Examining Mobile Applications for Diabetes Education

December 3, 2022

This article was written by Linda Siminerio, RN, PhD, DCES, Jason Ng, MD, Jodi Krall, PhD, and Neha Mehrotra, MD.

Diabetes mellitus (DM) requires the person living with the condition to make daily decisions about diet, activity, and medications, as well as to have adequate support to manage the disease successfully. Diabetes self-management education and support (DSMES) is considered to be a critical component of diabetes care.1 DSMES is designed to give the person with DM the knowledge, skills, and confidence to accept responsibility for their self-management. This includes collaborating with their team, making informed decisions, solving problems, developing personal goals and action plans, and coping with emotions and life stresses.2, 3, 4, 5 While research has repeatedly demonstrated that DSMES can improve clinical, behavioral, and psychosocial outcomes,3 patient receipt of DSMES services is low.6,7 Despite attempts to bolster participation, reports show that less than half (perhaps as little as 1/3) of patients receive this important health service.8 Unfortunately, patients who do not receive DSMES are found to be more likely to develop a complication and incur higher diabetes-related costs.9,10 While initial diabetes education is necessary and valuable, the benefits wane over time.3,11 Initial improvements in outcomes have been shown to diminish six months after conclusion of the diabetes education intervention.11 Ongoing support helps patients to implement and sustain the ongoing skills, knowledge, coping, and behavioral strategies needed to self-manage.3 With the growing number of people with DM who need DSMES, now, more than ever, opportunities that provide ongoing support and access need to be explored.

The National Standards for DSMES refer to the use of digital technology as a means to provide reach and real-time engagement in self-management.3,12 The National Standards note that while data supports that technology can aid in better outcomes, additional assessment must be considered.3 The Division of Endocrinology and Metabolism research team began to explore the use of technology and DSMES with our telemedicine for reach, education, access and treatment (TREAT) model that connects endocrinologists and diabetes education specialists (DCES) to patients and providers in a rural community through video-conferencing. In addition to finding significant improvements in patient clinical, behavioral, and psychosocial outcomes, patients, diabetes specialists, and local primary care providers reported high satisfaction with the program.13,14, 15,16

We expanded the TREAT model to include DCES ongoing support with our Treat On (Ongoing) study. Again, there was high patient satisfaction with the telehealth approach along with reduced DCES and patient travel costs as compared to traditional face-to-face DSMES services.17, 18, 19 These experiences, along with the growing number of educational mobile applications (apps) being introduced, led the research team to examine additional technological approaches for DSMES. The team followed up by seeking patients’ and providers’ insights regarding diabetes app use in both inpatient and outpatient settings.

The research team began by first determining the usability and satisfaction of a mobile app to support individuals with insulin therapy management. Methods to assure education access and support are critically important for patients being introduced to insulin therapy. A DM mobile app was developed to offer information on injection administration and self-management strategies. Ongoing support is built into the app in the form of articles and videos related to starting and using insulin.

The purpose of the team’s study was to evaluate patient and educator usability of, and satisfaction with, the app. Patients >18 years with type 2 DM (T2DM), new to or identified as having issues with insulin therapy, were recruited from in- and outpatient settings. Participants received insulin education according to standard practice and were then introduced to the app. Over the study period, participants were able to use the app as much or as little as preferred; use was tracked with app analytics. HbA1c was measured at baseline and three months, and satisfaction surveys were administered. Participants (n=22) were 27% female; mean age 55 years, with a baseline mean HbA1c of 11%. Glycemia significantly improved during the study period, with an average reduction in HbA1c of 3.2±2.9%.

All participants used the app; 86% launched it within one day of enrollment. Average use was 11 times over the course of the study, 55% were considered highly engaged (consistently used the app over the course of study). Participants were most likely to access the app curriculum (articles and videos) about insulin pen therapy followed by living with diabetes. Most participants found the app easy to use (75%), visually appealing (81%), and to contain helpful content, especially articles (77); 73% said that they would recommend the app to another person with diabetes. Educators reported high satisfaction and a positive experience in using the app (20). This positive experience raised additional questions, and set the stage for our next investigation entitled “Provider Perspectives: Digital Apps in Delivering Diabetes Self-Management Education and Support (DSMES).”

Sixty DM providers (33% diabetes care and education specialists (DCES), 21% endocrine clinicians) representing inpatient, outpatient, and community settings, completed a validated survey about experiences with and perspectives on app use for DSMES. Results were recorded and summarized to capture dominant themes. Of those who completed the survey, 17% (10/59) reported being very familiar with apps; 33% (20/59) had used an app to provide DM education while 25% (15/59) used an app for support. Respondents (77%, 46/60) primarily viewed apps as adjunct to DCES education, particularly for reinforcement. In terms of recommending apps, 90% of providers (54/60) rated patient app interest and access as the most important factors to consider. In addition, 70% (42/60) agreed apps may be particularly useful to patients who use telehealth or live far from clinics. Specific to insulin, 70% agreed apps could serve as a helpful tool to prepare those new to insulin and aid with injection skills, dosing decisions and titration. Features they viewed as useful included clear set-up instructions, goal setting, and digital coaching. Interestingly, outpatient DCESs reported willingness to use 15 or more minutes of a visit on setting up/teaching app use, while hospital-based providers were willing to spend five minutes. Appreciating that DM-related hospitalizations very often require an education intervention, our research team saw the opportunity to examine the use of a DM app as a practical resource to support inpatients. Shortened length of stay, patient acuity, and limited staff time frequently prohibit providing adequate education during a hospital stay. We then assessed provider perspectives on apps as a tool for self-management education and support in the inpatient setting. Health care professionals (n=33) who oversee or provide DM care and education to hospitalized patients completed a validated survey about DM mobile apps.

We found that only 21% of respondents had previously used an app for DM education. Of those who had never used a DM app, 100% indicated that they would consider recommending one to their patients. For 82% of respondents, patient access to and interest in app use were rated as the most important factors in their decision to recommend apps. Patient acuity and time were also noted as key considerations. In fact, 54% of respondents were only willing to spend five minutes to download and teach app use. Hospitalized patients considered best candidates for apps are those newly diagnosed with DM, new to insulin, admitted with a DM-related complication, or requiring additional education/support (change in treatment plan). Perceived benefits of apps in relation to self-management were to reinforce education (71%), support education with trustworthy information (62%), and serve as a resource after discharge (56%). Some respondents also foresaw a role for apps in teaching patients during hospitalization, especially younger patients generally viewed as more interested in apps. Most respondents agreed the following features are important for apps in education and support: Content is developed by DM experts (91%), answers provided to basic DM self-management questions (96%), user experience can be customized (91%), and features for logging/tracking glucose results (91%). Hospital-based providers offered valuable insights into DM app use.22

The research team’s findings support both patient and provider interest, and offer specific features that should be considered in choosing mobile apps for the provision of diabetes education. Over the years, diabetes education has evolved along with technological approaches that are now being applied to improve access and outcomes. We are fortunate to have UPMC leadership, our co-investigators, funding partners, and diabetes care providers and educators who recognize and support the team’s research efforts.

The research team’s studies, along with others, suggest that introducing digital tools3, 22 into clinical practice should be considered as health care systems continue to seek ways to support quality care and education for patients with diabetes.

Please refer to the Update in Endocrinology Fall 2022 CME course on UPMCPhysicianResources.com for a full list of references featured in this article.