View
106
Download
1
Category
Preview:
Citation preview
M. Byrd Page 1
Apps and Diabetic Management
By: Matt Byrd
BHIS 528
University of Illinois at Chicago
M. Byrd Page 2
Abstract
This paper is going to examine the opportunities, possible benefits and limitations of using apps
in mobile health (mHealth) to help manage diabetes. It will also offer a framework of what to
look for in a diabetic app to ensure the app is helping to empower the patient to better adhere
to all of their self-management guidelines.
Keywords: Diabetes, Diabetic Management, Applications, Apps, Healthcare Apps, Mobile
Health, mHealth, comprehensive diabetic management, disease management, chronic disease,
self-management, adherence
M. Byrd Page 3
Background
Both the Center of Disease Control (CDC) and the World Health Organization (WHO) list
diabetes as a top 10 cause of death in the United States and the World. According to the
American Diabetes Association (ADA) 29.1 million Americans, roughly 9% of the population,
suffer from diabetes and another 86 million people 20 and older are considered prediabetic
(2014). In looking at the top ten causes of death worldwide it is concerning to see that six
continue to grow in the number of lives they take each year; and diabetes is one of those
growing (WHO, 2014).
In addition to the problems diabetes cause for patients, and the number of deaths it is
responsible for each year, it is not just diabetes patients who suffer from its effects. Wodajo
says “The cost of managing chronic diseases is the largest portion of health care expenditures in
developed countries” (2011). In the United States, the ADA says total cost to manage diabetes
is $245 billion with $176 billion being direct medical costs and $69 billion coming from reduced
productivity of patients (2014).
What the prevalence and costs of diabetes shows is an opportunity and need to “develop cost
effective support tools and interventions for diabetes self-management” (Arsand, 2012).
Patients provide the majority of their care themselves and self-management apps can empower
the patient to take control of their chronic disease while providing the tools to do that. In
M. Byrd Page 4
addition, decisions that used to be made with a health care provider (HCP) every three months
can now be made quicker and in real time to help ensure better outcomes.
Patient Responsibilities
Diabetic patients are responsible for an extensive list of activities in managing their diabetes.
According to the Joslin Diabetes Center the comprehensive diabetes checklist patients should
follow includes: meal planning, self-monitoring blood glucose (BG) levels, medications, exercise,
knowledge of high and low BG levels and what to do in each case, foot care, sick day
management and urine testing for ketones (2014). In addition, there are nine tests they should
get at least once a year: A1C, kidney function, cholesterol (LDL, HDL and lipids), foot exam, eye
exam, blood pressure, physical, micro albuminuria and GFR.
Because of this, it is necessary to provide tools that will ensure that not only do patients record
information as they receive it, but, also, that the tools can serve as a reminder for the extensive
list of activities that ensure that patients stay compliant with their therapy. Sarasohn-Kahn says
“Studies on patient adherence to prescribed drug regimens have demonstrated that
compliance among patients with chronic illness may be as low as 20 percent” (2010). This can
be due to many factors, but by providing cost effective solutions that can help to improve
adherence patients may see a benefit in their health and society as a whole may see a
reduction in the amount of money spent on care.
M. Byrd Page 5
Opportunities/Benefits
In researching this topic, there are key opportunities that are leading to patients being able to
realize three important benefits. These opportunities are: cost, mobile broadband use and
access to information. In a study by Klonoff he said the average cost of apps looked at was
$2.86 with a range in price of $0.99-$6.99 (2013). While adherence to therapy is due to many
factors, by making it cheaper to find ways to help with adherence allows more people to
participate; breaking down socioeconomic barriers. For cost to matter patients must have the
device the app will run on and mobile broadband devices are rapidly growing with the
estimated number of devices in use currently around 1.5 billion. This number is expected to
quadruple in the next five years with every corner of the globe participating (Appendix 1). With
more people using mobile devices and the cost of the apps being cheap enough for anyone to
participate, more patients will have access to information and resources that will make a
difference in their care.
Because of the rise of mobile opportunities and access to information at a low cost three key
benefits are being realized by diabetic app users: tracking key categories of care, personalized
self-management and patient decision support. As mentioned in the Patient Data section,
diabetic patients are responsible for numerous areas in managing their care. The ability for an
app to help in managing this is big. Of the 71 apps Klonoff researched 100% tracked blood
glucose, 76% tracked medication, 68% tracked diet, 41% tracked exercise, 25% tracked weight
and 23% tracked blood pressure (2013). While not all of the areas important to care are
M. Byrd Page 6
included in the apps, the areas deemed most important appear in almost half of all apps
studied.
With the ability to track these care areas, it opens to the door for more personalized care in
managing a patient’s diabetes. If patients are able to show their health care provider (HCP)
specific numbers they have tracked between visits , more personalized goals can be set for each
patient instead of generic numbers all diabetics should try to adhere to. If a HCP would like a
patient under 100 on their LDL it does not make much sense to try for that as a goal if the
patient currently is around 200. By knowing their actual, up-to-date, number, it gives patients
and HCPs the opportunity to break the goals down into realistic pieces to aim for which can be
reevaluated at each visit. The point of the apps is not to cut the HCP out of the discussion, but,
rather to provide better data when discussing care and deciding on treatment.
While the diabetic app is not trying to cut the HCP out of the care process, it can offer decision
support in-the-moment for patients when needed. The majority of care a diabetic patient will
receive is self-managed throughout the year and sometimes there is not an ability to get in
touch with the HCP when it is necessary. “Without access to immediate data analysis or actual
treatment recommendations a patient must wait to see their HCP. By then, the patient might
be in a different metabolic state…” (Klonoff, 2013). Some apps do offer decision support based
on the information that is inputted, giving the patient evidenced based options in dealing with
different situations. Even if the app does not offer patient decision support, it does give an
M. Byrd Page 7
ability to see past numbers to help the patient determine a best course of action for them
based on preset plans they and their HCP have set up.
With the opportunities of low cost, growing mobile broadband markets and instant access to
information benefits in diabetic care are able to be realized. These benefits include tracking
key areas in diabetic care management, more personalized self-management and patient
decision support. As seen in 20 studies where apps were used without HCP feedback, patients
saw improvements in their HbA1c when using diabetic apps (Klonoff, 2013). Again this is not to
suggest that HCP involvement is not needed in the management of diabetes, but helps to show
the improvements in care that are possible when patients have tools available to them to
become more involved in their care.
Limitations/Concerns
As discussed above there are many benefits to using diabetic apps in helping to manage
patients’ diabetic care. While the benefits are promising, there are limitations and concerns to
the growing diabetic app market. One concern is the apps tend to focus on a part of care such
as diet, exercise or medication, but rarely combine all of these together in a way that would
better help in disease management. By forcing patients to use too many different apps to track
different behaviors and activities it may cause tool overload in the same way too much data
causes patients to freeze and lock up when they have information overload.
M. Byrd Page 8
A more serious concern is apps are ignoring evidenced based practices in the management of
diabetic care. Brandell says “As with mobile health apps in general, they too often ignore
evidence-based best practices. In a survey of over 973 diabetes self-management apps...there
are obvious gaps between the evidence-based recommendations and the functionality used”
(2013). One of these evidence-based best practices not being used enough is personalized
education. Klonoff, in a smaller sample of apps showed only 18% of apps offering education for
patients (2013). By increasing education available to patients through easy and accessible
means, such as an app on a mobile device, it may help patients in realizing the improvements
seen in data measurable from past studies.
While the improvements seen in studies of diabetic self-management apps is promising the lack
of apps involved in the studies is concerning. “…only 334 mobile health apps underwent clinical
trials between 1990 and 2010. Surprisingly, only 75 included a control group” (Brandell, 2013).
This may be due to the fact that mobile health apps are not considered devices, and, therefore,
do not need FDA approval to be used. However, in an industry that includes 97,000 health apps
growing at an annual rate near 40%, it would be nice to see more data on how these apps can
affect a patient’s health care.
The last concern at this time is very similar to the concerns with electronic medical records,
patient privacy. Not all apps fall under the Health Insurance Portability and Accountability Act
of 1996 (HIPAA). Apps where patients are entering their own information and using the app as
a log are not subject to HIPAA regulation. However, HIPAA does cover “mHealth applications
M. Byrd Page 9
where personal data are uploaded into a device or the Internet” (Klonoff, 2013). This means if
the app has the ability to interact with an EMR privacy of data should be more secure.
Best Apps Available
Healthline created a list of the top apps for diabetic management in 2014. This list of 11 apps
was chosen by Tracy Rosecrans and then medically reviewed by Kenneth R. Hirsch, MD. To help
figure out which apps were truly the best of the best I used the criteria from the Klonoff study
(Appendix B). In addition to this information, I added two categories, price and multiple
platforms. Price is important in making sure the tool is made available to all, and being
available on multiple platforms is important because with the increase in mobile devices
around the world the ability to adjust to multiple platforms is important in reaching the largest
amount of patients possible. In each category the app participated in, the app received 1 point
for having a capability deemed important to managing diabetes. While I thought it was
important to include price it was not a category that received a point value. The total for each
app on the list by Healthline was calculated so as to provide a ranking of the apps offered
(Appendix C). Based on my analysis and the information in this paper, it is my opinion that
Diabetes App is the best app available; with Diabetes Pilot and dbees being a very close second.
M. Byrd Page 10
Discussion
While my analysis has limitations in determining the best app, such as not including user
interface, there are some key takeaways in looking at the top apps. As discussed above, many
apps available today take pieces of diabetic management instead of looking comprehensively at
the disease state and what is required of the patient. One of the reasons Diabetes App came
out on top was because in all of the data areas Klonoff discussed as important the app was able
to provide all of those to patients. In addition, it offered functionality in communication with
providers, creating a record, and, most importantly, the educational ability so many diabetic
apps lack.
Of the apps that were chosen as the top apps in 2014 by Healthline, I thought it was interesting
that only one offered social networking capabilities and none offered patient decision support.
It was also noticed when looking at medication tracking that this usually did not include all
medications a diabetic patient would take, but, instead, only tracked their insulin levels. While I
think insulin levels are important to track, diabetic patients can take upwards of seven
medications and it would be helpful to track all of them to help with HCP interactions.
It was also interesting to note that only 5 of the 11 apps listed were offered on multiple
platforms. The only platforms listed as options were Android and iPhone; however, these are
two big names in apps. Hopefully as specific apps become more popular and are noticed as
being the best options they will be offered on more platforms. As discussed in the
M. Byrd Page 11
opportunities/benefits section, mobile broadband subscriptions are growing around the world,
and to meet the needs of different patients in different areas of the globe multiple platforms
will be needed.
Conclusion
The market for healthcare apps, and diabetic management apps in particular, is growing at a
rapid rate. While there are possible benefits to patients such as tracking key categories of care,
personalized self-management and patient decision support; the biggest benefit would be
helping to reduce key measurable such as A1C levels.
Although some studies do show that these patient benefits can lead to better numbers for
patients, there are concerns with the diabetic app market. Key concerns at this time are apps
that fail to look comprehensively at diabetes management, ignoring evidenced based practices,
a lack of studies in the industry and patient privacy.
The concerns listed are real, but there are apps out there that rise above these issues. Brandell
says “All diabetes management apps should conform to clinical best practices. This means we
must move beyond mere data logging and being building upon the tenets of today’s diabetes
self-management” (2013). By taking the categories offered by Klonoff and checking to see that
as many as possible are used in the chosen app, it can help to ensure the patient is using a tool
M. Byrd Page 12
that will truly empower them to take their self-management of diabetes to a new level. In
doing this, hopefully, over the next decade we will see a reduction in the amount of deaths
caused by diabetes, as well as, see the cost of this chronic disease begin to drop.
M. Byrd Page 13
References
American Diabetes Association. (2014). Statistics About Diabetes. National Diabetes Statistics
Report. Retrieved from http://www.diabetes.org/diabetes-basics/statistics/.
Arsand, E., Froisland, D.H., Skrovseth, S.O., Chomutare, T., Tatara, N., Hartvigsen, G., and
Tufano, J.T. (2012). Mobile Health Applications to Assist Patients with Diabetes: Lessons
Learned and Design Implications. Journal of Diabetes Science and Technology, 6(5), pp.
1197-1206.
Brandell, B. and Ford, C. (2013). Diabetes Professionals Must Seize the Opportunity in Mobile
Health. Journal of Diabetes Science and Technology, 7(6), pp. 1616-1620.
Klonoff, D. C. (2013). The Current Status of mHealth for Diabetes: Will It Be the Next Big Thing?
Journal of Diabetes Science and Technology, 7(3), pp. 749-758.
Sarasohn-Kahn, J. (2010). How Smartphones Are Chaning Healthcare for Consumers and
Providers. California HealthCare Foundation. Retrieved from
http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/H/PDF%20HowSmartphon
esChangingHealthCare.pdf.
Wodajo, F. (2011, February 2). Apps for management of diabetes could be vehicles for reducing
health care expenses in future [mHealth]. iMedicalApps. Retrieved from
www.imedicalapps.com/2011/02/apps-for-management-of-chronic-diseases-could-be-
future-vehicles-for-reducing-health-care-expenses/.
World Health Organization. (2014). The top 10 causes of death. Fact Sheets. Retrieved from
http://www.who.int/mediacentre/factsheets/fs310/en/.
M. Byrd Page 14
Appendix A
Active Mobile-Broadband Subscriptions by Region
Region
Number of
active mobile-broadband
subscriptions (millions)
2010 2011
Africa 14 27
Arab States 26 42
Asia and Pacific 281 422
Commonwealth of Independent States 63 87
Europe 174 226
The Americas 206 279
(Klonoff, 2013)
M. Byrd Page 15
Appendix B
Percentage of Applications Incorporating Data from Monitoring Tasks
Percentage of Applications Incorporating Support Tasks
Function Apple App
Store Literature
Function Apple App
Store Literature
Blood glucose 100 88
Education 100 88
Medication 76 38
Communication 76 38
Diet 68 75
Patient health record 68 75
Physical exercise 41 50
Decision support 41 50
Weight 25 6
Data entry automation 25 6
Blood pressure 23 16
Social networking 23 16
(Klonoff, 2013)
M. Byrd Page 16
Appendix C
App Educ Comm PHR Dec Sup DEA Soc Net
Fooducate X
Glooko X X X
Diabetic Audio Recipes Lite X
Diabetic Connect X
Glucose Buddy X
Diabetes App X X X
OnTrack Diabetes X
dbees.com X X
Glucool Diabetes X
Diabetes Pilot X X
WaveSense Diabetes Manager X
App BG Med Diet Exercise Weight BP Cost Mult Platforms Point Value
Fooducate x Free Yes 3
Glooko X X X Free Yes 7
Diabetic Audio Recipes Lite X Free No 2
Diabetic Connect X Free Yes 3
Glucose Buddy X X X X Free Yes 6
Diabetes App X X X X X X Free No 9
OnTrack Diabetes X X X Free No 4
dbees.com X X X X X Free Yes 8
Glucool Diabetes X X X X X X $4.99 No 7
Diabetes Pilot X X X X X X $11.99 No 8
WaveSense Diabetes Manager X X X Free No 4
Recommended