the integration of mobile health (m-Health) interventions has garnered increasing attention as a potential means to improve blood pressure (BP) management in adults. This updated systematic review with meta-analysis aimed to identify the effect of m-Health-based interventions on BP in adults and to evaluate the effect of m-Health on BP according to the characteristics of subjects, interventions, and countries. Methods: The search was carried out in PubMed, Embase, ResearchGate, and Cochrane databases in January 2022. Study selection and data extraction were performed by two independent reviewers. For analysis, random effects models were used with a confidence interval (CI) of 95% and p < 0.05. Results: Fifty studies were included in this review and in the meta-analysis. Interventions with m-Health reduced systolic BP in 3.5 mmHg (95% CI -4.3; -2.7; p < 0.001; I2 = 85.8%) and diastolic BP in 1.8 mmHg (95% CI -2.3; -1.4; p < 0.001; I2 = 78.9%) compared to usual care. The effects of m-Health interventions on BP were more evident in men and in older adults, in interventions lasting 6-8 weeks, with medication reminders, with the possibility of insertion of BP values (p < 0.05). Conclusion: The results of this study support the effectiveness of m-Health in reducing BP when compared to standard care. However, these effects are dependent on the characteristics of the subjects and interventions. Given the substantial heterogeneity among the results of this systematic review with meta-analysis, its interpretation should be cautious. Future research on this topic is warranted.

Behavioral Engagement and Activation Model Study (BEAMS): A latent class analysis of adopters and non-adopters of digital health technologies among people with Type 2 diabetes

Many people with Type 2 diabetes (T2D) who could benefit from digital health technologies (DHTs) are either not using DHTs or do use them, but not for long enough to reach their behavioral or metabolic goals. We aimed to identify subgroups within DHT adopters and non-adopters and describe their unique profiles to better understand the type of tailored support needed to promote effective and sustained DHT use across a diverse T2D population. We conducted latent class analysis of a sample of adults with T2D who responded to an internet survey between December 2021 and March 2022. We describe the clinical and psychological characteristics of DHT adopters and non-adopters, and their attitudes toward DHTs. A total of 633 individuals were characterized as either DHT "Adopters" (n = 376 reporting any use of DHT) or "Non-Adopters" (n = 257 reporting never using any DHT). Within Adopters, three subgroups were identified: 21% (79/376) were "Self-managing Adopters," who reported high health activation and self-efficacy for diabetes management, 42% (158/376) were "Activated Adopters with dropout risk," and 37% (139/376) were "Non-Activated Adopters with dropout risk." The latter two subgroups reported barriers to using DHTs and lower rates of intended future use. Within Non-Adopters, two subgroups were identified: 31% (79/257) were "Activated Non-Adopters," and 69% (178/257) were "Non-Adopters with barriers," and were similarly distinguished by health activation and barriers to using DHTs. Beyond demographic characteristics, psychological, and clinical factors may help identify different subgroups of Adopters and Non-Adopters.

Digital Interventions for Self-Management of Type 2 Diabetes Mellitus: Systematic Literature Review and Meta-Analysis

BACKGROUND

The proliferation of digital technology has the potential to transform diabetes management. One of the critical aspects of modern diabetes management remains the achievement of glycemic targets to avoid acute and long-term complications.

OBJECTIVE

This study aims to describe the landscape of evidence pertaining to the relative effectiveness or efficacy and safety of various digital interventions for the self-management of type 2 diabetes mellitus (T2DM), with a primary focus on reducing glycated hemoglobin A1c (HbA1c) levels.

METHODS

A systematic literature review (SLR) was conducted by searching Embase, MEDLINE, and CENTRAL on April 5, 2022. Study selection, data extraction, and quality assessment were performed by 2 independent reviewers. Eligibility criteria for the SLR included randomized controlled trials (RCTs) and comparative observational studies evaluating interventions containing both human (eg, coaching) and digital components (eg, glucose meter) in adult patients with T2DM. The primary meta-analysis was restricted to studies that reported laboratory-measured HbA1c. In secondary analyses, meta-regression was performed with the intensity of coaching in the digital intervention as a categorical covariate.

RESULTS

In total, 28 studies were included in this analysis. Most studies (23/28, 82%) used the reduction of HbA1c levels as the primary end point, either directly or as a part of a multicomponent outcome. In total, 21 studies reported statistically significant results with this primary end point. When stratified into 3 intervention categories by the intensity of the intervention supporting the digital health technology (analyzing all 28 studies), the success rate appeared to be proportional to the coaching intensity (ie, higher-intensity studies reported higher success rates). When the analysis was restricted to RCTs using the comparative improvement of HbA1c levels, the effectiveness of the interventions was less clear. Only half (12/23, 52%) of the included RCTs reported statistically significant results. The meta-analyses were broadly aligned with the results of the SLR. The primary analysis estimated a greater reduction in HbA1c associated with digital interventions compared with usual care (-0.31%, 95% CI -0.45% to -0.16%; P<.001). Meta-regression estimated reductions of -0.45% (95% CI -0.81% to -0.09%; P=.02), -0.29% (95% CI -0.48% to -0.11%; P=.003), and -0.28% (95% CI -0.65% to 0.09%; P=.20) associated with high-, medium-, and low-intensity interventions, respectively.

CONCLUSIONS

These findings suggest that reducing HbA1c levels in individuals with T2DM with the help of digital interventions is feasible, effective, and acceptable. One common feature of effective digital health interventions was the availability of timely and responsive personalized coaching by a dedicated health care professional.

Development of a Health Behavioral Digital Intervention for Patients With Hypertension Based on an Intelligent Health Promotion System and WeChat: Randomized Controlled Trial

BACKGROUND

The effectiveness of timely medication, physical activity (PA), a healthy diet, and blood pressure (BP) monitoring for promoting health outcomes and behavioral changes among patients with hypertension is supported by a substantial amount of literature, with "adherence" playing a pivotal role. Nevertheless, there is a lack of consistent evidence regarding whether digital interventions can improve adherence to healthy behaviors among individuals with hypertension.

OBJECTIVE

The aim was to develop a health behavioral digital intervention for hypertensive patients (HBDIHP) based on an intelligent health promotion system and WeChat following the behavior change wheel (BCW) theory and digital micro-intervention care (DMIC) model and assess its efficacy in controlling BP and improving healthy behavior adherence.

METHODS

A 2-arm, randomized trial design was used. We randomly assigned 68 individuals aged >60 years with hypertension in a 1:1 ratio to either the control or experimental group. The digital intervention was established through the following steps: (1) developing digital health education materials focused on adherence to exercise prescriptions, Dietary Approaches to Stop Hypertension (DASH), prescribed medication, and monitoring of BP; (2) using the BCW theory to select behavior change techniques; (3) constructing the intervention's logic following the guidelines of the DMIC model; (4) creating an intervention manual including the aforementioned elements. Prior to the experiment, participants underwent physical examinations at the community health service center's intelligent health cabin and received intelligent personalized health recommendations. The experimental group underwent a 12-week behavior intervention via WeChat, while the control group received routine health education and a self-management manual. The primary outcomes included BP and adherence indicators. Data analysis was performed using SPSS, with independent sample t tests, chi-square tests, paired t tests, and McNemar tests. A P value <.05 was considered statistically significant.

RESULTS

The final analysis included 54 participants with a mean age of 67.24 (SD 4.19) years (n=23 experimental group, n=31 control group). The experimental group had improvements in systolic BP (-7.36 mm Hg, P=.002), exercise time (856.35 metabolic equivalent [MET]-min/week, P<.001), medication adherence (0.56, P=.001), BP monitoring frequency (P=.02), and learning performance (3.23, P<.001). Both groups experienced weight reduction (experimental: 1.2 kg, P=.002; control: 1.11 kg, P=.009) after the intervention. The diet types and quantities for both groups (P<.001) as well as the subendocardial viability ratio (0.16, P=.01) showed significant improvement. However, there were no statistically significant changes in other health outcomes.

CONCLUSIONS

The observations suggest our program may have enhanced specific health outcomes and adherence to health behaviors in older adults with hypertension. However, a longer-term, larger-scale trial is necessary to validate the effectiveness.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200062643; https://www.chictr.org.cn/showprojEN.html?proj=172782.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/46883.

Effectiveness of digital health interventions on blood pressure control, lifestyle behaviours and adherence to medication in patients with hypertension in low-income and middle-income countries: a systematic review and meta-analysis of randomised controlled trials

Background

Digital health interventions can be effective for blood pressure (BP) control, but a comparison of the effectiveness and application of these types of interventions has not yet been systematically evaluated in low- and middle-income countries (LMICs). This study aimed to compare the effectiveness of digital health interventions according to the World Health Organisation (WHO) classifications of patients in terms of BP control, lifestyle behaviour changes, and adherence to medication in patients with hypertension in LMICs.

Methods

In this systematic review and meta-analysis, we searched the PubMed, Scopus, Web of Science, Embase, CINAHL, and Cochrane Library databases for randomised controlled trials (RCTs) published in English, comprised of adults (≥18 years old) with hypertension and the intervention consisted of digital health interventions according to WHO's classifications for patients in LMICs between January 1, 2009, and July 17, 2023. We excluded RCTs that considered patients with hypertension comorbidities such as diabetes and hypertension-mediated target organ damage (HMTOD). The references were downloaded into Mendeley Desktop and imported into the Rayyan web tool for deduplication and screening. The risk of bias was assessed using Cochrane Risk of Bias 2. Data extraction was done according to Cochrane's guidelines. The main outcome measures were mean systolic blood pressure (SBP) and BP control which were assessed using the random-effect DerSimonian-Laird and Mantel-Haenszel models. We presented the BP outcomes, lifestyle behaviour changes and medication adherence in forest plots as well as summarized them in tables. This study is registered with PROSPERO, CRD42023424227.

Findings

We identified 9322 articles, of which 22 RCTs from 12 countries (n = 12,892 respondents) were included in the systematic review. The quality of the 22 studies was graded as high risk (n = 7), had some concerns (n = 3) and low risk of bias (n = 12). A total of 19 RCTs (n = 12,418 respondents) were included in the meta-analysis. Overall, digital health intervention had significant reductions in SBP [mean difference (MD) = -4.43 mmHg (95% CI -6.19 to -2.67), I2 = 92%] and BP control [odds ratio (OR) = 2.20 (95% CI 1.64-2.94), I2 = 78%], respectively, compared with usual care. A subgroup analysis revealed that short message service (SMS) interventions had the greatest statistically significant reduction of SBP [MD = -5.75 mm Hg (95% Cl -7.77 to -3.73), I2 = 86%] compared to mobile phone calls [MD = 3.08 mm Hg (-6.16 to 12.32), I2 = 87%] or smartphone apps interventions [MD = -4.06 mm Hg (-6.56 to -1.55), I2 = 79%], but the difference between groups was not statistically significant (p = 0.14). The meta-analysis showed that the interventions had a significant effect in supporting changes in lifestyle behaviours related to a low salt diet [standardised mean difference (SMD) = 1.25; (95% CI 0.64-1.87), I2 = 89%], physical activity [SMD = 1.30; (95% CI 0.23-2.37), I2 = 94%] and smoking reduction [risk difference (RR) = 0.03; (95% CI 0.01-0.05), I2 = 0%] compared to the control group. In addition, improvement in medication adherence was statistically significant and higher in the intervention group than in the control group [SMD = 1.59; (95% CI 0.51-2.67), I2 = 97%].

Interpretation

Our findings suggest that digital health interventions may be effective for BP control, changes in lifestyle behaviours, and improvements in medication adherence in LMICs. However, we observed high heterogeneity between included studies, and only two studies from Africa were included. The combination of digital health interventions with clinical management is crucial to achieving optimal clinical effectiveness in BP control, changes in lifestyle behaviours and improvements in medication adherence.

Funding

None.

Promises and Perils of Consumer Mobile Technologies in Cardiovascular Care: JACC Scientific Statement

Direct-to-consumer (D2C) wearables are becoming increasingly popular in cardiovascular health management because of their affordability and capability to capture diverse health data. Wearables may enable continuous health care provider-patient partnerships and reduce the volume of episodic clinic-based care (thereby reducing health care costs). However, challenges arise from the unregulated use of these devices, including questionable data reliability, potential misinterpretation of information, unintended psychological impacts, and an influx of clinically nonactionable data that may overburden the health care system. Further, these technologies could exacerbate, rather than mitigate, health disparities. Experience with wearables in atrial fibrillation underscores these challenges. The prevalent use of D2C wearables necessitates a collaborative approach among stakeholders to ensure effective integration into cardiovascular care. Wearables are heralding innovative disease screening, diagnosis, and management paradigms, expanding therapeutic avenues, and anchoring personalized medicine.

Digital Health Interventions for Hypertension Management in US Populations Experiencing Health Disparities: A Systematic Review and Meta-Analysis

Importance

Hypertension remains a leading factor associated with cardiovascular disease, and demographic and socioeconomic disparities in blood pressure (BP) control persist. While advances in digital health technologies have increased individuals' access to care for hypertension, few studies have analyzed the use of digital health interventions in vulnerable populations.

Objective

To assess the association between digital health interventions and changes in BP and to characterize tailored strategies for populations experiencing health disparities.

Data Sources

In this systematic review and meta-analysis, a systematic search identified studies evaluating digital health interventions for BP management in the Cochrane Library, Ovid Embase, Google Scholar, Ovid MEDLINE, PubMed, Scopus, and Web of Science databases from inception until October 30, 2023.

Study Selection

Included studies were randomized clinical trials or cohort studies that investigated digital health interventions for managing hypertension in adults; presented change in systolic BP (SBP) or baseline and follow-up SBP levels; and emphasized social determinants of health and/or health disparities, including a focus on marginalized populations that have historically been underserved or digital health interventions that were culturally or linguistically tailored to a population with health disparities. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

Data Extraction and Synthesis

Two reviewers extracted and verified data. Mean differences in BP between treatment and control groups were analyzed using a random-effects model.

Main Outcomes and Measures

Primary outcomes included mean differences (95% CIs) in SBP and diastolic BP (DBP) from baseline to 6 and 12 months of follow-up between digital health intervention and control groups. Shorter- and longer-term follow-up durations were also assessed, and sensitivity analyses accounted for baseline BP levels.

Results

A total of 28 studies (representing 8257 participants) were included (overall mean participant age, 57.4 years [range, 46-71 years]; 4962 [60.1%], female). Most studies examined multicomponent digital health interventions incorporating remote BP monitoring (18 [64.3%]), community health workers or skilled nurses (13 [46.4%]), and/or cultural tailoring (21 [75.0%]). Sociodemographic characteristics were similar between intervention and control groups. Between the intervention and control groups, there were statistically significant mean differences in SBP at 6 months (-4.24 mm Hg; 95% CI, -7.33 to -1.14 mm Hg; P = .01) and SBP changes at 12 months (-4.30 mm Hg; 95% CI, -8.38 to -0.23 mm Hg; P = .04). Few studies (4 [14.3%]) reported BP changes and hypertension control beyond 1 year.

Conclusions and Relevance

In this systematic review and meta-analysis of digital health interventions for hypertension management in populations experiencing health disparities, BP reductions were greater in the intervention groups compared with the standard care groups. The findings suggest that tailored initiatives that leverage digital health may have the potential to advance equity in hypertension outcomes.

Understanding mHealth Adoption and Lifestyle Improvement: An Empirical Test of the Antecedents and Mediating Mechanisms

The potential of using mobile phones for health care service delivery has been well acknowledged. Despite that mobile health (mHealth) related research has proliferated in the past decade, mHealth is still in the fledgling stage with a low adoption rate. There is a research gap in understanding factors influencing mHealth adoption and examining the effects of mHealth use on health outcomes. The purpose of this study was thus to explore influential factors of mHealth use, and test mediation pathways through which mHealth use impacts healthy lifestyle behaviors (e.g. sleep, exercise, and social participation). Survey results from 432 online participants illustrate that performance expectancy, social influence, support conditions, and perceived reliability were significantly associated with mHealth use. However, the impact of effort expectancy on mHealth use was statistically nonsignificant. Moreover, the results indicate that mHealth use can not only contribute to the improvement of healthy lifestyle behaviors directly but also exert an impact through the mediating effect of health competence. Knowing what factors motivate people's mHealth use and how mHealth use contributes to lifestyle improvement can help trigger interventions to boost mHealth adoption and improve public health. Implications and limitations are discussed.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The effect of using mobile health on self-management of type 2 diabetic patients: A systematic review in Iran

Type 2 diabetes, as one of the most common chronic diseases, requires ongoing management and support from the patient; therefore, patient participation and self-management play a pivotal role in controlling and preventing this disease. The increasing use of smartphones has provided a good opportunity for controlling and managing patients with type 2 diabetes. This study aimed to investigate the effect of mobile health on the self-management of patients with type 2 diabetes in Iran. A systematic review study was conducted from 2010 to 2021. Searches in Persian and English scientific databases, IranDoc, MagIran, SID Web of science, and PubMed, were performed using keywords such as diabetes and mobile health. The process of reviewing and selecting articles based on inclusion and exclusion criteria was performed by two researchers independently. The study evaluation was performed by using a standard tool. After selecting articles, data extraction was performed using a data extraction form. Data analysis was performed with a content analysis approach. Finally, 23 articles were included from the 7767 articles found in the initial search stage, which examined patients' self-care in 11 areas using mobile health. Fourteen studies (61%) considered mobile health to be effective in increasing hemoglobin control. Other studies also found the use of mobile health in increasing adherence to exercise (n = 10), increasing adherence to medication (n = 9), increasing adherence to diet (n = 11), increasing care for diabetic foot ulcers (n = 8), increasing self-efficacy and empowerment (n = 5), increasing cholesterol control (n = 4), increasing awareness and attitude (n = 4), increasing control of insulin dose (n = 2), increasing adherence to education (n = 1), and increasing control of blood urea (n = 1), which were considered effective. The use of m-health effectively controls the disease and promotes self-management in type 2 diabetic patients. Considering the high cost of diabetes treatment, policymakers should implement appropriate interventions and strategies in the field of using mobile health to improve adherence to self-management of the disease.

A mixed-methods study on the implementation of a mobile health application (mHealth app) for stroke caregivers in Malaysia: healthcare providers' perspective

Introduction

Recognizing the burden experienced by caregivers of stroke survivors, an intervention using mobile health applications (mHealth apps) has been proposed to support and empower stroke caregivers. This study aimed to assess the acceptability and expectations of healthcare providers, who play a vital role as gatekeepers in the healthcare system, to ensure the effectiveness and sustainability of the intervention.

Methods

This was a concurrent mixed-method study design, with healthcare providers involved in stroke care management in the northeast regions of Malaysia as study participants. The qualitative component of the study was conducted using a phenomenological approach that involved in-depth interviews to explore the acceptability and expectations of healthcare providers regarding the adoption of mHealth apps in the context of stroke caregiving. The study was complemented by quantitative data collected through an online survey using an adjusted version of the technology acceptance model tool.

Results

In total, 239 participants from diverse backgrounds and professions were enrolled in the study, with 12 in the qualitative component and 227 in the quantitative component. The findings from the quantitative survey showed that over 80% of the participants expressed their intention to use mHealth apps. The qualitative component generated two themes related to the acceptability and expectations of mHealth apps, which were integrated with the quantitative findings. Additionally, in-depth interviews revealed a new theme, namely the key features of mHealth, with three sub-themes: availability of services for caregivers, provision of knowledge skills, and supporting caregivers in managing stroke patients.

Conclusion

Healthcare providers demonstrated excellent acceptability of this mHealth intervention as part of caregiving assistance, particularly with the inclusion of essential key features. However, future investigations are necessary to establish the feasibility of integrating the mHealth app into the healthcare system and to ensure its long-term sustainability.

Digital Phenotyping for Monitoring and Disease Trajectory Prediction of Patients With Cancer: Protocol for a Prospective Observational Cohort Study

BACKGROUND

Timely recognition of cancer progression and treatment complications is important for treatment guidance. Digital phenotyping is a promising method for precise and remote monitoring of patients in their natural environments by using passively generated data from sensors of personal wearable devices. Further studies are needed to better understand the potential clinical benefits of digital phenotyping approaches to optimize care of patients with cancer.

OBJECTIVE

We aim to evaluate whether passively generated data from smartphone sensors are feasible for remote monitoring of patients with cancer to predict their disease trajectories and patient-centered health outcomes.

METHODS

We will recruit 200 patients undergoing treatment for cancer. Patients will be followed up for 6 months. Passively generated data by sensors of personal smartphone devices (eg, accelerometer, gyroscope, GPS) will be continuously collected using the developed LAIMA smartphone app during follow-up. We will evaluate (1) mobility data by using an accelerometer (mean time of active period, mean time of exertional physical activity, distance covered per day, duration of inactive period), GPS (places of interest visited daily, hospital visits), and gyroscope sensors and (2) sociability indices (frequency of duration of phone calls, frequency and length of text messages, and internet browsing time). Every 2 weeks, patients will be asked to complete questionnaires pertaining to quality of life (European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire [EORTC QLQ-C30]), depression symptoms (Patient Health Questionnaire-9 [PHQ-9]), and anxiety symptoms (General Anxiety Disorder-7 [GAD-7]) that will be deployed via the LAIMA app. Clinic visits will take place at 1-3 months and 3-6 months of the study. Patients will be evaluated for disease progression, cancer and treatment complications, and functional status (Eastern Cooperative Oncology Group) by the study oncologist and will complete the questionnaire for evaluating quality of life (EORTC QLQ-C30), depression symptoms (PHQ-9), and anxiety symptoms (GAD-7). We will examine the associations among digital, clinical, and patient-reported health outcomes to develop prediction models with clinically meaningful outcomes.

RESULTS

As of July 2023, we have reached the planned recruitment target, and patients are undergoing follow-up. Data collection is expected to be completed by September 2023. The final results should be available within 6 months after study completion.

CONCLUSIONS

This study will provide in-depth insight into temporally and spatially precise trajectories of patients with cancer that will provide a novel digital health approach and will inform the design of future interventional clinical trials in oncology. Our findings will allow a better understanding of the potential clinical value of passively generated smartphone sensor data (digital phenotyping) for continuous and real-time monitoring of patients with cancer for treatment side effects, cancer complications, functional status, and patient-reported outcomes as well as prediction of disease progression or trajectories.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/49096.

Evaluating a WeChat-Based Health Behavioral Digital Intervention for Patients With Hypertension: Protocol for a Randomized Controlled Trial

BACKGROUND

Hypertension is the most prevalent chronic condition and a significant risk factor for cardiovascular and kidney diseases. The efficacy of health behavioral interventions in blood pressure (BP) control has been demonstrated by a large and expanding body of literature, with "adherence" playing a crucial role. WeChat is the most common social communication mobile app in China, and it has been shown to be an acceptable delivery platform for delivering health interventions. The WeChat-based health behavioral digital intervention program (WHBDIP) showed high feasibility and efficacy. However, the results regarding BP improvement between the WHBDIP and control groups were inconsistent.

OBJECTIVE

The objective of this study is to develop a WHBDIP and assess its efficacy in controlling BP and improving adherence among patients with hypertension.

METHODS

A 2-arm, parallel-group, and randomized trial design was used. Patients older than 60 years and with hypertension were randomly assigned to either the control group or the experimental group, which received a 12-week intervention. The program, primarily developed based on the Behavior Change Wheel (BCW) theory, offers health education on exercise, diet, BP monitoring, and medicine adherence (MA). It also includes other behavior interventions guided by an intervention manual, incorporating behavior change techniques (BCTs). The primary outcomes encompass BP and adherence indicators, while the secondary outcomes encompass cardiovascular function indicators, body composition indicators, learning performance, satisfaction, and acceptability. The exercise and blood pressure monitoring adherence (BPMA) indicators for the WHBDIP group were assessed weekly via WeChat during the initial 3 months, while other outcome data for both groups will be collected at the baseline assessment phase, 3 months after the intervention, and 1 year after the program.

RESULTS

The trial will assess the efficacy of WHBDIP for patients with hypertension (N=68). The WHBDIP seeks to enhance participants' knowledge of healthy behaviors and assist patients in developing positive health behaviors to improve their health outcomes. Patient recruitment for individuals with hypertension commenced on September 5, 2022, and concluded on September 19, 2022. The 3-month intervention and phased data collection were finalized in January 2023. Data analysis will commence in August 2023, and the final 1-year health outcome results will be collected in September 2023.

CONCLUSIONS

A successful WHBDIP will establish the management mode as a feasible approach for hypertension management in the community. Additionally, it will pave the way for the development of related mobile health programs.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200062643; https://tinyurl.com/mwyv67wk.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46883.

Effectiveness and Process Evaluation of Using Digital Health Technologies in Pharmaceutical Care in Low- and Middle-Income Countries: A Systematic Review of Quantitative and Qualitative Studies

Introduction: Digital health technology (DHT) has the potential to enhance remote health care delivery. However, little is known about the effectiveness of DHTs and factors that contribute to the limited uptake of DHTs in low- and middle-income countries (LMICs). Therefore, the objective of this study was to systematically review the effectiveness and evaluation process concerning the use of DHTs in pharmaceutical care in LMICs. Methods: A literature search on PubMed and Embase was conducted to identify experimental, descriptive, qualitative, and mixed-method studies that focused on the use of DHTs in pharmaceutical care as the main intervention, reported on the effects and/or the process of the DHT intervention, were performed by pharmacists, were conducted in LMICs, and had been published in English. Two reviewers independently conducted the study selection process. A qualitative narrative review of the effectiveness of using DHTs was conducted evaluating the population, intervention, comparators, and outcomes. We summarized the content and identified themes of the evaluation process under two categories-challenges and opportunities. Results: The search produced 589 studies, of which 16 met the eligibility criteria. The most common type of DHT was mobile health application (mHealth app; n = 8), followed by mobile phone call (n = 6) and mobile video call (n = 2). Eight studies assessed the effectiveness of using DHTs in pharmaceutical care. mHealth app, mobile phone call, mobile video call, text messages, home telemonitoring, and internet-based drug information centers improved some health-related outcomes. Two of these eight studies, however, did not find significant effects of a phone call or an mHealth app on certain health-related outcomes. Of the seven quantitative studies conducting a process evaluation, all showed that patients were satisfied with the use of DHTs in pharmaceutical care provided by pharmacists. Of the two mixed-methods and one qualitative study assessing the process evaluation concerning DHT usage, three distinct themes of challenges (patient-, DHT-, and health care system-related challenges) and opportunities (patient-, DHT-, and pharmacist-related opportunities) were identified. Conclusions: DHT is a promising approach in pharmaceutical care toward improving health-related outcomes in LMICs, despite the variable intervention effects. The challenges and opportunities identified are important considerations when developing and implementing DHTs in pharmaceutical care in LMICs.

Assessing the Effectiveness of mHealth Interventions for Diabetes and Hypertension Management in Africa: Systematic Review and Meta-Analysis

Background

Mobile health (mHealth) interventions are effective in improving chronic disease management, mainly in high-income countries. However, less is known about the efficacy of mHealth interventions for the reduction of cardiovascular risk factors, including for hypertension and diabetes, which are rapidly increasing in low- and middle-income countries.

Objective

This study aimed to assess the efficacy of mHealth interventions for diabetes and hypertension management in Africa.

Methods

We searched PubMed, Cochrane Library, Google Scholar, African Journals Online, and Web of Science for relevant studies published from inception to July 2022. The main outcomes of interest were changes in hemoglobin A1c (HbA1c), systolic blood pressure, and diastolic blood pressure. The random or fixed effect model was used for the meta-analysis, and the I2 statistic was used to gauge study heterogeneity. Z tests and P values were used to evaluate the effect of mHealth interventions on HbA1c and blood pressure levels.

Results

This review included 7 studies (randomized controlled trials) with a total of 2249 participants. Two studies assessed the effect of mHealth on glycemic control, and 5 studies assessed the effect of mHealth on blood pressure control. The use of mHealth interventions was not associated with significant reductions in HbA1c levels (weighted mean difference [WMD] 0.20, 95% CI -0.40 to 0.80; P=.51) among patients with diabetes and systolic blood pressure (WMD -1.39, 95% CI -4.46 to 1.68; P=.37) and diastolic blood pressure (WMD 0.36, 95% CI -1.37 to 2.05; P=.69) among patients with hypertension. After conducting sensitivity analyses using the leave-one-out method, the Kingue et al study had an impact on the intervention, resulting in a 2 mm Hg reduction in systolic blood pressure (WMD -2.22, 95% CI -3.94 to -0.60; P=.01) but was nonsignificant for diastolic blood pressure and HbA1c levels after omitting the study.

Conclusions

Our review provided no conclusive evidence for the effectiveness of mHealth interventions in reducing blood pressure and glycemic control in Africa among persons with diabetes and hypertension. To confirm these findings, larger randomized controlled trials are required.

A Review of Software and Mobile Apps to Support the Clinical Diagnosis of Hansen Disease

This scoping review indicates a lack of scientific articles that specifically explore software and mobile applications designed to assist in the clinical diagnosis of leprosy, and our findings have provided insights into the available tools, their usage methods, and the benefits offered by health technologies.

Perception, willingness, and practices of telemedicine in patients with chronic diseases: implication of digital health in patients' perspective at a tertiary care hospital in Ethiopia

Background

Technology-based healthcare services have important implications for the diagnosis, prevention, and treatment of diseases, as well as providing access to high-quality care that both the patient and the healthcare practitioner can benefit from. To access medical information, patients have also searched for methods of technology-based healthcare services like telemedicine (TM). However, little is known regarding the perceptions, willingness, and practices of TM among Ethiopian patients, especially in the study setting.

Objective

This study assessed the perceptions, willingness, and practice of TM among patients with chronic disease at the University of Gondar Comprehensive Specialized Hospital (UoGCSH), Northwest Ethiopia.

Methods

A cross-sectional study was conducted from June 1 to July 30, 2022, among patients with chronic diseases who were on follow-up at the UoGCSH. Eligible participants were included in the study using a systematic random sampling technique. A structured questionnaire was used and recorded in the Kobo data collection tool. The collected data were managed and analyzed using the Statistical Package for Social Science (SPSS) version 26.

Results

Out of 422 patients approached, 384 (91% response rate) were included in the final analysis. The mean (±SD) age of the participants was 48.07 ± 16.17 years. The overall perceptions mean (±SD) score of the respondents was 3.92 ± 1.06. Generally, near to three-fourths (71.1%) of the participants had a positive perception of TM services, and around two-thirds (63.3%) had a willingness to be involved in the TM service. However, only around one-fourth (24.5%) of the participants were perceived to have a high level of TM practice currently.

Conclusion

The findings suggest that although the level of perception and willingness of TM services among patients with chronic diseases was positive, their level of practice was low. Therefore, creating awareness and suitable conditions to improve their utilization of TM could be important.

Scale up of implementation of a multidimensional intervention to enhance hypertension and diabetes care at the primary care setting: A protocol for a cluster-randomized study in Brazil

BACKGROUND

Hypertension and diabetes mellitus (DM) are highly prevalent in low and middle-income countries (LMICs), and the proportion of patients with uncontrolled diseases is higher than in high-income countries. Innovative strategies are required to surpass barriers of low sources, distance and quality of health care. Our aim is to assess the uptake and effectiveness of the implementation of an integrated multidimensional strategy in the primary care setting, for the management of people with hypertension and diabetes mellitus in Brazil.

METHODS

This scale up implementation study called Control of Hypertension and diAbetes in MINas Gerais (CHArMING) Project has mixed-methods, and comprehends 4 steps: (1) needs assessment, including a standardized structured questionnaire and focus groups with health care practitioners; (2) baseline period, 3 months before the implementation of the intervention; (3) cluster randomized controlled trial (RCT) with a 12-months follow-up period; and (4) a qualitative study after the end of follow-up. The cluster RCT will randomize 35 centers to intervention (n = 18) or usual care (n = 17). Patients ≥18 years old, with diagnosis of hypertension and/or DM, of 5 Brazilian cities in a resource-constrained area will be enrolled. The intervention consists of a multifaceted strategy, with a multidisciplinary approach, including telehealth tools (decision support systems, short message service, telediagnosis), continued education with an approach to issues related to the care of people with hypertension and diabetes in primary care, including pharmacological and non-pharmacological treatment and behavioral change. The project has actions focused on professionals and patients.

CONCLUSIONS

This study consists of a multidimensional strategy with multidisciplinary approach using digital health to improve the control of hypertension and/or DM in the primary health care setting. We expect to provide the basis for implementing an innovative management program for hypertension and DM in Brazil, aiming to reduce the present and future burden of these diseases in Brazil and other LMICs.

CLINICAL TRIAL IDENTIFIER

This study was registered in ClinicalTrials.gov. (NCT05660928).

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The effectiveness of digital health technologies for patients with diabetes mellitus: A systematic review

Introduction

Diabetes mellitus (DM) is a leading cause of morbidity and mortality worldwide. At the same time, digital health technologies (DHTs), which include mobile health apps (mHealth) have been rapidly gaining popularity in the self-management of chronic diseases, particularly following the COVID-19 pandemic. However, while a great variety of DM-specific mHealth apps exist on the market, the evidence supporting their clinical effectiveness is still limited.

Methods

A systematic review was performed. A systematic search was conducted in a major electronic database to identify randomized controlled trials (RCTs) of mHealth interventions in DM published between June 2010 and June 2020. The studies were categorized by the type of DM and impact of DM-specific mHealth apps on the management of glycated haemoglobin (HbA1c) was analysed.

Results

In total, 25 studies comprising 3,360 patients were included. The methodological quality of included trials was mixed. Overall, participants diagnosed with T1DM, T2DM and Prediabetes all demonstrated greater improvements in HbA1c as a result of using a DHT compared with those who experienced usual care. The analysis revealed an overall improvement in HbA1c compared with usual care, with a mean difference of -0.56% for T1DM, -0.90% for T2DM and -0.26% for Prediabetes.

Conclusion

DM-specific mHealth apps may reduce HbA1c levels in patients with T1DM, T2DM and Prediabetes. The review highlights a need for further research on the wider clinical effectiveness of diabetes-specific mHealth specifically within T1DM and Prediabetes. These should include measures which go beyond HbA1c, capturing outcomes including short-term glycemic variability or hypoglycemic events.

Improving Glycemic Control in Type 2 Diabetes Using Mobile Applications and e-Coaching: A Mixed Treatment Comparison Network Meta-Analysis

OBJECTIVES

This study compared the effectiveness of glycemic control among usual care, care management using a mobile application (app), and management using an app with additional e-coaching for patients with type 2 diabetes mellitus (T2DM) using a mixed treatment comparison (MTC) network meta-analysis (NMA).

METHODS

A systematic search for published randomized controlled trials (RCTs) was conducted, which included Pubmed, Web of Science, Cochrane Central Register of Controlled Trials, CINAL, Koreamed, KMbase, and ScienceOn, until October 2020. Among the 10,391 studies identified after removing duplicates, 14 RCTs were finally included in the MTC NMA. Data extraction and methodological quality assessment using version 2 of the Cochrane tool for assessing the risk-of-bias in randomized trials (RoB 2) was performed. The comparative efficacy was analyzed using the random-effects NMA based on a frequentist model by the intervention group and main outcome variables.

RESULTS

At the 3-month follow-up after each intervention, a comparison of the P-scores revealed the app plus e-coaching intervention to be the most effective method for reducing the HbA1c level in a homogeneous gender ratio group (P-score 0.92). At the 6-month follow-up period, app intervention was the best in reducing the HbA1c level in the homogeneous gender ratio and under 60 years of age group (P-score 1.00).

CONCLUSIONS

Based on MTC analysis using the data from published RCTs, mobile apps or apps with e-coaching interventions for T2DM patients were more effective in improving the HbA1c values, FBS, and hypoglycemia frequency than usual care. Nevertheless, further research will be needed to clarify the effects of adding e-coaching to the app.

STUDY REGISTRATION

Research Registry UIN (reviewregistry780).

Willingness to Receive mHealth Messages Among Diabetic Patients at Mizan Tepi University Teaching Hospital: Implications for Digital Health

Background

The growing access and use of mobile technology provide new tools for diabetic care and management. Mobile-based technology (mHealth) is considered as a useful tool to deliver healthcare services as a makeshift alternative for consultations and follow-up of diabetic patients. Therefore, this study aimed to scrutinize the willingness to receive mHealth messages and its associated factors among diabetic patients at Mizan Tepi University Teaching Hospital (MTUTH).

Methods

A cross-sectional study was conducted among two hundred thirty-three diabetic patients. Data were collected using a structured and pre-tested interviewer-administered questionnaire. Epidata manager and SPSS software were used to enter and analyze the data, respectively. Multivariable logistic regression analysis was carried out to identify the independent factors associated with patients' willingness to receive mHealth messages.

Results

Two hundred and thirty-three patients participated in this study with a 95% response rate. Majority of the patients (213, 91.4%) had a mobile phone. Among those who had mobile phones, 59.1%, (95% CI: 48-64) of patients were willing to receive mHealth messages from providers, if they were offered the opportunity. In the multivariable binary logistic regression analysis, monthly income >3000 ETB (AOR = 2.43; 95% CI (1.36-3.81)), owning smartphone (AOR = 3.85; 95% CI (1.67-4.89)), internet access in their mobile phone (AOR = 2.74; 95% CI (1.42-4.61)), perceived usefulness (AOR = 4.66; 95% CI (2.38-6.83)) and perceived ease to use (AOR = 3.87; 95% CI (1.57-5.46)) were identified as significant factors associated with diabetic patients' willingness to receive mHealth messages.

Conclusion

A high proportion of patients who had mobile phones were willing to receive mHealth messages. Monthly income, type of mobile phone, access to the internet on the mobile phone, perceived ease of use, and perceived usefulness were associated with willingness to receive mHealth messages. Therefore, focusing on these factors could provide insight for designing and implementing mHealth messages for diabetic patients.

Virtual management of hypertension: lessons from the COVID-19 pandemic-International Society of Hypertension position paper endorsed by World Hypertension League and European Society of Hypertension

The coronavirus disease 2019 pandemic caused an unprecedented shift from in person care to delivering healthcare remotely. To limit infectious spread, patients and providers rapidly adopted distant evaluation with online or telephone-based diagnosis and management of hypertension. It is likely that virtual care of chronic diseases including hypertension will continue in some form into the future. The purpose of the International Society of Hypertension's (ISH) position paper is to provide practical guidance on the virtual management of hypertension to improve its diagnosis and blood pressure control based on the currently available evidence and international experts' opinion for nonpregnant adults. Virtual care represents the provision of healthcare services at a distance with communication conducted between healthcare providers, healthcare users and their circle of care. This statement provides consensus guidance on: selecting blood pressure monitoring devices, accurate home blood pressure assessments, delivering patient education virtually, health behavior modification, medication adjustment and long-term virtual monitoring. We further provide recommendations on modalities for the virtual assessment and management of hypertension across the spectrum of resource availability and patient ability.

Global eHealth capacity: secondary analysis of WHO data on eHealth and implications for kidney care delivery in low-resource settings

OBJECTIVE

To describe the use of electronic health (eHealth) in support of health coverage for kidney care across International Society of Nephrology (ISN) regions.

DESIGN

Secondary analysis of WHO survey on eHealth as well as use of data from the World Bank, and Internet World Stats on global eHealth services.

SETTING

A web-based survey on the use of eHealth in support of universal health coverage.

PARTICIPANTS

125 WHO member states provided response.

PRIMARY OUTCOME MEASURES

Availability of eHealth services (eg, electronic health records, telehealth, etc) and governance frameworks (policies) for kidney care across ISN regions.

RESULTS

The survey conducted by the WHO received responses from 125 (64.4%) member states, representing 4.4 billion people globally. The number of mobile cellular subscriptions was <100% of the population in Africa, South Asia, North America and North East Asia; the percentage of internet users increased from 2015 to 2020 in all regions. Western Europe had the highest percentage of internet users in all the periods: 2015 (82.0%), 2019 (90.7%) and 2020 (93.9%); Africa had the least: 9.8%, 21.8% and 31.4%, respectively. The North East Asia region had the highest availability of national electronic health record system (75%) and electronic learning access in medical schools (100%), with the lowest in Africa (27% and 39%, respectively). Policies concerning governance aspects of eHealth (eg, privacy, liability, data sharing) were more widely available in high-income countries (55%-93%) than in low-income countries (0%-47%), while access to mobile health for treatment adherence was more available in low-income countries (21%) than in high-income countries (7%).

CONCLUSION

The penetration of eHealth services across ISN regions is suboptimal, particularly in low-income countries. Increasing utilisation of internet communication technologies provides an opportunity to improve access to kidney education and care globally, especially in low-income countries.

Mortality attributable to type 2 diabetes mellitus in Latin America and the Caribbean: a comparative risk assessment analysis

INTRODUCTION

We quantified the proportion and the absolute number of deaths attributable to type 2 diabetes mellitus (T2DM) in Latin America and the Caribbean (LAC) using an estimation approach.

RESEARCH DESIGN AND METHODS

We combined T2DM prevalence estimates from the NCD Risk Factor Collaboration, relative risks between T2DM and all-cause mortality from a meta-analysis of cohorts in LAC, and death rates from the Global Burden of Disease Study 2019. We estimated population-attributable fractions (PAFs) and computed the absolute number of attributable deaths in 1990 and 2019 by multiplying the PAFs by the total deaths in each country, year, sex, and 5-year age group.

RESULTS

Between 1985 and 2014 in LAC, the proportion of all-cause mortality attributable to T2DM increased from 12.2% to 16.9% in men and from 14.5% to 19.3% in women. In 2019, the absolute number of deaths attributable to T2DM was 349 787 in men and 330 414 in women. The highest death rates (deaths per 100 000 people) in 2019 were in Saint Kitts and Nevis (325 in men, 229 in women), Guyana (313 in men, 272 in women), and Haiti (269 in men, 265 in women).

CONCLUSIONS

A substantial burden of all deaths is attributed to T2DM in LAC. To decrease the mortality attributable to T2DM in LAC, policies are needed to strengthen early diagnosis and management, along with the prevention of complications.

Effect of an Integrative Mobile Health Intervention in Patients With Hypertension and Diabetes: Crossover Study

Background

Obesity, hypertension, and type 2 diabetes mellitus (T2DM) are worldwide epidemics that inflict burdens on both public health and health care costs. Self-management plays an important role in the proper management of these 3 chronic diseases, and in this context, mobile health (mHealth) can be a cost-effective self-management tool.

Objective

The aim of this pilot study is to evaluate the effects of an integrative mHealth approach for obesity, hypertension, and T2DM on body fat, blood pressure, and blood glucose levels and demonstrate the clinical outcomes. The participants were patients aged 40 to 70 years who were treated for T2DM (hemoglobin A_1c [HbA_1c] above 6.0%) without insulin or hypertension and obesity, controlled with pharmacotherapy.

Methods

This pilot study was performed using a controlled, randomized, 3-month, 2-period crossover design. A total of 37 participants were recruited from 2 university hospitals in South Korea. Integrative mHealth comprised 4 parts: self-measuring home devices for monitoring blood glucose and blood pressure; 2 smartphone apps, where one gathered lifestyle data, giving them feedback with health information, and the other provided drug information and reminders of the medication schedule; unmanned kiosks for official measurement of blood pressure and body composition; and web-based access to participants’ health information.

Results

Data from the 32 participants were analyzed. Their mean HbA_1c level was 7.5% (SD 0.8, ranging from 6.1% to 9.4%). Approximately 38% (12/32) of the participants had hypertension. BMIs of all participants except 1 were >23 kg/m². The input rates of food intake and exercise to the smartphone app were very low (24.9% and 5.3%, respectively). On the contrary, the input rate of medicine intake was high (84.0%). Moreover, there was no significant difference in the input rate of taking medicine irrespective of whether the mHealth period was before or after the conventional treatment period (80.3% and 87.3%, respectively; P=.06). Among the 3 input functions of food intake, exercise, and medicine intake in smartphone apps, the input of medicine intake was a more helpful, easier to use, and better-designed function than the others. There were no significant differences in changes in body weight (−0.519 kg vs 0 kg), BMI (−0.133 kg/m² vs −0.167 kg/m²), body composition (body fat −0.255% vs 0.172%), blood pressure (systolic −0.226 mm Hg vs −2.839 mm Hg), and HbA_1c (−0.269% vs –0.009%) between the integrative mHealth and conventional treatment groups. However, in proportion to the elevation in the input rate of taking medicine, body fat mass (P=.04) and HbA_1c (P=.03) were lower in the integrative mHealth group.

Conclusions

Although smartphone apps can influence body fat and blood glucose levels, they have failed to show clinical improvement. A higher input rate of taking medicine was related to significantly lower body fat mass and HbA_1c levels.

10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

On the efficacy of behavior change techniques in mHealth for self-management of diabetes: A meta-analysis

BACKGROUND

Diabetes prevalence has become a global crisis. Due to the substantial rise in smartphone use, a variety of mobile interventions have been developed to help improve the clinical outcomes of diabetes patients.

OBJECTIVES

This study seeks to examine specific behavior change theories and techniques used in the design of self-management mobile app-based interventions aimed at achieving glycemic control in type 1 and type 2 diabetes.

METHODS

A meta-analysis of randomized control trials published in PubMed/Medline and Web of Science between January 2010 and October 2020 was conducted using studies that included diabetes patients, reported on well-described mobile app-based interventions, compared mHealth to usual care, and evaluated glycated hemoglobin (HbA1c) at baseline and follow-up.

RESULTS

We reported on 21 studies with a total of 1,920 diabetes patients. Our findings show that mHealth apps led to statistically significant clinical outcomes as compared to standard care for glycemic control (-0.38, 95% CI = -0.50 to -0.25, p < 0.0001) indicating that such interventions result in a reduction in HbA1c. Interventions that used behavior theory for developing mHealth apps were not statistically different from those that did not (p = 0.18). However, increased use of behavior change techniques (BCTs) may result in slightly higher HbA1c reduction. Among all BCTs, the most effective ones appear to be "Action planning" and "Self-monitoring of outcome(s) of behavior.

CONCLUSIONS

The current meta-analysis provides evidence that mHealth is likely to be beneficial for diabetes patients when the right behavior change techniques are applied to realize the full advantage of the intervention. Further investigation of the role of theory in the design of mHealth app-based interventions is warranted.

Hypertension in Low- and Middle-Income Countries

In recent decades low- and middle-income countries (LMICs) have been witnessing a significant shift toward raised blood pressure; yet in LMICs, only 1 in 3 are aware of their hypertension status, and ≈8% have their blood pressure controlled. This rising burden widens the inequality gap, contributes to massive economic hardships of patients and carers, and increases costs to the health system, facing challenges such as low physician-to-patient ratios and lack of access to medicines. Established risk factors include unhealthy diet (high salt and low fruit and vegetable intake), physical inactivity, tobacco and alcohol use, and obesity. Emerging risk factors include pollution (air, water, noise, and light), urbanization, and a loss of green space. Risk factors that require further in-depth research are low birth weight and social and commercial determinants of health. Global actions include the HEARTS technical package and the push for universal health care. Promising research efforts highlight that successful interventions are feasible in LMICs. These include creation of health-promoting environments by introducing salt-reduction policies and sugar and alcohol tax; implementing cost-effective screening and simplified treatment protocols to mitigate treatment inertia; pooled procurement of low-cost single-pill combination therapy to improve adherence; increasing access to telehealth and mHealth (mobile health); and training health care staff, including community health workers, to strengthen team-based care. As the blood pressure trajectory continues creeping upward in LMICs, contextual research on effective, safe, and cost-effective interventions is urgent. New emergent risk factors require novel solutions. Lowering blood pressure in LMICs requires urgent global political and scientific priority and action.

On-demand mobile health infrastructures to allow comprehensive remote atrial fibrillation and risk factor management through teleconsultation

BACKGROUND

Although novel teleconsultation solutions can deliver remote situations that are relatively similar to face-to-face interaction, remote assessment of heart rate and rhythm as well as risk factors remains challenging in patients with atrial fibrillation (AF).

HYPOTHESIS

Mobile health (mHealth) solutions can support remote AF management.

METHODS

Herein, we discuss available mHealth tools and strategies on how to incorporate the remote assessment of heart rate, rhythm and risk factors to allow comprehensive AF management through teleconsultation.

RESULTS

Particularly, in the light of the coronavirus disease 2019 (COVID-19) pandemic, there is decreased capacity to see patients in the outpatient clinic and mHealth has become an important component of many AF outpatient clinics. Several validated mHealth solutions are available for remote heart rate and rhythm monitoring as well as for risk factor assessment. mHealth technologies can be used for (semi-)continuous longitudinal monitoring or for short-term on-demand monitoring, dependent on the respective requirements and clinical scenarios. As a possible solution to improve remote AF care through teleconsultation, we introduce the on-demand TeleCheck-AF mHealth approach that allows remote app-based assessment of heart rate and rhythm around teleconsultations, which has been developed and implemented during the COVID-19 pandemic in Europe.

CONCLUSION

Large scale international mHealth projects, such as TeleCheck-AF, will provide insight into the additional value and potential limitations of mHealth strategies to remotely manage AF patients. Such mHealth infrastructures may be well suited within an integrated AF-clinic, which may require redesign of practice and reform of health care systems.