The Evidence for Diabetes Technology

I think everyone can agree that Type 2 diabetes is a big problem, both in the US and worldwide. It’s big from a social standpoint. It’s big from a financial standpoint. That means it has a tremendous potential for financial and social ROI if effectively targeted.

I can’t even remember when it was that I first wrote about diabetes and lifestyle decisions in health and how technology has such an incredible potential in this area. I may have lumped diabetes in with metabolic syndrome in this post from 2011; it’s fun to go back and skim some of these old posts to see how the industry and my own perspective have changed over time.

I’ve also written countless times about how hard it is to target Type 2 diabetics as a patient population. Most recently I’ve written about Omada Health, which as a mission seems to be targeting pre-disease patients, starting with pre-diabetes.

With that background, I thought it was interesting to see this recent Cochrane Review article about the effectiveness of HIT-enabled interventions on diabetes self management. Cochrane Reviews are fantastic because they filter and sum up evidence for specific topic areas. In the review linked above, the authors reviewed studies on the effectiveness of technological interventions for diabetes.

The review, which ultimately combined results from 16 studies and more than 3,500 patients, found that HIT-enabled interventions were only marginally beneficial to patients with type 2 diabetes, and only when it came to glucose control. There was no evidence that the tech-driven interventions helped with weight or other health-related issues.

I’ll pause for the collective "damn it!" It does suck. It really does, mostly because it would have been great if the review had found that tech-based interventions were overwhelmingly cost effective, clinically efficacious, and loved by both patients and providers. If those were the findings, then we would have seen 20 more health startups peddling diabetes self-management platforms, but more importantly, we would have seen more providers and payers get interested these types of offerings.

The silver lining in the findings is that the review found mobile interventions to be more effective than web-based interventions. Web and mobile are converging and in time will be one. But in the mean time, mobile has to be a key component of any self-management platform, period. Self-management is about ongoing, always-on, closed feedback loop, in-your-pocket support, and mobile is essential for those.

Here’s my overall impression of this review. We don’t have great evidence from randomized controlled trials (RCTs) that technology-enabled self management is hugely effective for diabetes, but, that’s because we’re still so early in the market and product stage where things are evolving extremely rapidly. Technologies and products available today were not even possible a few years ago, so we’re still light on the data.

It shows that a one size approach doesn’t work. Charlene Quinn, whose research was part of what the Cochrane team reviewed, said, "In our studies, we learned people needed an individualized approach to manage their diabetes, feedback and communication with a trusted source (health provider, diabetes educator, trained lay person or peer)." I had the pleasure of meeting Charlene last year at an event and I would trust her judgment.

This post isn’t all about diabetes. It’s about evidence and research for new technologies and new forms of care delivery. Evidence is king in medicine these days, with good reason. When I was a med student, I had to do countless EBM (evidence-based medicine) projects and write-ups on patients. We would even get chastised by more intense attendings and chiefs for quoting things like Cochrane Reviews or UpToDate articles instead of reading and citing the primary source. The need for evidence in support of medical decisions runs deep.

But evidence shouldn’t hold back health technology integration into medicine, and the Cochrane diabetes review, while informative, shouldn’t be too discouraging. I’m not saying we ignore it — it’s helpful from an informational and educational perspective. Quite the opposite. I think we use it to dig deeper into not just the results, but the reasons behind the results. We then tailor and test new tech-based interventions. In this new testing, will the app owners and champions please collect data, even if it’s not part of a RCT?

The main thing that keeps me optimistic in spite of these findings is the clear evidence that we need changes in the way we deliver care and interact with patients. The evidence clearly shows that our current systems (both health and social) don’t work when it comes to preventing or effectively managing diabetes. If evidence is king, we should be running from what we do now in search of a better alternative.

Apps and technology are not a panacea. But in time, we will have evidence that shows that intelligent tech-enabled or tech-augmented interventions are cost effective, clinically efficacious, and loved by both patients and providers.

Travis Good is an MD/MBA involved with health IT startups. More about me.

  • lesterd1955

    Travis, you make some very valid points here. I am often suspicious of these types of analyses. The reality is that these technologies are enablers. They on their own will not provide the solution, they are part of a solution, and solutions as we all know for diabetes are very complex. We must manage our expectations.

  • Travis Good

    Very true. You’re right. I think the lessons we really need to learn are how to use these technologies as extensions, not one-off or tech-only solutions.

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