Mobile App for Improved Self-Management of Type 2 Diabetes: Multicenter Pragmatic Randomized Controlled Trial

Abstract

Background: As the increasing prevalence of type 2 diabetes mellitus has put pressure on health systems to appropriately manage these patients, there have been a growing number of mobile apps designed to improve the self-management of diabetes. One such app, BlueStar, has been shown to significantly reduce hemoglobin A_1c (HbA_1c) levels in small studies and is the first app in the United States to receive Food and Drug Administration approval as a mobile prescription therapy. However, the impact of the app across real-world population among different clinical sites and health systems remains unclear.

Objective: The primary objective of this study was to conduct a pragmatic randomized controlled trial of the BlueStar mobile app to determine if app usage leads to improved HbA_1c levels among diverse participants in real-life clinical contexts. We hypothesized that this mobile app would improve self-management and HbA_1c levels compared with controls.

Methods: The study consisted of a multicenter pragmatic randomized controlled trial. Overall, 110 participants randomized to the immediate treatment group (ITG) received the intervention for 6 months, and 113 participants randomized to the wait-list control (WLC) group received usual care for the first 3 months and then received the intervention for 3 months. The primary outcome was glucose control measured by HbA_1c levels at 3 months. Secondary outcomes assessed intervention impact on patient self-management, experience of care, and self-reported health utilization using validated scales, including the Problem Areas in Diabetes, the Summary of Diabetes Self-Care Activities, and the EuroQol-5D. Intervention usage data were collected directly from the app.

Results: The results of an analysis of covariance controlling for baseline HbA_1c levels did not show evidence of intervention impact on HbA_1c levels at 3 months (mean difference [ITG-WLC] -0.42, 95% CI -1.05 to 0.21; P=.19). Similarly, there was no intervention effect on secondary outcomes measuring diabetes self-efficacy, quality of life, and health care utilization behaviors. An exploratory analysis of 57 ITG participants investigating the impact of app usage on HbA_1c levels showed that each additional day of app use corresponded with a 0.016-point decrease in participants' 3-month HbA_1c levels (95% CI -0.03 to -0.003). App usage varied significantly by site, as participants from 1 site logged in to the app a median of 36 days over 14 weeks (interquartile range [IQR] 10.5-124); those at another site used the app significantly less (median 9; IQR 6-51).

Conclusions: The results showed no difference between intervention and control arms for the primary clinical outcome of glycemic control measured by HbA_1c levels. Although there was low usage of the app among participants, results indicate contextual factors, particularly site, had a significant impact on overall usage. Future research into the patient and site-specific factors that increase app utilization are needed.

Trial registration: Clinicaltrials.gov NCT02813343; https://clinicaltrials.gov/ct2/show/NCT02813343 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT02813343).

Keywords: blood glucose self-monitoring; diabetes mellitus, type 2; mobile apps; pragmatic clinical trial; randomized controlled trial; self-management.

Figure 1

Flowchart of enrollment. HbA_1c: hemoglobin A_1c.

Figure 2

Mean HbA_1c (hemoglobin A_1c) values for intervention and control groups from baseline to 6 months.

Figure 3

Mean number of observations recorded by feature and site for immediate treatment group (ITG) participants over 14 weeks.