Glooko, a mobile support platform for diabetes care, helps fill the gaps created by the shortage of endocrinologists. Self-care is key to reducing the number of hypoglycemia incidents.
Healthcare apps are revolutionizing the fundamental principles of health and wellness, for both the provider and the patient. Apps allow continuous care monitoring, which creates a window of opportunity for early, preventive interventions that can significantly impact healthcare utilization. While apps give providers the ability to monitor their patients in near-real time, they can also create incentives for patients to engage in better self-care—for wellness as well as disease management.
This was the premise of “The Digital Path to Improved Patient Engagement in Self-Care,” a talk by Howard Wolpert, MD, director of the Joslin Institute for Technology Translation and associate professor of medicine at Harvard Medical School, on the second day of Patient- Centered Diabetes Care (PCDC) 2015. He spoke about an app he has developed in collaboration with Glooko,a company that provides a unified platform for improved diabetes care using various tools.
NEED TO REPLACE THE ACUTE CARE CLINICAL MODEL
Wolpert explained that the widely practiced therapeutic model of acute care in diabetes warrants transformation. First, it has not been very successful, and second, there are not enough endocrinologists to serve the patient population. The acute care model is very prescriptive, he said, because the patient is given a set of instructions to follow—dietary recommendations, dose adjustment—that do not require any real engagement in self-management. Wolpert thinks the routine office visits with the endocrinologist every 3 to 6 months do not address the needs of a patient with a chronic condition like diabetes, where 24/7 guidance is often needed to keep the hyperglycemia and hypoglycemia under control, and to avoid hospitalization or emergency department (ED) visits that drive up the cost of care.
THE ECONOMICS OF HYPOGLYCEMIA CONTROL
The American Journal of Managed Care
Several publications in recent years have drawn attention to the spiraling cost of hypoglycemia-related episodes of care, many of which are avoidable. Some of these studies, said Wolpert, show that in terms of healthcare costs, hypoglycemia is a much bigger issue than hyperglycemia. One such retrospective study, published in 2011 in , evaluated the incidence rates and costs of hypoglycemia among 536,581 working-age type 2 diabetes mellitus (T2DM) patients. The study found a gender bias, with women being more susceptible than men to hypoglycemic events. Further, hypoglycemia was attributed to 1% of all inpatient costs, 2.7% of all ED costs, and 0.3% of outpatient costs, the mean costs being $17,564 for an in-patient admission, $1387 for an ED visit, and $394 for an outpatient visit.2 A more recent study in among Medicare Advantage enrollees assessed healthcare resource utilization and costs based on claims data of plan members with T2DM. Using a Diabetes Complications Sever- ity Index (DCSI) to analyze healthcare resource utilization, the authors found that a 1-point increase in DCSI was associated with a $2744 increase in total costs. Subgroups with high rates of complications included the elderly, men, and those who suffered from depression and hypoglycemia.3
JAMA Internal Medicine
Wolpert reviewed data from a study published last year in that scanned the Medicare database for hyperglycemia- and hypoglycemia- associated hospitalizations among Medicare beneficiaries between 1999 and 2011 (see ). While a drastic reduction in the number of hospitalizations for hyperglycemia was discovered, the graph shows a steady rate of hypoglycemia-related hospitalizations during the study period. Wolpert pointed to the lack of tools and technologies to monitor this complication of diabetes as a likely reason for this finding. He highlighted a study, presented at the annual meeting of the American Diabetes Association in 2013, which found that the annual cost for severe hypoglycemia-related hospitalizations among T2DM patients (Medicare, Medicaid, and private insurance plans) was $12 billion, and $1 billion for patients with type 1 diabetes mellitus.
Explaining the pathophysiology of hypoglycemia, Wolpert indicated that patients who suffer from severe hypoglycemia develop a condition called “hypoglycemia unawareness,” characterized by cognitive dysfunction. What’s more, he said, hypoglycemia tends to recur in certain individuals, with important implications for population management. “If you look at the data related to hospitalizations for severe hypoglycemia, 75% of those episodes are occurring in 10% of the population; 50% of those episodes are just 5% of the population,” Wolpert said. These “frequent fliers,” he thinks, are repeatedly being admitted with severe hypoglycemia, most likely because the care is being delivered in silos: in the ED or in hospitals, without any follow-up visits in the clinic, which minimizes opportunities for intervention. Wolpert suggested a need to identify these high-risk patients so they can receive the guidance necessary to avoid recurrent episodes.
However, Wolpert said, the primary barrier to early intervention is the lack of adequate data analysis tools. The data collected by current models can account for only a very small portion of a patient’s daily spectrum of events, with no contextual information, he says; and the patient cannot usually provide much context, because he or she is likely to have no recollection of a significant event that may have occurred days or weeks earlier.
TECHNOLOGY TO IMPROVE OUTCOMES
Wolpert went ahead to describe a collaborative project he is working on, with the technology company Glooko, to develop an app that can closely monitor events that lead to these hypoglycemic episodes—and provide a context that would make problems easier to remedy. Glooko, he said, has developed a system to record a patient’s glucose data on their smartphone, which is then relayed to iCloud, creating an opportunity for improved case management.
At Joslin, meanwhile, Wolpert is developing the HypoMap app,which “prompts the patient for contextual information related to hypo events.” The patient is as a result better engaged in self-care because the app forces a thought process around what may have led to the hypoglycemic episode. Wolpert provided examples of patient-recorded data on symptoms that they experienced, such as trembling, sweating, or slurred speech. With a drop in glucose level, the system prompts the patient to record the symptoms and sends a reminder if they fail to do so within a predetermined period of time—the focus here being patient engagement. According to Wolpert, following an episode of hypoglycemia, a patient will usually forget about the event, even that same day, but “[the app] gets the patient engaged in terms of thinking about their numbers and why they’re having glycemic fluctuations. The patient is prompted around what they thought the cause of the event was.” Wolpert expects that the analytics provided by the app can create a profile to help guide patients so they do not overcompensate their hypoglycemia, essentially creating an evidence base that can guide treatment decisions in the clinic.
Because this is a Cloud-based system, the patients who record recurrent episodes of hypoglycemia could be identified and called for a follow-up in the clinic, said Wolpert. Because this does not currently happen, such patients usually end up visiting the ED or a hospital.
Another app feature is a pattern recognition report that can isolate random events of hypoglycemia from a predictable pattern. Wolpert provided a case study in which a patient experienced hypoglycemia late in the morning on 2 days of the week, which, it turned out, followed an early-morning workout in each case. “The goal here is to identify those associations and pull them out from the data set so patients can actually see the relationship between their particular behaviors and practices and the hypoglycemic events,” he said. Wolpert believes that tools such as HypoMap provide an evidence base that clinicians can exploit for rational treatment decisions. Additionally, they can prove to be a successful platform to trigger patient engagement in self-care and help move away from the traditional prescriptive approach to care in diabetes, he concluded.
1. Make diabetes management easier. Glooko website. https://www.glooko.com/patients/. Accessed May 19, 2015.
Am J Manag Care
Quilliam BJ, Simeone JC, Ozbay AB, Kogut SJ. The incidence and costs of hypoglycemia in type 2 diabetes. . 2011;17(10):673- 680.
Am J Manag Care
Hazel-Fernandez L, Li Y, Nero D, Moretz C, et al. A relationship of diabetes complications severity to healthcare utilization and costs among Medicare Advantage beneficiaries. . 2015;21(1):e62-e70.
Joslin Institute for Technology Translation (JITT) and Glooko introduce hypoglycemia awareness product designed to improve hypoglycemia self-management for people with diabetes [press release]. http://www.joslin.org/news/JITT- and-glooko-introduce-hypoglycemia-awareness- product%20.html. Boston, MA, and Palo Alto, CA: Joslin Diabetes Center; June 11, 2014.