Impact of DSMES app interventions on medication adherence in type 2 diabetes mellitus: systematic review and meta-analysis

Integrating neural substrates, diabetes self-management, and behavior change for tailored lifestyle interventions in type-2 diabetes: A neurobehavioral perspective

Understanding the neural mechanisms that underlie behavior change is critical for improving lifestyle management in type 2 diabetes. Individuals with type 2 diabetes face unique challenges in adopting and maintaining healthy behaviors, which can be influenced by alterations in brain function and plasticity, potentially leading to cognitive impairment. Diabetes self-management education and support (DSMES) programs aim to enhance lifestyle changes and promote better health outcomes while reducing cognitive decline. However, complex neural disruptions in critical regions for cognitive processes like the prefrontal cortex and parietal lobe present significant challenges. Given the likely role of neural mechanisms in behavioral choices, understanding how type 2 diabetes affects these neural substrates is crucial for developing effective interventions. Despite considerable research efforts aimed at testing lifestyle interventions, a critical gap remains in understanding the cognitive and behavioral components of successful diabetes self-management, the neural substrates of those components, and the impact of diabetes on those neural substrates. Bridging this gap necessitates a comprehensive examination integrating neural processes, DSMES strategies, and behavior change models. Thus, this perspective review highlights the urgent need to address the knowledge gaps surrounding the neural correlates of diabetes self-management and the integration of behavioral models into intervention frameworks. We propose a hypothesis-generating question and present preliminary findings comparing neural plasticity, executive functions, and lifestyle behavior among individuals with type 2 diabetes, pre-diabetes, and healthy controls. By elucidating the neural substrates underpinning diabetes and exploring their implications for DSMES and readiness to change, we can pave the way for more effective, personalized approaches to diabetes care.

Patient Adherence for Oral Combination Therapies in Diabetes Management: A Scoping Review

Background and Aims

Diabetes imposes a global healthcare burden, with Type 2 Diabetes Mellitus (T2DM) escalating due to demographic shifts and lifestyle changes. Combination therapies offer promise in managing T2DM, yet patient adherence remains a challenge. This scoping review aims to explore patient adherence to combination therapies in T2DM management.

Materials and Methods

This scoping review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. Electronic databases including PubMed, Scopus, and Web of Science were searched until July 10, 2024. Studies focused on patients with T2DM prescribed oral combination therapies were included. Data extraction and synthesis were conducted to identify adherence patterns, influencers, and strategies.

Results

The review identified nine eligible studies spanning from 2004 to 2021, primarily retrospective cohort and cross-sectional designs. Adherence assessment methods varied, with medication possession ratio being the most common. Both dual (loose-dose) and fixed-dose combination therapies were explored. Adherence rates varied across studies and therapies, influenced by factors such as glycemic control, weight management, economic considerations, complexity of regimens, and demographic factors. Bibliometric analysis revealed diverse geographic origins of the included studies and varied adherence assessment methods. Dual therapy regimens demonstrated adherence rates ranging from 49% to 80.8%, while FDC therapies showed adherence rates ranging from 60.3% to 98.9%. Factors influencing adherence included glycemic control, weight management, economic considerations, complexity of regimens, and demographic factors.

Conclusion

Patient adherence to oral combination therapies in diabetes management is complex, affected by clinical, economic, and psychosocial factors. Addressing these issues is crucial for enhancing treatment outcomes and alleviating the burden of diabetes. A patient-centered approach and innovative strategies can empower patients to adhere to medication regimens, improving health outcomes and quality of life.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mobile phone interventions to improve health outcomes among patients with chronic diseases: an umbrella review and evidence synthesis from 34 meta-analyses

This umbrella review of 34 meta-analyses, representing 235 randomised controlled trials done across 52 countries and 48 957 participants and ten chronic conditions, aimed to evaluate evidence on the efficacy of mobile phone interventions for populations with chronic diseases. We evaluated the strengths of evidence via the Fusar-Poli and Radua methodology. Compared with usual care, mobile apps had convincing effects on glycated haemoglobin reduction among adults with type 2 diabetes (d=0·44). Highly suggestive effects were found for both text messages and apps on various outcomes, including medication adherence (among patients with HIV in sub-Saharan Africa and people with cardiovascular disease), glucose management in type 2 diabetes, and blood pressure reduction in hypertension. Many effects (42%) were non-significant. Various gaps were identified, such as a scarcity of reporting on moderators and publication bias by meta-analyses, little research in low-income and lower-middle-income countries, and little reporting on adverse events.

Which behaviour change techniques work best for diabetes self-management mobile apps? Results from a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Self-management is pivotal in addressing noncommunicable diseases, such as diabetes. The increased availability of digital behaviour change interventions (DBCIs) delivered through mobile health apps offers unprecedented opportunities to enhance self-management and improve health outcomes. However, little is known about the characteristics of DBCIs for diabetes that significantly impact glycaemic control. Therefore, our systematic review with meta-analysis aimed to summarize characteristics and behaviour change components in DBCIs for diabetes self-management and explore potential associations with metabolic outcomes.

METHODS

A systematic search was conducted in PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Scopus to identify randomized controlled trials published until November 2023. The main outcome variable was the change in the mean difference of HbA1c levels between baseline and follow-up across intervention and control groups. Random-effects meta-regression was used to explore variation in glycaemic control as a function of prespecified characteristics of study designs and app interventions.

FINDINGS

A total of 57 studies was included in the analysis, showing a statistically significant percentage point reduction in HbA1c for the intervention group compared to the control arm (-0.36, 95% CI = -0.46 to -0.26, p < 0.001). The inclusion of "self-monitoring of behaviour" as a behaviour change technique (β = -0.22, p = 0.04) and "taking medication" as a target behaviour (β = -0.20, p = 0.05) was associated with improved metabolic outcomes.

INTERPRETATION

Our analyses endorse the use of diabetes self-management apps, highlighting characteristics statistically associated with intervention effectiveness and guiding the design of more effective DBCIs.

FUNDING

This project received funding from the European Union's Horizon 2020 programme.

Do digital health interventions hold promise for stroke prevention and care in Black and Latinx populations in the United States? A scoping review

BACKGROUND

Black and Latinx populations are disproportionately affected by stroke and are likely to experience gaps in health care. Within fragmented care systems, remote digital solutions hold promise in reversing this pattern. However, there is a digital divide that follows historical disparities in health. Without deliberate attempts to address this digital divide, rapid advances in digital health will only perpetuate systemic biases. This study aimed to characterize the range of digital health interventions for stroke care, summarize their efficacy, and examine the inclusion of Black and Latinx populations in the evidence base.

METHODS

We searched PubMed, the Web of Science, and EMBASE for publications between 2015 and 2021. Inclusion criteria include peer-reviewed systematic reviews or meta-analyses of experimental studies focusing on the impact of digital health interventions on stroke risk factors and outcomes in adults. Detailed information was extracted on intervention modality and functionality, clinical/behavioral outcome, study location, sample demographics, and intervention results.

RESULTS

Thirty-eight systematic reviews met inclusion criteria and yielded 519 individual studies. We identified six functional categories and eight digital health modalities. Case management (63%) and health monitoring (50%) were the most common intervention functionalities. Mobile apps and web-based interventions were the two most commonly studied modalities. Evidence of efficacy was strongest for web-based, text-messaging, and phone-based approaches. Although mobile applications have been widely studied, the evidence on efficacy is mixed. Blood pressure and medication adherence were the most commonly studied outcomes. However, evidence on the efficacy of the various intervention modalities on these outcomes was variable. Among all individual studies, only 38.0% were conducted in the United States (n = 197). Of these U.S. studies, 54.8% adequately reported racial or ethnic group distribution. On average, samples were 27.0% Black, 17.1% Latinx, and 63.4% White.

CONCLUSION

While evidence of the efficacy of selected digital health interventions, particularly those designed to improve blood pressure management and medication adherence, show promise, evidence of how these interventions can be generalized to historically underrepresented groups is insufficient. Including these underrepresented populations in both digital health experimental and feasibility studies is critical to advancing digital health science and achieving health equity.

An umbrella review of effectiveness and efficacy trials for app-based health interventions

Health interventions based on mobile phone or tablet applications (apps) are promising tools to help patients manage their conditions more effectively. Evidence from randomized controlled trials (RCTs) on efficacy and effectiveness of such interventions is increasingly available. This umbrella review aimed at mapping and narratively summarizing published systematic reviews on efficacy and effectiveness of mobile app-based health interventions within patient populations. We followed a pre-specified publicly available protocol. Systematic reviews were searched in two databases from inception until August 28, 2023. Reviews that included RCTs evaluating integrated or stand-alone health app interventions in patient populations with regard to efficacy/effectiveness were considered eligible. Information on indications, outcomes, app characteristics, efficacy/effectiveness results and authors' conclusions was extracted. Methodological quality was assessed using the AMSTAR2 tool. We identified 48 systematic reviews published between 2013 and 2023 (35 with meta-analyses) that met our inclusion criteria. Eleven reviews included a broad spectrum of conditions, thirteen focused on diabetes, five on anxiety and/or depression, and others on various other indications. Reported outcomes ranged from medication adherence to laboratory, anthropometric and functional parameters, symptom scores and quality of life. Fourty-one reviews concluded that health apps may be effective in improving health outcomes. We rated one review as moderate quality. Here we report that the synthesized evidence on health app effectiveness varies largely between indications. Future RCTs should consider reporting behavioral (process) outcomes and measures of healthcare resource utilization to provide deeper insights on mechanisms that make health apps effective, and further elucidate their impact on healthcare systems.

Effect and usability of mobile health applications for medication adherence in patients with heart failure: A systematic review

BACKGROUND

This review aimed to evaluate the effect of mobile health applications (apps) use on medication adherence in heart failure (HF) patients, and to verify their quality of use.

METHODS

We searched MEDLINE, Embase, Web of Science, Scopus, CINAHL, LILACS, Cochrane, Clinical Trial Registries, Google Scholar, ProQuest, Open Access Theses and dissertations (OATD), Annual Symposium Proceedings of the American Medical Informatics Association (AMIA).

RESULTS

Of the 836 records identified, eight studies (five randomized clinical trials (RCTs) and three observational studies) were included, totaling 484 participants, with a mean age ranging from 51.1 to 72 years and 65% were male. The apps improved medication adherence when compared with their comparators in only two RCTs (n = 111, Cohen d = 3.23, 95% confidence interval (CI) 2.66; 3.80 and n = 80, d = 1.20, 95% CI 0.71; 1.66), and two observational studies, one of them with large effect size (n = 142, Cohen d = 1.51, 95% CI 1.12; 1.90). Apps proved to be more effective interventions than their comparators allowed continuous monitoring of patients. All included studies used self-report measures to assess medication adherence behaviors and their results should be interpreted with caution, as such tools may cause social desirability bias or recall bias.

CONCLUSION

The included studies indicate a possible outcome in favor of the use of apps to improve medication adherence in HF patients, but with very low quality level of evidence. Further studies are needed to investigate the effects of the use of apps, optimal frequency and duration of its use in HF patients.

Adherence to Oral Antidiabetic Drugs in Patients with Type 2 Diabetes: Systematic Review and Meta-Analysis

Poor adherence to oral antidiabetic drugs (OADs) in patients with type 2 diabetes (T2D) can lead to therapy failure and risk of complications. The aim of this study was to produce an adherence proportion to OADs and estimate the association between good adherence and good glycemic control in patients with T2D. We searched in MEDLINE, Scopus, and CENTRAL databases to find observational studies on therapeutic adherence in OAD users. We calculated the proportion of adherent patients to the total number of participants for each study and pooled study-specific adherence proportions using random effect models with Freeman-Tukey transformation. We also calculated the odds ratio (OR) of having good glycemic control and good adherence and pooled study-specific OR with the generic inverse variance method. A total of 156 studies (10,041,928 patients) were included in the systematic review and meta-analysis. The pooled proportion of adherent patients was 54% (95% confidence interval, CI: 51-58%). We observed a significant association between good glycemic control and good adherence (OR: 1.33; 95% CI: 1.17-1.51). This study demonstrated that adherence to OADs in patients with T2D is sub-optimal. Improving therapeutic adherence through health-promoting programs and prescription of personalized therapies could be an effective strategy to reduce the risk of complications.

What is the effect of mobile phone text message reminders on medication adherence among adult type 2 diabetes mellitus patients: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Globally, type 2 diabetes has become increasing. As little is known about the effect of educational intervention on this population, this systematic review and meta-analysis evaluated the effectiveness of mobile phone text message reminders versus usual care to improve medication adherence among type 2 diabetes mellitus patients.

METHODS

PubMed, Google Scholar, Cochrane Library, Scopus, and African Journals Online, were searched. A random-effects model was employed to estimate combined effect sizes. Subgroup analyses were employed to investigate possible sources of heterogeneity between studies. The overall certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

A total of 9 trials with 1,121 participants were included in the review. The pooled estimated impact of mobile phone text message reminders on medication adherence was (SMD: 0.36; 95%CI; 0.14, 0.59) compared to usual care groups among patients with type 2 diabetes mellitus. In addition, subgroup analyses revealed greater medication adherence levels in those studies with intervention durations of more than six months and with self-report/refill adherence scale measurement (SMD: 0.21; 95%CI: 0.02, 0.40) and (SMD: 0.45; 95%CI: 0.22, 0.68), respectively.

CONCLUSION

Mobile phone text messages can potentially lead to improved medication adherence levels in patients with Type 2 diabetes despite heterogeneity across the studies. Therefore, mobile phone text messaging when delivered in addition to usual care, have the potential to produce significant improvements in medication adherence.

Availability of Evidence-Based Diabetes Programs in U.S. Children's Hospitals

Diabetes affects Americans across the lifespan requiring individual and community-level interventions for prevention and management. Nonprofit hospitals are required to address community health needs under current tax law. The study objective was to assess what strategies children's hospitals implemented in prevention and care of diabetes and determine how many hospitals used evidence-based strategies. We identified the most recent Children's Hospital Needs Assessments and implementation strategies for each hospital. Data were thematically coded. Twenty-nine of the 233 U.S. children's hospitals addressed diabetes in their community benefit investments. Of the 130 hospital programs, 48 (37%) aligned with the DSMES framework. Programs focused on prevention (32%), healthy eating (18%), education (15%), physical activity (12%), quality improvement (11%), and self-management (5%). Most children's hospital interventions (85%) did not state a focus on reducing health disparities and none addressed problem solving or diabetes technology. Minimal hospitals are using evidence-based programming for diabetes management and are not targeting health disparities which undercuts their efforts. Hospitals are not adopting structural evidence-based approaches, missing key opportunities to implement strategies shown to reduce diabetes prevalence and lower A1c. This study suggests that children's hospitals need improvement in their diabetes programming to better serve their communities.

Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycaemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional healthcare team providing diabetes care in the USA and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the healthcare system and physical activity behaviours including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional health care team providing diabetes care in the U.S. and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the health care system, and physical activity behaviors, including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Adherence to Medication in Older Adults with Type 2 Diabetes Living in Lubuskie Voivodeship in Poland: Association with Frailty Syndrome

Purpose: Diabetic patients aged 65 years or older are more likely to be frail than non-diabetic older adults. Adherence to therapeutic recommendations in the elderly suffering from diabetes and co-existent frailty syndrome may prevent complications such as micro- or macroangiopathy, as well as significantly affect prevention and reversibility of frailty. The study aimed at assessing the impact of frailty syndrome (FS) on the level of adherence to medication in elderly patients with type 2 diabetes (DM2). Patients and Methods: The research was carried out among 175 DM2 patients (87; 49.71% women and 88; 50.29% men) whose average age amounted to 70.25 ± 6.7. Standardized research instruments included Tilburg frailty indicator (TFI) to assess FS and adherence in chronic disease scale questionnaire (ACDS) to measure adherence to medications. Results: The group of 101 (57.71%) patients displayed medium, 39 (22.29%)—low, and 35 (20.00%)—high adherence. As many as 140 of them (80.00%) were diagnosed with frailty syndrome. The median of the average result of TFI was significantly higher in the low adherence group (p ˂ 0.001) (Mdn = 9, Q1–Q3; 7–10 pt.) than in the medium (Mdn = 6, Q1–Q3; 5–9 pt.) or high adherence (Mdn = 6.00, Q1–Q3; 4.5–8 pt.) ones. The independent predictors of the chance to be qualified to the non-adherence group included three indicators: TFI (OR 1.558, 95% CI 1.245–1.95), male gender (OR 2.954, 95% CI 1.044–8.353), and the number of all medications taken daily (each extra pill decreased the chance of being qualified to the non-adherence group by 15.3% (95% CI 0.728–0.954). Conclusion: Frailty syndrome in elderly DM2 patients influenced medical adherence in this group. The low adhesion group had higher overall TFI scores and separately higher scores in the physical and psychological domains compared to the medium and high adhesion groups.

The effectiveness of self-management programmes for people with type 2 diabetes receiving insulin injection: A systematic review and meta-analysis

BACKGROUND

People with type 2 diabetes (T2D) receiving insulin injection are reported to encounter challenges to achieve optimal glycaemic control. The evidence on effectiveness of self-management programmes for T2D people receiving insulin injection is far from conclusive.

AIM

To examine the effectiveness of self-management programmes for people with T2D receiving insulin injection.

METHODS

Twelve databases were searched from dates of inception to June 2021. All randomised controlled trials (RCTs) and controlled clinical trials examining the effectiveness of self-management programmes were included. The methodological quality was appraised using the Joanna Briggs Institute critical appraisal tools by two independent researchers. Data were summarised narratively or pooled statistically where appropriate.

RESULTS

Nine RCTs involving 2613 participants were included. At post-intervention, meta-analysis results showed that self-management programmes significantly improved glycated haemoglobin A1c (HbA1c) (mean difference [MD]: -0.21, 95% confidence interval [CI] -0.29 to -0.12, P < .001), self-management behaviours (standardised MD [SMD]: 0.23, 95% CI: 0.12 to 0.33, P < .001) and self-efficacy (SMD: 0.20, 95% CI: 0.09 to 0.31, P = .0002). Only one intensive lifestyle intervention reported significant improvements in body weight and waist circumference. Three RCTs demonstrated significant improvements in body mass index compared with the control group. Only one study demonstrated significant improvements in total cholesterol and triglycerides in favour of the intervention group. At six months post-intervention, pooled results of two studies revealed decreased diabetes-related distress (MD: -2.98, 95% CI: -5.15 to -0.82, P = .007). No significant changes in blood pressure, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, depression and anxiety were found.

CONCLUSIONS

Self-management programmes have the potential to improve glycaemic control, weight management, blood lipids, self-management behaviours, self-efficacy and diabetes-related distress of people with T2D receiving insulin injection. More rigorous experimental trials are warranted to examine the effectiveness of self-management programme and its maintenance.