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Leveraging Technology to Engage Patients with Diabetes

Korey K. Hood, Ph.D.

Professor Staff Psychologist

Stanford University School of Medicine

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guide

During today’s webinar, we will:

Review the technology and diabetes landscapes

Focus on the process of using technology to engage patients

Discuss different ways to conceptualize diabetes technologies

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assumptions

Management is complex and demanding

Technology is intended to make management easier and more fully integrated into daily life

Improved management leads to better health outcomes

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landscape

Highlights of the Pew Internet Project’s research related to mobile technology. As of January 2014: 90% of American adults have a cell phone 58% of American adults have a smartphone 32% of American adults own an e-reader 42% of American adults own a tablet

http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/ 5

Pew Internet

%Adults with a Smartphone

All Adults 58%

Gender

Men 61

Women 57

Race/ethnicity*

Caucasion 53

African American 59

Hispanic 61

Age Group

18-29 83 bcd

30-49 74 cd

50-64 49 d

65+ 19

Education Level

High School Grad or less 44

Some College 67 a

College+ 71 a

Household Income

Less than 30K/yr 47

30K-49K 53

50K-75K 61 a

75K+ 81 abc

Community Type

Urban 64 c

Suburban 60 c

Rural 43

Source, Pew Research Center Internet Project Survey, Jan.9-12, 2014. N=1,006 adults. Note: Percentages marked with a letter indicate a statistically significant difference between that row and the row designated by that letter, among categories of each demographic characteristic. * The results for race/ethnicity are based off a combined sample from two weekly omnibus surveys, Jan. 9-12 and Jan. 23-26, 2014. The combined total n for these surveys was 2,008; n=1,421 for whites, n=197 for African-Americans, and n=236 for Hispanics.

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Question 1

What percentage of cell phone owners use their mobile devices to access health information?

a) 5%

b) 24%

c) 31%

d) 47%

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Pew Internet 8

diabetes in the U.S.

29.1 million people in the U.S. have diabetes ~8% have type 1 diabetes (2 million)

• Over 90% of adults with diabetes have type 2; about 90% of youth with diabetes have type 1

• Diabetes care represents 11% of total U.S. health care expenditures – nearly $176 billion

• Health care costs for a person with diabetes are 2.3 times that of someone without

• Incidence and prevalence of both types of diabetes are on the rise

Centers for Disease Control and American Diabetes Association 9

In one generation (1950-64 vs 1965-80), life expectancy increased nearly 15 years.

“Further investigation shows this life expectancy is similar to community-based life expectancy.”

Improvements in the Life Expectancy of Type 1 Diabetes The Pittsburgh Epidemiology of Diabetes Complications Study Cohort Rachel G. Miller, Aaron M. Secrest, Ravi K. Sharma, Thomas J. Songer, and Trevor J. Orchard

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Question 2

Are people with chronic conditions (like diabetes) more or less likely to use technologies than people without chronic conditions?

a) MORE

b) LESS

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Pew Internet

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Pew Internet 13

Pew Internet

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landscape

Most people with diabetes will use the latest technologies.

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landscape

Most people with diabetes will use the latest technologies. Many will use those devices to access health information.

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landscape

Most people with diabetes will use the latest technologies. Many will use those devices to access health information. And almost all who access health information perceive no harm from this information.

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Case Example - Martin

Martin is 47 years old, African-American, married, and has had type 2 diabetes for 2 years

Martin is on metformin and injectable GLP-1

Martin misses 1-2 doses per week of each med

Martin tends to “overeat” and gets little exercise

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In your visit, you need to…

Assess diabetes self-management and make realistic, achievable goals for Martin

Determine if changes need to be made to Martin’s medication doses or if new medications need to be added

Find some way to “empower” or “motivate” Martin to take better care of his diabetes

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Summary of 5-step approach

1. Breakdown of Health Behaviors

2. Select one Health Behavior

3. Identify Barriers to Carrying Out Behavior

4. Identify Reinforcement for Behavior

5. Offer Strategies, some of which can include technology

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Self-Management Model

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Pediatrics Official Journal of the American Academy of Pediatrics 2012:129:e-473:orginally published online Jan. 4, 2012

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Question 3

Which of these are modifiable influences?

a) Level of health literacy

b) Ability to problem solve

c) Socioeconomic Status

d) Occupation

e) A and B

f) C and D

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use of technology

target these influences

and

take advantage of the tech-savvy, quick-paced, and short-attention

spanned nature of the user

and

use technology as scaffolding 25

scaffolding

temporary framework for support and access to learning opportunities

promotes mastery and eventually, autonomy with self-management

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what works, or will work?

reduced burden

solid and appealing

technology scaffolding

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direct technology

data support the use of pumps, meters, trackers to optimize

direct management and control

some support for quality of life benefit

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Systematic literature review: quality of life associated with insulin pump use in Type 1 diabetes DIABETICMedicine K.D. Barnard, C.E. Lloyd and T.C. Skinner DOI:10.1111/j. 1464-5491.2007.02120.x

Demographic and Clinical Correlates of Diabetes-Related Quality of Life among Youth with Type 1 Diabetes The Journal of Pediatrics-www.jpeds.com Jean M. Lawrence, ScD, MPH, MSSA, Joyce P. Yi-Frazier, PhD, Andrea Anderson, MS, Korey Hood, PhD, Guseppina Imperatore, MD, PhD, Georgeanna J. Klingensmit, MD, Michelle Naughton, PhD, Elizabeth, J. Mayer-Davis, PhD, and Michael Seid, PhD, for the SEARCH for Diabetes in Youth Study Group

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direct+ technology

direct programs plus layer of data synthesis or trend analysis

examples are CGM systems and trend programs

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direct+ technology

automate pattern management

empower self-management

reduce burden

improve glycemic control

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continuous glucose monitoring

A1c reduction in adults with type 1 (ages 25+), but not in the 8-14 and 15-24 age groups 1

In a “clinical care environment” 2

– adults used more and had more benefit

– less hypoglycemia overall

1. JDRF CGM Study Group. NEJM, 2008

2. JDRF CGM Study Group, Diabetes Care, 2010 32

new advances

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PREVENTION OF NOCTURNAL HYPOGLYCEMIA USING PREDICTIVE ALARM ALGORITMS AND INSULIN PUMP SUSPENSION

Which in many instances was probably the result of severe nocturnal hypoglycemia. The availability of CGM systems has allowed determination of the incidence of nocturnal hypoglycemia in the home environment. In a randomized trial evaluation daily CGM use over a 6-month period

CONCLUSIONS-Using algorithms to shut off the insulin pump when hypoglycemia is predicted, it is possible to prevent hypoglycemia on 75% of nights (84% of events) when it would otherwise be predicted to occur. Diabetes Care 33:1013-1017, 2010

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CONCLUSIONS A closed-loop system without meal announcement and using subcutaneous insulin delivery in insulin-naïve patients with type 2 diabetes appears feasible and safe. Improvement in postprandial glucose control may require further optimization of system performance.

Feasibility of Closed-Loop Insulin Delivery in Type 2 Diabetes: A Randomized Controlled Study Diabetes Care Vol. 37 May 2014 Kovita Kumareswaran, Hood Thabit, Lolantha Leelarathna, Karen Coldwell, Daniela Elleri, Janet Allen, Marianna Nodale, Malgorzata Wilinska, Mark Evans, and Roman Hovorka

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facilitators technology

novel ways to engage and motivate

and

facilitate easier diabetes management

and, ultimately

improve health outcomes

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mHealth - What is Known?

mHealth is being used clinically in diabetes care.

Several states have tele-health laws requiring 3rd party payers to reimburse for tele-health.

Strong empirical support for behavioral health delivered via technology.

Most mHealth research in diabetes done with adults.

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mHealth and Diabetes

• Meta-analysis (26 studies) of home tele-monitoring and telephone support with adults with diabetes (Polisena, et al., 2009).

–Improved glycemic control and reduced hospitalizations.

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“…these results provide some support for the use of digital exergames using the current state of technology as a complement to, rather than a replacement, for regular exercise.”

Virtual Reality and Interactive Digital Game Technology : New Tools to Address Obesity and Diabetes

Journal of Diabetes Science and Technology Vol 5, Issue 2 March 2011 © Diabetes Technology Society Alber “Skip” Rizzo, Belinda Lange, Evan Suma and Mark Bolas

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review article

Pumpers, skypers, surfers and texters : technology to improve the management of diabetes in teenagers M.A. Harris Oregon Health &Science University K.K. Hood University of California, San Francisco and S. A. Mulvaney Vanderbilt University Medical Center Diabetes, Obesity and Metabolism 2012 ©Blackwell Publishing Ltd DOI: 10.1089/dia. 2008.0022

Computerized Automated Reminder Diabetes System (CARDS): E-mail and SMS Cell Phone Text Messaging Reminders to Support Diabetes Management Hanauer, Wentzell, Laffel, Laffel Diabetes Technology & Therapeutics Vol. 11, Number 2 2009 © Mary Ann Liebert, Inc. COI: 10.1089/dia.2008.0022

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apps

Slide provided by Catherine Pastor and Alison Campbell from the Diabetes Program at The Hospital for Sick Children

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facilitators technology

feasible and user-friendly

promising results

but, are they sustainable?

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Question 4

Which type of technology is focused on synthesizing data and offering information on trends?

a) direct

b) direct+

c) facilitators

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strategies

1) Focus on behavioral patterns

2) Matter-of-fact approaches with validation of emotions

3) Use contingencies

4) Teach problem solving

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BEHAVIORS If the goal is to improve health, targeting health care will not be enough

We should focus on changing behavioral patterns

Schroeder, NEJM, 2007; Figure adapted from McGinnis et al, Health Aff, 2002 48

matter-of-fact style

Principle and applications supported by decades of research with people with diabetes

Strategies specific to diabetes:

1. Think of blood sugars as information

2. Do not react (as hard as it sounds)

3. Increase likelihood diabetes tasks will happen again by positive reinforcement

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contingencies

If I do this, I will get that.

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Operant Conditioning

The frequency and strength of a behavior is going to be increased or decreased depending on the consequence

Antecedents to the Behavior are contextual factors and situations that cue behaviors

The Consequence is either reinforcement or punishment

A-B-C model of human behavior

Skinner. The Behavior of Organisms: An experimental analysis. 1938

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contingencies

Rare for people to do something because “it is good for them.” Especially if they do not like that thing.

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Age, Relative Autonomy and Change in Health Locus of Control Beliefs : A Longitudinal Study of Members of a Health-Promotion Facility J Health Psychol 2010 15:326 Daniel S Bailis, Alexander Segall and Judith G. Chipperfield

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contingencies

• Help develop a scaffolding to internalize the importance

• Apps and diabetes devices can be used in this way – Reminders, rewards, unlocking game levels,

positive affirmations

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Problem Solving

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Problem Solving in Diabetes Self-management A systematic review of the literature Hill-Briggs & Gemmell, 2007 Diabetes Educator

Is defined as a learned behavior that includes

generating a set of potential strategies for

problem resolution, selecting the most

appropriate strategy, applying the strategy.

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Results of Review

• Associations with self-management and control

• Interventions have largest impact on self-management and psychosocial outcomes

–Less so on glycemic control 57

It all starts with a GOAL

Goals should be SMART:

Specific

Measurable

Attainable

Realistic

Time-bound

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Support

Susan E. Collins, MS, RD, CHES, and Dana M. Lewis, BA CLINICAL DIABETES-VOLUME 31, NUMBER 3, 2013

Social Media Made Easy: Guiding Patients to Credible Online Health Information and Engagement Resources

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social support

• In-person supports – Community groups; clinic-sponsored events; diabetes

camps

– Ask your diabetes care team for a referral

• Online supports – tuDiabetes, childrenwithdiabetes.com, diabetes.org

– Feel supported by others who know what you are going through; share stories and strategies

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Summary

Leveraging technology requires:

a) Scaffolding and sound behavioral principles

b) Direction from a health care professional (not discouragement)

c) Education and support

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thank you. questions or comments?

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