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Evidence-Based Diabetes Management September 2018

From High Tech to Low, Livongo Meets People With Diabetes at Decision Points

Mary Caffrey
Livongo’s technology is built around the idea that a person living with diabetes must make multiple decisions every day, and the cumulative effect of all those decisions drives outcomes.
For people living with diabetes, having an insurance company dictate your supply of blood glucose test strips doesn’t make sense. Some days you’re sick. Some days you’re exercising a lot. If you’re taking a new medication, an extra test for a few days is wise. When keeping blood glucose in range is the goal, fighting for extra test strips is more than a headache—it can be a roadblock to optimal health.

Enter Livongo, a diabetes management system that features a “smart” blood glucose meter plus diabetes coaching from a Certified Diabetes Educator (CDE). The platform records data in the cloud and shares the information with family members and the health system—but only if the user approves. “That’s a very individual choice,” said Jennifer Schneider, MD, MS, chief medical officer at Livongo. The company has also entered into a partnership with Glytec, a leader in automated insulin titration that the companies say will help “connect more dots” for more patients.1 All of this drives a system that will offer Livongo users better tips, insights, and guidance from their CDEs, driven by choices the person with diabetes makes.

But for all the advances in technology, leaders at Livongo say one of its most popular features is a low-tech one: an option to let people order test strips when they need them, with the click of a button and without phone calls and battles with the insurance company.

“We’re really taking the market by storm,” said Schneider in an interview with Evidence-Based Diabetes Management™. “Our design shows why healthcare hasn’t been beneficial to people with chronic conditions.”

Livongo’s technology is built around the idea that a person living with diabetes must make multiple decisions every day, and the cumulative effect of all those decisions drives outcomes. So, the Livongo system tries to be there for the person at the decision point—to nudge the person if blood glucose strays out of range, to order test strips before they run out, and to connect the person to a coach who can offer encouragement and advice, especially to those who feel burned out from managing their disease.

As Schneider pointed out, however, good disease management means the system must allow each person to adapt it to individual needs. “We should not call during dinner,” she said. People who use Livongo can tailor the alerts based on when they want to be contacted, as highlighted in a review by Healthline’s Mike Hoskins, a longtime journalist with type 1 diabetes, who wrote that getting the level of coaching just right took some adjusting. Still, Hoskins wrote, he’d recommend the system for those who want a “bright, clear interactive meter” and more active coaching.2

As Schneider said, “All people are motivated differently. Some people really love that we give them unlimited blood glucose strips, or [because] they have diabetes that requires very frequent monitoring.” A person with newly diagnosed diabetes or someone with less experience managing a new medication would benefit from input from a CDE, for example.

Jenna Bollyky, MD, vice president of clinical research and analytics at Livongo, likened the relationship as less “Big Brother” and more “Big Sister,” one that holds the person accountable and offers feedback in an individualized way. People with diabetes do not get Livongo directly; it’s obtained through health systems, health plans, and employers. These are partners who have an interest in seeing those with diabetes manage their disease and not end up in the hospital, and Livongo has provided evidence that its system has created cost savings—an average of $83 per member per month for large self-insured employers.3

At the most recent American Diabetes Association Scientific Sessions in Orlando, Florida, Bollyky presented data that compared medical spending and clinical outcomes for 2027 Livongo users with a matched set of nonusers (n = 8385) for 12 months. The study found that a 10% increase in the monthly Livongo usage rate was associated with a 2.1% decrease in medical spending (P <.01), which was driven by a 2.9% reduction in spending on office-based services.4

It’s not a surprise, then, that Humana and an investment group created by several Blue Cross Blue Shield health plans are among Livongo’s financial backers, Schneider said. However, she and Bollyky see employers as the real forces driving change. A paper published this spring in the Journal of Diabetes Research addressed a problem often seen with employer-based interventions: engagement starts off strong, but then tapers off. Researchers showed that Livongo users with T2D who had hit a plateau could benefit from short, intensive periods of coaching.5

Researchers randomized study participants into 3 intervention groups: Livongo users who were given a connected scale, Livongo users who received a scale and light coaching, and Livongo users who received the scale and intensive coaching. A control group was also followed. Results showed that users with the highest glycated hemoglobin (A1C) levels at the start of the intervention saw the most improvement. Using calculations based on the costs of coaching and the number of texts sent to each group, the authors calculated 12-week costs for each group:

• $92 for the scale-only group, which translated into $84 per pound lost, or $230 per 1% decrease in A1C
• $120 for the scale plus lightweight coaching, which translated into $29 per pound lost, or $300 per 1% decrease in A1C
• $240 for the scale plus intensive coaching, which translated into $38 per pound lost, or $329 per 1% decrease in A1C.

“Though the overall intervention effect size was greatest in the intensive coaching arm, lightweight coaching was more cost-effective for weight loss and change in mean [blood glucose],” they wrote. Based on existing studies, the cost savings attributable to A1C reduction ranged from $113 to $179 per month. The authors, led by Bollyky, concluded, “lifestyle coaching may be a cost-effective adjunctive therapy for reaching target glucose control for selected participants.”
References

1. Livongo partnership with Glytec supports members and providers with insulin titration [news release]. Mountainview, CA: Glytec; April 18, 2017. glytecsystems.com/News/livongo-partnership-with-glytec-supports-members-and-their-providers-with-insulin-titration.html. Accessed August 13, 2018.

2. Hoskins M. Livongo coaching product review. DiabetesMine website. healthline.com/diabetesmine/livongo-coaching-product-review. Published January 12, 2017. Accessed August 13, 2018.

3. Livongo demonstrates cost savings for self-insured employers [news release]. Mountainview, CA: Livongo Health; June 22, 2017. prnewswire.com/news-releases/livongo-demonstrates-cost-savings-for-self-insured-employers-300478005.html. Accessed August 13, 2018.

4. Bollyky J, Lu W, Schneider J, Whaley C. Cost savings associated with usage and blood glucose control for members of the Livongo for diabetes program. Presented at: 78th American Diabetes Association Scientific Sessions; June 22-26, 2018; Orlando, FL. Abstract 1330-P.

5. Bollyky J, Bravata D, Yang J, Williamson, Schneider J. Remote lifestyle coaching plus a connected glucose meter with certified diabetes educator support improves glucose and weight loss for people with diabetes [published May 16, 2018]. J Diabetes Res. doi.org/10.1155/2018/3961730.
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