A systematic review of IT for diabetes self-management: are we there yet?

Digital health interventions for non-communicable disease management in primary health care in low-and middle-income countries

Current evidence on digital health interventions is disproportionately concerned with high-income countries and hospital settings. This scoping review evaluates the extent of use and effectiveness of digital health interventions for non-communicable disease (NCD) management in primary healthcare settings of low- and middle-income countries (LMICs) and identifies factors influencing digital health interventions' uptake. We use PubMed, Embase, and Web of Science search results from January 2010 to 2021. Of 8866 results, 52 met eligibility criteria (31 reviews, 21 trials). Benchmarked against World Health Organization's digital health classifications, only 14 out of 28 digital health intervention categories are found, suggesting critical under-use and lagging innovation. Digital health interventions' effectiveness vary across outcomes: clinical (mixed), behavioral (positively inclined), and service implementation outcomes (clear effectiveness). We further identify multiple factors influencing digital health intervention uptake, including political commitment, interactivity, user-centered design, and integration with existing systems, which points to future research and practices to invigorate digital health interventions for NCD management in primary health care of LMICs.

Mobile Health Apps for the Control and Self-management of Type 2 Diabetes Mellitus: Qualitative Study on Users' Acceptability and Acceptance

BACKGROUND

Mobile health apps are promising tools to help patients with type 2 diabetes mellitus (T2DM) improve their health status and thereby achieve diabetes control and self-management. Although there is a wide array of mobile health apps for T2DM available at present, apps are not yet integrated into routine diabetes care. Acceptability and acceptance among patients with T2DM is a major challenge and prerequisite for the successful implementation of apps in diabetes care.

OBJECTIVE

This study provides an in-depth understanding of the perceptions of patients with T2DM before use (acceptability) and after use (acceptance) regarding 4 different mobile health apps for diabetes control and self-management.

METHODS

A descriptive qualitative research design was used in this study. Participants could choose 1 of the 4 selected apps for diabetes control and self-management (ie, Clear.bio in combination with FreeStyle Libre, mySugr, MiGuide, and Selfcare). The selection was based on a systematic analysis of the criteria for (functional) requirements regarding monitoring, data collection, provision of information, coaching, privacy, and security. To explore acceptability, 25 semistructured in-depth interviews were conducted with patients with T2DM before use. This was followed by 4 focus groups to discuss the acceptance after use. The study had a citizen science approach, that is, patients with T2DM collaborated with researchers as coresearchers. All coresearchers actively participated in the preparation of the study, data collection, and data analysis. Data were collected between April and September 2021. Thematic analysis was conducted using a deductive approach using AtlasTi9.

RESULTS

In total, 25 coresearchers with T2DM participated in this study. Of them, 12 coresearchers tested Clear, 5 MiGuide, 4 mySugr, and 4 Selfcare. All coresearchers participated in semistructured interviews, and 18 of them attended focus groups. Personal health was the main driver of app use. Most coresearchers were convinced that a healthy lifestyle would improve blood glucose levels. Although most coresearchers did not expect that they need to put much effort into using the apps, the additional effort to familiarize themselves with the app use was experienced as quite high. None of the coresearchers had a health care professional who provided suggestions on using the apps. Reimbursement from insurance companies and the acceptance of apps for diabetes control and self-management by the health care system were mentioned as important facilitating conditions.

CONCLUSIONS

The research showed that mobile health apps provide support for diabetes control and self-management in patients with T2DM. Integrating app use in care as usual and guidelines for health care professionals are recommended. Future research is needed on how to increase the implementation of mobile health apps in current care pathways. In addition, health care professionals need to improve their digital skills, and lifelong learning is recommended.

Efficacy of Web-Based Supportive Interventions in Quality of Life in COPD Patients, a Systematic Review and Meta-Analysis

Background: Adults living with Chronic Obstructive Pulmonary Disease (COPD) often have difficulties when trying to access health care services. Interactive communication technologies are a valuable tool to enable patients to access supportive interventions to cope with their disease. The aim of this revision and meta-analysis is to analyze the content and efficacy of web-based supportive interventions in quality of life in COPD. Methods: Medline (via PubMed), Web of Science, and Scopus were the databases used to select the studies for this systematic review. A screening, analysis, and assessment of the methodological quality was carried out by two independent researchers. A meta-analysis of the extracted data was performed. Results: A total of 9 of the 3089 studies reviewed met the inclusion criteria. Most repeated web content elements were educational and involved communication with healthcare professional content. Finally, seven of the nine studies were included in a quantitative analysis. Web-based supportive interventions significantly improved quality of life when added to usual care (SMD = −1.26, 95% CI = −1.65, −0.86; p < 0.001) but no significant differences were found when compared with an autonomous pedometer walking intervention (p = 0.64) or a face-to-face treatment (p = 0.82). Conclusion: This systematic review and meta-analysis suggests that web-based supportive interventions may complement or accompany treatments in COPD patients due to the advantages of online interventions. The results obtained should be treated with caution due to the limited number of studies in this area and methodological weaknesses.

Factors Affecting the Extent of Patients' Electronic Medical Record Use: An Empirical Study Focusing on System and Patient Characteristics

Background

Patients’ access to and use of electronic medical records (EMRs) places greater information in their hands, which helps them better comanage their health, leading to better clinical outcomes. Despite numerous benefits that promote health and well-being, patients’ acceptance and use of EMRs remains low. We study the impact of predictors that affect the use of EMR by patients to understand better the underlying causal factors for the lower use of EMR.

Objective

This study aims to examine the critical system (eg, performance expectancy and effort expectancy) and patient characteristics (eg, health condition, issue involvement, preventive health behaviors, and caregiving status) that influence the extent of patients’ EMR use.

Methods

We used secondary data collected by Health Information National Trends Survey 5 cycle 3 and performed survey data analysis using structural equation modeling technique to test our hypotheses. Structural equation modeling is a technique commonly used to measure and analyze the relationships of observed and latent variables. We also addressed common method bias to understand if there was any systematic effect on the observed correlation between the measures for the predictor and predicted variables.

Results

The statistically significant drivers of the extent of EMR use were performance expectancy (β=.253; P<.001), perceived behavior control (β=.236; P<.001), health knowledge (β=–.071; P=.007), caregiving status (β=.059; P=.013), issue involvement (β=.356; P<.001), chronic conditions (β=.071; P=.016), and preventive health behavior (β=.076; P=.005). The model accounted for 32.9% of the variance in the extent of EMR use.

Conclusions

The study found that health characteristics, such as chronic conditions and patient disposition (eg, preventive health behavior and issue involvement), directly affect the extent of EMR use. The study also revealed that issue involvement mediates the impact of preventive health behaviors and the presence of chronic conditions on the extent of patients’ EMR use.

Your Physical Activity Is in Your Hand-Objective Activity Tracking Among University Students in Hungary, One of the Most Obese Countries in Europe

Inadequate physical activity is currently one of the leading risk factors for mortality worldwide. University students are a high-risk group in terms of rates of obesity and lack of physical activity. In recent years, activity trackers have become increasingly popular for measuring physical activity. The aim of the present study is to examine whether university students in Hungary meet the health recommendations (10,000 steps/day) for physical activity and investigate the impact of different variables (semester-exam period, days-weekdays, days, months, sex) on the level of physical activity in free-living conditions for 3 months period. In free-living conditions, 57 healthy university students (male: 25 female: 32 mean age: 19.50 SD = 1.58) wore MiBand 1S activity tracker for 3 months. Independent sample t-tests were used to explore differences between sexes. A One-way analysis of variance (ANOVA) was used to explore differences in measures among different grouping variables and step count. A Two-way ANOVA was conducted to test for differences in the number of steps by days of the week, months, seasons and for sex differences. Tukey HSD post-hoc tests were used to examine significant differences. Students in the study achieved 10,000 steps per day on 17% of days (minimum: 0%; maximum: 76.5%; median: 11.1%). Unfortunately, 70% of the participants did not comply the 10,000 steps at least 80% of the days studied. No statistical difference were found between sexes. However, significant differences were found between BMI categories (underweight <18.50 kg/m²; normal range 18.50–24.99 kg/m²; overweight: 25.00–29.99 kg/m² obese > 30 kg/m², the number of steps in the overweight category was significantly lower (F = 72.073, p < 0.001). The average daily steps were significantly higher in autumn (t = 11.457, p < 0.001) than in winter. During exam period average steps/day were significantly lower than during fall semester (t = 13.696, p < 0.001). On weekdays, steps were significantly higher than on weekends (F = 14.017, p < 0.001), and even within this, the greatest physical activity can be done by the middle of the week. Our data suggest that university students may be priority groups for future physical activity interventions. Commercial activity trackers provide huge amount of data for relatively low cost therefore it has the potential to objectively analyze physical activity and plan interventions.

Protocol for a qualitative study exploring the perception of need, importance and acceptability of a digital diabetes prevention intervention for women with gestational diabetes mellitus during and after pregnancy in Malaysia (Explore-MYGODDESS)

INTRODUCTION

Women who develop gestational diabetes mellitus (GDM) have an increased risk of developing type 2 diabetes, and to reduce this risk the women have to adopt healthy behaviour changes. Although previous studies have explored the challenges and facilitators to initiate behaviour change among women with GDM, there is limited data from Malaysian women. Thus, this study will explore the factors affecting the uptake of healthy behaviour changes and the use of digital technology among women and their healthcare providers (HCPs) to support healthy behaviour changes in women with GDM.

METHODS AND ANALYSIS

The study will be modelled according to the Capability, Opportunity, Motivation and Behaviour and Behaviour Change Wheel techniques, and use the DoTTI framework to identify needs, solutions and testing of a preliminary mobile app, respectively. In phase 1 (design and development), a focus group discussion (FGDs) of 5-8 individuals will be conducted with an estimated 60 women with GDM and 40 HCPs (doctors, dietitians and nurses). Synthesised data from the FGDs will then be combined with content from an expert committee to inform the development of the mobile app. In phase 2 (testing of early iterations), a preview of the mobile app will undergo alpha testing among the team members and the app developers, and beta testing among 30 women with GDM or with a history of GDM, and 15 HCPs using semi-structured interviews. The outcome will enable us to optimise an intervention using the mobile app as a diabetes prevention intervention which will then be evaluated in a randomised controlled trial.

ETHICS AND DISSEMINATION

The project has been approved by the Malaysia Research Ethics Committee. Informed consent will be obtained from all participants. Outcomes will be presented at both local and international conferences and submitted for publications in peer-reviewed journals.

Diabetes Engagement and Activation Platform for Implementation and Effectiveness of Automated Virtual Type 2 Diabetes Self-Management Education: Randomized Controlled Trial

BACKGROUND

Patients with type 2 diabetes require recommendations for self-management education and support.

OBJECTIVE

In this study, we aim to design the Diabetes Engagement and Activation Platform (DEAP)-an automated patient education tool integrated into primary care workflow-and examine its implementation and effectiveness.

METHODS

We invited patients aged 18-85 years with a hemoglobin A_1c (HbA_1c) level ≥8 to participate in a randomized controlled trial comparing DEAP with usual care. DEAP modules addressing type 2 diabetes self-management education and support domains were programmed into patient portals, each with self-guided educational readings, videos, and questions. Care teams received patient summaries and were alerted to patients with low confidence or requesting additional help. HbA_1c, BMI, and systolic and diastolic blood pressure (DBP) were measured.

RESULTS

Out of the 680 patients invited to participate, 337 (49.5%) agreed and were randomized. All of the 189 intervention patients accessed the first module, and 140 patients (74.1%) accessed all 9 modules. Postmodule knowledge and confidence scores were high. Only 18 patients requested additional help from the care team. BMI was lower for intervention patients than controls at 3 months (31.7 kg/m² vs 32.1 kg/m²; P=.04) and 6 months (32.5 kg/m² vs 33.0 kg/m²; P=.003); improvements were even greater for intervention patients completing at least one module. There were no differences in 3- or 6-month HbA_1c or blood pressure levels in the intent-to-treat analysis. However, intervention patients completing at least one module compared with controls had a better HbA_1c level (7.6% vs 8.2%; P=.03) and DBP (72.3 mm Hg vs 75.9 mm Hg; P=.01) at 3 months.

CONCLUSIONS

The findings of this study concluded that a significant proportion of patients will participate in an automated virtual diabetes self-management program embedded into patient portals and health systems show promise in helping patients manage their diabetes, weight, and blood pressure.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02957721; https://clinicaltrials.gov/ct2/show/NCT02957721.

Providing Medical Information to Older Adults in a Web-Based Environment: Systematic Review

Background

Cancer is a disease that predominantly affects older adults, and several organizations recommend the completion of a geriatric assessment to help with cancer treatment decision-making. Owing to a shortage of geriatric teams and the vast number of older adults diagnosed with cancer each year, a web-based geriatric assessment may improve access to geriatric assessment for older adults. We systematically reviewed the literature to obtain the latest evidence for the design of our web-based geriatric assessment tool Comprehensive Health Assessment for My Plan.

Objective

This review aimed to probe the following questions: what is the impact of providing health test results to older adults in a web-based environment without the presence of a health care provider for patient-centered outcomes, including satisfaction, perceived harm, empowerment, quality of life, and health care use (eg, hospitalization, physician visits, emergency room visits, and costs), and what recommendations do older adults and developers have for designing future apps or websites for older adults?

Methods

This systematic review was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) statement. Studies were limited to publications in English that examined a web-based tool that provided test results to older adults (aged ≥65 years) without the presence of a health care provider. A health sciences librarian performed the search on November 29, 2019, on the following electronic databases: MEDLINE, Embase, CINAHL, PsycINFO, and the Cochrane Library. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool Version 2018. The findings are summarized narratively and in tabular format.

Results

A total of 26,898 titles and abstracts were screened by 2 independent reviewers, of which 94 studies were selected for a full-text review, and 9 studies were included in this review. There were only 2 randomized controlled trials of high quality that explored the effects of receiving health care results on the web via eHealth tools for older adults or provided evidence-based recommendations for designing such tools. Older adults were generally satisfied with receiving screening results via eHealth tools, and several studies suggested that receiving health screening results electronically improved participants’ quality of life. However, user interfaces that were not designed with older adults in mind and older adults’ lack of confidence in navigating eHealth tools proved challenging to eHealth uptake and use. All 9 studies included in this systematic review made recommendations on how to design eHealth tools that are intuitive and useful for older adults.

Conclusions

eHealth tools should incorporate specific elements to ensure usability for older adults. However, more research is required to fully elucidate the impact of receiving screening and results via eHealth tools without the presence of a health care provider for patient-centered outcomes in this target population.

A Scoping Review and General User's Guide for Facilitating the Successful Use of eHealth Programs for Diabetes in Clinical Care

The vast eHealth literature in diabetes can provide a useful foundation to aid in the selection, adoption, and implementation of eHealth methodologies in clinical care. Despite clear potential to enhance reach, efficiency, and clinical effectiveness, research has yielded mixed and often contradictory results, and wide-spread adoption and maintenance of eHealth programs in clinical care has been limited. Furthermore, few reports have identified the unique challenges that clinicians and health systems face when attempting to incorporate eHealth systems into clinical care. To address these gaps, we address two goals in this report: first, to summarize and integrate the major findings of the diabetes-related eHealth literature based on currently available systematic and narrative reviews; and second, based on the review, to provide practical guidelines to assist clinicians and health systems in selecting and implementing eHealth programs into diabetes care using dissemination and implementation science principles and perspectives.

Health Information Technology and Diabetes Management: A Review of Motivational and Inhibitory Factors

BACKGROUND

Health information technology helps patients to take better care of themselves and improves health status of patients with chronic diseases, such as diabetes.

OBJECTIVE

This study aimed to identify factors influencing the use of health information technology in diabetes management.

METHODS

This was a review study conducted in 2019. To obtain the related articles, databases, including Scopus, Web of Science, Proquest, and PubMed, were searched and the time frame was between 2010 and 2018. Initially, 1159 articles were retrieved and after screening, 28 articles were selected to be included in the study.

RESULTS

Factors influencing the use of health information technology in diabetes management could be divided into the motivational and inhibitory factors, and each of them could be categorized into five groups of organizational, technical, economic, individual, and ethical/legal factors. The motivational factors included training, system ease of use, economic support, having computer literacy, and maintaining privacy and confidentiality. The inhibitory factors included a lack of long-term planning, technical problems, inadequate financial resources, old age, and concerns over confidentiality issues.

CONCLUSION

Identifying motivational and inhibitory factors can help to make better use of technology for diabetes management. This approach, in turn, can improve the acceptability of the technology and save cost, reduce long-term complications of diabetes, and improve the quality of life in diabetic patients.

Mobile Clinical Decision Support System for the Management of Diabetic Patients With Kidney Complications in UK Primary Care Settings: Mixed Methods Feasibility Study

BACKGROUND

Attempts to utilize eHealth in diabetes mellitus (DM) management have shown promising outcomes, mostly targeted at patients; however, few solutions have been designed for health care providers.

OBJECTIVE

The purpose of this study was to conduct a feasibility project developing and evaluating a mobile clinical decision support system (CDSS) tool exclusively for health care providers to manage chronic kidney disease (CKD) in patients with DM.

METHODS

The design process was based on the 3 key stages of the user-centered design framework. First, an exploratory qualitative study collected the experiences and views of DM specialist nurses regarding the use of mobile apps in clinical practice. Second, a CDSS tool was developed for the management of patients with DM and CKD. Finally, a randomized controlled trial examined the acceptability and impact of the tool.

RESULTS

We interviewed 15 DM specialist nurses. DM specialist nurses were not currently using eHealth solutions in their clinical practice, while most nurses were not even aware of existing medical apps. However, they appreciated the potential benefits that apps may bring to their clinical practice. Taking into consideration the needs and preferences of end users, a new mobile CDSS app, "Diabetes & CKD," was developed based on guidelines. We recruited 39 junior foundation year 1 doctors (44% male) to evaluate the app. Of them, 44% (17/39) were allocated to the intervention group, and 56% (22/39) were allocated to the control group. There was no significant difference in scores (maximum score=13) assessing the management decisions between the app and paper-based version of the app's algorithm (intervention group: mean 7.24 points, SD 2.46 points; control group: mean 7.39, SD 2.56; t₃₇=-0.19, P=.85). However, 82% (14/17) of the participants were satisfied with using the app.

CONCLUSIONS

The findings will guide the design of future CDSS apps for the management of DM, aiming to help health care providers with a personalized approach depending on patients' comorbidities, specifically CKD, in accordance with guidelines.

Competitive neural layer-based method to identify people with high risk for diabetic foot

BACKGROUND AND OBJECTIVE

To automatically identify patients with diabetes mellitus (DM) who have high risk of developing diabetic foot, via an unsupervised machine learning technique.

METHODS

We collected a new database containing 54 known risk factors from 250 patients diagnosed with diabetes mellitus. The database also contained a separate validation cohort composed of 73 subjects, where the perceived risk was annotated by expert nurses. A competitive neuron layer-based method was used to automatically split training data into two risk groups.

RESULTS

We found that one of the groups was composed of patients with higher risk of developing diabetic foot. The dominant variables that described group membership via our method agreed with the findings from other studies, and indicated a greater risk for developing such a condition. Our method was validated on the available test data, reaching 71% sensitivity, 100% specificity, and 90% accuracy.

CONCLUSIONS

Unsupervised learning may be deployed to screen patients with diabetes mellitus, pointing out high-risk individuals who require priority follow-up in the prevention of diabetic foot with very high accuracy. The proposed method is automatic and does not require clinical examinations to perform risk assessment, being solely based on the information of a questionnaire answered by patients. Our study found that discriminant variables for predicting risk group membership are highly correlated with expert opinion.

A Facilitated Web-Based Self-Management Tool for People With Type 1 Diabetes Using an Insulin Pump: Intervention Development Using the Behavior Change Wheel and Theoretical Domains Framework

BACKGROUND

Type 1 diabetes (T1D) requires intensive self-management (SM). An insulin pump is designed to better support personal T1D management, but at the same time, it exacerbates the complexity and requirements of SM. Research shows that people with diabetes are likely to benefit from navigating and connecting to local means of social support and resources through web-based interventions that offer flexible, innovative, and accessible SM. However, questions remain as to which behavior change mechanisms within such resources benefit patients most and how to foster engagement with and endorsement of SM interventions.

OBJECTIVE

The aim of this study was to evaluate the perspectives and experiences of people with T1D using an insulin pump and specialist health care professionals (HCPs) and determine what behavior change characteristics and strategies are required to inform the optimization of an existing web-based social network (SN) intervention to support SM.

METHODS

Focus groups with insulin pump users (n=19) and specialist HCPs (n=20) in 6 National Health Service (NHS) trusts across the south of England examined the barriers and enablers to incorporating and self-managing an insulin pump. An analysis was undertaken using the Behavior Change Wheel and Theoretical Domains Framework, followed by a taxonomy of behavior change techniques (BCTs) to identify the contents of and strategies for the implementation of a complex health intervention.

RESULTS

A total of 4 themes represent the SM perspectives and experiences of stakeholders: (1) a desire for access to tailored and appropriate resources and information-the support and information required for successful SM are situational and contextual, and these vary according to time and life circumstances, and therefore, these need to be tailored and appropriate; (2) specific social support preferences-taking away isolation as well as providing shared learnings and practical tips, but limitations included the fear of judgment from others and self-pity from peers; (3) the environmental context, that is, capacity and knowledge of pump clinic HCPs-HCPs acknowledge the patient's need for holistic support but lack confidence in providing it; and (4) professional responsibility and associated risks and dangers, whereas HCPs are fearful of the consequences of promoting non-NHSSM support, and they question whether SM support fits into their role. BCTs were identified to address these issues.

CONCLUSIONS

The use of behavioral theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers and enablers of self-managing T1D with an insulin pump. A web-based SN intervention appears to offer additional forms of SM support while complementing NHS services. However, for intervention implementation, HCPs' apprehensions about responsibility when signposting to non-NHS SM support would need to be addressed, and opportunistic features would need to be added, through which pump users could actively engage with other people living with T1D.

Mapping the Evidence on the Effectiveness of Telemedicine Interventions in Diabetes, Dyslipidemia, and Hypertension: An Umbrella Review of Systematic Reviews and Meta-Analyses

Background

Telemedicine is defined by three characteristics: (1) using information and communication technologies, (2) covering a geographical distance, and (3) involving professionals who deliver care directly to a patient or a group of patients. It is said to improve chronic care management and self-management in patients with chronic diseases. However, currently available guidelines for the care of patients with diabetes, hypertension, or dyslipidemia do not include evidence-based guidance on which components of telemedicine are most effective for which patient populations.

Objective

The primary aim of this study was to identify, synthesize, and critically appraise evidence on the effectiveness of telemedicine solutions and their components on clinical outcomes in patients with diabetes, hypertension, or dyslipidemia.

Methods

We conducted an umbrella review of high-level evidence, including systematic reviews and meta-analyses of randomized controlled trials. On the basis of predefined eligibility criteria, extensive automated and manual searches of the databases PubMed, EMBASE, and Cochrane Library were conducted. Two authors independently screened the studies, extracted data, and carried out the quality assessments. Extracted data were presented according to intervention components and patient characteristics using defined thresholds of clinical relevance. Overall certainty of outcomes was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool.

Results

Overall, 3564 references were identified, of which 46 records were included after applying eligibility criteria. The majority of included studies were published after 2015. Significant and clinically relevant reduction rates for glycated hemoglobin (HbA_1c; ≤−0.5%) were found in patients with diabetes. Higher reduction rates were found for recently diagnosed patients and those with higher baseline HbA_1c (>8%). Telemedicine was not found to have a significant and clinically meaningful impact on blood pressure. Only reviews or meta-analyses reporting lipid outcomes in patients with diabetes were found. GRADE assessment revealed that the overall quality of the evidence was low to very low.

Conclusions

The results of this umbrella review indicate that telemedicine has the potential to improve clinical outcomes in patients with diabetes. Although subgroup-specific effectiveness rates favoring certain intervention and population characteristics were found, the low GRADE ratings indicate that evidence can be considered as limited. Future updates of clinical care and practice guidelines should carefully assess the methodological quality of studies and the overall certainty of subgroup-specific outcomes before recommending telemedicine interventions for certain patient populations.

Recent trends in diabetes-related consumer health information technology research

Diabetes-related consumer health information technology (CHIT) has been designed to facilitate self-management practices, and its use has improved health outcomes for many consumers. This analysis sought to identify tendencies in diabetes-related CHIT research from 2010-2015 to help researchers find novel research topics, periodicals, collaborators, and funding agencies and experts and lay consumers to find scholarly information. Six search engines encompassing computer science, engineering, and medicine yielded potential diabetes-related CHIT publications. Abstracts and full texts were screened based on inclusion and exclusion criteria. Information on year, periodical, periodical domain, keywords, author location, author institutions, authors, and funding agencies were collected from included publications. The screening process yielded 1551 publications. Studies were published in a core of twenty periodicals, commonly comprising medicine or technology domains. "Telemedicine" was the most frequently used keyword. Harvard University, Dr. Eirik Årsand, and the National Institute of Diabetes and Digestive Kidney Diseases were the most frequent author institution, author, and funding agency, respectively, associated with publications. This analysis revealed potential for novel research on the sociology and economics of diabetes-related CHIT, among other topics. A lack of collaboration between top authors in the field indicates potential for new, impactful collaborations. Ongoing bibliometric research will be necessary to assess changes in this field. The opportunity exists to inform lay consumers and researchers through bibliometric analyses of other consumer health informatics topics.

Impact of Socio-Demographic Factors on the Acceptance of Information Communication and Technology (ICT) for Diabetes Self-care

This research investigates the impact of socio-demographic factors such as age, gender, income and location on ICT acceptance for diabetes self-care. The investigation is due to the increasing number of diabetic patients in South Africa, where large segments of the population experience technological forms of exclusions. The context warrants research in geographical areas where ICT use is not pervasive yet. This research, used the UTAUT model with purposive sampling for 497 diabetic respondents, residing in low socio-economic communities. It analysed survey data using linear regression. It found that age had a strong moderating effect on all four UTAUT constructs. Gender only had a moderating effect on performance expectancy and social influence. In contrast to findings in the extant literature, income and location had no significant moderating effect in this context.

Correlation between hip osteoarthritis and the level of physical activity as measured by wearable technology and patient-reported questionnaires

This study evaluates physical activity in patients with advanced hip OA using Fitbit and whether a correlation exists between the number of steps taken per day (SPD) and the reported outcome.

Methods

122 patients were prospective enrolled. Patient-reported outcomes were collected. Patients were asked to wear a Fitbit for 24 h a day on seven consecutive days.

Result

The mean number of SPD was 5721 ± 3920. The UCLA, HHS and SF-12 PCS demonstrated a statistically significant positive correlation with the SPD.

Conclusion

Wearable technology is reliable in objectively measuring the level of physical activity in hip OA and correlates with reported outcomes.

Pilot randomized controlled trial of a complex intervention for diabetes self-management supported by volunteers, technology, and interprofessional primary health care teams

Background

Most health care for people with diabetes occurs in family practice, yet balancing the time and resources to help these patients can be difficult. An intervention empowering patients, leveraging community resources, and assisting self-management could benefit patients and providers. Thus, the feasibility and potential for effectiveness of “Health Teams Advancing Patient Experience, Strengthening Quality through Health Connectors for Diabetes Management” (Health TAPESTRY-HC-DM) as an approach supporting diabetes self-management was explored to inform development of a future large-scale trial.

Methods

Four-month pilot randomized controlled trial (RCT), sequential explanatory qualitative component. Participants—patients of an interprofessional primary care team—were over age 18 years, diagnosed with diabetes and hypertension, and had Internet access and one of the following: uncontrolled HbA1c, recent diabetes diagnosis, end-stage/secondary organ damage, or provider referral. The Health TAPESTRY-HC-DM intervention focused on patient health goals/needs, integrating community volunteers, eHealth technologies, interprofessional primary care teams, and system navigation. Pilot outcomes included process measures (recruitment, retention, program participation), perceived program feasibility, benefits and areas for improvement, and risks or safety issues. The primary trial outcome was self-efficacy for managing diabetes. There were a number of secondary trial outcomes.

Results

Of 425 eligible patients invited, 50 signed consent (11.8%) and 35 completed the program (15 intervention, 20 control). Volunteers (n = 20) met 28 clients in 234 client encounters (home visits, phone calls, electronic messages); 27 reports were sent to the interprofessional team. At 4 months, controlling for baseline, most outcomes were better in the intervention compared to control group; physical activity notably better. The most common goal domains set were physical activity, diet/nutrition, and social connection. Clients felt the biggest impact was motivation toward goal achievement. They struggled with some of the technologies. Several participants perceived that the program was not a good fit, mostly those that felt they were already well-managing their diabetes.

Conclusions

Health TAPESTRY-HC-DM was feasible; a large-scale randomized controlled trial seems possible. However, further attention needs to be paid to improving recruitment and retention. The intervention was well received, though was a better fit for some participants than others.

Trial registration

ClinicalTrials.gov, NCT02715791. Registered 22 March 2016—retrospectively registered.

Mobile Apps for Individuals With Rheumatoid Arthritis: A Systematic Review

BACKGROUND

Mobile health applications (apps) have the potential to help individuals with chronic illnesses learn about, monitor, and manage their condition, but these apps are largely unexamined, with the state and direction of development unclear.

OBJECTIVE

We performed a systematic review of publicly available apps, directed toward individuals with rheumatoid arthritis (RA); described their current features; and determined areas of unmet need.

METHODS

We searched the iTunes and Google Play App Stores for the term "arthritis" and reviewed the descriptions of these apps for specific mentions of RA. Applications that met inclusion criteria were downloaded and reviewed. Using a set of quality measures identified from literature review, we assessed each app for 4 features: basic characteristics, content source, functionality, and security. Frequencies for each feature were recorded, and percentages were calculated.

RESULTS

Twenty apps intended for use by RA patients were identified in December 2016. Fifty percent of apps (n = 10) offered only symptom tracking. Five (20%) provided only information about RA, and 5 (20%) engaged patients by providing both symptom tracking and educational information. Fewer than 50% of apps provided means to contact health care providers or link to an online community, and only 6 (30%) offered security protection for the user.

CONCLUSIONS

Most current RA apps do not provide a comprehensive experience for individuals with RA. Areas for optimization include the implementation of smartphone accessibility features and secure methods of protecting individual health information.

Factors influencing behavioural intention to use a smart shoe insole in regionally based adults with diabetes: a mixed methods study

Background

Smart insole technologies that provide biofeedback on foot health can support foot-care in adults with diabetes. However, the factors that influence patient uptake and acceptance of this technology are unclear. Therefore, the aim of this mixed-methods study was to use an established theoretical framework to determine a model of psychosocial factors that best predicts participant intention to use smart insoles.

Methods

Fifty-three adults with diabetes from regional Australia completed the validated Unified Theory of Acceptance and Use of Technology (UTAUT) questionnaire. Multiple regression analysis was used to determine the psychosocial factors that best predict behavioural intention to adopt a smart insole. Additionally, a focus group was conducted and thematic analysis was performed to explore barriers and enablers to adopting this technology.

Results

The multiple regression model that best predicted intention to adopt the smart insole (adjusted R² = 0.51, p < 0.001) identified that self-efficacy (β = 0.67, p = 0.001) and attitude (β = 0.72, p < 0.001) were significant predictors of behavioural intention, while effort expectancy (β = − 0.52, p = 0.003) and performance expectancy (β = − 0.40, p = 0.040) were moderating factors. Thematic analysis illustrates the importance of attitude and self-efficacy on participants’ behavioural intentions, influenced by participant’s belief in the device’s clinical efficacy and anticipated effort expectancy.

Conclusions

This mixed-methods study demonstrates that attitude, self-efficacy, performance expectancy and effort expectancy combine to predict intention to adopt smart insole technology. Clinicians should consider these psychosocial factors when they prescribe and implement smart soles with patients at high risk of foot ulceration.

Electronic supplementary material

The online version of this article (10.1186/s13047-019-0340-3) contains supplementary material, which is available to authorized users.

A Self-Regulation-Based eHealth and mHealth Intervention for an Active Lifestyle in Adults With Type 2 Diabetes: Protocol for a Randomized Controlled Trial

Background

Adoption of an active lifestyle plays an important role in the management of type 2 diabetes. Online interventions targeting lifestyle changes in adults with type 2 diabetes have provided mixed results. Previous research highlights the importance of creating theory-based interventions adapted to the population’s specific needs. The online intervention “MyPlan 2.0” targets physical activity and sedentary behavior in adults with type 2 diabetes. This intervention is grounded in the self-regulation framework and, by incorporating the feedback of users with type 2 diabetes, iteratively adapted to its target population.

Objective

The aim of this paper is to thoroughly describe “MyPlan 2.0” and the study protocol that will be used to test the effectiveness of this intervention to alter patients’ levels of physical activity and sedentary behavior.

Methods

A two-arm superiority randomized controlled trial will be performed. Physical activity and sedentary behavior will be measured using accelerometers and questionnaires. Furthermore, using questionnaires and diaries, patients’ stressors and personal determinants for change will be explored in depth. To evaluate the primary outcomes of the intervention, multilevel analyses will be conducted.

Results

The randomized controlled trial started in January 2018. As participants can start at different moments, we aim to finish all testing by July 2019.

Conclusions

This study will increase our understanding about whether and how a theory-based online intervention can help adults with type 2 diabetes increase their level of physical activity and decrease their sedentary time.

International Registered Report Identifier (IRRID)

DERR1-10.2196/12413

Evaluation of clinical decision support systems for diabetes care: An overview of current evidence

BACKGROUND

Systematic reviews (SRs) have shown that clinical decision support systems (CDSSs) have the potential to improve diabetes care. However, methods of measuring and presenting outcomes are varied, and conclusions have been inconsistent. In addition, the reporting and methodological quality in this field is unknown, which could affect the integrity and accuracy of research. Therefore, it is difficult to confirm whether CDSSs are effective in improving diabetes care.

OBJECTIVE

To comprehensively evaluate the effects of CDSS on diabetes care and to examine the methodological and reporting qualities.

METHODS

We searched PubMed, EMBASE, and Cochrane Library from their inception to February 2017. Systematic reviews investigating the effects of CDSS on diabetes care were included. Outcomes were determined in advance and assessed separately for process of care and patient outcomes. Methodological and reporting qualities were assessed by AMSTAR and PRISMA, respectively.

RESULTS

Seventeen SRs, consisting of 222 unique randomized controlled trials and 102 nonrandomized controlled trials, were included. Evidence that CDDS significantly impacted patient outcomes was found in 32 of 102 unique studies of the 15 SRs that examined this effect (31%). A significant impact of CDSS on process of care was found in 117 out of 143 unique studies of the 11 SRs that examined this effect (82%). Ratings for overall scores of AMSTAR resulted in a mean score of 6.5 with a range of scores from 3.5 to 10.0. Reporting quality related to methodological domains was particularly incomplete.

CONCLUSIONS

Clinical decision support systems improved the quality of diabetes care by inconsistently improving process of care or patient outcomes. There is evidence that CDSS for providing alerts, reminders, or feedback to participants were most likely to impact diabetes care. Poor reporting of methodological domains, together with qualitative or narrative methods to combine findings, may limit the confidence in research evidence.

Assessment of Rwandan diabetic patients' needs and expectations to develop their first diabetes self-management smartphone application (Kir'App)

BACKGROUND

Knowledge of and coping with diabetes is still poor in some communities in Rwanda. While smartphone applications (or apps) have demonstrated improving diabetes self-care, there is no current study on the use of smartphones in the self-management of diabetes in Rwanda.

METHODS

The main objective of this study was to assess the needs and expectations of Rwandan diabetic patients for mobile-health-supported diabetes self-management in order to develop a patient-centred smartphone application (Kir'App).

RESULTS

Convenience sampling was used to recruit study participants at the Rwanda Diabetes Association. Twenty-one patients participated in semi-structured, in-depth, face-to-face interviews. Thematic analysis was performed using Mayring's method of qualitative content analysis.

CONCLUSIONS

The study included 21 participants with either type 1 (female = 5, male = 6) or type 2 (female = 6, male = 4) diabetes. Participants' age ranged from 18 to 69 years with a mean age of 35 and 29 years, respectively. Eight main themes were identified. These were (a) diabetes education and desired information provision; (b) lack of diabetes knowledge and awareness; (c) need for information in crisis situations; (d) required monitoring and reminder functions; (e) information on nutrition and alcohol consumption; (f) information on physical activity; (g) coping with burden of disease, through social support and network; (h) app features. This study provides recommendations that will be used to design the features of the first Rwandan diabetes self-management smartphone application (Kir'App). The future impact of the application on the Rwandan diabetic patients' self-management capacity and quality of life will be evaluated afterwards.

Mobile phone applications and their use in the self-management of Type 2 Diabetes Mellitus: a qualitative study among app users and non-app users

BACKGROUND

Mobile phone applications (apps) have been shown to successfully facilitate the self-management of chronic disease. This study aims to evaluate firstly the experiences, barriers and facilitators to app usage among people with Type 2 Diabetes Mellitus (T2DM) and secondly determine recommendations to improve usage of diabetes apps.

METHODS

Participants were aged ≥ 18 years with a diagnosis of T2DM for ≥ 6 months. Semi-structured phone-interviews were conducted with 16 app and 14 non-app users. Interviews were based on the Technology Acceptance Model, Health Information Technology Acceptance Model (HITAM) and the Mobile Application Rating Scale. Data were analysed using deductive content analysis.

RESULTS

Most app-users found apps improved their T2DM self-management and health. The recommendation of apps by health professionals, as well as positive interactions with them, improved satisfaction; however, only a minority of patients had practitioners involved in their app use. All non-app users had never had the concept discussed with them by a health professional. Facilitators to app use included the visual representation of trends, intuitive navigation and convenience (for example, discretion and portability). Barriers to app use were participant's lack of knowledge and awareness of apps as healthcare tools, perceptions of disease severity, technological and health literacy or practical limitations such as rural connectivity. Factors contributing to app use were classified into a framework based on the Health Belief Model and HITAM. Recommendations for future app design centred on educational features, which were currently lacking (e.g. diabetes complications, including organ damage and hypoglycaemic episodes), monitoring and tracking features (e.g. blood glucose level monitoring with trends and dynamic tips and comorbidities) and nutritional features (e.g. carbohydrate counters). Medication reminders were not used by participants. Lastly, participants felt that receiving weekly text-messaging relating to their self-management would be appropriate.

CONCLUSIONS

The incorporation of user-centred features, which engage T2DM consumers in self-management tasks, can improve health outcomes. The findings may guide app developers and entrepreneurs in improving app design and usability. Given self-management is a significant factor in glycaemic control, these findings are significant for GPs, nurse practitioners and allied health professionals who may integrate apps into a holistic management plan which considers strategies outside the clinical environment.

Self-tracking of Physical Activity in People With Type 2 Diabetes: A Randomized Controlled Trial

The purpose of this study was to determine the efficacy of an online self-tracking program on physical activity, glycated hemoglobin, and other health measures in patients with type 2 diabetes. Seventy-two patients with type 2 diabetes were randomly assigned to an intervention or control group. All participants received usual care. The intervention group received an activity tracker (Fitbit Zip) connected to an online lifestyle program. Physical activity was analyzed in average steps per day from week 0 until 12. Health outcome measurements occurred in both groups at baseline and after 13 weeks. Results indicated that the intervention group significantly increased physical activity with 1.5 ± 3 days per week of engagement in 30 minutes of moderate-vigorous physical activity versus no increase in the control group (P = .047). Intervention participants increased activity with 1255 ± 1500 steps per day compared to their baseline (P < .010). No significant differences were found in glycated hemoglobin A1c, with the intervention group decreasing -0.28% ± 1.03% and the control group showing -0.0% ± 0.69% (P = .206). Responders (56%, increasing minimally 1000 steps/d) had significantly decreased glycated hemoglobin compared with nonresponders (-0.69% ± 1.18% vs 0.22% ± 0.47%, respectively; P = .007). To improve effectiveness of eHealth programs, additional strategies are needed.

Challenges in everyday life among recently diagnosed and more experienced adults with type 2 diabetes: A multistage focus group study

AIMS AND OBJECTIVES

To identify perceived challenges related to self-management among recently diagnosed adults and those with longer experience of type 2 diabetes as a foundation for the future development of a person-centred information and communication technology service.

BACKGROUND

Learning self-management of type 2 diabetes includes mastering the skills required to complete complex emotional and physical tasks. A service developed with the participation of stakeholders may be an alternative way to meet rising needs for self-management.

DESIGN

Qualitative descriptive design influenced by a participatory approach.

METHODS

Multistage focus group interviews among one group of recently diagnosed (≤3 years, n = 4) adults and one group with longer experience (≥5 years, n = 7) of type 2 diabetes.

RESULTS

Challenges in self-management in everyday life with type 2 diabetes were identified: understanding; developing skills and abilities; and mobilising personal strengths. Both groups described challenges in understanding the causes of fluctuating blood glucose and in developing and mobilising skills for choosing healthful food and eating regularly. The recently diagnosed group was more challenged by learning to accept the diagnosis and becoming motivated to change habits while the experienced group was mainly challenged by issues about complications and medications.

CONCLUSION

Adults with diabetes have different needs for support during different phases of the disease. From a person-centred perspective, it would be desirable to meet individual needs for self-management on peoples' own terms through a technological service that could reach and connect to a large number of people.

RELEVANCE TO CLINICAL PRACTICE

Diabetes nurses need to address the knowledge needs of patients with diabetes and support them in developing self-management skills. Consistent with person-centred care, practitioners should also encourage patients' abilities to mobilise their own personal strengths to maintain self-management.

Experiences and Opinions of Adults with Type 2 Diabetes Regarding a Self-Regulation-Based eHealth Intervention Targeting Physical Activity and Sedentary Behaviour

Background: Online interventions targeting a healthy lifestyle in adults with type 2 diabetes are more effective when informed by behaviour change theories. Although these theories provide guidance in developing the content of an intervention, information regarding how to present this content in an engaging way is often lacking. Consequently, incorporating users’ views in the creation of eHealth interventions has become an important target. Methods: Via a qualitative interview study with 21 adults with type 2 diabetes who had completed an online self-regulation-based intervention (‘MyPlan 2.0’), we assessed participants’ opinions regarding the usefulness of the implemented self-regulation techniques, the design of the programme as well as their knowledge regarding physical activity and sedentary behaviour. A directed content analysis was performed to synthesize the interview data. Results: Participants experienced difficulties completing the coping planning component. The simple design of the website was considered helpful, and most participants were aware of the beneficial effects of an active lifestyle. Conclusions: ‘MyPlan 2.0’ was well-accepted by the majority of participants. However, the coping planning component will need to be adapted. Based on these findings, recommendations on how to tailor eHealth interventions to the population of adults with type 2 diabetes have been formulated.

Mobile Diabetes Intervention Study of Patient Engagement and Impact on Blood Glucose: Mixed Methods Analysis

Background

Successful treatment of diabetes includes patient self-management behaviors to prevent or delay complications and comorbid diseases. On the basis of findings from large clinical trials and professional guidelines, diabetes education programs and health providers prescribe daily regimens of glucose monitoring, healthy eating, stress management, medication adherence, and physical activity. Consistent, long-term commitment to regimens is challenging. Mobile health is increasingly being used to assist patients with lifestyle changes and self-management behaviors between provider visits. The effectiveness of mobile health to improve diabetes outcomes depends on patient engagement with a technology, content, or interactions with providers.

Objectives

In the current analysis, we aimed to identify patient engagement themes in diabetes messaging with diabetes providers and determine if differences in engagement in the Mobile Diabetes Intervention Study (MDIS) influenced changes in glycated hemoglobin A_1c (HbA_1c) over a 1-year treatment period (1.9% absolute decrease in the parent study).

Methods

In the primary MDIS study, 163 patients were enrolled into 1 of 3 mobile intervention groups or a usual care control group based on their physician cluster randomization assignment. The control group received care from their physicians as usual. Participants in each intervention group had access to a patient portal where they could record monitoring values for blood glucose, blood pressure, medication changes, or other self-management information while also assigned to varying levels of physician access to patient data. Intervention participants could choose to send and receive messages to assigned certified diabetes educators with questions or updates through the secure Web portal. For this secondary analysis, patient engagement was measured using qualitative methods to identify self-care themes in 4109 patient messages. Mixed methods were used to determine the impact of patient engagement on change in HbA_1c over 1 year.

Results

Self-care behavior themes that received the highest engagement for participants were glucose monitoring (75/107, 70.1%), medication management (71/107, 66.4%), and reducing risks (71/107, 66.4%). The average number of messages sent per patient were highest for glucose monitoring (9.2, SD 14.0) and healthy eating (6.9, SD 13.2). Compared to sending no messages, sending any messages about glucose monitoring (P=.03) or medication (P=.01) led to a decrease in HbA_1c of 0.62 and 0.72 percentage points, respectively. Sending any messages about healthy eating, glucose monitoring, or medication combined led to a decrease in HbA_1c of 0.54 percentage points compared to not sending messages in these themes (P=.045).

Conclusions

The findings from this study help validate the efficacy of the mobile diabetes intervention. The next step is to determine differences between patients who engage in mobile interventions and those who do not engage and identify methods to enhance patient engagement.

Trial Registration

ClinicalTrials.gov: NCT01107015; https://clinicaltrials.gov/ct2/show/NCT01107015 (Archived by WebCite at http://www.webcitation.org/6wh4ekP4R)

Teleconsultation in type 1 diabetes mellitus (TELEDIABE)

AIMS

The growing incidence of diabetes and the need to contain healthcare costs empower the necessity to identify new models of care. Telemedicine offers an acknowledged instrument to provide clinical health care at a distance, increasing patient compliance and the achievement of therapeutical goals. The objective was to test the feasibility and the efficacy in the improvement of the glycemic control of the teleconsultation for patients with type 1 diabetes mellitus.

METHODS

A randomized open-label, parallel arms, controlled trial was conducted in two diabetes centers in Italy. Participants affected by type 1 diabetes mellitus have been randomly (1:1) assigned to receive their visits as standard or a web-based care. Patients in the teleconsultation group can arrange their appointments on a Web site and can also have access to web educational courses or to nutritional and psychological counseling. The primary outcome was the assessment of glycemic control by HbA1c measurement after a 12-month follow-up.

RESULTS

Overall 74 participants were followed for 1 year. HbA1c changes were not statistically different within (p = 0.56 for standard care group; p = 0.45 for telemedicine group) and between (p = 0.60) groups when considering differences from baseline to the end of the study. Patients randomized to teleconsultation reported reduced severe hypoglycemic episodes (p = 0.03). In addition, they were largely satisfied with the activities, perceived a good improvement in the self-management of the diabetes, and reported to have a time saving and a cost reduction.

CONCLUSIONS

In conclusion, TELEDIABE proposes a new system for the management of patients with type 1 diabetes mellitus.

Do health information technology self-management interventions improve glycemic control in medically underserved adults with diabetes? A systematic review and meta-analysis

Objective

The purpose of this systematic review and meta-analysis was to examine the effect of health information technology (HIT) diabetes self-management education (DSME) interventions on glycemic control in medically underserved patients.

Materials and Methods

Following an a priori protocol, 5 databases were searched. Studies were appraised for quality using the Cochrane Risk of Bias assessment. Studies reporting either hemoglobin A1c pre- and post-intervention or its change at 6 or 12 months were eligible for inclusion in the meta-analysis using random effects models.

Results

Thirteen studies met the criteria for the systematic review and 10 for the meta-analysis and represent data from 3257 adults with diabetes (mean age 55 years; 66% female; 74% racial/ethnic minorities). Most studies ( n  = 10) reflected an unclear risk of bias. Interventions varied by HIT type: computer software without Internet ( n  = 2), cellular/automated telephone ( n  = 4), Internet-based ( n  = 4), and telemedicine/telehealth ( n  = 3). Pooled A1c decreases were found at 6 months (-0.36 (95% CI, -0.53 and -0.19]; I 2  = 35.1%, Q  = 5.0), with diminishing effect at 12 months (-0.27 [95% CI, -0.49 and -0.04]; I 2  = 42.4%, Q  = 10.4).

Discussion

Findings suggest that medically underserved patients with diabetes achieve glycemic benefit following HIT DSME interventions, with dissipating but significant effects at 12 months. Telemedicine/telehealth interventions were the most successful HIT type because they incorporated interaction with educators similar to in-person DSME.

Conclusion

These results are similar to in-person DSME in medically underserved patients, showing that well-designed HIT DSME has the potential to increase access and improve outcomes for this vulnerable group.

Functionality, Implementation, Impact, and the Role of Health Literacy in Mobile Phone Apps for Gestational Diabetes: Scoping Review

BACKGROUND

The increasing ownership of mobile phones and advances in hardware and software position these devices as cost-effective personalized tools for health promotion and management among women with gestational diabetes mellitus (GDM). Numerous mobile phone apps are available online; however, to our knowledge, no review has documented how these apps are developed and evaluated in relation to GDM.

OBJECTIVE

The objective of our review was to answer the following 2 research questions: (1) What is known from the existing literature about the availability, functionality, and effectiveness of mobile phone apps on GDM prevention and management? (2) What is the role of health literacy in these apps?

METHODS

We searched 7 relevant electronic databases for original research documents using terms related to mobile phone apps, GDM, and health literacy. We thematically categorized selected articles using a framework adapted from Arksey and O'Malley.

RESULTS

We included 12 articles related to 7 apps or systems in the final analysis. We classified articles around 2 themes: (1) description of the development, feasibility, or usability of the apps or systems, and (2) trial protocols. The degree of personalization varied among the apps for GDM, and decision support systems can be used to generate time-efficient personalized feedback for both patients and health care providers. Health literacy was considered during the development or measured as an outcome by some apps.

CONCLUSIONS

There is a limited body of research on mobile phone apps in relation to GDM prevention and management. Mobile phone apps can provide time- and cost-efficient personalized interventions for GDM. Several randomized controlled trials have been launched recently to evaluate the effectiveness of the apps. Consideration of health literacy should be improved when developing features of the apps.

Designing Patient-Centered Text Messaging Interventions for Increasing Physical Activity Among Participants With Type 2 Diabetes: Qualitative Results From the Text to Move Intervention

Background

Type 2 diabetes mellitus (T2DM) is a disease affecting approximately 29.1 million people in the United States, and an additional 86 million adults have prediabetes. Diabetes self-management education, a complex health intervention composed of 7 behaviors, is effective at improving self-care behaviors and glycemic control. Studies have employed text messages for education, reminders, and motivational messaging that can serve as “cues to action,” aiming to improve glucose monitoring, self-care behaviors, appointment attendance, and medication adherence.

Objectives

The Text to Move (TTM) study was a 6-month 2-parallel group randomized controlled trial of individuals with T2DM to increase physical activity, measured by a pedometer. The intervention arm received text messages twice daily for 6 months that were tailored to the participant’s stage of behavior change as defined by the transtheoretical model of behavior change.

Methods

We assessed participants’ attitudes regarding their experience with text messaging, focusing on perceived barriers and facilitators, through two focus groups and telephone interviews. All interviews were audiorecorded, transcribed verbatim, coded, and analyzed using a grounded theory approach.

Results

The response rate was 67% (31/46 participants). The average age was 51.4 years and 61% (19/31 participants) were male. The majority of individuals were English speakers and married, had completed at least 12th grade and approximately half of the participants were employed full-time. Overall, participants were satisfied with the TTM program and recalled the text messages as educational, informational, and motivational. Program involvement increased the sense of connection with their health care center. The wearing of pedometers and daily step count information served as motivational reminders and created a sense of accountability through the sentinel effect. However, there was frustration concerning the automation of the text message program, including the repetitiveness, predictability of text time delivery, and lack of customization and interactivity of text message content. Participants recommended personalization of texting frequency as well as more contact time with personnel for a stronger sense of support, including greater surveillance and feedback based on their own results and comparison to other participants.

Conclusions

Participants in a theory-based text messaging intervention identified key facilitators and barriers to program efficacy that should be incorporated into future texting interventions to optimize participant satisfaction and outcomes.

Trial Registration

Clinicaltrials.gov NCT01569243; http://clinicaltrials.gov/ct2/show/NCT01569243 (Archived by Webcite at http://www.webcitation.org/6pfH6yXag)

Usability, Acceptability, and Adherence to an Electronic Self-Monitoring System in Patients With Major Depression Discharged From Inpatient Wards

Background

Patients suffering from depression have a high risk of relapse and readmission in the weeks following discharge from inpatient wards. Electronic self-monitoring systems that offer patient-communication features are now available to offer daily support to patients, but the usability, acceptability, and adherence to these systems has only been sparsely investigated.

Objective

We aim to test the usability, acceptability, adherence, and clinical outcome of a newly developed computer-based electronic self-assessment system (the Daybuilder system) in patients suffering from depression, in the period from discharge until commencing outpatient treatment in the Intensive Outpatient Unit for Affective Disorders.

Methods

Patients suffering from unipolar major depression that were referred from inpatient wards to an intensive outpatient unit were included in this study before their discharge, and were followed for four weeks. User satisfaction was assessed using semiqualitative questionnaires and the System Usability Scale (SUS). Patients were interviewed at baseline and at endpoint with the Hamilton depression rating scale (HAM-D17), the Major Depression Inventory (MDI), and the 5-item World Health Organization Well-Being Index (WHO-5). In this four-week period patients used the Daybuilder system to self-monitor mood, sleep, activity, and medication adherence on a daily basis. The system displayed a graphical representation of the data that was simultaneously displayed to patients and clinicians. Patients were phoned weekly to discuss their data entries. The primary outcomes were usability, acceptability, and adherence to the system. The secondary outcomes were changes in: the electronically self-assessed mood, sleep, and activity scores; and scores from the HAM-D17, MDI, and WHO-5 scales.

Results

In total, 76% of enrolled patients (34/45) completed the four-week study. Five patients were readmitted due to relapse. The 34 patients that completed the study entered data for mood on 93.8% of the days (872/930), sleep on 89.8% of the days (835/930), activity on 85.6% of the days (796/930), and medication on 88.0 % of the days (818/930). SUS scores were 86.2 (standard deviation [SD] 9.7) and 79% of the patients (27/34) found that the system lived up to their expectations. A significant improvement in depression severity was found on the HAM-D17 from 18.0 (SD 6.5) to 13.3 (SD 7.3; P<.01), on the MDI from 27.1 (SD 13.1) to 22.1 (SD 12.7; P=.006), and in quality of life on the WHO-5 from 31.3 (SD 22.9) to 43.4 (SD 22.1; P<.001) scales, but not on self-assessed mood (P=.08). Mood and sleep parameters were highly variable from day-to-day. Sleep-offset was significantly delayed from baseline, averaging 48 minutes (standard error 12 minutes; P<.001). Furthermore, when estimating delay of sleep-onset (with sleep quality included in the model) during the study period, this showed a significant negative effect on mood (P=.03)

Conclusions

The Daybuilder systems performed well technically, and patients were satisfied with the system and had high adherence to self-assessments. The dropout rate and the gradual delay in sleep emphasize the need for continued clinical support for these patients, especially when considering sleep guidance.

Enablers and barriers to using two-way information technology in the management of adults with diabetes: A descriptive systematic review

Background This systematic review aimed to explore the enablers and barriers faced by adults with diabetes using two-way information communication technologies to support diabetes self-management. Methods Relevant literature was obtained from five databases using search strategies combining four major constructs: adults with diabetes, biomedical technology, communication technology and patient utilisation. Results Of 8430 unique articles identified, 48 were included for review. Risk of bias was assessed using either the Newcastle-Ottowa or Cochrane risk of bias assessment tools. Seventy-one percent of studies were of cohort design with the majority of studies assessed at high or unclear risk of bias. Consistently identified barriers included poorly designed interfaces requiring manual data entry and systems that lacked functionalities valued by patients. Commonly cited enablers included access to reliable technology, highly automated data entry and transmission, graphical display of data with immediate feedback, and supportive health care professionals and family members. Conclusions People with diabetes face a number of potentially modifiable barriers in using technology to support their diabetes management. In order to address these barriers, end users should be consulted in the design process and consideration given to theories of technology adoption to inform design and implementation. Systems should be designed to solve clinical or behavioural problems that are identified by patients as priorities. Technology should be as automated, streamlined, mobile, low cost and integrated as possible in order to limit the burden of usage for the patient and maximise clinical usefulness.

Mobile App-Based Interventions to Support Diabetes Self-Management: A Systematic Review of Randomized Controlled Trials to Identify Functions Associated with Glycemic Efficacy

Background

Mobile health apps for diabetes self-management have different functions. However, the efficacy and safety of each function are not well studied, and no classification is available for these functions.

Objective

The aims of this study were to (1) develop and validate a taxonomy of apps for diabetes self-management, (2) investigate the glycemic efficacy of mobile app-based interventions among adults with diabetes in a systematic review of randomized controlled trials (RCTs), and (3) explore the contribution of different function to the effectiveness of entire app-based interventions using the taxonomy.

Methods

We developed a 3-axis taxonomy with columns of clinical modules, rows of functional modules and cells of functions with risk assessments. This taxonomy was validated by reviewing and classifying commercially available diabetes apps. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Chinese Biomedical Literature Database, and ClinicalTrials.gov from January 2007 to May 2016. We included RCTs of adult outpatients with diabetes that compared using mobile app-based interventions with usual care alone. The mean differences (MDs) in hemoglobin A_1c (HbA_1c) concentrations and risk ratios of adverse events were pooled using a random-effects meta-analysis. After taxonomic classification, we performed exploratory subgroup analyses of the presence or absence of each module across the included app-based interventions.

Results

Across 12 included trials involving 974 participants, using app-based interventions was associated with a clinically significant reduction of HbA_1c (MD 0.48%, 95% CI 0.19%-0.78%) without excess adverse events. Larger HbA_1c reductions were noted among patients with type 2 diabetes than those with type 1 diabetes (MD 0.67%, 95% CI 0.30%-1.03% vs MD 0.37%, 95% CI –0.12%-0.86%). Having a complication prevention module in app-based interventions was associated with a greater HbA_1c reduction (with complication prevention: MD 1.31%, 95% CI 0.66%-1.96% vs without: MD 0.38%, 95% CI 0.09%-0.67%; intersubgroup P=.01), as was having a structured display (with structured display: MD 0.69%, 95% CI 0.32%-1.06% vs without: MD 0.69%, 95% CI –0.18%-0.53%; intersubgroup P=.03). However, having a clinical decision-making function was not associated with a larger HbA_1c reduction (with clinical decision making: MD 0.19%, 95% CI –0.24%-0.63% vs without: MD 0.61%, 95% CI 0.27%-0.95%; intersubgroup P=.14).

Conclusions

The use of mobile app-based interventions yields a clinically significant HbA_1c reduction among adult outpatients with diabetes, especially among those with type 2 diabetes. Our study suggests that the clinical decision-making function needs further improvement and evaluation before being added to apps.

A web-based clinical decision support system for gestational diabetes: Automatic diet prescription and detection of insulin needs

BACKGROUND

The growth of diabetes prevalence is causing an increasing demand in health care services which affects the clinicians' workload as medical resources do not grow at the same rate as the diabetic population. Decision support tools can help clinicians with the inspection of monitoring data, providing a preliminary analysis to ease their interpretation and reduce the evaluation time per patient. This paper presents Sinedie, a clinical decision support system designed to manage the treatment of patients with gestational diabetes. Sinedie aims to improve access to specialized healthcare assistance, to prevent patients from unnecessary displacements, to reduce the evaluation time per patient and to avoid gestational diabetes adverse outcomes.

METHODS

A web-based telemedicine platform was designed to remotely evaluate patients allowing them to upload their glycaemia data at home directly from their glucose meter, as well as report other monitoring variables like ketonuria and compliance to dietary treatment. Glycaemia values, not tagged by patients, are automatically labelled with their associated meal by a classifier based on the Expectation Maximization clustering algorithm and a C4.5 decision tree learning algorithm. Two finite automata are combined to determine the patient's metabolic condition, which is analysed by a rule-based knowledge base to generate therapy adjustment recommendations. Diet recommendations are automatically prescribed and notified to the patients, whereas recommendations about insulin requirements are notified also to the physicians, who will decide if insulin needs to be prescribed. The system provides clinicians with a view where patients are prioritized according to their metabolic condition. A randomized controlled clinical trial was designed to evaluate the effectiveness and safety of Sinedie interventions versus standard care and its impact in the professionals' workload in terms of the clinician's time required per patient; number of face-to-face visits; frequency and duration of telematics reviews; patients' compliance to self-monitoring; and patients' satisfaction.

RESULTS

Sinedie was clinically evaluated at "Parc Tauli University Hospital" in Spain during 17 months with the participation of 90 patients with gestational diabetes. Sinedie detected all situations that required a therapy adjustment and all the generated recommendations were safe. The time devoted by clinicians to patients' evaluation was reduced by 27.389% and face-to-face visits per patient were reduced by 88.556%. Patients reported to be highly satisfied with the system, considering it useful and trusting in being well controlled. There was no monitoring loss and, in average, patients measured their glycaemia 3.890 times per day and sent their monitoring data every 3.477days.

CONCLUSIONS

Sinedie generates safe advice about therapy adjustments, reduces the clinicians' workload and helps physicians to identify which patients need a more urgent or more exhaustive examination and those who present good metabolic control. Additionally, Sinedie saves patients unnecessary displacements which contributes to medical centres' waiting list reduction.

Barriers to Remote Health Interventions for Type 2 Diabetes: A Systematic Review and Proposed Classification Scheme

Background

Diabetes self-management involves adherence to healthy daily habits typically involving blood glucose monitoring, medication, exercise, and diet. To support self-management, some providers have begun testing remote interventions for monitoring and assisting patients between clinic visits. Although some studies have shown success, there are barriers to widespread adoption.

Objective

The objective of our study was to identify and classify barriers to adoption of remote health for management of type 2 diabetes.

Methods

The following 6 electronic databases were searched for articles published from 2010 to 2015: MEDLINE (Ovid), Embase (Ovid), CINAHL, Cochrane Central, Northern Light Life Sciences Conference Abstracts, and Scopus (Elsevier). The search identified studies involving remote technologies for type 2 diabetes self-management. Reviewers worked in teams of 2 to review and extract data from identified papers. Information collected included study characteristics, outcomes, dropout rates, technologies used, and barriers identified.

Results

A total of 53 publications on 41 studies met the specified criteria. Lack of data accuracy due to input bias (32%, 13/41), limitations on scalability (24%, 10/41), and technology illiteracy (24%, 10/41) were the most commonly cited barriers. Technology illiteracy was most prominent in low-income populations, whereas limitations on scalability were more prominent in mid-income populations. Barriers identified were applied to a conceptual model of successful remote health, which includes patient engagement, patient technology accessibility, quality of care, system technology cost, and provider productivity. In total, 40.5% (60/148) of identified barrier instances impeded patient engagement, which is manifest in the large dropout rates cited (up to 57%).

Conclusions

The barriers identified represent major challenges in the design of remote health interventions for diabetes. Breakthrough technologies and systems are needed to alleviate the barriers identified so far, particularly those associated with patient engagement. Monitoring devices that provide objective and reliable data streams on medication, exercise, diet, and glucose monitoring will be essential for widespread effectiveness. Additional work is needed to understand root causes of high dropout rates, and new interventions are needed to identify and assist those at the greatest risk of dropout. Finally, future studies must quantify costs and benefits to determine financial sustainability.

Designing an ICT self-management service: suggestions from persons with type 2 diabetes

This paper reports the wishes and needs of people with type 2 diabetes (T2DM) for a future information and communication technology (ICT) self-management service to help manage their condition and their everyday life. Diabetes is a chronic disease affecting more and more people and placing increasing demands on health care. The self-management of diabetes includes instrumental and, decision-making skills and skills in managing daily activities, which may be supported by an ICT service. In this study we used a participatory design including two sessions of Future Workshop (FW) as part of a larger research project on the self-management of diabetes. Adults with type 2 diabetes participated in two FW sessions in which their expressed wishes and needs for an ICT service all fell under the broad category of Acceptance of the diagnosis, with three other suggestions; Trust in partnerships, Communication, and Individualized information. The participants' experience of the FW as a democratic process and their appreciation of mutual learning contributed to these results, which are consistent with the aims of person-centred care.

The effectiveness of text message-based self-management interventions for poorly-controlled diabetes: A systematic review

BACKGROUND

Poorly controlled diabetes leads to debilitating complications at a significant cost to health systems. Text messaging is an ideal platform for the delivery of self-management interventions to patients with poorly controlled diabetes due to the ubiquity of mobile phones, and the ability of text messaging to reach people in their everyday lives when self-management of the condition is vital. This systematic review aimed to assess the effectiveness of short message service-based diabetes self-management interventions on glycaemic control in adults with poorly controlled diabetes.

METHODS/DESIGN

MEDLINE, PubMed, EMBASE, The Cochrane Library and PsychINFO were searched from inception through to 23 January 2017 for randomised controlled trials investigating the use of text messaging based self-management interventions on haemoglobin A1c for patients with poorly controlled diabetes.

RESULTS

Seven studies met the inclusion criteria and were included in the review. Three of the studies reported a significant decrease in haemoglobin A1c from baseline to follow-up in the intervention group compared to the control group. No clear relationship between positive outcomes and intervention dose, content and functionality was seen.

DISCUSSION

Evidence supporting text messaging for improvements in glycaemic control in people with poorly controlled diabetes is mixed. Previous reviews have reported positive impacts on glycaemic control for short message service interventions in patients with diabetes; however, when limited to those with poorly controlled diabetes the evidence is less clear. Large-scale studies with robust methodology and longer-term follow-up are needed to further understand the impact of text-messaging-based self-management interventions for people with poorly controlled diabetes.

Impact of Information Technology-Based Interventions for Type 2 Diabetes Mellitus on Glycemic Control: A Systematic Review and Meta-Analysis

BACKGROUND

Information technology-based interventions are increasingly being used to manage health care. However, there is conflicting evidence regarding whether these interventions improve outcomes in people with type 2 diabetes.

OBJECTIVE

The objective of this study was to conduct a systematic review and meta-analysis of clinical trials, assessing the impact of information technology on changes in the levels of hemoglobin A_1c (HbA_1c) and mapping the interventions with chronic care model (CCM) elements.

METHODS

Electronic databases PubMed and EMBASE were searched to identify relevant studies that were published up until July 2016, a method that was supplemented by identifying articles from the references of the articles already selected using the electronic search tools. The study search and selection were performed by independent reviewers. Of the 1082 articles retrieved, 32 trials (focusing on a total of 40,454 patients) were included. A random-effects model was applied to estimate the pooled results.

RESULTS

Information technology-based interventions were associated with a statistically significant reduction in HbA_1c levels (mean difference -0.33%, 95% CI -0.40 to -0.26, P<.001). Studies focusing on electronic self-management systems demonstrated the largest reduction in HbA_1c (0.50%), followed by those with electronic medical records (0.17%), an electronic decision support system (0.15%), and a diabetes registry (0.05%). In addition, the more CCM-incorporated the information technology-based interventions were, the more improvements there were in HbA_1c levels.

CONCLUSIONS

Information technology strategies combined with the other elements of chronic care models are associated with improved glycemic control in people with diabetes. No clinically relevant impact was observed on low-density lipoprotein levels and blood pressure, but there was evidence that the cost of care was lower.

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

OBJECTIVE

To investigate the effect of mobile phone applications (apps) on glycemic control (HbA_1c) in the self-management of diabetes.

RESEARCH DESIGN AND METHODS

Relevant studies that were published between 1 January 1996 and 1 June 2015 were searched from five databases: Medline, CINAHL, Cochrane Library, Web of Science, and Embase. Randomized controlled trials that evaluated diabetes apps were included. We conducted a systematic review with meta-analysis and GRADE (Grading of Recommendations Assessment, Development and Evaluation) of the evidence.

RESULTS

Participants from 14 studies (n = 1,360) were included and quality assessed. Although there may have been clinical diversity, all type 2 diabetes studies reported a reduction in HbA_1c. The mean reduction in participants using an app compared with control was 0.49% (95% Cl 0.30, 0.68; I² = 10%), with a moderate GRADE of evidence. Subgroup analyses indicated that younger patients were more likely to benefit from the use of diabetes apps, and the effect size was enhanced with health care professional feedback. There was inadequate data to describe the effectiveness of apps for type 1 diabetes.

CONCLUSIONS

Apps may be an effective component to help control HbA_1c and could be considered as an adjuvant intervention to the standard self-management for patients with type 2 diabetes. Given the reported clinical effect, access, and nominal cost of this technology, it is likely to be effective at the population level. The functionality and use of this technology need to be standardized, but policy and guidance are anticipated to improve diabetes self-management care.

The Relationship Between Depressive Symptoms and Self-Management Behaviors in Patients With T2DM and Stage 3 CKD

PURPOSE

This study aimed to assess the relationship of depressive symptoms with self-management by adults with type 2 diabetes mellitus and chronic kidney disease.

DESIGN AND METHODS

Using a descriptive correlational design, participants completed Beck's Depression Inventory (BDI-II) and Summary of Diabetes Self-Care Activities measure.

FINDINGS

Reported were energy loss, sleep change, and fatigue. Performed less were exercise, physical activity, eating vegetables, and blood checks. Significant correlations were BDI-II total score with feet checking, energy loss with feet checking and exercise, and sleep change with feet soaking.

PRACTICE IMPLICATIONS

Depressive symptoms were associated to self-management behaviors that require physical energy. Assess for advancing symptoms.

eHealth in Modern Patient-Caregiver Communication: High Rate of Acceptance Among Physicians for Additional Support of Breast Cancer Patients During Long-Term Therapy

Background

Lack of adherence and compliance with drug regimens among breast cancer patients represent substantial problems in oral therapies, leading to significant impacts on mortality. Where other systems have failed, electronic health (eHealth) could be a possible solution to improve medication intake, along with the doctor-patient relationship. Initial results from studies concerning new interventions for therapy support are promising, but reports suggest that general acceptance of new treatment support tools is needed among patients and physicians alike.

Objective

The aim of this study was to investigate the actual use of the Internet and other modern media among physicians involved in breast cancer treatment.

Methods

Using a standardized questionnaire, actual utilization of new media among physicians was analyzed. Internet-related behaviors in private, as well as in business life, were investigated. Attention was focused on physicians’ opinions regarding modern eHealth tools and how patients could be best supported to enhance adherence.

Results

A total of 120 physicians, all participating in breast cancer care, completed the questionnaire (median age 41 years). Almost all participants (99.2%, 119/120) used the Internet for general purposes and 98.3% (118/120) used it for medical issues as well. Virtually all medical professionals (99.2%, 119/120) reported that they owned a computer, while more recently invented technologies such as tablets and smartphones were owned by 31.9% (38/119) and 73.1% (87/119), respectively. The Internet was favored by 66.4% (79/119) of the physicians in our survey as a source for patient support; 71.2% (84/118) would also favor modern media for side effect registration. Based on our analysis, the most frequent Internet-utilizing physicians were characterized by age <60, worked in a hospital, and were employed as a junior physician.

Conclusions

This study demonstrated a high usage of Internet-related technologies among physicians, indicating that the use of eHealth for advanced and individualized support in breast cancer care is a promising addition to treatment management. Such technologies have the potential to enhance adherence and compliance in therapy among cancer patients.