Review
A systematic review of IT for diabetes self-management: Are we there yet?

https://doi.org/10.1016/j.ijmedinf.2013.05.006Get rights and content

Highlights

  • Confirms the potential for IT to improve the self-management of diabetes.

  • Identifies research gaps to be addressed for wide-scale adoption IT interventions.

  • Gaps include ease of use, timely feedback, integration with EMR, and fit.

  • Highlights the need to apply user-centered and socio-technical design principles.

Abstract

Background

Recent advances in information technology (IT) coupled with the increased ubiquitous nature of information technology (IT) present unique opportunities for improving diabetes self-management. The objective of this paper is to determine, in a systematic review, how IT has been used to improve self-management for adults with Type 1 and Type 2 diabetes.

Methods

The review covers articles extracted from relevant databases using search terms related information technology and diabetes self-management published after 1970 until August 2012. Additional articles were extracted using the citation map in Web of Science. Articles representing original research describing the use of IT as an enabler for self-management tasks performed by the patient are included in the final analysis.

Results

Overall, 74% of studies showed some form of added benefit, 13% articles showed no-significant value provided by IT, and 13% of articles did not clearly define the added benefit due to IT. Information technologies used included the Internet (47%), cellular phones (32%), telemedicine (12%), and decision support techniques (9%). Limitations and research gaps identified include usability, real-time feedback, integration with provider electronic medical record (EMR), as well as analytics and decision support capabilities.

Conclusion

There is a distinct need for more comprehensive interventions, in which several technologies are integrated in order to be able to manage chronic conditions such as diabetes. Such IT interventions should be theoretically founded and should rely on principles of user-centered and socio-technical design in its planning, design and implementation. Moreover, the effectiveness of self-management systems should be assessed along multiple dimensions: motivation for self-management, long-term adherence, cost, adoption, satisfaction and outcomes as a final result.

Introduction

According to the National Diabetes Information Clearinghouse [1], in 2005–2008, 79 million Americans of US population aged 20 years or older (35% of population aged 20 years or older) had pre-diabetes. Diabetes affected 25.8 million (8.3% of population) in the US alone with direct and indirect medical cost amounting to 116 and 58 billion dollars in 2007, respectively [1]. Medical expenses for people with diabetes are twice as high as the medical expenses for people without diabetes [1]. Those numbers are growing at an ever-increasing rate. Consequences for the mismanagement of diabetes include kidney failure, non-traumatic lower limb amputations, and cases of blindness. Diabetes was found to be the seventh leading cause of mortality in United States [1].

Researchers and practitioners are challenged to find efficient and effective solutions to improve diabetes management. Self-management focuses on patients’ behavior with respect to their care for their chronic condition. Related terms include Patient Empowerment and Patient Self-Care. McGowan [2] provides a background of various definitions of self-management as well as related terms and misconceptions. Self-management often includes preparing people to manage their health behaviors on day-to-day basis, participating in treatment or education designed to attain specific results, practicing tasks and developing attitudes that reduce the emotional or physical impact of illness, with or without assistance from clinicians [2]. For the purpose of this systematic review, the authors will follow the definition provided by Adams, Greiner [3]. According to this definition, “Self-management relates to the tasks that an individual must undertake to live well with one or more chronic conditions. These tasks include gaining confidence to deal with medical management, role management, and emotional management.” A key characteristic of this definition is the depiction of self-management as a set of behaviors by the patient, i.e., the patient is the primary actor (as opposed to the provider). With respect to diabetes, self-management includes self-monitoring of blood glucose, physical activity or exercise, nutrition, and medication [4], [5]. In addition to these basic tasks, recent advances reflected in clinical guidelines recommend other self-management related activities including self-management education and personalized feedback, weight management, communication and patient monitoring by clinicians, other therapeutics (foot, eye care), immunization, and complication management [6], [7], [8], [9].

Attempts to leverage IT in diabetes self-management dates back to the late seventies and have shown promising outcomes [10]. An area that has received considerable attention is the use of IT interventions such as, Internet, computer, electronic equipment, smart phones and health analytics in self-monitoring of the daily physiological behaviors. As a result, a large number of studies have reported different attempts to leverage various kinds of IT in diabetes self-management. Recent reviews have evaluated the potential benefit of technologies in diabetes management [11], and how different technologies have been used to enhance the care of patients with diabetes [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]. Conclusions drawn from these studies are important and provide several implications. Yet, they tend to focus on a specific technology, they do not necessarily adhere to a clear definition of self-management where the patient is the primary actor, and they tend to focus on blood glucose monitoring as opposed to a holistic view of diabetes self-management. The objective of the paper is to determine, in a systematic review, how information technology (IT) has been used to enhance self-management for adults with Type 1 and 2 diabetes. The paper identifies key information technologies that are used (or proposed) for the self-management of diabetes, highlights reported clinical outcomes, and identifies challenges and research directions for leveraging IT for diabetes self-management.

Section snippets

Data source

The articles were identified by conducting a search in PubMed, Web of Science, IEEE, ABI/INFORM, and ACM using keywords: (Diabetes OR insulin OR Blood glucose OR Blood Sugar) AND (Information System OR Information Technology OR Internet OR Web OR Online OR Telemedicine OR Data Mining OR Analytics OR Mobile OR Smartphone OR PDA OR Phone) covering a period from 1970 to August 2012. In order to extract relevant articles, keywords were searched within each document's title and keyword list.

Result

Overall, 1096 articles from the five databases matched the initial search criteria. Removing duplicate studies resulted in 756 studies. In the first phase, an abstract and title review of these articles resulted in identifying 196 research articles pertaining to self-management.

In the second phase, a full text review was performed for those articles. The full text review resulted in the selection of 104 articles for our review procedure. The articles evaluation procedure was grounded on the

Discussion and implications

Overall, our findings indicate that technologies can assist diabetes self-monitoring and care [43], [49], [57], [69], [70]. However, while there is a great promise for IT interventions to improve the self-management of diabetes, there are significant issues that need to be addressed if such interventions are to realize their full potential. The issues revolve around benefits, e.g., a large number of studies did not achieve desired glucose management levels [26], [34], [50], adoption, and

Conclusion

The outcomes of this review supplement the emerging body of evidence that IT can have positive impacts on self-management of chronic illness. Apart from the positive side, our review analyzes studies that did not produce significant improvement in self-care. Overall, there is a distinct need for a more comprehensive framework, in which several technologies are integrated in order to produce complex management [21] and, in which principles of user-centered and socio-technical design are built

Authors’ contributions

All authors have contributed to conceptualizing the study, analyzing and interpreting findings, drafting and revising the article for important intellectual content, and final approval of the submitted version.

Conflict of interest

The authors do not have any conflict of interest to acknowledge or disclose.

Summary points

What was already known?

  • Diabetes management requires continuing medical care and ongoing self-management education & support.

  • IT interventions for diabetes self-management have received considerable attention.

  • IT interventions have shown promise for improving self-management of diabetes.

What this study adds in knowledge base?

  • Confirms earlier findings regarding the potential for IT to improve the

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