Transcription:
Type 1 Diabetes Care

Bill Klaproth (Host):  Children’s Health encourages patient’s families to use the diabetes advisor app on their smart phones to manage concerns related to diabetes. With the app, you can access diabetes management resources including around the clock children’s healthcare and real-time advice on how to address common issues. This is Pediatric Insights: Advances and Innovations with Children’s Health, where we explore the latest in pediatric care and research. I’m Bill Klaproth. And with me, is Dr. Soumya Adhikari, a Pediatric Endocrinologist at Children’s Health and Associate Professor of Pediatrics at UT Southwestern. Dr. Adhikari, thank you for your time. So, let’s start here. What are the biggest hurdles or challenges you see with patients in managing type one diabetes?

Soumya Adhikari, MD (Guest):  Yeah, well if I can set the stage just a little bit. Type one diabetes is a condition where your body struggles to control it’s blood sugar levels because your pancreas has lost its ability to make the hormone to help control your blood sugar levels which is insulin. Which every person with type one diabetes knows well but I think it’s important to put that out there. I think when you think of or when I think of out team’s approach to diabetes care; everything we do, really lines up with probably one of a few different concepts, quality of life, glycemic control or blood sugar control or research towards a cure.

Everything we do should really line up with one of those above concepts. I think diabetes is – it’s hard. It’s certainly not unique in this regard in comparison to other chronic medical conditions. But living with diabetes is hard on an easy day. A person with diabetes makes so many decisions about their day which are at least partly influenced by the fact that they have diabetes. It’s not directly necessary for no other reason than the fact that they have diabetes and we’re talking consequential decisions. Should I eat now? Should I exercise now? Am I safe to drive now? Should I drink this cup of coffee in the morning? I’m tired, I could really use the caffeine, but my blood sugar is already a little bit high. All these things that many people without diabetes take for granted, a person with diabetes has to make really consequential decisions about all of these things and really several dozen times a day.

And there is a mental burden that kind of accumulates with that. Any of us could deal with that for an hour or a day, maybe a week. But a person with type one diabetes has to make these decisions constantly 24/7 and you never really get to take a day off. So, that’s the background we think of when we think of how can we push the envelope.

Host:  Right. It is very, very challenging and you laid that out for us. So, you were talking about quality of life and there are a lot of decisions that a person with diabetes has to make. So, how is Children’s Health advancing care for type one diabetes patients?

Dr. Adhikari:  I think we have some things that we do that are very consistent with how diabetes is cared for across the country. We have a team-based approach when a young child is diagnosed with diabetes, they don’t just have a doctor who is part of their team. They have a diabetes educator, nurses and dieticians and social workers and other such things but in the last few years, especially, I think we’ve made an effort to acknowledge a couple of things related to the quality of life concept if you will, including that type one diabetes is unique. I think amongst medical conditions for patients being very technology reliant, very device reliant, to care for themselves at a minimum a child with type one diabetes is carrying around a blood sugar meter, if not an insulin pump or a continuous glucose monitor that’s tracking something about their body and they may be tracking a lot of these things on their cell phone or their parents may be tracking a lot of these things about their child on their parent’s cell phone. So, our patients tend to be a pretty tech savvy and technology reliant out of necessity population.

So, we also have tried to leverage that, that that’s the population that we are working with. How can we move into that space to address some of the challenges that we face?

Host:  Absolutely. Well advances in technology certainly has helped people manage their diabetes. So, let’s talk about the Children’s Health Diabetes Advisor app. Why did Children’s Health decide to create this app?

Dr. Adhikari:  That’s a great question. I think the app today is many things to many people. But it really started out of a very simple conversation in a faculty meeting where a group of about 20 faculty members and we have a division wide meeting almost once a week where we talk about any number of things. One of these weeks a few years ago we were talking about how is our protocol for how kids should care for themselves on sick days, how up to date is it and how consistent is it with best practice recommendations that are put forth by agencies who are invested in these sorts of things.

And I don’t remember who first posed the question, but somewhere in the course of our discussion, we kind of started asking ourselves well, before the app existed, we offered six day support to our families with children with diabetes over the phone. Which is great. Because you get personal assistance. You have somebody there to hold your hand and walk you through the challenges of what to do for your child now that your child is sick or throwing up or has a stomach flu or whatever else and that’s certainly necessary on many sick days. But a lot of what happens on those phone calls is heh tell me your child’s blood sugar. Tell me your child’s blood ketone level. Tell me if they are able to keep fluids down or not. Meaning a lot of factoids that once you give me that information, I’m on the other side of the line essentially going through an algorithm in terms of deciding whether to ask you to seek medical advice or whether to give you some advice about how much insulin to take.

And the piece of that that’s formulaic, the piece of it that’s just a little bit a complicated math we thought very consistent with our general approach and wanting to make families independent, that a mobile decision support tool might bring some value to families that have a little bit of savvy in how to deal with sick days but maybe your child hasn’t been sick in 18 or 24 months. So, it’s been awhile since you’ve had to think about how do I approach insulin dosing on a day that my child is sick? If they are really sick, and the app will walk you though this a little bit to the extent that an app can; you should seek medical attention and you should call us.

But sometimes a person with diabetes is just dealing with the fact that their blood sugars are higher than usual, and they have ketones and they generally don’t feel that sick and that means you need to take everything you do about your diabetes and adjust it a little bit but how you adjust it is really just fancy math. And having that decision support tool in your hands and feeling like I know I can call the diabetes clinic if I need to but let me just see if I can navigate this on my own; we thought that that would bring some value to families.

So, we set out to build that decision support tool essentially to supplement all the in person services that we provide to our families and of course, when the idea really started mushrooming, what grew out of that was well if we are going to put a mobile app in our patient’s hands, then why stop with a decision support tool. Everything we do when it comes to diabetes care is really focused on diabetes education. I can’t make your diabetes go away today. So, let me teach you how to better care for yourself now that you have diabetes. So, in addition to the decision support tool, of course, very early on we were tempted to think about loading the app with as much educational content as we could.

Again, not because you are not going to have other sources of educational content available to you as well. It’s on our website, et cetera, et cetera. But why not align them? Why not merge then? Why not make as much of our content available in that handheld platform as we can as it lends itself to.

Host:  Right. Well the more information you can give, the more useful that tool is. So, it sounds like you took all of the questions people have and daily management tactics and you rolled it all into this decision support tool as you call it, really focusing on diabetes education. Did it take a long time to create this app?

Dr. Adhikari:  Yeah, I mean this was our – certainly my first experience with anything of this sort. I had never dipped my toes into how does one make an app much less seen it from inception of idea to releasing it on an app store. So, it was quite the experience in that regard. I think I reached out to the virtual health team at Children’s Health to ask heh is this something that you guys would have any interest in having some conversations with and from the day I first sent that email to the day that it was in the hands of the first patient; a good couple of years went by.

Host:  That would make sense. I mean this is such a robust tool. So, then when did the app finally launch in the app store?

Dr. Adhikari:  Almost just over a year ago to the day. Meaning I want to say it was in October to November of 2018 that we released it in the Apple. Right now it’s IOS only but in the IOS app store.

Host:  Okay, got you. And what should people search for if they are looking for it? What do they need to plug in?

Dr. Adhikari:  Yeah, we – it’s amazing how many names we went through in trying to come up with something that would be representative of what we think it is and what service we think it provides to families and such. But ultimately, we settled on something pretty simple. Something that we think gets the message across. It’s called the Diabetes Advisor and if you search in the app store for Diabetes Advisor, it should come up pretty readily.

Host:  Okay. So, search Diabetes Advisor in the app store. So, Dr. Adhikari, can you share with us how it’s changed patient’s care routine for the better?

Dr. Adhikari:  I can share with you what we hear from our patients. And I guess a little bit trackable once you upload apps into app stores and such so, we follow about 2000 families with type one diabetes in our practice. And the app has had – it’s not limited to being downloaded by only our patients. But it’s had about 1000 downloads. There is a sort of public facing functionality of the app. All of our educational content is completely accessible to the general public. But the interactive piece of the application can really only be unlocked by our families. We want to make sure that if you’re interacting with the application that you have been through our diabetes education program because some of the way that the application will interact back with you really, relies on an understanding of how we approach diabetes or how we encourage families to approach diabetes.

So, and there’s been about 200 registered unlocks of that sick day advisor piece if you will amongst our families. And I think the families that have had an opportunity to interact with the advisor have shared with us that it’s nice to have a just in time tool to help you organize your thoughts on a day when frankly, it’s hard to organize your thoughts because again, everything about diabetes care is hard enough as it is on a typical day. When your child is throwing up, and your ketone meter reads one number versus another number, it’s hard to remember what exactly you are supposed to do with each of those things. So, the sick day advisor piece of things is really just designed to remove some of that mental burden from how do I navigate how much fluid am I supposed to give my child, how much insulin am I supposed to give my child and I think most of the feedback that we’ve received from our families has really been on that. It’s just nice to have somebody or something there to reaffirm or help me organize my thoughts about how to approach all this.

And actually the app, again, and I want to stress this. The purpose of the app is not to try to steer families away from calling us. Within the app, you can click a little button that says call the clinic if what the app is advising you to do is either not clear to you or if you have any questions, it makes it easier to call our clinic because it has our clinic’s phone number built in and obviously you are interacting with it in the cell phone so, it’s got the phone functionality built into it.

Host:  Wow, that is really good and really putting technology to good use. So, remember just search Diabetes Advisor in the app store. Dr. Adhikari, thank you so much for your time today. This has been very informative.

Dr. Adhikari:  Any time.

Host:  That’s Dr. Soumya Adhikari, a Pediatric Endocrinologist at Children’s Health and Associate Professor of Pediatrics at UT Southwestern. Thanks for listening to Pediatric Insights. For more information please visit www.childrens.com/diabetes, that’s www.childrens.com/diabetes. And if you found this podcast helpful, please rate and review or share the episode and please follow Children’s Health on your social channels. This is Pediatric Insights: Advances and Innovations with Children’s Health. Thanks for listening.