Digital Diabetes Teaching Techniques: Too Costly or Worthwhile?

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Dr. Anne L. Peters

Digital coaching systems for type 2 diabetes “reduce the need for expensive personal visits,” said Anne L. Peters, MD, arguing for the pro-side during a debate at the recent 81st virtual scientific sessions of the American Diabetes Association ( ADA). whether such coaching systems are worth the cost.

They provide another way for patients to deal with chronic health problems like diabetes, high blood pressure, weight management, and mental health, among other things, she said, adding, “My only caveat is that it only works when people are using it.”

Given the prevalence of these systems over the past 5 years, the topic is topical.

But Kasia J. Lipska, MD argues for the cons and wonders if such systems are a good investment. While digital coaching has potential, we don’t yet have solid evidence that it is effective, she added.

“Many patients still do not have access to the health care and drugs (including insulin) necessary to sustain life, so digital technology is the right application for us [limited] Resources? ”Wondered Lipska, associate professor of medicine at the Yale School of Medicine, New Haven, Connecticut.

“Marketing is way ahead of science. Let’s get better evidence before we start cashing our patients’ checks.”

What is a digital coaching system for type 2 diabetes?

Following the debate, Medscape Medical News invited speakers to delve deeper into the subject.

A digital coaching system “includes a smartphone / computer / tablet that connects a patient to a program that includes glucose monitoring, counseling [from a health coach] about dealing with diabetes, weight, blood pressure, and even mental health, “said Peters, professor of clinical medicine at the University of Southern California’s Keck School of Medicine, noting that patients generally pay a monthly fee.

“We talked about commercial systems that support patients with their diabetes caregiver between clinic visits,” explained Lipska.

The systems can consist of a blood glucose meter that triggers algorithmic responses based on blood glucose readings in the form of text messages, or a “real” (human) coach can connect with a patient via text or video.

Diabetes coaching systems reduce costs

Most diabetes coaching programs started out as diabetes prevention programs, Peters said.

According to a report by Close Concerns released in January 2021, Noom has the largest membership (more than 50 million members), but this is also a weight management program, Peters pointed out.

The next 10 largest programs specifically aimed at managing diabetes or prediabetes are One Drop, mySugr, Lark Health, Livongo (now Teladoc), Omada Health, Cecelia Health, Canary Health, Dario Health, Onduo, and Virta Health.

According to Peters, the programs are generally “more similar than dissimilar”.

Treatment for diabetes is expensive, especially when patients develop complications. Therefore, employers and other insurance groups are looking for ways to cut costs.

A recent study reported cost savings and reduced health care from employees in Michigan using a digital diabetes prevention program (J Health Econ Outcomes Res. 2020; 7: 139-147).

Compared to last year, healthcare spending decreased by more than $ 1,000 per person in the first year the program was used, mainly due to fewer hospital admissions and shorter stays.

In another study, 10,000 employees with diabetes were invited to take part in a Livongo diabetes coaching program, the costs of which are covered by the employer (J Med Econ. 2019; 22: 869-868). About 2,000 people joined and 8,000 did not. Use of the program was associated with a 22% lower rate of medical expenditure (P <0.01).

Another study evaluated the self-management program Better Choices, Better Health Diabetes (BCBHD) in 558 patients compared to control persons (J Med Internet Res. 2018; 20: e207). Emergency admissions and outpatient visits decreased among program users, with direct and indirect cost savings of $ 815 / year and $ 1,504 / year, respectively.

Other researchers evaluated a digital program for gestational diabetes in 161 women. The women randomized to the digital program had 56% fewer doctor visits and 16% lower direct costs, but there were no differences between the groups for A1c or maternal or child outcomes (Diabetes Technol Ther. 2020; 22: 195 -202.). ).

And another study of a user utility score, which measures patient engagement with a diabetes coaching system over 12 months, found that higher scores (more interaction) were associated with lower A1c scores (JMIR Mhealth Uhealth 2021 ; 9: e17573).

It is important to note that patients must have intact cognitive skills, digital access and the ability to use email, as well as insurance coverage or the ability to pay for themselves, stressed Peters, which excludes certain patients.

But “if someone is interested and connected to this digital world” [and is insured or can cover the cost], that can help. These programs can help reduce costs; they can help improve the quality. “

Diabetes coaching systems do not cut costs

Lipska determined that the digital diabetes care market will be valued at $ 742 million in 2022, according to a report (Research2Guidance report).

Some companies sell memberships to a digital diabetes coaching system to consumers (like Noom for $ 59 / month and mySugr for $ 49 / month) while others like Lark Health, Livongo (now part of Teladoc), Omada Health, and Onduo have theirs Companies, health insurance companies or employers sell services to insurance companies. Some companies do both.

“I will disappoint you,” said Lipska, “because there is not much evidence that these coaching systems work. Longer-term evidence of clinical effectiveness is really lacking.”

A one-arm study without a control group evaluated digital diabetes prevention coaching from Omada Health (J Aging Health. 2018; 30: 692-710). Of the 9,498 patients who were invited, 796 (8%) responded and 501 were enrolled. At 12 months they had a 7.5% weight loss, a 0.14% decrease in A1c (available for only 14% of participants), and a decrease in total cholesterol (only available for 27%), but this study had inherent weaknesses .

In a stronger study, unpublished results from the PREDICTS study presented at Obesity Week 2020 showed that out of 599 people who were placed in a control group or received digital diabetes prevention coaching from Omada Health for 12 months, A1c in those who received coaching decreased more. but the difference was less than 1% (Omada Health press release).

And in a study from New Zealand, 429 adults were randomly assigned to a control group or the BetaMe / Melon mobile device and the web-based program of health coaching for 12 months. The study was well done and published, but the intervention didn’t work (Diabetologia. 2020; 63: 2559-2570), Lipska said.

“I’m a little skeptical that digital coaching can replace this human personal relationship,” she said, emphasizing, “What is really needed is this patient-clinician feedback, based on a robust relationship that we build over time.”

And patients can feel a little overwhelmed with all of the feedback from digital systems, she said. “I get free strips, I just ignore all calls,” one of her patients told her.

“What really bothers me about these digital coaching systems,” added Lipska, “is that they are really not tailored to the health team. They usually work outside of the healthcare system. I have no control over what kind of feedback my patient receives, what goals are set for him. “

This can lead to incoherent and confusing care in some patients.

However, Lipska agreed with Peters that digital coaching systems are best suited for patients who have the skills necessary to use the technology, familiarize themselves with comprehensive behavior monitoring, and have insurance or can pay for these programs themselves.

The debaters’ rebuttals

“The topic of the debate was cost, not effectiveness,” said Peters. “These programs are unlikely to be used to conduct high quality randomized controlled trials, and the end result is to demonstrate non-inferiority to ‘personal’ programs.”

Digital coaching systems can be cost effective because they don’t require a physical office building for staff and patients, she pointed out. “If they are useful to some, but not all, patients, I think that is a good thing, as many patients are not getting the care they currently need and participating in a digital health program could bridge the gap.”

“There is no one-size-fits-all solution to diabetes management,” concluded Peters, “but if we work to develop multiple high-quality approaches to treatment it will be a win-win for both patients and the healthcare system.”

On the other hand, Lipska said: “I agree with many points made by Dr. Peters. And of course I am not philosophically against digital coaching systems. However, we still differ on some points.”

The question is whether digital coaching systems are worth the cost. To answer this question, we have to ask ourselves whether they work – that is, whether they improve results, Lipska emphasized.

“Once we have a solid foundation with this and know how big the benefits are (if they actually exist) and who they are working for, we can see if they are associated with cost savings.”

“I’m still not convinced we have enough data to say it works. The studies are small, often uncontrolled, often not randomized and are therefore subject to selection bias. The few studies that were randomized and controlled showed no benefit or were of a tiny order of magnitude, “she affirmed.

“I saw nothing in Dr. Peters’ presentation that changed my position on the state of the evidence,” Lipska concluded.

Peters has reported serving on advisory boards for Abbott, Eli Lilly, Medscape, Novo Nordisk, Vertex and Zealand; Received research grants from Dexcom and Insulet and devices from Abbott; and receiving stock options from Omada and Teladoc (formerly Livongo). Lipska has not reported any relevant financial relationships.

Scientific meetings of the ADA 2021. Presented on June 26th, 2021.

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