JMIR Publications

ABSTRACT

Background:

A significant cause of morbidity and mortality, Type 2 diabetes affects 30 million Americans. Self-management support (SMS) is an important component of chronic illness care and is a key pillar of the Chronic Care Model. Face-to-face teaching and patient education materials suffer from being static or incompatible with mobile lifestyles. Digital applications (apps) provide an SMS alternative that is convenient and scalable.

Objective:

This pilot study tested the real-world deployment of a self-guided mobile app for diabetes education (titled Time2Focus), which utilizes evidence-based content and gamification to deliver an interactive learning experience.

Methods:

Primary care providers were approached for permission to invite their patients to participate. Eligible patients were 18 to 89 years of age, had a diagnosis of Type 2 diabetes, hemoglobin A1c (HbA1c) ≥8% and <12% in the past 3 months, an active online patient portal account (tied to the electronic health record), and access to an iOS or Android smartphone. Interested patients were emailed a baseline survey, and once this was completed, sent instructions for downloading the Time2Focus app (MicroMass Communications, Inc; Cary, NC). After completing all 12 levels, participants were sent a follow-up survey. The primary outcome was change in HbA1c. Secondary outcomes included medication adherence, self-care activities, self-reporting of physical activities, diabetes self-efficacy, illness perceptions, diabetes distress scale, and users’ engagement with and rating of the app.

Results:

Of 1355 potentially eligible patients screened, 201 were consented. One hundred (49.7%) did not download the app. Seventeen (8.4%) downloaded the app but completed zero levels. Twenty-six (12.9%) completed 1 through 4 levels, 10 (5.0%) completed 5 through 11 levels, and 48 (23.9%) completed all 12 levels. Those completing one or more levels had a mean pre-/post-HbA1c change of -0.41% (compared to -0.32% among those who completed zero levels). The unadjusted 2-tailed t-test was not statistically significant (p=0.73). Diabetes self-efficacy showed a large and significant increase during app usage (ΔM=1.28, p<.001, d=0.83). Severity of illness perceptions showed a small but significant decrease during app usage (ΔM=-0.51, p=.004, d=0.43). Diabetes distress showed a small but significant decrease during app usage (ΔM=-0.45, p=.006, d=0.41). Net Promoter Score (NPS) was 62.5, indicating those who completed all levels of the app rated it highly and would recommend it to others.

Conclusions:

Participants who used the Time2Focus mobile application showed an improvement in diabetes self-efficacy and a decrease in severity of illness perceptions. The decrease in HbA1c observed in app users relative to nonusers during this limited pilot study was not statistically significant. However, uptake and application of lessons learned from SMS may be delayed. Further research is needed to address how to increase engagement through SMS and to investigate if follow up over a longer period of time demonstrates significant change in outcomes like HbA1c. Clinical Trial: none