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Diabetes Self-Management Apps and Structured Education

Delivered June 21st, 2019. Contributors: Anna C., Gene E., Cristina G. and

Part
01
of three
Part
01

Apps - User Retention Stats

The standard expected rate of usage for health-related self-management apps, particularly apps designed to help manage Type 2 diabetes, is between 4 weeks and 12 months. The standard retention rate of mHealth apps in general is at 7% with more than 50,000 active users.

USAGE FOR HEALTH-RELATED SELF-MANAGEMENT APPS (DIABETES)

  • STANDARD EXPECTED RATE OF USAGE
• In a study to evaluate Type 2 diabetes apps such as BlueStar, mDiab, Health Coach, Gather Health, and WellTang, participants used the apps up to 12 months.
• According to the American Diabetes Association (ADA), it is recommended for patients to use diabetes mobile applications for at least a couple of weeks before deciding whether it will work for them or not.
• In understanding the app evaluation process, registered testers should use the diabetes apps for four weeks and answer several criteria using a questionnaire. The results of the questionnaires will be reviewed and discussed during a final conference call.
  • STANDARD RETENTION RATE OF DIABETES APPS AND MHEALTH APPS IN GENERAL
• WellDoc’s work with payers includes the PCMH demonstration with Horizon Blue Cross Blue Shield New Jersey. They found that patients who use the BlueStar app and stick with it see results. Out of 89 patients with Type 2 diabetes, 86% used the app and filed a smart report with their doctor.
• There are only 7% of mHealth apps with more than 50,000 active users according to data from mHealth Developer Economics Research. Majority of these apps provide solutions for running, exercising, managing diabetes, improving women’s health or losing weight.
• According to a study done by PWC, two-thirds of people who downloaded a mobile health (mHealth) app used it only once. The low retention rate could stem from the incorrect use of the application.
• In a study called “Effect of self-monitoring on long-term patient engagement with mobile health applications”, it was found that 44% of the users had abandoned the app after one month.
  • FREQUENCY OF USE OF THE APPS
• Patients who use BlueStar app logged in an average of 6.5 a week.
• According to a study called “Popular Diabetes Apps and the Impact of Diabetes App Use on Self-Care Behavior”, patients of Type 2 diabetes either use mobile apps daily (28.6%), monthly (1.4%), weekly (5.7%), a few days a week (12.4%), every time they eat (45%), only when needing guidance (3.3%), or never (3.3%).

HELPFUL FINDINGS:

1) OTHER STATISTICS
• Type 2 diabetes patients find mobile apps to be extremely useful (26.3%), very useful (36.4%), somewhat useful (29.7%), not very useful (5.3%), or not at all useful (2.4%).
• There are 51.9% Type 2 diabetes patients who are interested in using a smartphone app to assist with their diabetes management.
2) APP USAGE FOR MOBILE APPS DESIGNED FOR DIABETES SELF-MANAGEMENT:
• Type 2 diabetes patients use apps mainly for tracking blood glucose (56.6%), blood pressure (51.9%), and food calories (48.1%).
• Among the 217 respondents, 106, or 48.8%, will continue using the app while 111, or 51.2%, will not continue using the app. The reasons for not using the app included not being interested (33.3%), the app's lack of awareness (46.8%), the inability to access it on a smartphone (10.8%), the lack of patients' access to the internet (7.2%), and the app being expensive (9%).
3) TYPE 2 DIABETES SELF-MANAGEMENT APPS:
• BlueStar Diabetes — This app is free to download and is available on Apple and Android OS. It was rated 85/100, which was the highest score of the apps that were used by patients. The FDA cleared BlueStar as a non-prescription device due to its low risk in 2017.
• mDiab — mDiab Lite (free) and mDiab are available on Apple and Android OS. For both mDiab Lite and mDiab, the user can track blood glucose, HbA1c, medication, physical activity, and weight. mDiab Lite scored a 47.5/100 and mDiab scored a 48.3/100. They both fall into the “not acceptable” usability category.
• NexJ Connected Wellness Platform: Health Coach + [NexJ] — This app is available on Apple and Android OS. It requires a prescription from a doctor to create an account. It allows the user to track blood glucose, HbA1c, carbohydrates, medication, physical activity, and weight.
• Gather Health — This app is available on Apple and Android OS. It requires a prescription from a doctor to create an account. The app allows users to track blood glucose, HbA1c, medications use, physical activity, and weight. [source 1]
• WellTang — This app is available in the Apple App Store and is only accessible by scanning a QR code on the WellTang website. The app is available in English and can help users track their blood glucose, HbA1c, meals and carbohydrates, medication use, physical activity, and weight.


Part
02
of three
Part
02

Best Practice - Maximizing User Retention and Usage

Gamification approach is used by MySugr to encourage diabetes patient engagement. It has activities and rewards and uses a "monster" feature to represent the patient's progress. Gamification is being used by 28% of mHealth apps publishers.

MySugr Uses Gamification

  •  MySugr is one of the market leaders and trusted voice in the diabetes digital health space.
  • MySugr encourages patient engagement through gamification mechanics, activities and rewards, and by using a "monster friend" to represent their progress.
  • According to a report, MySugr uses gamification to gain more than 90,000 users.
  • Currently, about 28% of mobile health (mHealth) app publishers make use of gamification approach to their apps. Badges and leadership boards can possibly increase fitness apps' user retention but these are not easy to integrate with other medical condition apps. Gamification, though it has a lower impact on healthcare apps' user retention, MySugr's use of the "monster" feature has contributed to the success of the app.

HELPFUL FINDINGS on mHealth Apps

  • According to 2018 mHealth App Developer Economics study by Research2Guidance, "User retention for digital healthcare solutions is still a major issue." Amongst digital health app portfolios, only 7% has more than 50,000 active users. These companies provide apps for running, exercising, diabetes, women’s health, or weight loss. The most effective approach user retention approach as seen by digital health market players is connecting to an HCP.
  • Recent surveys found that only a few of the people with diabetes mellitus use apps to manage their diabetes. One factor is that patients have different needs.
  • According to 2018 mHealth App Developer Economics study by Research2Guidance, dashboards are seen by the majority of the mHealth experts (60%) as the simplest and most effective feature to implement to re-engage users and drive behavior change, followed by personal reminders (49%).
  • This study also indicates that allowing the user to directly interact with doctors, e.g., sharing weekly test results and receiving feedback via the app, is seen as the approach that has the highest impact on behavior change and user retention but is the most difficult to implement.
  •  Retention rates for apps are higher when health care professionals prescribe health apps to patients rather than making general recommendations.
  • According to a study, more than 45,000 mHealth apps in mobile app stores are languishing. Over 200 diabetes mobile apps in the Apple and Google app stores were evaluated using a framework but none of them met all 15 important criteria.

Research Strategy:

To identify best practices for maximizing retention of users and usage for health apps, particularly with relation to the management of Type 2 diabetes, we initially looked for directly available information through several industry sources, industry publications, and medical and research institutes such as NCBI, Agency for Healthcare Research and Quality, Journal of Medical Economics, mHealth Intelligence, Research 2 Guidance, and others. However, we are not able to find any available best practices specific for type 2 diabetes that drives users retention and engagement for health apps. What we found are some helpful data around best practices in mHealth industry overall that drives users engagement, and others.

Secondly, we switched gears and look for any survey studies or research studies and reports that aim to find patients with diabetes preferences for health app features that make them more engaged to manage their type 2 diabetes. Our goal is to find the most effective ways that diabetes apps providers must focus and look if there were related existing industry best practices we could locate by consulting the industry sources or key major players in diabetes health apps overall. Here, based on the 2015 studies by SAGE Journals that the diabetes self-care mHealth marketplace is growing, but most effective/valued features are unknown, backed by 2018 most recent report by PLOS ONE stating that, there are limited research studies that have explored patients’ use, feature preferences and recommendations that could improve engagement with diabetes apps since only a few of them uses health apps to manage their condition. Also, some statistics based on the study by Research 2 Guide stating that only 7% of digital health app portfolios have more than 50,000 active users. We have assumed that these factors are the reasons for the unavailability and insufficient data to provide "industry" best practices.

Lastly, we tried to check the key players and providers of apps for managing type 2 apps such as MySugr, Diabetes:M, Center Health, and others and opted to focus on what are the best practices or features of their health apps that drive more users engagement and retention. However, only one best practice was found from one of the market leaders in providing diabetes apps which is MySugr. We added some helpful findings and related insights for the topic such as some best practices in mHealth apps in general that drives users engagement and retention.
Part
03
of three
Part
03

Primary Care Physicians - Incentives

While there was no preexisting information on the examples of incentives given to primary care clinicians or practice managers to encourage patients’ uptake of diabetes structured education course, we pooled together helpful information using the available data. Our research revealed that the Centers for Medicare & Medicaid Services provides incentive programs for physicians to reward them through the "high quality, high value clinicians pay raise,” which is additional money to their usual physician fee schedule. Also, we found that different Canadian provinces offer incentives to clinicians as compensation for following guidelines of evidence-based flow sheets in treating diabetic patients.

HELPFUL FINDINGS

UNITED STATES

  • Centers for Medicare & Medicaid Services provides incentive programs for physicians to reward them through the "high quality, high value clinicians pay raise,” which is additional money to their usual physician fee schedule. The eligible clinicians can apply for the Merit-based Incentive Payment Systems or MIPS to claim their reward.
  • MIPS nominates eligible clinicians using four performance categories, which include quality, cost, improvement activities, and advancing care.
  • A total score of hundred is obtained from the four categories, and the payment adjustment is determined based on the clinician's performance.
  • Based on the Advancing Care Information part of eligibility guideline, clinicians or physicians are expected to implement preventive approaches in their clinical practice by referring patients to CDC-accredited diabetes prevention program which operates under the National Diabetes Prevention Program.
  • This performance category bonus can earn physicians a 10% increase in their pay.
  • The MIPS incentive was noted in a reported in which the author stated that while physicians do not get a direct financial payment on referrals, it counts on their MIPS score that may increase their reimbursement rates through Medicare.

CANADA

  • The Canadian healthcare system in national and provincial level adopted promotions to implement diabetes strategies and framework to improve patient outcomes. This was to encourage physicians to follow the provided guideline in diabetic care provided by the Canadian Diabetes Association.
  • Under the Chronic Care Model (CCM) for diabetes management guidelines, self-management support was listed as one of its components. These include activities such as education, providing internal and community resources to patients going into disease management programs, peer-led support, and monitoring.
  • Some provinces in Canada offer additional incentives to healthcare professionals as compensation for following guidelines of evidence-based flow sheets in treating diabetic patients. This financial incentive is given to primary care physicians who can achieve target clinical outcomes for patients.
  • Part of the incentive is for physicians who will enroll diabetic patients in a nationwide disease management program.
  • As an example, Ontario's Diabetes Management is providing a $60 annual per patient payment for physicians" who complete and document the required elements of care recommended by the Canadian Diabetes Association guidelines."

TAIWAN

  • A diabetes P4P program was implemented in Taiwan in 2001, where it covers several features to be eligible to participate.
  • In summary, the P4P program is for physicians specialized in metabolic disorder or endocrinology who adheres to the American Diabetes Association’s clinical guidelines, has at least two diabetic patients within three months.
  • The physician enrolls the patients in the program where they will receive “comprehensive care that includes medical history assessment, physical examination, laboratory evaluation, management plan evaluation, self-management, and health education.”
  • The physician will receive additional payment on top of his regular scheduled fees for improving process on patient outcomes.

UNITED KINGDOM

  • United Kingdom implemented the Quality Outcomes Framework (QOF) in 2004 as part of the contract with General Practitioners. The objective of the program is to "improve chronic disease care and outcomes.
  • The QOF has a set of quality indicators where they are scored up to 1,000, where 14% of QOF clinical domain points pertain to diabetic care.
  • The reward is for physicians who will follow the "evidence-based indicators developed by the National Institute for Health and Care Excellence (NICE)," which almost 99% of practices in England follows.
  • This Pay-for-Performance scheme accounted for 10-15% of income by GPs in the country.
  • Part of the QOF indicators is for physicians to refer newly diagnosed diabetic patients to a structured education program.

RESEARCH STRATEGY:

We initially searched for industry reports, research reports, media news article and press releases to find any information on unique incentives offered to primary care clinician, physicians and general practitioners to encourage their patients in taking diabetes structured education courses from sources such as Forbes, Medscape, Mayo Clinic, BMJ, Elsevier, Research Gate and similar sites. However, none of the said sources provided the needed information. While they have articles and publications relating to patient education or diabetes program, none of them pertains to an incentive to physicians for referring patients to these programs.
Next, we searched for government health institutions in English-speaking countries such as in the US, UK, New Zealand, Australia among others with hope to see if they have introduced or launched an initiative for giving a reward or incentive to physicians for referring patient to diabetes education program as part of their advocacy in diabetes management. This proved to be unsuccessful as there is no direct initiative for this specific topic. However, we found information that was related to this. We found some publications describing the different diabetes strategies implemented by various governments in bridging the gap between diabetic patient and quality care. Each government found followed a specific framework or guidelines in ensuring effective management of diabetic patients, and part of these guidelines provides incentives to physicians to refer, enroll, and encourage patients to take diabetes prevention or management education programs. However, this 'referral' is not the sole basis of incentives, but only part of the components of the guidelines, which was the reason why this was not presented as a direct answer to the question. For this reason, we have provided this information as useful insight.
Lastly, we tried to get the information from education program vendors. We looked for some private or public diabetes education program providers' website to know if they have a referral programs or incentive programs for healthcare professionals. We visited the website of the American Association of Diabetes Educators and looked for Diabetes Education Accreditation Programs. Based on their list of education programs, they were being facilitated by hospitals and medical centers, which might be the reason why the information is unavailable because some physicians are resident of these hospitals. Also, we searched through the UK's National Institute for Health, and Care Excellence (NICE) accredited diabetes educators such as DAFNE, X-pert Diabetes program, and Desmond, but none of these websites had any information for any referral programs.
The unavailability of the information could be because there might be some ethical issues why information for these are not made publicly available.
Sources
Sources
From Part 01
e

mobile-health-applications-for-self-management-of-diabetes

effectivehealthcare.ahrq.gov
Publication Year: 2018
Quotes
  • "Study duration and length of time that participants used the apps ranged from 2 to 12 months."

Users’ preferences and design recommendations to promote engagements with mobile apps for diabetes self-management: Multi-national perspectives

journals.plos.org
Publication Year: 2018
Quotes
  • "A total of 217 respondents with type 1 DM (38.25%) or type 2 DM (61.8%), from 4 continents (Australia, Europe, Asia and America) participated in the survey. About half of the respondents (48%) use apps, mainly with features for tracking blood glucose (56.6%), blood pressure (51.9%) and food calories (48.1%)."

WellDoc’s BlueStar Seeks to Empower Patients With Type 2 Diabetes Through Real-Time Coaching, Provider Feedback

ajmc.com
Publication Year: 2017
Quotes
  • "Of the 89 patients with T2D who were offered the opportunity to receive telephone coaching and use the BlueStar technology, 43 accepted. Of these, 86% both used the app and filed a report, known as a SMART report, with their doctor."

Evaluation and Evolution of Diabetes Mobile Applications: Key Factors for Health Care Professionals Seeking to Guide Patients

spectrum.diabetesjournals.org
Publication Year: 2013
Quotes
  • "Patients should be encouraged to continue using a new app for at least a couple of weeks before deciding whether it will work for them. Navigating through an app may become easier in time, as proficiency improves with repetition."
m

Modern_Diabetes_Therapies

medica-tradefair.com
Publication Year: 2019
Quotes
  • "Our registered testers subsequently use the app for four weeks and check off our set of criteria using a questionnaire. Anyone who is interested in working with diabetes apps can register to become a tester."
f

Popular Diabetes Apps and the Impact of Diabetes App Use on Self-Care Behaviour

frontiersin.org
Publication Year: 2019
f

Popular Diabetes Apps and the Impact of Diabetes App Use on Self-Care Behaviour

frontiersin.org
Publication Year: 2019
m

only-7-of-mhealth-apps-have-more-than-50-000-monthly-active-users-best-mhealth-user-retention

medium.com
Publication Year: 2018
Quotes
  • "User retention for digital healthcare solutions is still a major issue. Only 7% of mHealth app portfolios count more than 50,000 active users."

Effect of self-monitoring on long-term patient engagement with mobile health applications

ncbi.nlm.nih.gov
Publication Year: 2018
Quotes
  • "According to recent statistics, more than two-thirds of people who downloaded a mobile health (mHealth) app used it only once and stopped using it. The low retention rate is a critical issue given the nature of chronic diseases, for which most mHealth apps are designed."
From Part 02

Users’ preferences and design recommendations to promote engagements with mobile apps for diabetes self-management: Multi-national perspectives

journals.plos.org
Publication Year: 2018

Press | mySugr.com

mysugr.com
Publication Year: 2019

Diabetes app best practises - Interview with mySugr CEO by Research2Guidance

research2guidance.com
Publication Year: 2018

mySugr Diabetes Logbook

rankedhealth.com
Publication Year: 2016
s

Advancing Dietetic Practice through the Implementation and Integration of Smartphone Apps

ses.library.usyd.edu.au
Publication Year: 2018

monthly active users of mHealth apps: 7% have more than 50k MAUs | R2G

research2guidance.com
Publication Year: 2018

Diabetes mHealth Apps: Designing for Greater Uptake. - PubMed - NCBI

ncbi.nlm.nih.gov
Publication Year: 2017
From Part 03

QPP Overview - QPP

qpp.cms.gov
Publication Year: 2019
Quotes
  • "With the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS did away with the SGR. Now, we are able to reward high value, high quality Medicare clinicians with payment increases"
c

2018 MIPS Advancing Care Information Performance Category Fact Sheet

cms.gov
Publication Year: 2018
Quotes
  • "For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the CY 2018 performance period and 75 percent in future years, of CEHRT with documentation of referring eligible patients with prediabetes to a CDCrecognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program."
  • "MIPS eligible clinicians rticipating as individuals, will have their payment adjustment based on their individual performance."
  • "In the 2018 performance period, clinicians and groups that exclusively report the Advancing Care Information Objectives and Measures will earn a 10% bonus for using only 2015 Edition CEHRT."

Prediabetes screening, referral can help you succeed in MIPS

ama-assn.org
Publication Year: 2018
Quotes
  • "Physicians will not get direct Medicare payment for the screening and referring services, but they will count as IAs, which will count toward their final MIPS score and will Medicare reimbursement rates in 2020."
  • "For patients found to have prediabetes, physicians have to attest that they referred 60 percent of their patients to a diabetes prevention program recognized by the Centers for Disease Control and Prevention (CDC) operating under the framework of the National Diabetes Prevention Program for at least 90 consecutive days within the 2018 reporting period. The 60 percent threshold for both of these IAs will rise to 75 percent in 2019."

Organization of Diabetes Care

diabetes.ca
Publication Year: 2018
Quotes
  • "Some provinces have added incentive billing codes for the care of people with diabetes so that health-care providers can be financially compensated for the use of evidence-based flow sheets as well as time spent collaborating with the person with diabetes for disease planning."
  • "A recent review of systematic reviews of QI strategies stated that they were unable to find any high-quality systematic reviews on financial incentives and the quality of diabetes care."
  • "Incentives to physicians to enroll people with diabetes and provide care within a nationwide disease management program appear to improve quality of care, as does infrastructure incentive payments that encourage the CCM. A meta-analysis that included physician incentives as a QI has shown mixed results for improved outcomes. "
c

Performance-Based Financial Incentives for Diabetes Care: An Effective Strategy?

canadianjournalofdiabetes.com
Publication Year: 2014
Quotes
  • "In Canada, several provinces have introduced incentive programs in the form of enhanced billing or condition-based payments. Physicians can receive additional payments for each patient with diabetes who is managed in accordance with practice guidelines."
  • " For example, Ontario’s Diabetes Management Incentive provides a $60 annual, per-patient payment to physicians who complete and document the required elements of care recommended by the Canadian Diabetes Association guidelines."
  • "Taiwan introduced a voluntary incentive program (DM-P4P) for diabetes care in 2001. The design by Taiwan’s National Health Insurance initially involved case management fees provided to physicians for achieving process-based outcomes, such as follow up and annual evaluation visits"
  • ". Service items required for each of these visits include nutrition education, physical examination and laboratory testing. Participating physicians are required to complete specialized training in diabetes management (Diabetes Shared Care Program) and are permitted to select which patients are eligible for the program."

Peer Reviewed: A Diabetes Pay-for-Performance Program and Risks of Cancer Incidence and Death in Patients With Type 2 Diabetes in Taiwan

ncbi.nlm.nih.gov
Publication Year: 2017
Quotes
  • "A diabetes P4P program was implemented by Taiwan’s NHIA in 2001 to improve the quality of health care for diabetes patients."
  • "only physicians who specialize in metabolic disorders or endocrinology or who attend a training program for diabetes care are eligible to participate in and voluntarily enroll patients into this P4P program. "
  • "in addition to regular and usual care, P4P patients receive extra comprehensive care, including medical history assessment, physical examination, laboratory evaluation, management plan evaluation, self-management and health education"
  • "Finally, participating P4P physicians receive extra incentive payments in addition to regular physician fees depending on incentive targets for improving process "
  • "Pay-for-performance (P4P) or value-based purchasing programs have been embraced by many developed nations as a strategic tool to stimulate delivery of long-term, multidisciplinary diabetes management and to allow investment of less money on incentives while efficiently improving diabetes care quality (8–10). For example, the United Kingdom’s Quality and Outcome Framework and Australia’s P4P program pay bonuses to reward improvements in care for diabetes patients."

The role of the Quality and Outcomes Framework in the care of long-term conditions: a systematic review

ncbi.nlm.nih.gov
Publication Year: 2017
Quotes
  • "It rewards general practices financially for delivering interventions and achieving patient outcomes using evidence-based indicators developed by the National Institute for Health and Care Excellence (NICE).1 Although the QOF is voluntary, nearly 99% of practices in England participate, on average deriving 10–15% of total practice income from the scheme."
  • "QOF indicators 2016/2017 relating to care of long-term: Patients newly diagnosed with diabetes referred to a structured education programme"