Welcome to the new world

Although he never actually set foot on our shores Christopher Columbus is given credit for discovering America. The same can be said for our friends at Livongo although they did not invent digital diabetes everyone is giving them credit for inventing it. Perhaps today’s news coming from Abbott will reinforce what we have been stating, Livongo is NOT the only digital diabetes player and has lots of competition.

Per a press release;

“Abbott (ABT) and Omada Health announced today they are partnering to integrate Abbott’s revolutionary FreeStyle Libre system, a continuous glucose monitoring (CGM) technology, with Omada Health’s pioneering digital care program, aiming to create a new paradigm for people with Type 2 diabetes.”

No disrespect to the good people at Omada but they do basically the same thing Livongo does, only they have been doing it longer. However this deal does reinforce another thing we have been saying in that Livongo is using old outdated technology that patients really don’t like while others as this deal points out have left the old world of SMBG and found the new world of CGM.

This deal also reaffirms Abbott’s commitment to the Libre platform and in some respects is a response to what Dexcom has done in the intensively managed space. It also signals another trend that we predicted with Dexcom becoming the preferred choice for intensively managed patients while Abbott is entering the larger yet more difficult space of non-intensively managed patients. Finally it just confirms that CGM is becoming the standard for glucose measurement.

But let’s get back to the digital diabetes aspect just for a moment. As another piece of news confirms something else we have been saying, when it comes to digital diabetes it’s not about how many deals a company has it’s all about getting patients enrolled and keeping them enrolled. According to a study published in this month’s Lancet Digital Health Journal that looked at four smartphone-based coaching interventions to get people on their feet and boost their average daily step counts showed the coaching worked up to a limited extent but comes with one very big downside- a low retention rate for participants and a significant drop in interaction with the app as the study progressed.

This is the exact problem we have with Livongo and all the platforms such as Omada’s which target less intensively managed patients. The harsh reality is intensively managed patients due to their therapy regimen must be more engaged with their diabetes management. Additionally these patients see an immediate and direct impact from any changes made to their therapy regimen. This contrasts with less intensively managed patients, the majority of which are on orals alone, who don’t experience immediate results from the changes in behavior these coaching platforms are recommending.

While these programs were not diabetes related the study’s findings notes several limitations that apply to diabetes. One that caught our eye given how Livongo believes they can magically reach a 70% enrollment rate as only 17% of the study participants completed the study. The study also noted;

“Furthermore, although participants were requested to carry their mobile phone on their person at all times during the study and were asked to complete a daily questionnaire to document the percentage of time, they carried their mobile phone, no immediate mechanism was implemented to ensure compliance.”

This is another flaw in the Livongo program and frankly any other which does not use CGM, the reality is and this very true with non-intensively managed patients the less toys they care around the better. CGM usage makes getting glucose data easy and does not require the patient to carry around a lancing device and test strips. Additionally the data goes direct to the patient’s smartphone, something Libre does not have yet but will have when the Libre2 gets here.

What everyone is missing here when it comes digital diabetes is even with all this way cool whiz bang technology available when it comes to less intensively managed patients, we are dealing with a group of patients that have a chronic disease they do not want, don’t really understand and requires some heavy lifting to manage properly. Worse for these patients is unlike intensively managed patients who see an immediate impact from therapy changes the less intensively managed patient does not. Is it any wonder so many drop out?

Yet just as the myth that Columbus discovered America persists the myth that digital diabetes works continues to persist. The reality is you can have all the shiny new toys you want, all the cool artificial intelligence programs and coaching but in the end if you don’t have an engaged motivated patient who stays motivated and engaged you have nothing at all.

This is really about giving less intensively managed what intensively managed patients have, real skin in the game. Give them something anything that has an immediate and direct impact, something that makes doing all the heavy lifting worth the effort. Otherwise we will continue this cycle of the less intensively managed patient playing with the toy for a short period of time and then throwing it away because they are no better off than they were when they weren’t playing with the toy.

As Momma Kliff used to say people don’t like to do anything, make any changes unless there is something in it for them. Something they can see feel or touch. This is particularly true when you are asking them to change long established patterns of behavior. What’s in it for them? What do they get other than the “possibility” they will avoid complications? What they get is nothing and the sooner everyone understands that the better.