Diabetes Management: Mobile Phone Applications Used Within Healthcare Systems for Type 2 Diabetes Self-Management

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Snapshot

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends the use of diabetes self-management mobile phone applications (apps), when implemented in healthcare systems, to improve blood glucose among patients with type 2 diabetes. Apps may provide automated feedback or send messages from healthcare providers.

The CPSTF has related findings for mobile phone applications used within healthcare systems for type 1 diabetes (insufficient evidence).

Intervention

Mobile phone applications (apps) are used within healthcare systems to improve diabetes self-management among patients with type 2 diabetes. Patients enter data into apps or use medical equipment that transmits data directly. The apps then provide patients with feedback from healthcare professionals or automated systems. The interventions aim to facilitate communication between patients and healthcare providers and improve diabetes care.

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

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What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on results from the published review, additional information from the included studies, and expert input from team members and the CPSTF.

Hou C, Carter B, Hewitt J, Francisa T, Mayor S. Do mobile phone applications improve glycemic control (HbA1c) in the self-management of diabetes? A systematic review, meta-analysis, and GRADE of 14 randomized trials. Diabetes Care 2016; 39:2089-95.

The review included nine studies that had patients with type 2 diabetes (search period January 1996—June 2015). The team examined each of the studies included in the systematic review and abstracted supplemental information about study, intervention, and population characteristics.

The CPSTF finding is based on results from the published review, additional information from the included studies, and expert input from team members and the CPSTF.

Context

Mobile phone (both cell phone and smart phone) ownership in the Unites States reached 95% in 2016 (Pew Research Center, 2017). Apps have been developed to help users manage chronic diseases, and about 70% of these apps are specific to diabetes (Fatehi et al., 2017).

Mobile apps may help patients manage chronic diseases by providing constant monitoring and tracking of self-management tasks, sending self-management tips, and delivering clinically accurate feedback when needed.

Currently, there are no guidelines in the field on how to assess the effectiveness of these apps.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

Compared with usual care, mobile phone apps implemented in healthcare settings reduced blood glucose levels (A1c) by a median of 0.4% (9 studies).
Apps that provided feedback from healthcare professionals produced greater reductions in blood glucose levels when compared to apps that only offered automated feedback (mean reductions in A1c of 0.58% and 0.44%, respectively).
Patients 55 years of age or younger experienced greater reductions in A1c when compared with patients over 55 years of age (mean reductions in A1c of 1.03% and 0.41%, respectively).

Summary of Economic Evidence

A systematic review of economic evidence has not been conducted.

Applicability

Based on results for interventions in different settings and populations, findings should be applicable to women and men with type 2 diabetes who are living in high income countries.

Evidence Gaps

Additional research and evaluation are needed to answer the following questions and fill existing gaps in the evidence base.

Are diabetes self-management apps available in app stores effective in reducing A1c levels for users with type 2 diabetes?
What factors influence app effectiveness?
- Number of functionalities offered?
- Specific functionalities offered?
- Type of feedback (i.e., none, automated, personalized feedback from healthcare professionals, or a combination of the latter two)?
- Demographic characteristics such as race and ethnicity, income, and education?
- Users’ health literacy?

Study Characteristics

Interventions were implemented in healthcare systems in the following countries:

Studies were conducted in the United States (3 studies), Finland (1 study), Japan (1 study), Korea (1 study), Norway (1 study), and the United Kingdom (2 studies).
All of the studies evaluated mobile phone apps implemented within a healthcare system.

Study participants had the following demographic characteristics:

Mean age of 57.7 years (8 studies)
43.7% female (8 studies)
Diagnosis of type 2 diabetes for a mean of 8.8 years (6 studies)

Intervention characteristics:

Eight unique apps with the following functionalities were evaluated.
- Medication adjustment support (3 apps)
- Graphical feedback (5 apps)
- Automated feedback (6 apps)
- Healthcare professional feedback (6 apps)
Apps tracked users’ diabetes-related outcomes
- Blood glucose levels (8 apps)
- Blood pressure (2 apps)
- Body weight (3 apps)
- Food intake (3 apps)
- Diabetes medication adherence (5 apps)
Intervention duration ranged from 3 to 12 months, with a median of 6 months

Supporting Materials

Analytic Framework

Content not available.

Summary Evidence Table

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on a previously published systematic review (Hou et al., 2016).

Included Studies

The following studies from Hou et al. (2016) evaluated interventions for type 2 diabetes. The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Faridi Z, Liberti L, Shuval K, Northrup V, Ali A, Katz DL. Evaluating the impact of mobile telephone technology on type 2 diabetic patients’ self-management: the NICHE pilot study. Journal of Evaluation in Clinical Practice 2008;14(3):465-9.

Holmen H, Torbjørnsen A, Wahl AK, et al. A mobile health intervention for self-management and lifestyle change for persons with type 2 diabetes, part 2: one-year results from the Norwegian randomized controlled trial RENEWING HEALTH. JMIR mHealth and uHealth 2014;2(4).

Istepanian R, Zitouni K, Harry D, et al. Evaluation of a mobile phone telemonitoring system for glycaemic control in patients with diabetes. Journal of Telemedicine and Telecare 2009;15(3):125-8.

Nagrebetsky A, Larsen M, Craven A, et al. Stepwise self-titration of oral glucose-lowering medication using a mobile telephone-based telehealth platform in type 2 diabetes: a feasibility trial in primary care. Journal of Diabetes Science and Technology 2013;7(1):123-34.

Orsama A-L, Lähteenmäki J, Harno K, et al. Active assistance technology reduces glycosylated hemoglobin and weight in individuals with type 2 diabetes: results of a theory-based randomized trial. Diabetes Technology & Therapeutics 2013;15(8):662-9.

Quinn CC, Clough SS, Minor JM, Lender D, Okafor MC, Gruber-Baldini A. WellDoc™ mobile diabetes management randomized controlled trial: change in clinical and behavioral outcomes and patient and physician satisfaction. Diabetes Technology & Therapeutics 2008;10(3):160-8.

Quinn CC, Shardell MD, Terrin ML, Barr EA, Ballew SH, Gruber-Baldini AL. Cluster-randomized trial of a mobile phone personalized behavioral intervention for blood glucose control. Diabetes Care 2011;34(9):1934-42.

Waki K, Fujita H, Uchimura Y, et al. DialBetics: a novel smartphone-based self-management support system for type 2 diabetes patients. Journal of Diabetes Science and Technology 2014;8(2):209-15.

Yoo H, Park M, Kim T, et al. A ubiquitous chronic disease care system using cellular phones and the internet. Diabetic Medicine 2009;26(6):628-35.

Search Strategies

Information about the search strategy can be found in the published systematic review (Hou et al., 2016).

Review References

Fatehi F, Gary LC, Russell W. Mobile Health (mHealth) for diabetes care: opportunities and challenges. Diabetes Technology & Therapeutics 2017;19(1):1-3

Pew Research Center [Internet]. Mobile Fact Sheet. 2017 [cited 8-7-17]. Available from URL: http://www.pewinternet.org/fact-sheet/mobile/

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

All of the included studies evaluated the effectiveness of these apps when used within healthcare systems. The CPSTF finding is limited to interventions used in these settings, and the CPSTF does not endorse any specific mobile applications or technology.
For U.S. healthcare systems to implement effective mobile phone apps within their patient populations, certain issues need to be taken into consideration.
- Involvement of healthcare professionals. Review findings suggest that when healthcare professionals (including patients’ primary care providers) delivered feedback, patients had greater reductions in A1c levels when compared to patients who only received automated feedback.
- Compliance with Health Insurance Portability and Accountability Act (HIPAA) . Implementers should understand state policies regarding application of HIPAA to electronic communications with patients.
- Resource requirements for patients. Disparities in smart phone ownership and access to data services exist across population groups with different levels of income or educational attainment (Pew Research Center, 2017). To use these apps in healthcare systems, implementers need to ensure all patients with diabetes have equal access to, and opportunity for, long-term use.
- Ease of using mobile phone apps. Older adults are much less likely to own a mobile phone (Pew Research Center, 2017). Findings from this review suggest that interventions were less effective with patients over 55 years of age when compared to patients 55 years or younger. Implementers need to be aware of this age divide and consider providing more training for older patients.
None of the included studies examined apps available via app stores, providing no further guidance on ways to determine their effectiveness.
The fast-growing number of mobile health apps has drawn attention from healthcare professionals. The American Medical Association (AMA) issued guidelines in 2016) about the potential to incorporate these apps into daily care. AMA encourages its members to follow evidence-based guidelines where available and use apps proven to support care delivery that is patient-centered, promotes care coordination, and facilitates team-based communication.

Crosswalks

Healthy People 2020

Healthy People 2020 includes the following objectives related to this CPSTF recommendation.

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