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Tools For Improving Adherence to Treatment in Diabetes

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Presentation at the 2014 Asia-Pacific Endocrine Conference: Optimal Management of Diabetes & Thyroid Diseases. 7 June 2014 at New World Hotel, Manila.

Presentation at the 2014 Asia-Pacific Endocrine Conference: Optimal Management of Diabetes & Thyroid Diseases. 7 June 2014 at New World Hotel, Manila.

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  • 1. Tools for Improving Adherence to Treatment in Diabetes Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM @endocrine_witch #HealthXPH Associate Professor, University of the Philippines College of Medicine Chief, University of the Philippines Medical Informatics Unit App Sketching by Johan Larsson, https://flic.kr/p/dHLKPt
  • 2. Disclosure Statement of Financial Interest I, Iris Thiele Isip Tan DO NOT have a financial interest/ arrangement or affiliation with any healthcare related companies that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
  • 3. Adherence & mHealth Black and White Crime 2 by Egahen, http://www.freeimages.com/photo/1115701 The App Store by PhotoAtelier, https://flic.kr/p/9rCQw8 Apps for diabetes Runkeeper and health on iPhone by Jason Howie, https://flic.kr/p/e5CBwN Apps (un)regulated
  • 4. Adherence & mHealth Black and White Crime 2 by Egahen, http://www.freeimages.com/photo/1115701 The App Store by PhotoAtelier, https://flic.kr/p/9rCQw8 Apps for diabetes Runkeeper and health on iPhone by Jason Howie, https://flic.kr/p/e5CBwN Apps (un)regulated
  • 5. Eating salad for health by typexmick, http://www.freeimages.com/photo/1432591 “Adherence WHO definition (2003) the extent to which a person’s behavior - taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider
  • 6. In developed countries, adherence to long-term therapies in the general population is around 50% and is much lower in developing countries. WHO report (2003) “ Take your medicine! by Morgan, https://flic.kr/p/6jfAxH
  • 7. The Five Dimensions of Adherence WHO (2003) Adherence to Long-term Therapies: Evidence for Action
  • 8. mobile phone-conference image by xristine_faulkner https://flic.kr/p/4Xn9Q7 medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs) and other wireless devices “mHealth WHO definition (2011)
  • 9. mHealth research 2002-2012 Mobile phone in hand 2 by DragonTash, http://www.freeimages.com/photo/1438235 Health promotion (38%) Self-management (33%) Communication (22%) Remote monitoring (21%) Data gathering (21%) Improvement of adherence (20%) Training/education (17%) mHealth Research Impact Areas Fiordelli M et al. Mapping mHealth research: a decade of evolution J Med Internet Res 2013;15(5):e95
  • 10. Conditions addressed by mHealth research Fiordelli M et al. Mapping mHealth research: a decade of evolution J Med Internet Res 2013;15(5):e95 Diabetes Obesity/Overweight Mental health Tobacco use Other kind of chronic condition HIV Other acute conditions Well-being Cancer Medication compliance/Appointment reminder Sexual health Cardiovascular condition Tuberculosis 0 5 10 15 20 25
  • 11. Measurement On-person or embedded sensor sampling in real time Ecological Momentary Assessment Global positioning system Diagnostic Point-of-care diagnostics Portable imaging Biomarker sensing Clinical decision support Sensor sampling for diagnostics Treatment/Prevention Prevention & wellness interventions Remote behavioral treatment Medication adherence tracking Chronic disease management Dissemination of health information Disaster support/care Global Access to healthcare services Remote behavioral treatment Dissemination of health information Disease surveillance Medication tracking and safety Prevention & wellness interventions Continuum of mHealth Tools Kumar S. et al. Mobile Health Technology Evaluation: The mHealth Evidence Workshop. Am J Prev Med 2013;45(2):228–236 Arrow background by ralev_com, http://www.freeimages.com/photo/1169793
  • 12. conectandonos by El_Turista_Accidental, https://flic.kr/p/7EWqg3 There’s an app for that! Patient Apps for Improved Healthcare: From Novelty to Mainstream (Oct 2013) IMS Institute for Healthcare Informatics 40,000+ healthcare apps on US Apple iTunes app store
  • 13. Adherence & mHealth Black and White Crime 2 by Egahen, http://www.freeimages.com/photo/1115701 The App Store by PhotoAtelier, https://flic.kr/p/9rCQw8 Apps for diabetes Runkeeper and health on iPhone by Jason Howie, https://flic.kr/p/e5CBwN Apps (un)regulated
  • 14. Patient Apps for Improved Healthcare IMS Institute for Healthcare Informatics Oct 2013 n= 43,689 apps Healthcare & Fitness or Medical n= 20,007 apps Miscategorized or only loosely health related n= 23,682 apps Genuine healthcare related n= 16,275 apps Consumer oriented n= 7,407 apps Healthcare professional oriented 1,980 therapy area specific apps 270 apps for endocrine, nutritional & metabolic diseases
  • 15. Patient Apps for Improved Healthcare IMS Institute for Healthcare Informatics Oct 2013 Functionality score + User score = IMS Health App Score No. of reviews + star rating[ ] 25 individual criteria information provided how user data tracked/captured communication processes quantity of device capabilities[ ]
  • 16. Top diabetes apps strong functionality with ease of use IMS Health App Score IMS Institute for Healthcare Informatics Oct 2013 Daily Carb Maxwell Software Glucose Buddy Azumio, Inc. GoMeals Sanofi Diabetes 1 2 3
  • 17. Currently, there are more than 15,000 health-related apps (free and paid) on app stores, but we were not able to find any study assessing any of them. So what is publicly available has not been evaluated, and what has been evaluated is not publicly available. Mapping mHealth Research: A Decade of Evolution Fiordelli M, Diviani N, Schulz PJ. J Med Internet Res 2013;15(5):e95 “ Puzzle 1 by jakubson http://www.freeimages.com/photo/1072527
  • 18. Features of Mobile Diabetes Apps: Review of the Literature & Analysis of Current Apps Compared Against Evidence-based Guidelines Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65 iPhone Android Blackberry Nokia online markets + journal databases + gray literature on mobile apps INCLUSION criterion self-monitoring of blood glucose EXCLUSION criteria No English user interface Intended exclusively for HCPs n = 973 n = 137 (101 online + 26 literature search) Smartphone icon by Loraw200, http://www.freeimages.com/photo/1377498
  • 19. Features of Mobile Diabetes Apps: Review of the Literature & Analysis of Current Apps Compared Against Evidence-based Guidelines Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65 SELF- MONITORING Blood glucose Weight Insulin & medication BP EDUCATION Disease- related ALERTS & REMINDERS Integration of SOCIAL MEDIA functions Disease- related DATA EXPORT & COMMUNICATION Synchronization with Personal Health Record (PHR) systems or patient portals Features from brainstorming of authors; focus group discussions between MDs and patients
  • 20. A tree on the horizon by Ydiot, http://www.freeimages.com/photo/1113494 GAP ANALYSIS [ Literature typically reflects emerging applications and new trends ... “ ... the market gives a good indication of mature applications and functionality. Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65
  • 21. A tree on the horizon by Ydiot, http://www.freeimages.com/photo/1113494 GAP ANALYSIS [ Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65 Literature Search PHR or Web server synchronization 18 (69%) Insulin & medication recording 17 (65%) Diet recording 17 (65%) Data export & communication 16 (62%) Insulin & medication recording 63 (62%) Data export & communication 61 (60%) Diet recording 47 (47%) Weight management 43 (43%) Online Market
  • 22. #1 Insulin/meds #2 Communication #3 Diet #4 Physical Activity #5 Weight #6 BP #7 PHR #8 Education #9 Social Media #10 Alerts Features of Mobile Diabetes Apps: Review of the Literature & Analysis of Current Apps Compared Against Evidence-based Guidelines Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65 A CB Variables in diabetes self- management NOT addressed Personalized feedback Patient monitoring by primary care physician Foot & eye care Psychosocial care Immunization Complication management
  • 23. Very little influence of social media on current diabetes mobile applications Provide link to groups on FB or Twitter No functional links or integration between information in app & social media Instagram and other social media apps by Jason Howie, https://flic.kr/p/d41HES Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65
  • 24. Mobile Apps for Diabetics: A Systematic Review & Expert- based Usability Evaluation Considering the Special Requirements of Diabetes Patients Age 50 Years or Older Amhold M, Quade M, Kirch W. J Med Internet Res 2014;16(4):e104 iOS n=276 Android n=266 Both n=114 Smartphone icon by Loraw200, http://www.freeimages.com/photo/1377498 GENERAL INFORMATION Name/language Date of release/ update Desktop app OPERATING SYSTEM iOS Android Both DEVELOPER INFORMATION Name POPULARITY/ USER RATINGS No. of downloads/ installations User rating No. of user ratings TARGET USER GROUPS Patients Physicians/qualified health personnel Both INTERFACES Interface/ connectivity to external sensor(s)/ device ACQUISITION COSTS Freeware Exact price Availability as”lite” version Feb-Apr 2013
  • 25. 0 25 50 75 100 Free Paid Paid/Lite iOS (n=276) Android (n=266) Both (n=114) Total (n=656) Price distribution of diabetes apps and “lite” versions Amhold M, Quade M, Kirch W. J Med Internet Res 2014;16(4):e104 %
  • 26. Worried senior woman talking by SalFalko, https://flic.kr/p/gFCeMN Usability & Assessment Criteria for Diabetes Apps for Elderly Amhold M, Quade M, Kirch W. J Med Internet Res 2014;16(4):e104 COMPREHENSIBILITY Use of understandable semantics, simple comprehensibility & interpretability of displayed images and depictions, simple self-explanatory menu structures USABILITY Instant and easily understandable feedback, intuitive usability, simple recognition of click-sensitive areas PRESENTATION (Image & Text) Sufficient color contrast, large size of operating elements, ability to adapt the size of operating elements and displayed images GENERAL CHARACTERISTICS High fault tolerance/efficient fault management, password-protected services Randomly selected 66/656 apps (iOs n=29, Android n=28, Both n=9)
  • 27. Comprehensibility Presentation Usability General characteristics 0 1 2 3 4 5 Likert Scale Usability Assessment of Diabetes Apps for Elderly Amhold M, Quade M, Kirch W. J Med Internet Res 2014;16(4):e104
  • 28. Adherence & mHealth Black and White Crime 2 by Egahen, http://www.freeimages.com/photo/1115701 The App Store by PhotoAtelier, https://flic.kr/p/9rCQw8 Apps for diabetes Runkeeper and health on iPhone by Jason Howie, https://flic.kr/p/e5CBwN Apps (un)regulated
  • 29. Patients face a dizzying array of healthcare apps to choose from, with little guidance on quality or support from their doctors. Some efforts are underway to help provide professional healthcare guidance in both the US and the UK but these are limited in scope and impact to date. “
  • 30. Hyperwall by Florian Plag https://flic.kr/p/8aro3Y It’s the Wild West out there. It’s hard to sort through them all and there’s little evidence about which ones really work. Murray Aitken Executive Director IMS Institute for Healthcare Informatics “
  • 31. Apple by VanessaGF, http://www.freeimages.com/photo/1427461 An app a day keeps the doctor away. “ When a prescription drug goes generic, it has at least seven years of data about its effectiveness and safety, which gives physicians assurance that patients can use it for self-care. Medical apps have no history of either effectiveness or safety. Mike Paskavitz Editor-In-Chief, Quantia Inc “
  • 32. Mobile apps that are NOT medical devices ... will NOT be regulated by FDA. device but because they pose a lower risk to the publi Mobile apps may meet the definition of a medical device but because they pose a lower risk to the public, FDA intends to exercise enforcement discretion.
  • 33. Caledos runner by Nicola, https://flic.kr/p/fP18Jx Although the FDA has focused on safety, it has largely left the review and certification of apps to the marketplace. The currently available reviews of mHealth apps have largely focused on personal impressions, rather than evidence-based, unbiased assessments of clinical performance and data security. Powell AC, Landman AB, Bates DW. In Search of a Few Good Apps JAMA. Published online March 24, 2014, doi:10.001/jama.2014.2564 “
  • 34. Mobile medical applications that FDA has cleared or approved http://www.fda.gov/MedicalDevices/ ProductsandMedicalProcedures/ConnectedHealth/ MobileMedicalApplications/ucm368784.htm
  • 35. http://spectrum.ieee.org/biomedical/devices/bluestar-the-first-prescriptiononly-app This is a piece of software getting the same treatment as a medical device. It’s pretty world-changing. Sonny Vu Cofounder, Misfit Wearables “
  • 36. Patient Apps for Improved Healthcare IMS Institute for Healthcare Informatics Oct 2013
  • 37. Evaluation & Evolution of Diabetes Mobile Apps: Key Factors for HCPs Seeking to Guide Patients Ristau R, Yang J, White J. Diabetes Spectrum 2103; 26(4):211–215 PATIENT DEMOGRAPHICS Older generation less likely to be technologically savvy FINANCIAL BURDEN Can the patient afford the device & the app? Busy woman by JetMedia, http://www.freeimages.com/photo/1070268
  • 38. Evaluation & Evolution of Diabetes Mobile Apps: Key Factors for HCPs Seeking to Guide Patients Ristau R, Yang J, White J. Diabetes Spectrum 2103; 26(4):211–215 DEVICE & APP PLATFORM Not all apps available for all platforms APP FEATURES Logging & tracking, data sharing & social support, SMS & reminders EASE OF USE Easy to navigate, modify, enter, retrieve & share data GUIDELINES & REGULATIONS Follow guidelines? FDA approved?Busy woman by JetMedia, http://www.freeimages.com/photo/1070268
  • 39. Adherence & mHealth Black and White Crime 2 by Egahen, http://www.freeimages.com/photo/1115701 The App Store by PhotoAtelier, https://flic.kr/p/9rCQw8 Apps for diabetes Runkeeper and health on iPhone by Jason Howie, https://flic.kr/p/e5CBwN Apps (un)regulated
  • 40. Measurable behavior change is the desired outcome of diabetes education. The diabetes professional community must step into the market void and embrace mobile technology as part of the solution. “

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