Want a Good Diabetes App? You May Have to Pay

Miriam E Tucker

May 08, 2015

Diabetes apps that cost a few dollars may prove more helpful to patients than the free ones, a new study suggests.

The findings were published May 7, 2015 in Preventing Chronic Disease by Charlene A Caburnay, PhD, from Washington University, St Louis, Missouri, and colleagues.

"If patients are looking for an app to help with checking and recording blood glucose levels or monitoring diet or physical activity, there are many apps to choose from. In general, paid apps were more likely than free apps to use design and content strategies that help to increase understanding and use.…The advice might be, 'You get what you paid for,' " Dr Caburnay told Medscape Medical News.

But it's not a huge amount of money: A majority of the 110 diabetes-related apps evaluated in the study — all of them for Apple's iOS devices (iPad and iPhone) — cost $5.99 or less, she noted.

Dr Caburnay offered some tips to pass along to patients in evaluating health-related apps. Since the average star rating for both free and paid apps was 3.4, patients could look for apps with higher star ratings than that. Then, they could look at the sample screens and the app description to determine whether the terminology is familiar and understandable. Reading user comments for the apps may also provide clues as to the greatest ease of use of the app.

Paid vs Free

Dr Caburnay and colleagues searched the Apple App Store in April 2014 using the keywords "diabetes," "diabetic," "type 1 diabetes" and "type 2 diabetes" and came up with 460 hits. Of those, they randomly selected 110 that they coded based on a scheme adapted from an Institute of Medicine discussion paper identifying features associated with "health-literate apps."

Of the 110 apps, 69% (76) were free. The 34 that weren't free ranged in price from $0.99 to $29.99, with a mean price of $4.57.

There were 65 apps with user ratings, with an average of 148 ratings per app and an average rating of 3.4 (where 5 was the highest rating). Most (87%) of the apps did not specify whether they were for type 1 or type 2 diabetes, with just five each specifying type 1 and type 2. Two-thirds of the apps focused on management/therapeutics, while the other third addressed diabetes prevention.

Paid diabetes apps were significantly more likely than free ones to use common, everyday words (91% paid vs 75.0% free, P = .05) and to avoid undefined technical or medical terms (85% vs 66%, P = .04). The paid apps also used more "action voice," "action words," and present tense than did the free ones.

More of the paid apps had links to a homepage or menu page (85% vs 68%, P = .06), and paid apps were significantly more likely to include a "back" button (97% vs 75%, P = .006).

One explanation for the findings is that with paid apps, developers may be making more effort, conducting more advanced research and usability testing, which would allow for revision to improve understanding and usability prior to product launch, the authors speculate.

What Apps Lack

The researchers also found that some aspects of both the paid and free diabetes-related apps were less than ideal. For example, only 44% of all the apps were integrated with other applications such as email, calendar, or maps.

And while 70% of all the apps had tailorable interactive content, "less than 17% had other engaging features such as printer-friendly tools, audio and visual features, or integration with new media such as Twitter or texting," Dr Caburnay and colleagues write.

Most apps (81%) used bold colors with contrast, but only 31% overall used images that facilitated learning, and there were no differences between free and paid apps on that measure, they note.

Improving Health Apps

Dr Caburnay told Medscape Medical News, "In general, these apps are designed to monitor behavior, provide assistance in managing diabetes, and provide feedback and information.

"Patients and clinicians will differ in what features are most useful, understandable, or informative to them. But in general, making sure that an app designed for a patient audience uses terminology that is written in plain language, with links, buttons, or other features that are clearly labeled and intuitive is especially important."

The study findings are of concern for disadvantaged patient populations, she and her colleagues note.

"Because low health literacy is more likely among people of low socioeconomic status, the cost of apps may be prohibitive for people with low health literacy. If these people are more likely to use free diabetes apps, they are more likely to have apps that lack features that enhance usability and understanding."

In general, "the findings of this study indicate that additional work should be done to improve [mobile health] apps. In particular, encouraging a development process for free diabetes-related apps to make them more user-friendly and accessible to diverse audiences could potentially increase their use and understandability among audiences, especially people with low health literacy," they conclude.

The study was funded by a grant from the National Institute of Digestive and Kidney Diseases, with support from the Washington University Institute for Public Health and the Washington University Center for Diabetes Translation Research. The authors have no further relevant financial relationships.

Prev Chronic Dis. Published May 7, 2015. Article

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