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App, doctor pep talks lower diabetes patients' blood sugar

By Ronnie Cohen

NEW YORK (Reuters Health) - Dr. Guillaume Charpentier believes a smartphone app he is testing on people with diabetes in France works best when it alerts doctors that frustrated patients need help managing their disease.

The Diabeo mobile phone program, which recommends insulin dosages, helped people with type 1 diabetes lower their blood-sugar levels in a six-month study. Now a new analysis of the data shows the app markedly improved glucose levels among patients who used it relatively infrequently, raising red flags for their healthcare providers who then intervened.

"What the electronic system is not able to do is the magic of the doctor - to give motivational support to the patient, to encourage the patient to do what the patient does not want to do," Charpentier told Reuters Health.

"This system is a very good tool to improve the contact between the patient and the doctor when the patient really needs the doctor. The system can alarm the doctor at the right time," he said.

Charpentier, from Sud-Francilien Hospital in Corbeil-Essonnes, France, co-authored a recent analysis published in Diabetes & Metabolism reviewing the results of a prior study he led on the Diabeo system, a smartphone coupled to a website.

The first study, completed in 2009, included 180 patients seen at 17 French hospitals with poorly controlled type 1 diabetes.

The app, given to two-thirds of the patients, analyzed self-monitored blood-glucose levels, carbohydrate counts, planned physical activity and other personal variables to calculate recommended insulin doses. Half of the app users regularly discussed their diabetes management on the phone with their doctors, who tracked information from the app online.

Those who used the app had significantly lower glucose levels than those who recorded their blood-glucose levels and other variables on paper, that study found. But the researchers wondered how much the automated advice on the insulin dose contributed to the improvement and how much the telephone consultations contributed.

To answer that question, Charpentier and his team re-examined the results and divided the patients who were given the app into one group that frequently used it and another that infrequently used it. Frequent users consulted the app for insulin doses at 90 percent of their meals, whereas infrequent users consulted it at less than one third of meals.

The app seemed to be most beneficial for infrequent users who had telephone consultations with their doctors, the study found. Low users reduced their glucose levels by more than 1 percent about 42 percent of the time, whereas high users lowered their glucose levels by the same amount only 16 percent of the time.

However, the average drop in blood sugar was not significantly different between high and low users.

Charpentier believes the results highlight the benefits of doctors monitoring glucose levels in their patients with diabetes, particularly for patients struggling to comply with diet and exercise recommendations.

In the current study, doctors reached out to patients in the group with phone consultations whenever the patients seemed to be veering off course, on average every 20 days, he said.

Generally-compliant patients tended to take advantage of the smartphone system to help them monitor their insulin needs, while noncompliant patients often did not. But doctors frequently could talk their patients into compliance when they tracked their progress online, saw they were not using the system and contacted them, Charpentier said.

"It appears that for a number of patients - most likely those who have the greatest difficulty in coping with diabetes and its constraints - the primary benefit of the device was to facilitate interaction with a caregiver. This aspect is essential to ensure that the tool is not viewed by patients as simply a gadget, but as a valid means of providing proper medical support," the authors write.

"What this really speaks to is personalizing medicine," said Dr. Latha Palaniappan, from the Stanford University School of Medicine in California.

"This could help us figure out who's going to need the telephone consultation. It's just better tailoring of therapy for the right patient population," Palaniappan told Reuters Health. She studies diabetes and cardiovascular disease but was not involved in the current study.

Past research has been mixed on the use of telemedicine, or diagnosing and treating patients using telecommunications technology, for diabetes. A review of 16 studies suggested that computer and mobile phone programs that tailor advice and support to people with diabetes may do little to improve their health and quality of life (see Reuters Health story of March 28, 2013 here: http://reut.rs/1d7UHrP).

But Charpentier said he believes the Diabeo system, currently being tested on 700 patients in France, will prove itself so useful that the French National Health Insurance system will pay to give it to all of the country's 200,000 people with type 1 diabetes.

The system is not currently available in the United States, he said.

Palaniappan noted that the Diabeo system cut glucose levels in the current study by more than another common system has done in previous trials.

"This is at least as good as continuous glucose monitoring, which is currently reimbursed by insurance," she said. A continuous glucose monitor helps patients detect when their glucose values are approaching dangerous levels.

People with diabetes frequently feel "depressed, discouraged," Charpentier said. With the app, he said, "You can help your patient at the right time. It is the best way to use the time of the doctor when the patient really needs it."

Telemedicine is improving at a rapid rate, Palaniappan said.

"As our technology is getting better, we're seeing better effects on chronic health conditions," she said. "We can't be stuck in the old conclusions. We have to continuously reevaluate because there's some cool stuff going on with technology now."

Sanofi-Aventis and CERITD, a French nonprofit diabetes research organization, funded the study. Charpentier said neither he nor any of his colleagues on the research team have financial ties to the Diabeo system.

SOURCE: http://bit.ly/1nEFxir Diabetes & Metabolism, February 2014.

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