The Effectiveness of Self-Management Mobile Phone and Tablet Apps in Long-term Condition Management: A Systematic Review

Background Long-term conditions and their concomitant management place considerable pressure on patients, communities, and health care systems worldwide. International clinical guidelines on the majority of long-term conditions recommend the inclusion of self-management programs in routine management. Self-management programs have been associated with improved health outcomes; however, the successful and sustainable transfer of research programs into clinical practice has been inconsistent. Recent developments in mobile technology, such as mobile phone and tablet computer apps, could help in developing a platform for the delivery of self-management interventions that are adaptable, of low cost, and easily accessible. Objective We conducted a systematic review to assess the effectiveness of mobile phone and tablet apps in self-management of key symptoms of long-term conditions. Methods We searched PubMed, Embase, EBSCO databases, the Cochrane Library, and The Joanna Briggs Institute Library for randomized controlled trials that assessed the effectiveness of mobile phone and tablet apps in self-management of diabetes mellitus, cardiovascular disease, and chronic lung diseases from 2005–2016. We searched registers of current and ongoing trials, as well as the gray literature. We then checked the reference lists of all primary studies and review papers for additional references. The last search was run in February 2016. Results Of the 9 papers we reviewed, 6 of the interventions demonstrated a statistically significant improvement in the primary measure of clinical outcome. Where the intervention comprised an app only, 3 studies demonstrated a statistically significant improvement. Interventions to address diabetes mellitus (5/9) were the most common, followed by chronic lung disease (3/9) and cardiovascular disease (1/9). A total of 3 studies included multiple intervention groups using permutations of an intervention involving an app. The duration of the intervention ranged from 6 weeks to 1 year, and final follow-up data ranged from 3 months to 1 year. Sample size ranged from 48 to 288 participants. Conclusions The evidence indicates the potential of apps in improving symptom management through self-management interventions. The use of apps in mHealth has the potential to improve health outcomes among those living with chronic diseases through enhanced symptom control. Further innovation, optimization, and rigorous research around the potential of apps in mHealth technology will move the field toward the reality of improved health care delivery and outcomes.

Control group: Advised to continue with usual care which involved a minimum of an annual visit to the GP for HbA1c measurement.

Intervention groups:
Participants in both intervention groups received a mobile phone with the Few Touch Application (FTA) selfmanagement system. The FTA system provided the user with a diabetes diary app designed to increase self-management through awareness, overview of relevant factors, and motivational feedback through symbols such as smiling faces and colour codes in the app. The participants measured blood glucose levels with a glucometer (LifeScan OneTouch Ultra Easy), which enabled automatic transfer of the measurement to the diary mobile app through a wireless Bluetooth connection and provided visual graphs, trend reports, and feedback through colour coding (below normal, normal, and above normal). The app also consisted of a food habit registration system, a physical activity registration system, a personal goal-setting system, and a general information system. The user entered information about food intake, physical activity, and personal goals. The second intervention group involved the use of the FTA as above and patient received monthly counselling sessions via phone with a diabetes specialist nurse.

Frequency of data input by participant:
Unclear how often patients were asked to enter data. Participants were classified as substantial and non-substantial users.
Real-time feedback: Yes, in the form of graphs and symbols such as smiling faces and colour codes.
Additional software: Unclear whether a web portal/platform was also used. Intervention participants, asked to download the app "Glucose Buddy". This is freely available app. Users can enter blood glucose levels, insulin dosages, other medications, diet (food items in grams), and physical activities (in minutes). Users can view their data on a graph and export the data via email. A website was also available through which that patients could enter and view their data.

Frequency of data input by participant:
No minimum or maximum level of input stipulated.

Real-time feedback:
Patients could click on graph option to see plot of results but no realtime messages or feedback.
Additional software: Also able to input data and review results via the website.

Intervention group:
The software used was a Java application (Java 2 Micro Edition (J2ME)) designed by the National Centre for High-Performance Computing (Hsinchu, Taiwan). It is compatible with most commercial J2ME-enabled cell phones with General Packer Radio Service (GPRS). The present study adopted the Sony Ericsson K600i1 cell phone (Sony, Tokyo, Japan) to execute the J2ME application for the endurance walking exercise by music pacing and data uploading through GPRS to a website.
Frequency of data input by participant: Once daily.

Real-time feedback:
Feedback was available immediately on the website, unclear whether this could be accessed by the smartphone or whether patients had to log into the website to access this. Unknown fulfilled the criterion of poorly controlled asthma 12 years and over.

Control group:
Clinical care based on best practice (3 monthly clinic visits).
Intervention group: Eligible patients either had a contract with a compatible mobile phone network and a compatible handset or patients with an incompatible handset but who subscribed to a compatible network were offered the opportunity of borrowing a handset for the duration of the trial. The t+ Asthma application (OBS medical) was loaded onto the phone and functionality tested. The t+ Asthma application enabled twice daily recording and transmission of symptoms, drug use, and peak flow.

Frequency of data input by participant: Twice daily
Real-time feedback: Yes, the recorded peak flow was displayed within the traffic light zones and patients encouraged to follow their action plan.
6 months with a 6 month follow-up.