Katharine Willet, BSN, RN, CEN
and Roseanne Fairchild, PhD, RN, CNE
Frazetta, D., Willet, K. and Fairchild, R. (October 2012). A systematic review of smartphone application use for type 2 diabetic patients. Online Journal of Nursing Informatics (OJNI), 16 (3), Available at http://ojni.org/issues/?p=2041
Background: The aim of this systematic review was to evaluate the use of smartphone technology for management of patients with type 2 diabetes, including the efficacy of smartphone applications in the reduction of patients’ glycosylated hemoglobin (HbA1c). Methods: A systematic review of peer-reviewed articles published in the last 5 years was conducted and seven randomized control trials (RCTs) were identified. Four additional descriptive studies were added to the review to evaluate changes in technology and difficulties with use. Results: Four of the RCTs showed statistical reduction in HbA1c. Descriptive studies gave insight into patient and provider perceptions and practice implications. Conclusion: This technology seems well-suited for patients’ self-management of type 2 diabetes. However, more studies with newer applications are needed before adoption for widespread use.
type 2 diabetes, mobile phone, smartphone, self-management, disease management
According to the Centers for Disease Control (CDC) 2010 factsheet, 10.9 million Americans aged 65 years and older have diabetes, and it is estimated that 79 million American adults 20 years and older have pre-diabetes (CDC, 2010). Diabetic complications include kidney failure, nontraumatic lower limb amputations, blindness, heart disease, and stroke (CDC, 2010). Patients who suffer from diabetic complications are estimated to incur medical expenses that are 2.4 times higher than that of non-diabetic individuals (Boutati & Raptis, 2009). The American Diabetes Association (ADA) indicated that the estimated cost of diabetes was $174 billion in 2007, with the largest expenditure attributed to inpatient hospitalizations (2008). Furthermore, the ADA delineated that $58 billion of these costs could be linked to absenteeism from work, decreased productivity at home and work, disability claims, and premature mortality (2008). In an era when health care costs and the number of uninsured patients are soaring, the call to reduce diabetes complications could not be more significant. In a recent study, patients with an average HbA1c of 8.4% which increased an average of 0.15% per year are expected to incur medical costs of $47,240 over 30 years in the effort to control complications (Caro, Ward, & O’Brien, 2002). The greatest of these expenditures was for the management of microvascular disease (Caro, et al., 2002).
The Diabetes Control and Complications Trial (DCCT) revealed that microvascular complications, including neuropathy and retinopathy, can be reduced when HbA1c is maintained at near normal levels (DCCT Research Group, 1993). While the HbA1c level provides information regarding long-term glycemic control, this measurement does not provide immediate indication of hyperglycemic or hypoglycemic events. Patient self-monitoring of capillary blood sugar has become the standard measurement for diabetes management at home. The real-time measurement offered by home glucometers can assist the patient and practitioner in decision- making regarding changes in medications and overall diabetic care. These immediate alterations in care will undoubtedly lead to the long-term improvement in HbA1c and the reduction of microvascular complications.
The use of home glucose monitoring is typically an isolated event involving only the patient. While patients may seek emergency care for severe hypoglycemic or hyperglycemic events, immediate feedback from practitioners is not provided during at-home monitoring. Those patients who attempt to contact their providers via telephone regarding an abnormal glucose reading may find a delay in the response time as practitioners have varying protocols for patient contacts. Most frequently, the glucose readings are reviewed by providers only during face-to-face contacts at follow-up visits.
Advances in information technology are finding their way into the healthcare community as a means to communicate with, and treat, patients in a more comprehensive, effective, and efficient manner. Telehealth is a means of communication between practitioners and patients when face-to-face visits are not convenient, accessible, or cost effective (Marineau, 2005). Telehealth has increased in usage recently, especially in rural areas where patients may be unable to travel long distances to healthcare facilities (Marineau, 2005). Some advances in telehealth include electronic medical records and secure messaging websites such as MiCare launched by RelayHealth (Pomeroy & Stock, 2012). Another more recently introduced technological resource is the use of a smartphone for immediate transmission of health information and education (Eonta, Christon, Hourigan, Ravindran, Vrana & Southam-Gerow, 2011).
The use of smartphones has revolutionized the way that people communicate with each other and the world around them. Owners of smartphones typically carry the device with them wherever they go (Boschen & Casey, 2008). The smartphone supersedes the capability of the cellular phone, as it offers the user Internet access, in addition to various applications for social, financial, entertainment, and healthcare needs. According to Smith, as of February, 2012, 46% of Americans own a smartphone (2012). Based upon these numbers, it has been reported that smartphones usage now supersedes the use of basic cellular phones (Smith, 2012).
Not surprisingly, however, smartphone use by individuals 65 years of age and older has only increased by 13% (Smith, 2012). Although smartphone use by the elderly population may be limited at the current time, the largest age group currently affected by diabetes is between 40-59 years (International Diabetes Federation, 2010). Use of smartphone applications for blood glucose monitoring and trending are already available. Therefore, it is the purpose of this systematic review to evaluate if patients with Type 2 diabetes are reported to maintain better glycemic control with the use of a smartphone application as compared to usual in-office care. Usual care is defined as home glucose monitoring with face-to-face practitioner follow-up visits.
An electronic literature search was conducted to identify peer-reviewed articles on cellular phone applications used for the management of type 2 diabetes. The Cochrane and Pub Med databases were searched using the terms “diabetes” and “cellular phone,” MeSH Terms “diabetes” AND “mellitus” or “diabetes mellitus” AND “cellular” AND “phone” or “cellular phone” or “mobile” AND “phone” or “mobile phone” in English language for the past 5 years. Five years was the period of time selected due to the rapid change in technology and improvements in applications over relatively brief periods of time. Cochrane returned 6 review articles and 2 trials. Pub Med identified 83 articles. The title and abstracts were reviewed for randomized control trials (RCTs) that included an intervention using a cellular phone for type 2 diabetics. References of review articles were also used to identify any additional potential articles for inclusion. Initially, full text articles were screened for the following:
Seven articles met the search criteria, and summaries of the studies are included in Table 1. During review, it became apparent that cell phone interventions varied from study to study. Some included uploading capillary blood glucose (CBG) and medications for review by researchers at regular intervals (Istepanian et al., 2009, Kim & Song, 2008). Other studies included a teaching intervention and/or the ability to enter self-management information (Quinn et al., 2011; Faridi et al., 2008). In addition to self-care management, the Novel UCDC system used by Yoo, et al. (2009) had an algorithm that gave immediate feedback for problem solving and decision-making, as well as reminders to collect data and communication via e-mail or text message. Noh, et al. (2010) compared an educational intervention only, while Cho, et al. (2009) compared computer use and asynchronous communication (e-mail) to cell phone use and real-time communication (text-messaging).
Table 1. Summary of Randomized Control Trials
In spite of the various differences in approach to the utilization of smartphone applications, researchers in four of the studies reported that their technology-based intervention resulted in a statistically significant lowering of HbA1c. For example, intervention group participants in the Kim and Song (2008) study experienced decreases in HbA1c from 8.16 (± 1.9 %) to 7.07 (± 1.5 %; P < .05 when compared to control group results (7.66 ± 0.6% to 7.66 ± 0.5%). Quinn, et al. (2011) also reported decreases in HbA1c of 1.9 % (95% CI 1.5-2.3%) when compared to results for control group participants 0.7% (95% CI 0.3 -1.1) at 12 months. Yoo and colleagues (2009) demonstrated a reduction in HbA1c for the intervention group at 3 months, from 7.6 (± 0.9%) to 7.1 (± 0.8 % , P < 0.001), compared to a 7.4 (± 0.9%) to 7.5 (±1.0% , P= 0.03) increase in HbA1c for control group participants. In addition, Cho, et al. (2009) reported a decrease of 1.2% in the smartphone intervention group’s baseline HbA1c of 8.31± 2.3 %, compared to 0.7% decrease in the computer intervention group’s baseline HbA1c of 7.6± 1.9%. Overall, there were no significant differences between the smartphone and computer groups (P= 0.27), and there was no usual care (control) group in this study (Cho et al., 2009).
The review of the quantitative studies reveals that smartphone applications can be a useful tool for type 2 diabetes self-management. However, critical analysis of these studies suggested difficulties were encountered by patients while using the technology-based applications. Two of the studies (Faridi, et al., 2008; Istepanian, et al., 2009) had high dropout rates, and both cited problems with technology. Another study (Noh, et al., 2010) had no provider interaction except during regular visits, and utilized only an education intervention that failed to show a significant change in HbA1c. Concerned about user technology-based issues, we examined additional, more descriptive studies, as summarized in Table 2.
Table 2. Summary of Qualitative Studies
This additional search revealed that smartphone applications have evolved rapidly. Applications initially designed by research teams and available only as part of a research study had changed over time. For example, Rao, et al. (2010) reviewed three different iPhone applications (Apps) taken from a list of 12 and then had users rank them according to features and ease of learning to use the application. These applications did not exist five years ago. In addition, the Apps are available to anyone with a smartphone at a minimal cost and some are free. Granted, one must first own an iPhone and pay the operating costs. The Apps allow patients to organize self-monitoring information like medications, blood sugars, exercise and diet information with improved, easy to use menus and autosynch to a website. The biggest difference is that this tool truly supports self management; it can be used independent of the provider. It gives patients the ability to decide how they will share and use all this data.
Other studies (Harris, et al., 2010; Årsand, et al., 2010) gave insight into technology issues reported in several studies. Both studies reported algorithms and automated messages got mixed reviews; users indicated these messages were not always helpful or pertinent as designed. Pedometer interface and data entry was considered difficult by users, which could explain missing data and failure to complete studies (Faridi et al., 2008, Istepanian et al., 2008). For providers who participated in these studies, practice problems emerged, such as how to provide adequate support to patients, yet continue to encourage self management. Other provider concerns about secure networks for e-mail and text-messaging to maintain confidentiality were identified. Practical implications of when (synchronously or asynchronously), by whom and how to respond to messages and data entry also became apparent (Turner et al., 2009), raising the possibility that these additional duties may put a strain on provider staffs’ daily tasks.
Everett Rogers’ (2003) Theory of Diffusion of Innovation describes five intrinsic characteristics that influence an individual’s decision to adopt or reject an innovation: compatibility, complexity trialability, observability, and relative advantage. This theory can be applied to both the patient and the provider in the adoption of smartphone applications. Compatibility applies to how easily these applications can be integrated into practice for the provider and lifestyle for the patient. Complexity relates to how difficult the application is to understand and how practical it is to use day to day. Trialabilty is the ability to experience and use the innovation. Observability is how easy it is for others to see someone using the technology successfully. Relative advantage, discerns whether or not a particular innovation is better than the previous way. Rogers (2003) recognized that perception of the advantage plays a major role. The perception can be more powerful than the objective measures. Objectively, smartphone applications seem very suited for diabetic self-management. They are portable, organize and store information, enable the user to set and measure goals, give Internet access and a way to communicate this information to the provider. Whether patients and/or providers perceive these advantages and are able to easily use these applications may ultimately determine if this technology is adopted for widespread use.
Diabetic treatment goals and target HbA1c should be individualized. One challenge to providers is finding ways to communicate with patients between visits, so that they can assist with diabetic management to maintain the patient’s glucose goals. The traditional means of communication has been primarily through telephone contact. However, as smartphone usage increases, many individuals are seeking to use applications and texting as a major form of communication.
With a smartphone, patients have a handheld computer at their fingertips at all times. Importing the patient’s smartphone data directly to the provider’s office would allow for accurate reporting and instantaneous uploading for immediate feedback, and/or entry into the patient’s electronic record. When a traditional visit is not warranted, this technology would provide a means of communication (e.g., texting results), that would involve a more timely, seamless response when compared to a traditional phone call.
Technology for self-management of diabetes is a growing field that holds promise for widespread future use. While the analyzed studies revealed a reduction in HbA1c, there are also concerns regarding high dropout rates, Bluetooth and pedometer malfunction, and cumbersome software that was not considered user-friendly. In addition, in the time that has lapsed since these studies were conducted, the technology continues to change and is becoming even more advanced and more reliable. In addition to the creation of better smartphone applications, the cellular technology of Bluetooth and broadband speeds has vastly surpassed its previous functioning. Burgeoning technological advancements in the field will require practicing nurses, nurse researchers, and nurse educators in information technology to continually update their knowledge and practice-based skills in the field.
When considering the use of a smartphone for diabetic monitoring the benefits include: portability, inclusive Internet access, transfer of information to provider that is instantaneous, and trending. Creating software that contains algorithms within the application will help with diabetes self-management and problem solving. Inclusion of diet, medications, reminders, and exercise regimen within the application will provide the patient with the ability to monitor all the facets of their care as well as assist with goal setting creating a handheld database of diabetic care. Ultimately, this could enable the patient to avoid the microvascular and macrovascular complications of diabetes.
Rogers (2003) described a bell curve graph of diffusion for innovations. There are five types of adopters of innovation or change: innovators comprise the first 2.5%, followed by early adopters (13.5%), early majority (34%), late majority (34%) and finally, laggards comprise the last 16%. The diffusion of innovation thus occurs in a predictable fashion. At this point in time, smartphone applications seem best suited for highly motivated, technology sophisticated patients and providers (the early adopters). As practice interface becomes more clearly defined and the applications become more user friendly; the process of diffusion will continue with the early majority. More RCTs with newer technology that demonstrate user satisfaction and reduction in HbA1c will aid in this process.
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Diane Frazetta has been a nurse for 14 years and has been employed in the clinical areas of school nursing, labor and delivery, cardiac catheterization, and nurse educator. She is currently employed as a family health nurse, supporting the mission of Airmen at Hurlburt Field, FL.
Katharine Willet has been a nurse for 34 years in a variety of clinical settings. She is currently employed at the University of New Mexico hospital as a clinical educator.
Dr. Roseanne Fairchild is Assistant Professor of Nursing at Indiana State University, and is a board certified nurse educator. She has 15 years of experience as faculty in the areas of nursing administration, nursing education, health informatics, medical-surgical and critical care nursing, pharmacology, and anatomy and physiology. In the clinical practice arena, Dr. Fairchild has 10 years of experience in emergency and critical care nursing, traumatic brain injury, cardio-pulmonary nursing, and hospice/palliative care. In addition to teaching, Dr. Fairchild serves as a Principal Investigator in health services and educational research in rural and urban settings, with emphasis on supporting innovative improvements in health care quality, patient safety, and information technology from an inter-professional perspective. A current project funded by Lilly Endowment focuses on sustainability of best practices in rural critical access hospitals. Dr. Fairchild is also involved in theory development in the areas of work motivation, ethical reasoning skills, and healthcare system complexity, and has numerous peer-reviewed publications in these areas. She currently serves as a member of the Board of Directors of the Indiana Rural Health Association and on the educational and research committees for IRHA, is an active member of the university’s Inter-professional education Research Committee, and has recently been appointed by the Indiana State Health Commissioner as a member of the Executive Committee for Indiana’s State Health Improvement Plan.