NEW YORK – Add diabetes management to the standard cell phone repertoire of talking, texting, browsing, and playing "Fruit Ninja," an e-health advocate said at the annual advanced postgraduate course held by the American Diabetes Association.
"The phone is no longer really a phone. We call it a ‘cell phone’ or ‘mobile’ in Europe, but here we’re really holding a handheld computer, which has tremendous capabilities for communication between individuals as well as tremendous opportunities for exchange of information," said Dr. Richard J. Katz, professor of medicine and director of the division of cardiology at George Washington University Medical Center in Washington, D.C.
Dr. Richard Katz
General, patient-centric mobile health applications (apps) empower patients and help them become better partners in their own health maintenance, Dr. Katz said.
Integrated mobile health systems can help providers with clinical decision support, get access to real-time clinical data, analyze and recognize treatment and disease patterns, and improve adherence to evidence-based guidelines.
For patients with diabetes, apps and diabetes-specific programs can help to improve treatment adherence and can provide reinforcement of treatment goals, better understanding of the effect of specific behaviors on disease control, reminders and coaching, and easy access to diabetes education resources.
Although there are hundreds of simple text-based, unidirectional apps that push messages such as treatment or appointment reminders to the phones of patients or caregivers, better apps are devoted to promoting behavior change, either with bidirectional communication between patients and their health care teams or, better still, with a multidirectional system involving all members of a health care team, including endocrinologists or primary care physicians, case managers, nurses, physician assistants, disease management services, hospital discharge teams, and community health workers.
What do patients want?
Ideally, technology should help patients with real-time decision making tools and give them the ability to share information with their health care team and connect to others for support, Dr. Katz said.
For example, a medication-reminder app can list diabetes medications, remind patients about when and how to take specific drugs, remind them when a refill is needed, and, if desired, click to send a refill order to the patient’s chosen pharmacy.
Dr. Katz and colleagues conducted a study (not published) to see whether a unidirectional drug app could improve adherence to hypertension medications among 50 patients on Medicaid. They found that a pill-reminder program showed a trend toward improving adherence (P = .098) from about 75% at baseline to about 82%. When the reminder was turned off, adherence significantly declined to about 72% (P = .001).
"There’s some potential for improvement there, but it’s short term and you have to keep patients engaged," Dr. Katz said.
A more promising approach, he noted, is a comprehensive chronic disease management program such as WellDoc’s mHealth Solution. The program uses a cell phone–resident app that the patient can use to record blood glucose, receive real-time coaching and out-of-bounds alerts, testing and medication reminders, metabolic target ranges, and caregiver alerts and support. The system can be customized to provide a range of support services – from simple reminders to more complex management and self-management support.
For the clinical care team, the system provides a dashboard that shows glucose readings by day and time, highlighting both hypo- and hyperglycemic excursions, and provides a checklist for comparing individual patient parameters (blood pressure, lipids, renal, etc.) and their medical specialty visits against evidence-based standards of care. For example, the list can highlight abnormal urine microalbuminuria-to-creatinine ratios and alert providers that a patient is overdue for eye or foot exams.
Apps put to the test
Dr. Katz cited a 2011 meta-analysis by Chinese investigators, who found that, among 22 trials with a total of 1,657 participants, mobile-phone interventions for diabetes self-management were associated with a mean 0.5% reduction in hemoglobin A1c over a median of 6 months’ follow-up. The effect was stronger among patients with type 2 diabetes than among those with type 1, the authors found (Diabet. Med. 2011;28:455-63).
More dramatic results were seen in a cluster-randomized trial in which 26 primary care practices were randomly assigned to treat 163 adults with type 2 diabetes and an HbA1c of 7.5% or greater with either standard therapy (controls) or with one of three combinations of interventions: a diabetes coach only; a coach and a diabetes-specific mobile-phone portal between the primary care practitioner (PCP) and patient; or a coach and PCP portal with decision support, include access to patient data and links to evidence-based guidelines (Diabetes Care 2011;34:1934-42).
The mean decline in HbA1c levels was 1.9% in the PCP portal with decision-support group, compared with 0.7% in the usual-care group, a difference of 1.2% (P less than .001) over 12 months.