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

Features, functions, and quality of mobile applications for type 2 diabetes care in China: Systematic search of app stores

BACKGROUND

Type 2 diabetes (T2DM) is highly prevalent in China, affecting over 114 million people. While mHealth interventions have shown promise, there is limited research on T2DM management apps in real-world app stores.

OBJECTIVE

This study aimed to systematically search and analyze T2DM care mobile apps in the Chinese market, describing their features, and functions, and evaluating the quality of the most popular apps using validated tools.

METHODS

We conducted a comprehensive search in Chinese Android and iOS app stores for T2DM management apps. We downloaded 138 eligible ones for a general review of their key features and function. We also assessed the quality of the top 20 apps from both platforms using the Mobile App Rating Scale (MARS) by both researcher and patient.

RESULTS

A total of 3524 apps were searched. 138 eligible apps were downloaded for general review and 29 popular apps were included for quality assessment. Most apps were designed for patient users (87.0 %) and developed by commercial companies (85.5 %). Common functions included blood glucose monitoring, diabetes education, integration with measuring devices, medication adherence reminders, teleconsultation services, and diabetes risk factor tracking. The researcher's evaluation yielded an average MARS score of 4.0 out of 5 for popular apps, with subscale scores of functionalities (4.5), aesthetics (4.1), engagement (3.7), and information (3.6). However, patient ratings were lower in functionality (3.5), aesthetics (3.4), and engagement (2.6), and the patient faced difficulties with information-related items. Similar trends were observed in subject quality items.

CONCLUSION

App developers should engage caregivers, and family members as target users, and involve government agencies as partners to improve T2DM management apps. Future apps should incorporate scientifically proven advanced functions to enhance their effectiveness. The quality assessment highlighted weaknesses in engagement and information and the importance of user-centric approaches in app development.

Efficacy of a smartphone application for helping individuals with type 2 diabetes mellitus manage their blood glucose: a protocol for factorial design trial

BACKGROUND

China has the largest number of individuals with type 2 diabetes mellitus (T2DM) in the world, and most lack knowledge about glycemic control and health management. This trial will examine whether a smartphone application can improve blood glucose management among individuals with T2DM.

METHODS

This will be a 2-center, factorial design, equal proportional distribution, superiority trial conducted in outpatient endocrinology clinics at two tertiary hospitals in Chengdu, China. The trial will enroll smartphone-literature individuals at least 18 years old who have been diagnosed with T2DM based on glycosylated hemoglobin (HbA1c) of at least 7.0%. Individuals will be randomly assigned to receive routine care with standard education about T2DM and glycemic control (Control), routine care as well as weekly telephone reminders to self-monitor blood glucose (Reminder), routine care and a smartphone application providing information about glycemic control and health management with T2DM (App), or the combination of routine care, the smartphone application, and weekly telephone reminders (App + Reminder). After 6 months of these interventions, participants will be analyzed for the primary outcome of HbA1c as well as the secondary outcomes of blood glucose monitoring frequency, body mass index, blood pressure, knowledge about diabetes, health beliefs related to diabetes, diabetes self-management behavior, and satisfaction with the smartphone application.

DISCUSSION

This trial will determine whether a smartphone application can improve glycemic management among Chinese with T2DM. The findings may help guide the development of effective applications in China and elsewhere.

TRIAL REGISTRATION

Registration in the Chinese Clinical Trial Registry (ChiCTR) under registration number ChiCTR2100042297: https://www.chictr.org.cn/bin/userProject . 17 January 2021.

Crowdsourcing Operational and Design Flaws of Diabetes Mobile Apps

Unfortunately, many of the diabetes mobile apps have operational and design flaws that are debarring users from maximizing from the self-management paradigm. We, therefore, aim to identify the markers of operational and design flaws of diabetes mobile apps to facilitate a better user-centred design. e crowdsourced negative user review comments (rating score: 1-3) of 47 diabetes mobile apps from the google play store. A total of 781 negative user comments (rating score 1-3) from the apps are coded to identify and categorize the themes relating to the operational and design flaws. The operational and design flaws account for 50.32% of the challenges faced by the unhappy diabetes mobile apps users. Among them, 44.73% have issues with app crashing, 17.3% are concerned about device compatibility that inhibits seamless operations, 9.67% are worried about the problem of data uploading. Poor design is a worry to 19.29% of the users who complain of the crowded user interface, poor data management, poor analytics, difficulty scheduling doctors' appointments, and transferring data. More patients with diabetes can be encouraged to continue using diabetes mobile apps for self-management of diabetes through improved design and a pace-wise software advancement to match the ever-growing enhancements in android operating systems and telecommunication devices. This will help to counter most of the challenges identified in this study.

Standardized evaluation of the quality and persuasiveness of mobile health applications for diabetes management

This study evaluates diabetes self-management mobile health applications available from European app stores with respect to quality, concordance with recommended self-management tasks and implementation of persuasive system design principles. The European Play Store and Apple App Store were systematically searched and relevant apps were tested. Two raters independently assessed app quality using the Mobile Application Rating Scale and conducted a content analysis of provided persuasive system design principles and self-management tasks. A total of 2,269 mobile health applications were identified and 120 could be included in the evaluation. The overall quality was rated as moderate M = 3.20 (SD = 0.39, min = 2.31, max = 4.62), with shortcomings in the subcategories of engagement (M = 2.80, SD = 0.67) and information quality (M = 2.26, SD = 0.48). Scientific evidence is available for 8% of the apps. The reviewed apps implemented a median of three persuasive system design principles (range 0-15) and targeted a median of 4.5 (range 1-8) self-management tasks, however, with a lack of information about psychosocial coping strategies. Most available diabetes self-management apps lack a scientific evidence base. Persuasive system design features are underrepresented and may form a promising tool to improve app quality. Furthermore, the interaction of physical and behavioral health should be improved in existing diabetes self-management mobile health applications.

Knowledge, Attitude, and Practice of Metformin Extended-Release Tablets Among Clinicians in China: A Cross-Sectional Survey

Background: Metformin extended-release (XR) is a once-daily alternative conventional immediate-release (IR) tablet for adults with type 2 diabetes.

Aim: This study aimed to investigate the knowledge, attitude, and practice of the use of metformin XR tablets among clinicians.

Methods: We conducted a cross-sectional online survey among endocrinologists, general practitioners, and internists, who are taking routine care of adults with type 2 diabetes in health institutes at all levels in Sichuan Province, China. We designed an online questionnaire including the demographic information, knowledge, attitude, and practice about metformin XR tablets.

Results: We included 158 clinicians, 67.7% of whom were females and 63.9% were from tertiary hospitals. The median age was 39.6 years (ranging between 22 and 62 years). Only 8.2% of the clinicians correctly answered the knowledge questions, 82.3% and 62.0% of the responders assumed that metformin XR had superior efficacy and tolerability to the metformin IR, respectively. Only 46.8% of the clinicians prescribed the metformin XR based on the patient’s preference for once daily frequency.

Conclusion: The knowledge, attitude, and practice of metformin XR among Chinese clinicians need improving. Clinicians need credible information to support their clinical decision-making regarding metformin XR.

Mobile Apps for Drug-Drug Interaction Checks in Chinese App Stores: Systematic Review and Content Analysis

Background

As a computerized drug–drug interaction (DDI) alert system has not been widely implemented in China, health care providers are relying on mobile health (mHealth) apps as references for checking drug information, including DDIs.

Objective

The main objective of this study was to evaluate the quality and content of mHealth apps supporting DDI checking in Chinese app stores.

Methods

A systematic review was carried out in November 2020 to identify mHealth apps providing DDI checking in both Chinese iOS and Android platforms. We extracted the apps’ general information (including the developer, operating system, costs, release date, size, number of downloads, and average rating), scientific or clinical basis, and accountability, based on a multidimensional framework for evaluation of apps. The quality of mHealth apps was evaluated by using the Mobile App Rating Scale (MARS). Descriptive statistics, including numbers and percentages, were calculated to describe the characteristics of the apps. For each app selected for evaluation, the section-specific MARS scores were calculated by taking the arithmetic mean, while the overall MARS score was described as the arithmetic mean of the section scores. In addition, the Cohen kappa (κ) statistic was used to evaluate the interrater agreement.

Results

A total of 7 apps met the selection criteria, and only 3 included citations. The average rating score for Android apps was 3.5, with a minimum of 1.0 and a maximum of 4.9, while the average rating score for iOS apps was 4.7, with a minimum of 4.2 and a maximum of 4.9. The mean MARS score was 3.69 out of 5 (95% CI 3.34-4.04), with the lowest score of 1.96 for Medication Guidelines and the highest score of 4.27 for MCDEX mobile. The greatest variation was observed in the information section, which ranged from 1.41 to 4.60. The functionality section showed the highest mean score of 4.05 (95% CI 3.71-4.40), whereas the engagement section resulted in the lowest average score of 3.16 (95% CI 2.81-3.51). For the information quality section, which was the focus of this analysis, the average score was 3.42, with the MCDEX mobile app having the highest score of 4.6 and the Medication Guidelines app having the lowest score of 1.9. For the overall MARS score, the Cohen interrater κ was 0.354 (95% CI 0.236-0.473), the Fleiss κ was 0.353 (95% CI, 0.234-0.472), and the Krippendorff α was 0.356 (95% CI 0.237-0.475).

Conclusions

This study systematically reviewed the mHealth apps in China with a DDI check feature. The majority of investigated apps demonstrated high quality with accurate and comprehensive information on DDIs. However, a few of the apps that had a massive number of downloads in the Chinese market provided incorrect information. Given these apps might be used by health care providers for checking potential DDIs, this creates a substantial threat to patient safety.

Efficiency of an mHealth App and Chest-Wearable Remote Exercise Monitoring Intervention in Patients With Type 2 Diabetes: A Prospective, Multicenter Randomized Controlled Trial

BACKGROUND

Exercise has been recommended as a cornerstone for diabetes management. Supervised exercise is more efficient than unsupervised exercise but is less convenient and accessible.

OBJECTIVE

We aimed to determine the efficiency of exercise using a fitness app and heart rate band to remotely monitor patients with type 2 diabetes in comparison with that of traditional exercise.

METHODS

Patients with type 2 diabetes without severe complications or comorbidities were recruited to participate in this multicenter randomized controlled trial and were allocated to either the intervention or control group (1:1 ratio). Participants in both groups were asked to engage in moderate to vigorous physical activity for at least 150 minutes per week; each participant was prescribed individualized exercises. Participants in the intervention group were asked to follow exercise videos on the app and to wear a chest band; heart rate, exercise duration, and exercise intensity were recorded by the app. Participants in the control group self-reported exercise intensity and duration. Cardiopulmonary endurance, body composition, blood glucose level, and insulin level were assessed before and after a 3-month exercise program.

RESULTS

Of the 101 participants who were enrolled, the majority of them (85/101, 84.2%) completed the study. Both groups had similar baseline characteristics, with the exception that participants in the intervention group were slightly younger and less likely to have hypertension. Self-reported exercise duration was longer than app-recorded exercise duration (control: mean 214 minutes/week; intervention: mean 193 minutes/week); in addition, a higher proportion of participants in the control group (29/41, 71%) than in the intervention group (18/44, 41%) met the 150-minute target for moderate to vigorous physical activity. However, compared with the control group, the intervention group had a larger increase in cardiopulmonary endurance (mean difference -2.0 bpm [beats per minute] vs 1.0 bpm; P=.02) and a larger decrease in body fat percentage (mean difference -1.8% vs -0.8%; P=.01). There was no difference in hemoglobin A1c level reduction between the two groups, yet more participants in the intervention group stopped taking their antidiabetic drugs or had their dosages lowered by an endocrinologist, compared with those in the control group. There were no serious adverse events in either group.

CONCLUSIONS

This was the first randomized controlled trial in China, to our knowledge, to test the efficiency of exercise using a fitness app and heart rate band to remotely monitor prescribed exercise in patients with type 2 diabetes. The findings of our study suggest that exercise programs may be more efficient if participants are remotely monitored with an app and heart rate band than if participants are not monitored.

TRIAL REGISTRATION

Chinese Clinical Trial Register ChiCTR1800015963; http://www.chictr.org.cn/showprojen.aspx?proj=27080.

Effectiveness of the Family Portal Function on the Lilly Connected Care Program (LCCP) for Patients With Type 2 Diabetes: Retrospective Cohort Study With Propensity Score Matching

Background

Diabetes is a major health concern worldwide. Family member engagement in diabetes self-management education programs can improve patients’ diabetes management. However, there is limited evidence that the family portal on diabetes management apps is effective in the glycemic control of patients with diabetes.

Objective

We aimed to evaluate the effectiveness of family support through the family portal function on Lilly Connected Care Program (LCCP) platform.

Methods

This retrospective cohort study included patients with type 2 diabetes recruited to the LCCP platform from September 1, 2018, to August 31, 2019. Propensity score matching was used to match family (group A) and non–family (group B) portal use groups with similar baseline characteristics. The patients were followed up with for 12 weeks. The main objectives were differences in mean fasting blood glucose, proportion of patients achieving fasting blood glucose target <7mmol/L, mean postprandial blood glucose, proportion of patients achieving postprandial blood glucose target <10mmol/L, proportion of patients achieving both fasting blood glucose <7mmol/L and postprandial blood glucose <10mmol/L, self-monitoring of blood glucose frequency at week 12 and the number of diabetes education courses patients completed during the 12 weeks. Moreover, logistic regression analysis was used to explore the baseline factors which may be associated with the use of family portal, and odds ratios with 95% confidence intervals were calculated.

Results

A total of 6582 adult patients (aged ≥18 years) with type 2 diabetes who were receiving insulin therapy were enrolled in the study. Overall, 6.1% (402/6582) of the patients chose to engage their family members to use the family portal. Two groups of 394 patients were well-matched regarding baseline characteristics. After matching, mean fasting blood glucose and postprandial blood glucose at week 12 were significantly lower in group A than in group B (fasting blood glucose: 7.12 mmol/L, SD 1.70 vs 7.42 mmol/L, SD 1.88, respectively, P=.02; postprandial blood glucose: 8.56 mmol/L, SD 2.51 vs 9.10 mmol/L, SD 2.69, respectively, P=.002). When comparing group A to group B, the proportion of patients achieving both fasting blood glucose <7mmol and postprandial blood glucose <10mmol/L at week 12 (46.8% vs 39.4%, respectively, P=.04), self-monitoring of blood glucose frequency at week 12 (8.92 times per week, SD 6.77 vs 8.02 times per week, SD 5.97, respectively, P=.05) and number of diabetes education courses completed in 12 weeks (23.00, IQR9.00-38.00 vs 15.00, IQR 4.00-36.00, respectively, P<.001) was higher. Additionally, multivariate logistic regression analysis showed that higher age (OR=0.987, 95% CI 0.978-0.996, P=.006) and higher baseline fasting blood glucose (OR=0.914, 95% CI 0.859-0.972, P=.004) were correlated with less use of the family portal function, while increased baseline self-monitoring of blood glucose frequency (OR=1.022, 95% CI 1.012-1.032], P<.001) as well as increased education courses (OR=1.026, 95% CI 1.015-1.036, P<.001) were associated with more use of the family portal function.

Conclusions

Family support through the LCCP family portal is effective for glycemic control and self-management behavior improvement in type 2 diabetes patients.

Comparing a Social and Communication App, Telephone Intervention, and Usual Care for Diabetes Self-Management: 3-Arm Quasiexperimental Evaluation Study

Background

Many technology-assisted innovations have been used to manage disease. However, most of these innovations are not broadly used by older adults due to their cost. Additionally, disease management through technology-assisted innovations has not been compared with other interventions.

Objective

In this study, we tested the employment of a free and widely used social and communication app to help older adults with diabetes manage their distress and glycemic control. We also compared the effectiveness of the app with 2 other methods, namely telephone and conventional health education, and determined which subgroup experiences the most effects within each intervention.

Methods

Adults aged ≥50 years with type 2 diabetes were recruited from Southern Taiwan (N=231) and were allocated to different 3-month interventions. Informed consent was obtained at the Ministry of Science and Technology and approved by the National Cheng Kung University Hospital Institutional Review Board (No. A-ER-102-425).

Results

Participants in the mobile-based group had significant reductions in hemoglobin A1c compared with the telephone-based and usual care groups (mean changes of –0.4%, 0.1%, and 0.03%, respectively; P=.02). Diabetes-specific distress decreased to a greater extent in the mobile-based group compared to the other 2 groups (mean changes of –5.16, –3.49, and –2.44, respectively, P=.02). Subgroup analyses further revealed that the effects on reducing blood glucose levels in the social and communication app groups were especially evident in patients with lower distress scores, and diabetes-related distress was especially evident in participants who were younger than 60 years or had higher educational levels.

Conclusions

The findings of this study inform more flexible use of social and communication apps with in-person diabetes education and counselling.

Social Support and User Characteristics in Online Diabetes Communities: An In-Depth Survey of a Large-Scale Chinese Population

:Objective: To determine the characteristics of members of online diabetes communities as well as those factors affecting the provision and acceptance of social support. Methods: A cross-sectional STAR questionnaire survey was conducted among patients with diabetes who were members of online diabetes groups. Univariate and multivariate binary logistic regression analysis were adopted to explore the relative analysis of providing and accepting social support compared with the characteristics of members in virtual diabetics' groups. Results: A total of 1297 respondents were collected. The map distribution of patients in China was mainly located in the Guangdong, Jiangsu, Shandong, Henan, and Hebei provinces. As for their demographic characteristics, respondents had diabetes or prediabetes and were between the ages of 21 and 50 years (Median age was 35.0 (interquartile range from 28.0 to 44.0)). Most respondents were married and lived in cities. The education level of patients was mainly distributed throughout junior high, technical secondary, high school, junior college, and undergraduate levels. Age, marital status, and education level varied by gender, and the total score of the patients aged 41 to 50 for social support had a statistical significance between male and female. In addition, when group members were in junior high school or below, or were undergraduate students, their total social support scores varied by gender. Binary logistic regression showed that in 21 independent variables the total score and the total score grade of relationship intensity in the online group and reorganize of age were significant. The patients' social support acceptance of the map of respondents score grading of relationship intensity in the online group was 5.420 times higher than that of the lower score grading of relationship intensity in the group. At the same time, the patients' social support acceptance of the patients at the age of less than or equal to 31 years old was 19.608 times higher than that of group members aged more than 31 years old. Conclusion: Age and education background of the patients affects scores of social supports between males and females. The higher the total score and the score grade of relationship intensity in the online group, the higher the patients' social support acceptance. The younger patients had a better utilization of social support.

Effectiveness of Lilly Connected Care Program (LCCP) App-Based Diabetes Education for Patients With Type 2 Diabetes Treated With Insulin: Retrospective Real-World Study

Background

Diabetes poses heavy economic and social burdens worldwide. Mobile apps show great potential for diabetes self-management education. However, there is limited evidence for the effectiveness of providing general diabetes education through mobile apps.

Objective

The aim of this study was to clarify the effectiveness of Lilly Connected Care Program (LCCP) app-based diabetes education for glycemic control.

Methods

This retrospective cohort study included patients with diabetes recruited to the LCCP platform from September 1, 2018, to May 31, 2019. Each patient was followed for 12 weeks. According to the number of diabetes education courses they had completed, the patients were divided into the following three groups: group A (0-4 courses), group B (5-29 courses), and group C (≥30 courses). The main outcomes were the change in blood glucose at the 12th week compared with baseline and the differences in blood glucose at the 12th week among the three groups. The associations of the number of diabetes education courses completed with the average blood glucose and frequency of self-monitoring of blood glucose (SMBG) at the 12th week were assessed by multivariate linear regression analyses controlling for other confounding covariates. Univariate and multivariate linear regression analyses were used to assess factors influencing patients’ engagement in the diabetes education courses.

Results

A total of 5011 participants were enrolled. Their mean fasting blood glucose (FBG) and postprandial blood glucose (PBG) were significantly lower at the 12th week than at baseline (FBG, 7.46 [standard deviation (SD) 1.95] vs 7.79 [SD 2.18] mmol/L, P<.001; PBG, 8.94 [SD 2.74] vs 9.53 [SD 2.81] mmol/L, P<.001). The groups that completed more diabetes education courses had lower FBG (group B, β=−0.14, 95% CI −0.26 to −0.03; group C, β=−0.29, 95% CI −0.41 to −0.16; P for trend <.001) and PBG (group B, β=−0.29, 95% CI −0.46 to −0.11; group C, β=−0.47, 95% CI −0.66 to −0.28; P for trend <.001) and a higher frequency of SMBG at the 12th week (group B, β=1.17, 95% CI 0.81-1.53; group C, β=4.21, 95% CI 3.81-4.62; P for trend <.001) when compared with the findings in group A. Age and education were related to patients’ engagement in the diabetes education courses. Middle-aged patients (35-59 years old) and elderly patients (≥60 years old) completed more diabetes education courses (middle-aged group, β=2.22, P=.01; elderly group, β=2.42, P=.02) than young patients (18-34 years old).

Conclusions

LCCP app-based diabetes education is effective for glycemic control and SMBG behavior improvement in patients with type 2 diabetes receiving insulin therapy. Young patients’ engagement in the education courses was relatively low. We need to conduct in-depth interviews with users to further improve the curriculum.