Improving type 1 diabetes management with mobile tools: a systematic review

Telehealth model versus in-person standard care for persons with type 1 diabetes treated with multiple daily injections: an open-label randomized controlled trial

Objective

Increasing evidence indicates that the telehealth (TH) model is noninferior to the in-person approach regarding metabolic control in type 1 diabetes (T1D) and offers advantages such as a decrease in travel time and increased accessibility for shorter/frequent visits. The primary aim of this study was to compare the change in glycated hemoglobin (HbA1c) at 6 months in T1D care in a rural area between TH and in-person visits.

Research design and methods

Randomized controlled, open-label, parallel-arm study among adults with T1D. Participants were submitted to in-person visits at baseline and at months 3 and 6 (conventional group) or teleconsultation in months 1 to 4 plus 2 in-person visits (baseline and 6 months) (TH group). Mixed effects models estimated differences in HbA1c changes.

Results

Fifty-five participants were included (29 conventional/26 TH). No significant differences in HbA1c between groups were found. Significant improvement in time in range (5.40, 95% confidence interval (CI): 0.43-10.38; p < 0.05) and in time above range (-6.34, 95% CI: -12.13- -0.55;p < 0.05) in the TH group and an improvement in the Diabetes Quality of Life questionnaire (EsDQoL) score (-7.65, 95% CI: -14.67 - -0.63; p < 0.05) were observed. In TH, the costs for the participants were lower.

Conclusions

The TH model is comparable to in-person visits regarding HbA1c levels at the 6-month follow-up, with significant improvement in some glucose metrics and health-related quality of life. Further studies are necessary to evaluate a more efficient timing of the TH visits.

Improving the Quality of Life of Patients with an Underactive Thyroid Through mHealth: A Patient-Centered Approach

Background: Three hundred fifty million people worldwide suffer from underactive thyroid conditions, which can lead to infertility, obesity, heart disease, and impaired mental health when poorly managed. Although mobile health (mHealth) applications can be a useful solution for self-managing one's condition, the impact of digital solutions for improving the health of thyroid patients remains unknown. Methods: We used a mixed methods analysis to assess the ways in which a digital approach might benefit thyroid patients. A cross-sectional study was conducted among users of BOOST Thyroid, an mHealth application for patients with an underactive thyroid. We collected data using a modified Short Form 36 Health Survey Questionnaire to measure the impact of in the app on participants' perceived health and quality of life. Participants were asked to (1) score their quality of life before and after using the app, and (2) describe whether and how using the app helped them. Results: We enrolled 406 users (380 females and 26 males), aged 18-78 years. Most participants (95.8%) reported using the app was helpful; of which 68% reported it improved their quality of life and 70.8% reported it had a positive impact on their health. Participants who found the app useful experienced less symptoms and a lower intensity of remaining symptoms. A key factor reported by these participants as helping with managing their health is the information provided in the app. Conclusions: The results support the idea that a patient-centered treatment would benefit from including mHealth tools for a daily self-management of underactive thyroid condition, as it can increase health literacy and improve both one's health status and quality of life.

American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus

OBJECTIVE

To provide evidence-based recommendations regarding the use of advanced technology in the management of persons with diabetes mellitus to clinicians, diabetes-care teams, health care professionals, and other stakeholders.

METHODS

The American Association of Clinical Endocrinology (AACE) conducted literature searches for relevant articles published from 2012 to 2021. A task force of medical experts developed evidence-based guideline recommendations based on a review of clinical evidence, expertise, and informal consensus, according to established AACE protocol for guideline development.

MAIN OUTCOME MEASURES

Primary outcomes of interest included hemoglobin A1C, rates and severity of hypoglycemia, time in range, time above range, and time below range.

RESULTS

This guideline includes 37 evidence-based clinical practice recommendations for advanced diabetes technology and contains 357 citations that inform the evidence base.

RECOMMENDATIONS

Evidence-based recommendations were developed regarding the efficacy and safety of devices for the management of persons with diabetes mellitus, metrics used to aide with the assessment of advanced diabetes technology, and standards for the implementation of this technology.

CONCLUSIONS

Advanced diabetes technology can assist persons with diabetes to safely and effectively achieve glycemic targets, improve quality of life, add greater convenience, potentially reduce burden of care, and offer a personalized approach to self-management. Furthermore, diabetes technology can improve the efficiency and effectiveness of clinical decision-making. Successful integration of these technologies into care requires knowledge about the functionality of devices in this rapidly changing field. This information will allow health care professionals to provide necessary education and training to persons accessing these treatments and have the required expertise to interpret data and make appropriate treatment adjustments.

Telemetric Interventions Offer New Opportunities for Managing Type 1 Diabetes Mellitus: Systematic Meta-review

BACKGROUND

The prevalence of diabetes mellitus (DM) is increasing rapidly worldwide. Simultaneously, technological advances are offering new opportunities for better management of type 1 diabetes mellitus (T1DM). Telemetry, the remote acquisition of patient data via a telecommunication system, is a promising field of application in eHealth and is rapidly gaining importance.

OBJECTIVE

The aim of this study was to summarize the current evidences available on the effectiveness of telemetric approaches in T1DM management. This systematic meta-review examined different types of interventions of the technologies used in communication between health care professionals and patients as well as the key outcomes.

METHODS

We performed a systematic search in Web of Science Core Collection, EMBASE, Cochrane Library, MEDLINE via PubMed, and CINAHL databases in April 2020 with regard to the effectiveness of telemetric interventions for T1DM. We classified the interventions into 4 categories according to the technology used: (1) real-time video communication, (2) real-time audio communication, (3) asynchronous communication, and (4) combined forms of communication (real-time and asynchronous). We considered various study designs such as systematic reviews, clinical trials, meta-analyses, and randomized controlled trials and focused on the key outcomes. Additionally, a funnel plot based on hemoglobin A_1c (HbA_1c) values and different quality assessments were performed.

RESULTS

We identified 17 (6 high quality and 9 moderate quality) eligible publications: randomized controlled trials (n=9), systematic reviews and meta-analyses (n=5), cohort studies (n=2), and qualitative publications (n=1). Of 12 studies, 8 (67%) indicated a (significant or nonsignificant) reduction in HbA_1c levels; 65% (11/17) of the studies reported overall (mildly) positive effects of telemetric interventions by addressing all the measured outcomes. Asynchronous interventions were the most successful for patients diagnosed with T1DM, but no technology was clearly superior. However, there were many nonsignificant results and not sustained effects, and in some studies, the control group benefited from telemetric support or increased frequency of contacts.

CONCLUSIONS

Based on the currently available literature, this systematic meta-review shows that telemetric interventions cause significant reduction in HbA_1c levels and result in overall positive effects in T1DM management. However, more specified effects of telemetric approaches in T1DM management should be analyzed in detail in larger cohorts.

Effects of mobile health interventions on improving glycemic stability and quality of life in patients with type 1 diabetes: A meta-analysis

This meta-analysis aimed to examine the effects of mobile-health-based (mHealth) interventions on improving glycemic stability and quality of life (QOL) in patients with type 1 diabetes (T1D). Various databases, including PubMed, Embase, CINAHL, Cochrane Library, ProQuest, Chinese Electronic Periodical Services, and China Knowledge Resource Integrated, were used to search for relevant articles. A fixed-effects model or random-effects model was used to examine the overall effect. Various methods, including Egger's test, Begg's test, and trim-and-fill, were adopted to examine publication bias. In total, 26 studies were recruited. Results of the random-effects model showed that the use of mHealth-based interventions significantly decreased glycated hemoglobin (HbA1c) (mean difference = -0.37, 95% confidence interval (CI) = -0.53 to -0.22, p < .001), and improved life satisfaction (Hedges' g = 0.30, 95% CI = 0.10 to 0.50, p = .003), worry of diabetes (Hedges' g = -0.25, 95% CI = -0.41 to 0.08, p = .004), and mental health (Hedges' g = 0.36, 95% CI = 0.08 to 0.64, p = .012). Both adults and youths with T1D can benefit from mHealth-based interventions to improve HbA1c (Hedges' g = -0.44, p = .002 vs. -0.30, p = .003). The effect of mHealth-based interventions on improving QOL in both adults and youths could not be examined due to only one study published in adults with T1D. Moreover, those studies that included the function of feedback from professionals showed a significant effect of decreasing HbA1c compared to those without that function (Hedges' g = -0.48 vs. -0.16, p = .019). Mobile devices are convenient, instantaneous, and easy to use to communicate. Applying mHealth-based interventions with the function of feedback from professionals can be considered an alternative healthcare service to achieve optimal glycemic stability in adults and youths with T1D.

E-health education interventions on HbA1c in patients with type 1 diabetes on intensive insulin therapy: A systematic review and meta-analysis of randomized controlled trials

AIMS

Patient-centered education improves glycemic control in subjects with type 1 diabetes (T1D). E-health technologies are widely used to support medical decision-making, patient advising or teleconsultations; however, the active participation of a patient is missing. Challenges remain whether e-health education can be effectively incorporated into clinical pathways. The purpose of the study was to examine the effects of e-health education, compared to standard care, on HbA_1c. MATERIAL AND METHODS: We conducted a literature search (EMBASE, MEDLINE, The Cochrane Library and Web of Science) up to February 2018 for randomized controlled trials (RCTs) of Internet-/ mobile application-based educational interventions, with the active involvement of patients, provided in addition to, or substituting usual care in patients with T1D on intensive insulin therapy. The primary outcome was the standardized difference in means (SDM) of HbA_1c change from baseline between intervention and comparator groups.

RESULTS

Eight RCTs involving 757 subjects were included on 6335 screened citations. After excluding two trials with a high risk of bias from the meta-analysis, the HbA_1c change from baseline did not significantly differ between intervention and comparator groups (SDM = -0.154, 95% CI: -0.335 to 0.025; P = 0.01, random-effect model). The number of studies is limited with a relatively short duration. Reporting of educational outcomes was not rigorous.

CONCLUSIONS

The effect of e-health educational interventions on HbA_1c in patients with T1D is comparable to the standard care. This review highlights the need for further well-designed RCTs that will investigate the opportunities of incorporating e-health education into clinical pathways.

Patient experiences with technology enabled care across healthcare settings- a systematic review

BACKGROUND

Healthcare services are facing extensive challenges due to the increased proportion of elderly persons and persons with chronic disease. Technology enabled care (TEC) is a collective term for telecare, telehealth, telemedicine, mobile (m)-, digital- and electronic (e) health services. TEC is increasingly seen as a solution to many of the challenges facing the health sector. Patient perspectives may provide a useful evaluation tool for new healthcare technologies that have limited clinical data to support their effectiveness. More studies need to be done to better understand the acceptance of technology in healthcare. This review aim to summarize empirical studies exploring patient experiences with TEC. Findings in this study can be used to better understand what is needed to develop, implement and improve such services.

METHODS

Systematic searches were conducted in the Pubmed, Psycinfo, Cinahl, Embase, Cochrane systematic reviews and Cochrane clinical trials databases. These studies were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, subjected to quality appraisals using the Critical Appraisal Skills Program (CASP), and synthesized via integrative analysis.

RESULTS

After removal of duplicates, languages other than English, and non-scientific records, 4087 titles and abstracts were screened. After assessment against inclusion and exclusion criteria, 69 records were screened in full-text, and underwent quality appraisal. 21 records were included in the integrative analysis. Patients' experiences with TEC related to 1) technological features, namely functionality and appearance, and 2) evolving independence, namely empowerment, autonomy and security. Technological challenges lead to frustrations and negative experiences, while a stigmatizing appearance lead to patients not using the solution. Through the use of TECs, patients felt more empowered, learning about their condition, increasing awareness to their symptoms and treatment, and feeling more safe and self-efficient. Patient participation was seen as a central aspect of the development of the TECT, as well as when using it.

CONCLUSION

This review deepens the understanding of patients' experiences with technology enabled care solutions. Patients' experiences not only relate to the practical/technical element of the device or solution, but to how this impact on their everyday life. Patient participation in development and planned use of such solutions should be considered an integral part in healthcare quality initiatives.

Testing Usability and Feasibility of a Mobile Educator Tool for Pediatric Diabetes Self-Management: Mixed Methods Pilot Study

BACKGROUND

Mobile interventions hold promise as an intervention modality to engage children in improving diabetes self-management education, attitudes, and behaviors.

OBJECTIVE

This pilot study aimed to explore the usability, acceptability, and feasibility of delivering a mobile diabetes educational tool to parent-child pairs in a clinical setting.

METHODS

This mixed methods pilot study comprised two concurrent phases with differing study participants. Phase 1 used user testing interviews to collect qualitative data on the usability and acceptability of the tool. Phase 2 used a single-arm pre- and poststudy design to quantitatively evaluate the feasibility and preliminary efficacy of the intervention. Study participants (English-speaking families with youth aged 5-14 years with insulin-dependent diabetes) were recruited from an urban hospital in Massachusetts, United States. In phase 1, parent-child pairs were invited to complete the intervention together and participate in 90-min user testing interviews assessing the tool's usability and acceptability. Interview transcripts were analyzed using a directed content analysis approach. In phase 2, parent-child pairs were invited to complete the intervention together in the clinical setting. Measures included parental and child knowledge, attitudes, and behaviors related to diabetes management (self-report surveys) and child hemoglobin A1c levels (medical record extractions); data were collected at baseline and 1-month follow-up. Pre- and postoutcomes were compared using paired t tests and the Fisher exact test.

RESULTS

A total of 11 parent-child pairs (N=22) participated in phase 1 of the study, and 10 parent-child pairs (N=20) participated in phase 2 of the study. Participants viewed the mobile educational tool as acceptable (high engagement and satisfaction with the layout, activities, and videos) and identified the areas of improvement for tool usability (duration, directions, and animation).

CONCLUSIONS

The findings from this pilot study suggest that the mobile educational tool is an informative, engaging, and feasible way to deliver diabetes self-management education to parents and children in an urban hospital setting. Data will inform future iterations of this mobile diabetes educational intervention to improve usability and test intervention efficacy.

Efectividad de las tecnologías de la información y comunicación en la adherencia terapéutica de pacientes con Hipertensión Arterial y Diabetes Mellitus

2222 Enferm Nefrol. 2020 Ene-Mar;23(1):22-32ResumenIntroducción: La hipertensión arterial y la diabetes me-llitus son dos de las principales causas de morbimortali-dad, siendo las precursoras de la enfermedad renal cróni-ca, catalogándose como un problema de salud pública que afecta a uno de cada diez adultos en el mundo. La falta de cumplimiento al tratamiento es la mayor causa de fra-caso en los programas de promoción y prevención, con esta revisión sistemática se busca aportar a los profesio-nales de enfermería evidencia científica a través del uso de las tecnologías de la información y la comunicación que permitan mejorar la adherencia terapéutica.Objetivo: Identificar la efectividad de las tecnologías de la información y la comunicación en la adherencia tera-péutica en personas con Hipertensión Arterial y Diabetes Mellitus. Material y Método. Se realizó una revisión sistemática de literatura en las bases de datos CUIDEN, CINAHL, COCHRANE, LILACS, PUBMED y OVID NURSING. Después de aplicar filtros de selección y listas de verifica-cion de calidad metodológica se obtuvieron 18 artículos para análisis, 12 ensayos clínicos aleatorizados, 3 estu-dios cuasi-experimentales y 3 revisiones sistemáticas. Se clasificó el nivel de evidencia de los estudios según el ins-tituto Joanna Briggs. Resultados. Se establecieron 3 categorías: Interven-ciones unicomponente, intervenciones multicomponente y rol de enfermería en el uso de TICs para favorecer la adherencia. Conclusiones. Dentro del cuidado de la salud actualmen-te hay hallazgos iniciales que apoyan la efectividad del uso de las tecnologías de la información y la comunica-ción convirtiéndola en una herramienta que favorece la adherencia al tratamiento en pacientes con hipertensión arterial y diabetes mellitus.

Mobile Health to Support Ageing in Place

The study reported in this article aimed to identify: i) the most relevant application domains of mHealth to support older adults in their domiciles; ii) the most relevant chronic conditions of older adults, whose management is being supported by mHealth; iii) the characteristics, outcomes and impacts of mHealth tools that might support older adults in their domiciles. The method of a systematic review of reviews and meta-analyses was performed based on a search of the literature. The result of a total of 66 reviews and meta-analyses across several chronic diseases were retrieved. These studies compare mHealth interventions with usual care. The conclusion is that mHealth interventions have positive effects on various health related outcomes, but further research is required to allow their incorporation in the clinical practice.

Real-World Assessments of mySugr Mobile Health App

Mobile health (mHealth) solutions such as diabetes self-management apps improve glycated hemoglobin, particularly those that provide a feedback loop between patient and health care provider. mHealth apps that incorporate behaviorally designed interventions can improve patient access to diabetes self-management education and ongoing support. The mySugr mobile app was designed to support patients in their diabetes self-management. Most studies of mHealth apps were conducted under controlled conditions and did not elucidate the nuances of patient perceptions and utilization of these apps in everyday life. In this article, we discuss findings from real-world observations of changes in glycemic control and patient satisfaction associated with the use of the mySugr mHealth app.

Internet videoconferencing for patient-clinician consultations in long-term conditions: A review of reviews and applications in line with guidelines and recommendations

Background

The use of internet videoconferencing in healthcare settings is widespread, reflecting the normalisation of this mode of communication in society and current healthcare policy. As the use of internet videoconferencing is growing, increasing numbers of reviews of literature are published.

Methods

The authors conducted a review of the existing reviews of literature relating to the use of internet videoconferencing for consultations between healthcare professionals and patients with long-term conditions in their own home. The review was followed with an assessment of United Kingdom National Institute for Health and Clinical Excellence guidelines for patient care in the context of common long-term illnesses to examine where videoconferencing could be implemented in line with these recommendations.

Results

The review of reviews found no formal evidence in favour of or against the use of internet videoconferencing. Patients were satisfied with the use of videoconferencing but there was limited evidence that it led to a change in health outcomes. Evidence of healthcare professional satisfaction when using this mode of communication with patients was limited. The review of guidelines suggested a number of opportunities for adoption and expansion of internet videoconferencing. Implementing videoconferencing in line with current evidence for patient care could offer support and provide information on using a communication channel that suits individual patient needs and circumstances. The evidence base for videoconferencing is growing, but there is still a lack of data relating to cost, ethics and safety.

Conclusions

While the current evidence base for internet videoconferencing is equivocal, it is likely to change as more research is undertaken and evidence published. With more videoconferencing services added in more contexts, research needs to explore how internet videoconferencing can be implemented in ways that it is valued by patients and clinicians, and how it can fit within organisational and technical infrastructure of the healthcare services.

Mobile phone applications for diabetes management: A systematic review

INTRODUCTION

The number of mobile applications (apps) related to health is increasing, and diabetes mellitus (DM) is not an exception. The aim of this study was to assess the free mobile applications for the management of diabetes available, in Spanish, in the Spanish market.

METHODS

GooglePlay (Android) and AppStore (iOS) were reviewed to identify free apps, in Spanish, aimed at people with diabetes. Their main functions and a series of quality and usability features were evaluated and scored. These scores were used to make a top list with the best apps.

RESULTS

Out of 794 registered apps, 42 were evaluated and included in the quality assessment, while 34 apps were included in the usability assessment. The main function of most of the apps was to act as a blood glucose diary (n: 30; 71.43%). As for privacy, most of the applications (33 apps; 78.6%) access device/personal data. Only a minority of apps [3 (7.1%)] reported being based on evidence, and only 3 apps (7.1%) had a quality label. The top scored apps were: OneTouch Reveal™, Social Diabetes™, mySugr: App Diario de diabetes™, Diabetes menú™, Tactio SALUD™ and Diabetes:M™.

CONCLUSIONS

There are few free apps for diabetes management available in Spanish, most lack quality certification and very few provide scientific references about their content. Furthermore, most of the apps access personal/device data.

Adolescents' participation in their healthcare: A sociomaterial investigation of a diabetes app

OBJECTIVE

This article explores how a diabetes app called Diapplo affected adolescents' participation in their healthcare by investigating adolescents' meaning-making in relation to their use of the app.

METHODS

Using a qualitative single case-study design, we adopted a multimethod responsive approach to data generation that included written data from the app development process, individual and group interviews and observations of the adolescents in the clinical situation. This article presents the results from a qualitative content analysis of group and individual semi-structured interviews conducted with five adolescents diagnosed with type 1 diabetes during and after the four-week test phase of a prototype of the app.

RESULTS

The adolescents appreciated the diabetes app's design and interface and having an overview of their blood glucose values. However, they stated that the app's content only partly met their needs and they considered several of its features unnecessary. They would have liked the app to have a social platform and emphasized that the app should be compatible with their blood glucose monitors and pumps for them to continue using it.

CONCLUSIONS

The participants in our study highlighted the value of social platforms integrated in health apps for patient participation, as well as their preference for health app features that reduced the effort of managing their chronic condition and facilitate greater knowledge. Theories of sociomateriality and material participation helped to account for the challenges of integrating users' perspectives, suggesting the value of early, comprehensive identification and prioritization of users' values when developing mobile health technologies.

mHealth App Patient Testing and Review of Educational Materials Designed for Self-Management of Gout Patients: Descriptive Qualitative Studies

BACKGROUND

Gout is a form of chronic arthritis caused by elevated serum uric acid (SUA) and culminates in painful gout attacks. Although effective uric acid-lowering therapies exist, adherence is low. This is partly due to the lack of support for patients to self-manage their disease. Mobile health apps have been used in the self-management of chronic conditions. However, not all are developed with patients, limiting their effectiveness.

OBJECTIVE

The objective of our study was to collect feedback from gout patients to design an effective gout self-management app.

METHODS

Two descriptive qualitative studies were conducted. In Study 1, researchers developed a short educational video and written materials about gout management, designed to be embedded into an app; 6 interviews and 1 focus group were held with gout patients to gather feedback on these materials. Usability testing in Study 2 involved additional gout patients using a pilot version of Healthy.me Gout, a gout self-management app, for 2 weeks. Following the trial, patients participated in an interview about their experiences using the app.

RESULTS

Patients viewed the gout educational material positively, appreciating the combined use of video, text, and images. Patients were receptive to using a mobile app to self-manage their gout. Feedback about Healthy.me Gout was generally positive with patients reporting that the tracking and diary features were most useful. Patients also provided suggestions for improving the app and educational materials.

CONCLUSIONS

These studies involved patients in the development of a gout self-management app. Patients provided insight to improve the app's presentation and usability and general lessons on useful features for chronic disease apps. Gout patients enjoyed tracking their SUA concentrations and gout attack triggers. These capabilities can be translated into self-management apps for chronic diseases that require monitoring of pathological values, medication adherence, or symptoms. Future health app design should integrate patient input and be developed iteratively to address concerns identified by patients.

Comparative effectiveness of telemonitoring versus usual care for type 2 diabetes: A systematic review and meta-analysis

AIMS

This study evaluated clinical effectiveness of telemonitoring on the management of patients with type 2 diabetes.

METHODS

We searched Ovid-Medline, Ovid-EMBASE, and the Cochrane Library to identify randomized controlled trials that compared telemonitoring and usual care in patients with type 2 diabetes.

RESULTS

Thirty-eight studies (6855 patients) were included. Telemonitoring was associated with a significant decrease in glycated haemoglobin levels compared to usual care (weighted mean difference -0.42%, 95% confidence interval -0.56 to -0.27) but there was evidence of heterogeneity (I²= 96.9%). Telemonitoring was associated with a significant glycated haemoglobin reduction when biological data were transmitted through a web-based device weekly, when voice feedback was performed daily or immediately and when patients were provided with counselling. Telemonitoring also reduced glycated haemoglobin level in studies that monitored patients' medication adherence, provided counselling, education and alarm message. The rate of achieving glycated haemoglobin levels of < 7% was 1.8 times higher in the telemonitoring group compared to the usual care group (risk ratio 1.83, 95% confidence interval 1.35 to 2.47, I²= 0%). There was also significant reduction in systolic blood pressure (weighted mean difference -1.33 mm Hg) and body mass index (weighted mean difference -0.25 kg/m²), but the clinical relevance of these results can be questioned. The data available on patient satisfaction, quality of life, medication adherence, prescription changes, stress and depression were limited.

CONCLUSIONS

Telemonitoring interventions may be a better option than usual care in improving glycated haemoglobin control of patients with type 2 diabetes. Further studies should assess clinical benefit according to specific delivery modes of the intervention and patient-reported outcomes.

Distal technologies and type 1 diabetes management

Type 1 diabetes requires intensive self-management to avoid acute and long-term health complications. In the past two decades, substantial advances in technology have enabled more effective and convenient self-management of type 1 diabetes. Although proximal technologies (eg, insulin pumps, continuous glucose monitors, closed-loop and artificial pancreas systems) have been the subject of frequent systematic and narrative reviews, distal technologies have received scant attention. Distal technologies refer to electronic systems designed to provide a service remotely and include heterogeneous systems such as telehealth, mobile health applications, game-based support, social platforms, and patient portals. In this Review, we summarise the empirical literature to provide current information about the effectiveness of available distal technologies to improve type 1 diabetes management. We also discuss privacy, ethics, and regulatory considerations, issues of global adoption, knowledge gaps in distal technology, and recommendations for future directions.

The role of digital communication in patient–clinician communication for NHS providers of specialist clinical services for young people [the Long-term conditions Young people Networked Communication (LYNC) study]: a mixed-methods study

Background

Young people (aged 16–24 years) with long-term health conditions tend to disengage from health services, resulting in poor health outcomes. They are prolific users of digital communications. Innovative UK NHS clinicians use digital communication with these young people. The NHS plans to use digital communication with patients more widely.

Objectives

To explore how health-care engagement can be improved using digital clinical communication (DCC); understand effects, impacts, costs and necessary safeguards; and provide critical analysis of its use, monitoring and evaluation.

Design

Observational mixed-methods case studies; systematic scoping literature reviews; assessment of patient-reported outcome measures (PROMs); public and patient involvement; and consensus development through focus groups.

Setting

Twenty NHS specialist clinical teams from across England and Wales, providing care for 13 different long-term physical or mental health conditions.

Participants

One hundred and sixty-five young people aged 16–24 years living with a long-term health condition; 13 parents; 173 clinical team members; and 16 information governance specialists.

Interventions

Clinical teams and young people variously used mobile phone calls, text messages, e-mail and voice over internet protocol.

Main outcome measures

Empirical work – thematic and ethical analysis of qualitative data; annual direct costs; did not attend, accident and emergency attendance and hospital admission rates plus clinic-specific clinical outcomes. Scoping reviews–patient, health professional and service delivery outcomes and technical problems. PROMs: scale validity, relevance and credibility.

Data sources

Observation, interview, structured survey, routinely collected data, focus groups and peer-reviewed publications.

Results

Digital communication enables access for young people to the right clinician when it makes a difference for managing their health condition. This is valued as additional to traditional clinic appointments. This access challenges the nature and boundaries of therapeutic relationships, but can improve them, increase patient empowerment and enhance activation. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, but clinicians and young people mitigate these risks. Workload increases and the main cost is staff time. Clinical teams had not evaluated the impact of their intervention and analysis of routinely collected data did not identify any impact. There are no currently used generic outcome measures, but the Patient Activation Measure and the Physicians’ Humanistic Behaviours Questionnaire are promising. Scoping reviews suggest DCC is acceptable to young people, but with no clear evidence of benefit except for mental health.

Limitations

Qualitative data were mostly from clinician enthusiasts. No interviews were achieved with young people who do not attend clinics. Clinicians struggled to estimate workload. Only eight full sets of routine data were available.

Conclusions

Timely DCC is perceived as making a difference to health care and health outcomes for young people with long-term conditions, but this is not supported by evidence that measures health outcomes. Such communication is challenging and costly to provide, but valued by young people.

Future work

Future development should distinguish digital communication replacing traditional clinic appointments and additional timely communication. Evaluation is needed that uses relevant generic outcomes.

Study registration

Two of the reviews in this study are registered as PROSPERO CRD42016035467 and CRD42016038792.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A Systematic Review of Reviews Evaluating Technology-Enabled Diabetes Self-Management Education and Support

BACKGROUND

Since the introduction of mobile phones, technology has been increasingly used to enable diabetes self-management education and support. This timely systematic review summarizes how currently available technology impacts outcomes for people living with diabetes.

METHODS

A systematic review of high quality review articles and meta analyses focused on utilizing technology in diabetes self-management education and support services was conducted. Articles were included if published between January 2013 and January 2017.

RESULTS

Twenty-five studies were included for analysis. The majority evaluated the use of mobile phones and secure messaging. Most studies described healthy eating, being active and metabolic monitoring as the predominant self-care behaviors evaluated. Eighteen of 25 reviews reported significant reduction in A1c as an outcome measure. Four key elements emerged as essential for improved A1c: (1) communication, (2) patient-generated health data, (3) education, and (4) feedback.

CONCLUSION

Technology-enabled diabetes self-management solutions significantly improve A1c. The most effective interventions incorporated all the components of a technology-enabled self-management feedback loop that connected people with diabetes and their health care team using 2-way communication, analyzed patient-generated health data, tailored education, and individualized feedback. The evidence from this systematic review indicates that organizations, policy makers and payers should consider integrating these solutions in the design of diabetes self-management education and support services for population health and value-based care models. With the widespread adoption of mobile phones, digital health solutions that incorporate evidence-based, behaviorally designed interventions can improve the reach and access to diabetes self-management education and ongoing support.

The Use of Mobile Health to Deliver Self-Management Support to Young People With Type 1 Diabetes: A Cross-Sectional Survey

BACKGROUND

Young people living with type 1 diabetes face not only the challenges typical of adolescence, but also the challenges of daily management of their health and evolving understanding of the impact of their diagnosis on their future. Adolescence is a critical time for diabetes self-management, with a typical decline in glycemic control increasing risk for microvascular diabetes complications. To improve glycemic control, there is a need for evidence-based self-management support interventions that address the issues pertinent to this population, utilizing platforms that engage them. Increasingly, mobile health (mHealth) interventions are being developed and evaluated for this purpose with some evidence supporting improved glycemic control. A necessary step to enhance effectiveness of such approaches is to understand young people's preferences for this mode of delivery.

OBJECTIVE

A cross-sectional survey was conducted to investigate the current and perceived roles of mHealth in supporting young people to manage their diabetes.

METHODS

Young adults (16-24 years) with type 1 diabetes in Auckland, New Zealand, were invited to take part in a survey via letter from their diabetes specialist.

RESULTS

A total of 115 young adults completed the survey (mean age 19.5 years; male 52/115, 45%; European 89/115, 77%), with all reporting they owned a mobile phone and 96% (110/115) of those were smartphones. However, smartphone apps for diabetes management had been used by only 33% (38/115) of respondents. The most commonly reported reason for not using apps was a lack of awareness that they existed. Although the majority felt they managed their diabetes well, 63% (72/115) reported wanting to learn more about diabetes and how to manage it. A total of 64% (74/115) respondents reported that they would be interested in receiving diabetes self-management support via text message (short message service, SMS).

CONCLUSIONS

Current engagement with mHealth in this population appears low, although the findings from this study provide support for the use of mHealth in this group because of the ubiquity and convenience of mobile devices. mHealth has potential to provide information and support to this population, utilizing mediums commonplace for this group and with greater reach than traditional methods.

The Mobile Phone Affinity Scale: Enhancement and Refinement

Background

Existing instruments that assess individuals’ relationships with mobile phones tend to focus on negative constructs such as addiction or dependence, and appear to assume that high mobile phone use reflects pathology. Mobile phones can be beneficial for health behavior change, disease management, work productivity, and social connections, so there is a need for an instrument that provides a more balanced assessment of the various aspects of individuals’ relationships with mobile phones.

Objective

The purpose of this research was to develop, revise, and validate the Mobile Phone Affinity Scale, a multi-scale instrument designed to assess key factors associated with mobile phone use.

Methods

Participants (N=1058, mean age 33) were recruited from Amazon Mechanical Turk between March and April of 2016 to complete a survey that assessed participants’ mobile phone attitudes and use, anxious and depressive symptoms, and resilience.

Results

Confirmatory factor analysis supported a 6-factor model. The final measure consisted of 24 items, with 4 items on each of 6 factors: Connectedness, Productivity, Empowerment, Anxious Attachment, Addiction, and Continuous Use. The subscales demonstrated strong internal consistency (Cronbach alpha range=0.76-0.88, mean 0.83), and high item factor loadings (range=0.57-0.87, mean 0.75). Tests for validity further demonstrated support for the individual subscales.

Conclusions

Mobile phone affinity may have an important impact in the development and effectiveness of mobile health interventions, and continued research is needed to assess its predictive ability in health behavior change interventions delivered via mobile phones.

9th Annual Symposium on Self-Monitoring of Blood Glucose, April 28-30, 2016, Madrid, Spain

International experts in the field of diabetes and diabetes technology met in Madrid, Spain, for the 9th Annual Symposium on Self-Monitoring of Blood Glucose. The goal of these meetings is to establish a global network of experts, thus facilitating new collaborations and research projects to improve the lives of people with diabetes. The 2016 meeting comprised a comprehensive scientific program, parallel interactive workshops, and two keynote lectures.

Development of the Mobile Phone Attachment Scale

Existing instruments that assess the individual's relationship with technology tend to focus on negative constructs and assume that a high use of technology reflects pathology. Since technology use can be beneficial, there is a need for a more balanced instrument. An initial survey to assess the individual's relationship with their mobile phone was developed, checked for face validity and the resulting survey was administered online to students at local colleges. 146 adults (mean age=25.5 years) completed surveys. Principal Component Analysis with varimax rotation produced a final 27-item scale with factor loadings from .50 to .81, representing 4 components: "Usefulness", "Anxious Attachment", "Addiction" and "24/7" (continuous use). This study produced an instrument to assess multiple aspects of the individuals' relationship to their mobile phone. Additional work is needed to validate this measure in other populations, with larger samples, and to assess its predictive ability in mHealth interventions delivered through mobile phones.

Using mobile technology to motivate adolescents with type 1 diabetes mellitus: A systematic review of recent literature

Introduction

Behavioural interventions have been shown to improve outcomes in patients with type 1 diabetes mellitus (T1DM). There are a small number of studies that suggest text-messages (TM), native mobile applications (NMAs), and other mobile tools may be useful platforms for delivering behavioural interventions to adolescents.

Aim

The aim of this study was to explore, by way of a systematic review of available literature, (a) the outcomes of interventions using mobile technology for youth with T1DM and (b) what mobile technologies, functional design elements and aesthetic design elements have the best evidence to support their use.

Methods

A search of six online databases returned 196 unique results, of which 13 met the inclusion criteria.

Results

Four studies were randomised controlled trials (RCTs), and all others prospective cohort studies. TM (10) was the most common intervention technology, while NMAs were used in four studies. The most common outcome measured was HbA1c (9); however, only three studies showed a significant decrease. Similarly, the results reported for other outcome measures were mixed. The studies included in this review suggest that interventions which have data collection and clinician support functionality may be more effective in improving adherence and glycaemic control, but more evidence is needed. Further, the evidence base supporting the use of NMAs in T1DM management for adolescents is weak, with most studies adopting TM as the intervention tool. Overall, the studies lack adequate descriptions of their methodology, and better quality studies are required to inform future intervention design.

Design, construction, and implementation of an online platform for patients with type 1 diabetes: EncoDiab

PURPOSE

The purpose of this study was to develop, build, and implement a virtual platform equipped with practical tools, relevant contents, and communication rooms, with the aim of facilitating patients' self-management of type 1 diabetes mellitus (T1DM).

MATERIALS AND METHODS

The design of the platform was based on the suggestions of T1DM patients who were being managed at two reference hospitals. Patients' needs and preferences were identified in group discussion sessions. Before having access to the platform, patients underwent a baseline assessment, which included physical examination and the administration of validated questionnaires for evaluation of clinical background, quality of life, treatment satisfaction, and well-being.

RESULTS

A total of 33 patients were included in the study; 54.5% of them were men, their median age was 34 (18-50) years, the median duration of diabetes was 15 (1-38) years, and the median A1C was 7.4% (6%-12.6%). Based on their suggestions and requests, the online platform EncoDiab was built and organized into four domains: a personal domain, two domains shared by the patients and the staff of each of the two participating hospitals, and one domain that was accessible to all participants. The platform included practical tools (a body mass index calculator, a carbohydrate counting tool, and an insulin-dose calculator), a library with relevant information (documents on prevention and treatment of acute complications, nutrition, exercise, etc), and a chat room.

CONCLUSION

Although the study is still ongoing, our current results demonstrate the feasibility of building and implementing an online platform for helping T1DM patients in the self-management of their disease in the public health setting.