Associations Between Psychosocial Needs, Carbohydrate-Counting Behavior, and App Satisfaction: A Randomized Crossover App Trial on 92 Adults With Diabetes.

To examine whether psychosocial needs in diabetes care are associated with carbohydrate counting and if carbohydrate counting is associated with satisfaction with diabetes applications' usability, a randomized crossover trial of 92 adults with type 1 or 2 diabetes requiring insulin therapy tested two top-rated diabetes applications, mySugr and OnTrack Diabetes. Survey responses on demographics, psychosocial needs (perceived competence, autonomy, and connectivity), carbohydrate-counting frequency, and application satisfaction were modeled using mixed-effect linear regressions to test associations. Participants ranged between 19 and 74 years old (mean, 54 years) and predominantly had type 2 diabetes (70%). Among the three tested domains of psychosocial needs, only competence-not autonomy or connectivity-was found to be associated with carbohydrate-counting frequency. No association between carbohydrate-counting behavior and application satisfaction was found. In conclusion, perceived competence in diabetes care is an important factor in carbohydrate counting; clinicians may improve adherence to carbohydrate counting with strategies designed to improve perceived competence. Carbohydrate-counting behavior is complex; its impact on patient satisfaction of diabetes application usability is multifactorial and warrants consideration of patient demographics such as sex as well as application features for automated carbohydrate counting.

Successful Change Management Strategies for Improving Diabetes Care Delivery Among High-Performing Practices.

PURPOSE: To learn how the highest-performing primary care practices manage change when implementing improvements to diabetes care delivery. METHODS: We ranked a total of 330 primary care practices submitting practice management assessments and diabetes reports to the Understanding Infrastructure Transformation Effects on Diabetes study in 2017 and 2019 by Optimal Diabetes Care performance. We ranked practices from the top quartile by greatest annual improvement to capture dynamic change. Starting with the top performers, we interviewed practice leaders to identify their most effective strategies for managing change. Interview transcripts were qualitatively analyzed to identify change management strategies. Saturation occurred when no new strategies were identified over 2 consecutive interviews. RESULTS: Ten of the top 13 practices agreed to interviews. We identified 199 key comments representing 48 key care management concepts. We also categorized concepts into 6 care management themes and 37 strategic approaches. We categorized strategic approaches into 13 distinct change management strategies. The most common strategies identified were (1) standardizing the care process, (2) performance awareness, (3) enhancing care teams, (4) health care organization participation, (5) improving reporting systems, (6) engaging staff and clinicians, (7) accountability for tasks, (8) engaging leadership, and (9) tracking change. Care management themes identified by most practices included proactive care, improving patient relationships, and previsit planning. CONCLUSIONS: Top-performing primary care practices identify a similar group of strategies as important for managing change during quality improvement activities. Practices involved in diabetes improvement activities, and perhaps other chronic conditions, should consider adopting these change management strategies.

App Design Features Important for Diabetes Self-management as Determined by the Self-Determination Theory on Motivation: Content Analysis of Survey Responses From Adults Requiring Insulin Therapy.

BACKGROUND: Using a diabetes app can improve glycemic control; however, the use of diabetes apps is low, possibly due to design issues that affect patient motivation. OBJECTIVE: This study aimed to describes how adults with diabetes requiring insulin perceive diabetes apps based on 3 key psychological needs (competence, autonomy, and connectivity) described by the Self-Determination Theory (SDT) on motivation. METHODS: This was a qualitative analysis of data collected during a crossover randomized laboratory trial (N=92) testing 2 diabetes apps. Data sources included (1) observations during app testing and (2) survey responses on desired app features. Guided by the SDT, coding categories included app functions that could address psychological needs for motivation in self-management: competence, autonomy, and connectivity. RESULTS: Patients described design features that addressed needs for competence, autonomy, and connectivity. To promote competence, electronic data recording and analysis should help patients track and understand blood glucose (BG) results necessary for planning behavior changes. To promote autonomy, BG trend analysis should empower patients to set safe and practical personalized behavioral goals based on time and the day of the week. To promote connectivity, app email or messaging function could share data reports and communicate with others on self-management advice. Additional themes that emerged are the top general app designs to promote positive user experience: patient-friendly; automatic features of data upload; voice recognition to eliminate typing data; alert or reminder on self-management activities; and app interactivity of a sound, message, or emoji change in response to keeping or not keeping BG in the target range. CONCLUSIONS: The application of the SDT was useful in identifying motivational app designs that address the psychological needs of competence, autonomy, and connectivity. User-centered design concepts, such as being patient-friendly, differ from the SDT because patients need a positive user experience (ie, a technology need). Patients want engaging diabetes apps that go beyond data input and output. Apps should be easy to use, provide personalized analysis reports, be interactive to affirm positive behaviors, facilitate data sharing, and support patient-clinician communication.

Health information technology to improve care for people with multiple chronic conditions.

OBJECTIVE: To review evidence regarding the use of Health Information Technology (health IT) interventions aimed at improving care for people living with multiple chronic conditions (PLWMCC) in order to identify critical knowledge gaps. DATA SOURCES: We searched MEDLINE, CINAHL, PsycINFO, EMBASE, Compendex, and IEEE Xplore databases for studies published in English between 2010 and 2020. STUDY DESIGN: We identified studies of health IT interventions for PLWMCC across three domains as follows: self-management support, care coordination, and algorithms to support clinical decision making. DATA COLLECTION/EXTRACTION METHODS: Structured search queries were created and validated. Abstracts were reviewed iteratively to refine inclusion and exclusion criteria. The search was supplemented by manually searching the bibliographic sections of the included studies. The search included a forward citation search of studies nested within a clinical trial to identify the clinical trial protocol and published clinical trial results. Data were extracted independently by two reviewers. PRINCIPAL FINDINGS: The search yielded 1907 articles; 44 were included. Nine randomized controlled trials (RCTs) and 35 other studies including quasi-experimental, usability, feasibility, qualitative studies, or development/validation studies of analytic models were included. Five RCTs had positive results, and the remaining four RCTs showed that the interventions had no effect. The studies address individual patient engagement and assess patient-centered outcomes such as quality of life. Few RCTs assess outcomes such as disability and none assess mortality. CONCLUSIONS: Despite a growing body of literature on health IT interventions or multicomponent interventions including a health IT component for chronic disease management, current evidence for applying health IT solutions to improve care for PLWMCC is limited. The body of literature included in this review provides critical information on the state of the science as well as the many gaps that need to be filled for digital health to fulfill its promise in supporting care delivery that meets the needs of PLWMCC.

Content Analysis: First-Time Patient User Challenges with Top-Rated Commercial Diabetes Apps.

Background/Introduction: Using a mobile application (app) may improve diabetes self-management. However, the use of diabetes apps is low, possibly due to design and usability issues. The purpose of this study was to identify barriers to app use among adult patients with diabetes who were testing diabetes apps for the first time. Materials and Methods: We conducted a content analysis of observation notes and patient comments collected during the testing of two top commercially available diabetes apps as part of a crossover randomized trial. Participants were adult patients with type 1 or type 2 diabetes on insulin therapy. We analyzed field notes and transcriptions of audio recordings. Open coding derived categories of usability issues, which then were grouped into themes and subthemes on usability problem types. Results: A total of 92 adult Android smartphone users were recruited online (e.g., Facebook) and in-person postings. Three major themes described problems with data input, app report display and presentation, and self-learning options. Data entry modes were problematic because of overcrowded app screens, complicated "save data" steps, and a lack of data entry confirmation. The app icons, wording, entry headings, and analysis reports were not intuitive to understand. Participants wanted self-learning options (e.g., pop-up messages) during app use. Conclusions: Patient testing of top commercially available diabetes apps revealed key usability design issues in data entry, app report, and self-help learning options. Good app training for patients is necessary for both initial use and long-term use of diabetes apps to support self-management.

Usability Evaluation of Four Top-Rated Commercially Available Diabetes Apps for Adults With Type 2 Diabetes.

Despite the many diabetes applications available, the rate of use is low, which may be associated with design issues. This study examined app usability compliance with heuristic design principles, guided by the Self-determination Theory on motivation. Four top-rated commercially available apps (Glucose Buddy, MyNetDiary, mySugr, and OnTrack) were tested for data recording, blood glucose analysis, and data sharing important for diabetes competence, autonomy, and connection with a healthcare provider. Four clinicians rated each app's compliance with Nielsen's 10 principles and its usability using the System Usability Scale. All four apps lacked one task function related to diabetes care competence or autonomy. Experts ranked app usability rated with the System Usability Scale: OnTrack (61) and Glucose Buddy (60) as a "D" and MyNetDairy (41) and mySugr (15) as an "F." A total of 314 heuristic violations were identified. The heuristic principle violated most frequently was "Help and Documentation" (n = 50), followed by "Error Prevention" (n = 45) and "Aesthetic and Minimalist Design" (n = 43). Four top-rated diabetes apps have "marginally acceptable" to "completely unacceptable." Future diabetes app design should target patient motivation and incorporate key heuristic design principles by providing tutorials with a help function, eliminating error-prone operations, and providing enhanced graphical or screen views.