In the JournalsPerspective

Most diabetes apps lack effective ‘action prompts’ during hyperglycemia, hypoglycemia

Detailed directives based on proven practice for hypoglycemia and hyperglycemia treatment are not always features of diabetes apps, which means people with type 2 diabetes must be careful when selecting apps to help manage their diabetes, according to findings published in Diabetes/Metabolism Research and Reviews.

“We uncovered two important problems regarding the capability of apps to support diabetes self-management. First, less than one-fifth of apps provided evidence-based steps to guide patients through hypoglycemia and hyperglycemia,” Elaine Lum, PhD, MClinPharm, BPharm, Adv Prac Pharm, senior research fellow at the Centre for Population Health Sciences of Lee Kong Chian School of Medicine at Nanyang Technological University in Singapore, and colleagues wrote. “Second, the majority of apps failed to provide just-in-time bite-size diabetes self-management education to prevent frequent or severe episodes of hypoglycemia and hyperglycemia.”

Lum and colleagues tested 371 smartphone applications — some free, some with required purchase — that were designed for diabetes management and required users to enter their blood glucose levels. All apps were listed in the 42Matters database; the researchers used recent updating as evidence of user support and app maintenance.

When the researchers entered blood glucose levels below 70 mg/dL to simulate hypoglycemia, they found that 217 apps provided a “hypoglycemia” notification and 45 of these apps (20.7%) included instructions or “action prompts” to address the condition. The researchers noted that suggestions that incorporated American Diabetes Association guidelines, such as consuming carbohydrates or waiting 15 minutes to measure blood glucose again, were presented by 39 of the apps (86.7%) that provided instructions. In contrast, 11 of these apps (24.4%) featured vague or unhelpful instructions when hypoglycemia occurred.

Photo of cell phone 
Detailed directives based on proven practice for hypoglycemia and hyperglycemia treatment are not always features of diabetes apps, which means people with type 2 diabetes must be careful when selecting apps to help manage their diabetes.
Source: Shutterstock

When the researchers entered in blood glucose of 180 mg/dL or more to simulate hyperglycemia, they found that 216 apps provided a “hyperglycemia” notification and 33 of these (15.3%) included an action prompt.. Suggestions that incorporated ADA guidelines, such as testing glucose more often and measuring urine ketones, were presented by 32 of the apps (97%) that featured action prompts. Alternatively, 11 of these apps (33.3%) featured vague or unhelpful instructions in these situations.

“Developers of diabetes self-management apps should involve diabetes specialists at the codesign stage so that educational evidence-based action prompts are triggered when out-of-range blood glucose values are recorded,” the researchers wrote. “If appropriately designed, action prompts could play a role in augmenting patient education of blood glucose management, which may translate to improved HbA1c without incurring severe hypoglycemic episodes.” – by Phil Neuffer 

Reference:

Lum E, et al. JAMA. 2019;doi:10.1001/jama.2019.1644.

Disclosures: The authors report no relevant financial disclosures.

Detailed directives based on proven practice for hypoglycemia and hyperglycemia treatment are not always features of diabetes apps, which means people with type 2 diabetes must be careful when selecting apps to help manage their diabetes, according to findings published in Diabetes/Metabolism Research and Reviews.

“We uncovered two important problems regarding the capability of apps to support diabetes self-management. First, less than one-fifth of apps provided evidence-based steps to guide patients through hypoglycemia and hyperglycemia,” Elaine Lum, PhD, MClinPharm, BPharm, Adv Prac Pharm, senior research fellow at the Centre for Population Health Sciences of Lee Kong Chian School of Medicine at Nanyang Technological University in Singapore, and colleagues wrote. “Second, the majority of apps failed to provide just-in-time bite-size diabetes self-management education to prevent frequent or severe episodes of hypoglycemia and hyperglycemia.”

Lum and colleagues tested 371 smartphone applications — some free, some with required purchase — that were designed for diabetes management and required users to enter their blood glucose levels. All apps were listed in the 42Matters database; the researchers used recent updating as evidence of user support and app maintenance.

When the researchers entered blood glucose levels below 70 mg/dL to simulate hypoglycemia, they found that 217 apps provided a “hypoglycemia” notification and 45 of these apps (20.7%) included instructions or “action prompts” to address the condition. The researchers noted that suggestions that incorporated American Diabetes Association guidelines, such as consuming carbohydrates or waiting 15 minutes to measure blood glucose again, were presented by 39 of the apps (86.7%) that provided instructions. In contrast, 11 of these apps (24.4%) featured vague or unhelpful instructions when hypoglycemia occurred.

Photo of cell phone 
Detailed directives based on proven practice for hypoglycemia and hyperglycemia treatment are not always features of diabetes apps, which means people with type 2 diabetes must be careful when selecting apps to help manage their diabetes.
Source: Shutterstock

When the researchers entered in blood glucose of 180 mg/dL or more to simulate hyperglycemia, they found that 216 apps provided a “hyperglycemia” notification and 33 of these (15.3%) included an action prompt.. Suggestions that incorporated ADA guidelines, such as testing glucose more often and measuring urine ketones, were presented by 32 of the apps (97%) that featured action prompts. Alternatively, 11 of these apps (33.3%) featured vague or unhelpful instructions in these situations.

“Developers of diabetes self-management apps should involve diabetes specialists at the codesign stage so that educational evidence-based action prompts are triggered when out-of-range blood glucose values are recorded,” the researchers wrote. “If appropriately designed, action prompts could play a role in augmenting patient education of blood glucose management, which may translate to improved HbA1c without incurring severe hypoglycemic episodes.” – by Phil Neuffer 

Reference:

Lum E, et al. JAMA. 2019;doi:10.1001/jama.2019.1644.

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Deborah A. Greenwood

    Deborah A. Greenwood

    With the explosion of diabetes related apps, the need for mechanisms to evaluate quality is imperative. The burden of managing diabetes may be minimized with supportive, evidence-based technology solutions, but low-quality apps may ultimately make diabetes more challenging.

    The findings of the study by Lum and colleagues are not unusual as so many diabetes apps are unregulated and are not evaluated prior to distribution. 

    The authors highlight the important fact that diabetes apps need to be co-designed with diabetes specialists incorporating evidence-based diabetes care and education principles.  In addition, including a person living with diabetes on the development team is extremely valuable, as they have firsthand experience in the day-to-day act of checking blood glucose, responding with behavior changes and making ongoing adjustments in their self-care.

    Finding mobile apps that have been vetted by diabetes specialists provides one opportunity to ensure quality.  The American Association of Diabetes Educators has a technology reference tool available for its members called DANA, Diabetes Advanced Network Access. DANA helps members evaluate apps based on multiple quality measures and compare across similar applications.

    A systematic review I co-authored in 2017  identified four key features of a technology-enabled self-management feedback loop that improve HbA1c outcomes, communication, use of patient-generated health data, tailored education and feedback (Greenwood DA, et al. J Diabetes Sci Technol. 2017;doi: 10.1177/1932296817713506). We suggest that these features can be used to both design and evaluate diabetes apps.

    The ability of diabetes apps to provide just-in-time decision support, in bite-size pieces, including glucose pattern analysis, tailored education with goal setting and action plans along with ongoing feedback and support is required to transform diabetes care and education.

    • Deborah A. Greenwood, PhD, RN, BC-ADM, CDE, FAADE
    • President, Deborah Greenwood Consulting
      Endocrine Today Editorial Board Member

    Disclosures: Greenwood reports she has served on the digital health advisory board for Novo Nordisk and as a consultant for Lifescan Diabetes Institute, Mytonomy and Silver Fern and received grant funding from Abbott Diabetes Care.