Background: Chronic disease represents a large and growing burden to the health care system worldwide. One method of managing this burden is the use of app-based interventions; however attrition, defined as lack of patient use of the intervention, is an issue for these interventions. While many apps have been developed, there is some evidence that they have significant issues with sustained use, with up to 98% of people only using the app for a short time before dropping out and/or dropping use down to the point where the app is no longer effective at helping to manage disease. Objective: Our objectives are to systematically appraise and perform a meta-analysis on dropout rates in apps for chronic disease and to qualitatively synthesize possible reasons for these dropout rates that could be addressed in future interventions. Methods: MEDLINE (Medical Literature Analysis and Retrieval System Online), PubMed, Cochrane CENTRAL (Central Register of Controlled Trials), and Embase were searched from 2003 to the present to look at mobile health (mHealth) and attrition or dropout. Studies, either randomized controlled trials (RCTs) or observational trials, looking at chronic disease with measures of dropout were included. Meta-analysis of attrition rates was conducted in Stata, version 15.1 (StataCorp LLC). Included studies were also qualitatively synthesized to examine reasons for dropout and avenues for future research. Results: Of 833 studies identified in the literature search, 17 were included in the review and meta-analysis. Out of 17 studies, 9 (53%) were RCTs and 8 (47%) were observational trials, with both types covering a range of chronic diseases. The pooled dropout rate was 43% (95% CI 29-57), with observational studies having a higher dropout rate (49%, 95% CI 27-70) than RCTs in more controlled scenarios, which only had a 40% dropout rate (95% CI 16-63). The studies were extremely varied, which is represented statistically in the high degree of heterogeneity (I2>99%). Qualitative synthesis revealed a range of reasons relating to attrition from app-based interventions, including social, demographic, and behavioral factors that could be addressed. Conclusions: Dropout rates in mHealth interventions are high, but possible areas to minimize attrition exist. Reducing dropout rates will make these apps more effective for disease management in the long term. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019128737; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019128737

Background: The health burden of type 2 diabetes can be mitigated by engaging patients in two key aspects of diabetes care: self-management and regular contact with health professionals. There is a clear benefit to integrating these aspects of care into a single clinical tool, and as mobile phone ownership increases, apps become a more feasible platform. However, the effectiveness of online health interventions is contingent on uptake by health care providers, which is typically low. There has been little research that focuses specifically on barriers and facilitators to health care provider uptake for interventions that link self-management apps to the user’s primary care physician (PCP). Objective: This study aimed to explore PCP perspectives on proposed features for a self-management app for patients with diabetes that would link to primary care services. Methods: Researchers conducted 25 semistructured interviews. The interviewer discussed potential features that would link in with the patient’s primary care services. Interviews were audio-recorded, transcribed, and coded. Framework analysis and the Consolidated Criteria for Reporting Qualitative Research checklist were employed to ensure rigor. Results: Our analysis indicated that PCP attitudes toward proposed features for an app were underpinned by perceived roles of (1) diabetes self-management, (2) face-to-face care, and (3) the anticipated burden of new technologies on their practice. Theme 1 explored PCP perceptions about how an app could foster patient independence for self-management behaviors but could also increase responsibility and liability for the PCP. Theme 2 identified beliefs underpinning a commonly expressed preference for face-to-face care. PCPs perceived information was more motivating, better understood, and presented with greater empathy when delivered face to face rather than online. Theme 3 described how most PCPs anticipated an initial increase in workload while they learned to use a new clinical tool. Some PCPs accepted this burden on the basis that the change was inevitable as health care became more integrated. Others reported potential benefits were outweighed by effort to implement an app. This study also identified how app features can be positively framed, highlighting potential benefits for PCPs to maximize PCP engagement, buy-in, and uptake. For example, PCPs were more positive when they perceived that an app could facilitate communication and motivation between consultations, focus on building capacity for patient independence, and reinforce rather than replace in-person care. They were also more positive about app features that were automated, integrated with existing software, flexible for different patients, and included secondary benefits such as improved documentation. Conclusions: This study provided insight into PCP perspectives on a diabetes app integrated with primary care services. This was observed as more than a technological change; PCPs were concerned about changes in workload, their role in self-management, and the nature of consultations. Our research highlighted potential facilitators and barriers to engaging PCPs in the implementation process.

Background: Diabetes is an increasingly prevalent and costly chronic disease worldwide, and a large cause of unnecessary disease burden. To address the growing burden of diabetes, care models should support management of diabetes in primary care to reduce reliance on overstretched hospital-based specialists services. Virtual care presents an opportunity to provide diabetes care remotely, potentially enhancing the accessibility and efficiency of healthcare services. This review aimed to identify existing evidence on the effectiveness of virtual care on diabetes management, and the extent to which video components are included in the evidence base. Methods: The protocol was registered in PROSPERO (CRD42022366125). Systematic search of the databases PubMed, Embase, Medline, Scopus, CINAHL and Cochrane CENTRAL, were conducted for studies on telemedicine, telehealth, or virtual interventions for type 2 diabetes management published between January 2011 to March 2022. The primary outcome was HbA1c, and secondary outcomes were blood glucose control, Body Mass Index (BMI), taking the prescribed medications, and self-management behaviour. The results were reported following the Preferred Reporting Items for Systematic Reviews (PRISMA) checklist. Quality of each review was appraised using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Results: From 10,708 articles, 63 underwent full-text review. Thirty systematic reviews were included. Overall quality of the included reviews was high. Among the 30 systematic reviews, there was significant overlap of the primary studies, with 48% of them appearing in multiple reviews. Of the 30 reviews, 28 reported that virtual care improved HbA1c compared to usual care. Meta-analysis of 16 reviews revealed a mean difference of -0.37% (-0.41% to -0.32%), I² of 77.1%. Significant non-clinical impacts were noted for BMI and secondary outcomes. Most reviews (25/30) included some studies with video components, however these studies did not disaggregate the impact of video from other aspects of complex interventions such as web-based and telephone support. Conclusions: This umbrella review strengthens the evidence that virtual care significantly improves clinical outcomes in people with type 2 diabetes, primarily affecting HbA1c. Fewer studies addressed other health outcomes such as BMI and taking medications. Effectiveness of virtual care varies by demographic and clinical characteristics, emphasising the need to tailor virtual care interventions to maximise impact. Future research could directly compare and identify the most effective virtual care strategies for different populations, including those with lower digital literacy.

Purpose: Type 2 diabetes mellitus has become a major concern of Australian healthcare providers. From rates of barely more than 1 percent in the mid-90s, diabetes is now the leading cause of morbidity in the country. To combat the growing diabetes epidemic, Western Sydney Local Health District created the Western Sydney Diabetes (WSD) initiative. One of the key components of the WSD initiative since 2014 has been joint specialist case conferencing (JSCC). The purpose of this paper is to evaluate the JSCC service including both individual- and practice-based changes. Design/methodology/approach: The authors evaluated the JSCC program by conducting an analysis of patient-level data in addition to a discrete practice-level study. The study aim was to examine both the effect on individual patients and the practice, as well as acceptability of the program for both doctors and their patients. The evaluation included data collection and analysis of primary patient outcomes, as well as a survey of GPs and patients. Patient data on primary outcomes were obtained by accessing and downloading them through GP practice management software by GP practice staff. Findings: The authors found significant improvements at both the patient levels, with reductions in BMI, HbA1c and blood pressure sustained at three years, and at the practice level with improvements in markers of patient management. The authors also found high acceptability of the program from both patients and GPs. Originality/value: This paper provides good evidence for the use of a JSCC program to improve diabetes management in primary care through capacity building with GPs.

Background: Clinicians’ experiences of providing care constitute an important outcome for evaluating care from a value-based healthcare perspective. Yet no currently available instruments have been designed and validated for assessing clinicians’ experiences. This research sought to address this important gap by developing and validating a novel instrument in a public health system in Australia.Methods: A multi-method project was conducted using co-design with 12 clinician leaders from a range of NSW Health Local Health Districts to develop the Clinician Experience Measure (CEM). Validity and reliability analyses were conducted in two stages, first assessing face and content validity with a pool of 25 clinicians and then using psychometric analysis with data from 433 clinicians, including nurses, doctors and allied health and representing all districts within one jurisdiction in Australia.Results: Data gathered from 25 clinicians via the face and content validity process indicated that the initial 31-items were relevant to the range of staff employed in the NSW state health system, with minor edits made to the survey layout and wording within two items. Psychometric analysis led to a rationalised 18-item final instrument, comprising four domains: psychological safety (4-items); quality of care (5-items); clinician engagement (4-items) and interprofessional collaboration (5-items). The 18-item four-factor model produced a good fit to the data and high levels of reliability, with factor loadings ranging from .62 to .94, with Cronbach’s alpha (range: .83 to .96) and composite reliability (range: .85 to .97).Conclusions: The CEM is an instrument to capture clinicians’ experiences of providing care across a health system. The CEM provides a useful tool for healthcare leaders and policy makers to benchmark and assess the impact of value-based care initiatives and direct change efforts.