Level of Digitalization in Germany: Results of the Diabetes Digitalization and Technology (D.U.T) Report 2020

Abstract

Background:

New diagnostic and therapeutic technologies are increasingly changing the treatment of people with diabetes (PWD), along with increased usage of digital tools. To date, however, there is little data to which level and how diabetologists and PWD implement digitalization. Also, not much is known about the view of diabetologists on the current status and future developments in this respect.

Method:

In an online survey, diabetologists working in clinics and practices across Germany provided responses regarding their view on digitalization and the adoption of new technologies in diabetology to 56 questions. These comments reflect the opinion of several experts about the current importance and use of specific digital/technological topics.

Results:

Overall, 326 diabetologists took part in the survey. They reported a positive attitude (75.8%) toward new technologies and digitalization, and they see more advantages rather than disadvantages. Younger age of the diabetologists was significantly associated with a more positive attitude (r = −0.176; P < .01), and there was no gender effect (P = .738). On average, in each practice, 5.5% of PWD are using an insulin pump for therapy, 4.8% a real-time continuous glucose monitoring system, 16.9% an intermittent scanning continuous glucose monitoring system, and 0.3% an automated insulin delivery (AID) system. With respect to digitalization, the three most important current topics are software for glucose data analysis (average rank on a scale from one to six, with one being the most important: 2.4), compatibility with other systems (2.9), and AID systems (3.8)).

Conclusions:

This survey, which is going to be repeated annually, showed that the diabetologists who participated predominantly have a positive attitude toward new technologies and digital applications and were aware of the associated advantages. However, perceived disadvantages need to be addressed to enable wider adoption of new technologies and digital solutions.

Introduction

The treatment of people with diabetes (PWD) has changed a lot in the last decades, mainly driven by improved technological systems. In addition, in the last decade, digitalization has changed many aspects of diabetes therapy.^1,2 In particular, continuous glucose monitoring (CGM) and the possibilities of analyzing CGM data by means of specialized software help PWD to control and optimize their therapy.^3,4 In clinical studies and also in daily practice, this development has led to better long-term glycemic control, reduced frequency of hypoglycemic and hyperglycemic events, a deeper understanding of the factors influencing the glucose swings during the day, and has promoted the use of new CGM parameters (eg, time-in-range) and new clinical targets.^5-9 The wide-spread availability of a number of different commercial systems for automated insulin delivery (AID) as well as the emergence of Do-it-Yourself (DIY) AID systems will likely have a huge impact on diabetes therapy of many people with type 1 diabetes (PW1D) in the future.^10,11

Diagnostic and therapeutic interventions based on artificial intelligence (AI) will increasingly support both physicians (eg, physician decision support systems) and PWD (eg, patient decision support systems) in therapy and training, as well as in coaching the PWD.^12,13 By using AI, research toward a more differentiated understanding of diabetes therapy will advance the development of personalized diabetes therapy.^14,15 Initial results also show that the therapy of PWD can be meaningfully supplemented by telemedical approaches, ¹⁶ use of mobile apps ¹⁷ , or digital programs to support lifestyle intervention. ¹⁸ Digital applications are available for the prevention of type 2 diabetes ¹⁹ and are particularly valuable for underserved populations. ²⁰

While the different diabetes technologies and digital applications demonstrate the impressive possibilities of these solutions, the use and success of such options, however, strongly depend on the patients’ and physicians’ attitudes and the practicability in everyday life. ²¹ So far, only a few studies have assessed the attitudes of diabetologists toward new technologies and digital applications.^22,23 Furthermore, data on the perceived or expected advantages and disadvantages of such developments are missing. ²⁴

Methods

The survey for the Diabetes Digitalization and Technology Report (D.U.T) 2020 was programmed as an online survey on a survey platform (“SurveyMonkey Europe, Dublin, Ireland”). A total of 56 questions was developed by FIDAM (Research Institute of the Diabetes Academy Mergentheim) in cooperation with the members of the “future board digitalization” (ZD), to which many authors of this article belong (LH, SH, WK, JK, BK, AL, HM, LS). Only people who identified themselves as diabetologists were allowed to answer this survey.

The following domains were part of the survey:

• demographic data (eg, number of treated PW1D, people with type 2 diabetes [PW2D], rural/urban location of the practice, number of patients with diabetes using new technologies)

• attitude toward digitalization, respectively, the potential of digitalization for diabetology, on a visual analog scale from 0 to 100 (0 = negative, resp. small; 100 = positive, great; categorization cut-offs at 40 and 60)

• perceived advantages and disadvantages of new technologies and digitalization on a five-point Likert scale (one = no advantage/no disadvantage; five = great advantage/great disadvantage; the proportion of participants rating four or five was calculated)

• the relevance and importance of various topics of digitalization in diabetology: participants ranked ten key areas according to the subjectively perceived importance, rank one indicating the most important topic, rank ten indicating less important topic.

• Perceived importance of several topics currently and in five years on a five-point Likert scale (one = not important; five = very important; the proportion of participants rating four or five was calculated)

• Diabetologists estimated the use of these topics (percentage of patients who use or are going to use the according service/technology)

The D.U.T was published in 2019 ²⁵ and again in 2020. ²⁶ The results of the 2020 survey are reported. The data for the D.U.T Report 2019 was collected in October 2018. The data for the D.U.T Report 2020 was collected in August-October 2019. Therefore, reported results are labelled with the years of data collection, 2018 and 2019, and not with the year of the reports’ publication, 2019 and 2020.

This survey is intended to answer the following ques-tions:

• What is the current state of digitalization and the adoption of technology in daily practice in Germany?

• To which extent are modern technologies used in diabetes treatment and which developments have taken place within the last year?

• How do diabetologists feel about digitalization and the adoption of technology?

• What is the perceived potential of technology and what are the advantages and disadvantages in practice?

• What are the perceived challenges and barriers of diabetologists?

• How important are different aspects of digitalization in diabetology (eg, glucose analysis software)? Which developments do physicians expect within the next five years with respect to the importance and usage of these aspects?

Results

A total of 326 diabetologists from all regions of Germany took part in the survey. The average age of the participants was 52.2 years; the proportion of diabetologists <40 years of age was approximately 10%. The diabetologists treated the patients with diabetes in outpatient settings (82%) or in mixed, outpatient, and inpatient settings (11%).

The median of treated PW1D per practice was 189; most diabetologists (36.9%) reported treating 200-500 PW1D, 9.4% treated <50 PW1D, while 12.8% treated >500 PW1Ds per quarter. The median of treated PW2D per practice was 850; most diabetologists (36.9%) reported treating 500-1000 PW2D, only a few diabetologists (4.1%) treated fewer PW2D (<200 PW2D). One out of four diabetologists reported treating >1500 PW2D (25.4%).

Use of New Technologies in Diabetology

On average, diabetologists estimated that they treat a total of 78 PWDs (type 1 and type 2 diabetes) using insulin pump therapy (CSII), 71 with real-time continuous glucose monitoring (rtCGM), and 241 with intermittent scanning continuous glucose monitoring (iscCGM; Figure 1).

Figure 1.

Average number of patients with diabetes (type 1 and type 2 diabetes) treated with new diagnostic and therapeutic technologies per practice.

The rtCGM systems were less frequently used than iscCGM systems, mainly by PW1D. The Frestyle Libre System (iscCGM) has been on the market in Germany since November 2014, and the Freestyle Libre 2 with alarm function has been available since 2018. It is the only available iscGM system and is used for both type 1 and type 2 diabetes. Proportionally, more PW1D used iscCGM than PW2Ds, but the absolute number of iscCGM systems users was higher in PW2D than in PW1D. Insulin pumps were mainly used by PW1D. The number of insulin-treated PW2D using insulin pumps was rather low. AID systems were still not often used in daily practice, neither hybrid AID systems nor DIY AID systems. Only a small group of PW1D uses them (total: 4%).

Attitude Toward Digitalization

With respect to their attitude toward digitalization, the majority of diabetologists reported a positive attitude (75.8%) and only 4.3% a negative attitude. One out of five of the participating diabetologists was yet neutral regarding digitalization and new technologies (19.9%). As per the predominantly quite positive attitude of the diabetologists toward digitalization in diabetes, 75.8% of diabetologists rated the potential for improvement of diabetes therapy through digitalization as high. Here, too, a fifth remained neutral (20.5%), and only a few diabetologists (3.7%) had doubts that digitalization can improve diabetes therapy.

The age of diabetologists had a significant influence on attitude toward digitalization: younger diabetologists reported a more positive attitude (r = −0.176; P = .002). Female and male diabetologists did not differ in their attitudes (average: women: M = 73.5 ± 18.7; men: M = 72.7 ± 21.1; P = .738).

Advantages and Disadvantages of Digitalization

The advantages of digitalization evaluated by the participants are perceived as very positive. The most important advantages relate to the patients: the highest rated advantages were “better communication with the patients,” “better support for treatment decisions,” “more patient empowerment,” and a “better quality of their treatment” (Figure 2). The further advantages more aimed at a better quality of care and practice organization. Only 41.0% of participants evaluated a “better communication with other physicians” as a great advantage.

Figure 2.

Advantages of digitalization and new technologies in diabetology. Percentage of physicians who rated possible advantages of digitalization and new technologies in diabetes as big or very big.

In general, physicians did not confirm the most items of possible disadvantages as real disadvantages. A “lack of reimbursement for digital services” was evaluated by participants as the largest disadvantage of digitalization. Eighty percent of the diabetologists expressed their concerns at this point (Figure 3). The financial concerns of participants were also emphasized with the evaluation of “high investment costs” by about half of the respondents as a large/very large disadvantage. Furthermore, “legal issues,” the “risk of misuse of patient data,” the “error susceptibility of digital services,” and “overwhelmed by technology” were considered as relevant disadvantages of digitalization. The arguments “digitalization replaces physician in many cases,” “impairment of the physician-patient relationship,” and “increased risk of incorrect treatment” represent only minor disadvantages of digitalization in the diabetology for most participants.

Figure 3.

Disadvantages of digitalization and new technologies in diabetology. Percentage of physicians who rated possible disadvantages of digitalization and new technologies in diabetes as big or very big.

All advantages were moderately to strongly positively associated with the general attitude toward digitalization and new technologies in diabetology (Table 1), while the disadvantages were negatively associated. Only “lack of reimbursement for digital services” showed no association with the general attitude. Despite being the most strongly endorsed disadvantage (80%), this aspect did not correlate with the general attitude of diabetologists toward digitalization and new technologies. Diabetologists’ positive attitude toward digitalization and new technologies does not seem to be affected by this most prominent disadvantage.

Table 1.

Correlations of Advantages and Disadvantages with the Attitude of Diabetologists Toward Digitalization in Diabetology.

	Correlation rs with attitude toward digitalization in diabetology
Advantages
Better treatment quality	0.498**
Better communication with the patient	0.563**
More patient assurance	0.385**
More patient empowerment	0.406**
More support for treatment decisions	0.332**
Better communication with other physicians	0.321**
More effective patient contacts	0.460**
Disadvantages
Difficult integration into the daily treatment routine	−0.357**
Too much effort—too little benefit	−0.470**
Overwhelmed by technology	−0.310**
Impairment of the physician patient relationship	−0.350**
Increased risk of incorrect treatment	−0.352**
Digitalization replaces physician in many cases	−0.144*
Risk of misuse of patient data	−0.281**
High investment costs	−0.240**
Error susceptibility of digital services	−0.208**
Legal issues	−0.204**
Lack of reimbursement of digital services	−0.038

^*p ≤ .05; **p ≤ .01.

Topics of Digitalization and New Technologies in Diabetology

“Software for glucose data analysis” (average ranking 2.4), “Compatibility with other systems” (2.9), and “AID systems” (3.8) were rated as the most important topics for current and future work (Figure 4). An improved analysis of glucose data may be important from the physicians’ point of view in order to achieve better communication with patients provide more support for the patient in carrying out therapy and, generally, improve patient empowerment and self-management.

Figure 4.

Average ranking of different topics, as ranked by diabetologists. Lower numbers indicate higher rating and therefore more importance.

Compatibility with other systems as the second important topic may refer to daily experiences or obstacles resulting from the fact that many systems have their own software, interfaces, plugs, and cables.

“Systems to support patient decisions” and “Diabetes mobile applications,” were rated as medium important followed by “Systems to support physician decisions” (5.0) and “Video consultation (telemedicine)” (5.1). Interestingly, “Digital education in general,” “Digital education to prevent type 2 diabetes,” and “Online communities (self-help)” were the least important issues related to diabetes technology and digitalization.

Relevance and Use at the Moment and in Five Years

Diabetologists rated the subjective importance and the use of several key areas of digitalization and new technologies by their patients differently (Table 2). Some topics are described as currently very important, and others are seen as topics of the future but with less relevance at the moment.

Table 2.

Evaluation of Different Topics Regarding their Use and Importance Both Currently and in Five Years from Now.

	Importance		Use
	Currently (%)	Growth over the next five years (%)	Currently	Growth over the next five years (%)
Software for glucose data analysis	72.3	15.9	30.8	24.5
Automated insulin delivery	22.9	58.6	N.A.	N.A.
Diabetes apps	26.7	41.8	22.9	22.1
Video consultation (telemedicine)	9.6	37.7	2.3	18.1
Digital education	8.6	34.8	7.4	20.4
Social media	25.7	26.4	N.A.	N.A.

Diabetologists assessed the subjective importance of these topics and the estimated use of their patients.

N. A., Not applicable since this question was not asked in the survey.

Software for Glucose Data Analysis

Diabetologists (72.3%) stated that this is currently an important topic (Table 2), but diabetologists assessed that currently, only 30.8% of their patients on average make use of this option. Physicians indicated that they expect an increase (24.5%) in patient use within the next five years.

Diabetes Apps

Diabetologists (26.7%) rated the current use of diabetes apps in the context of diabetes therapy as important; they expected this rating to increase to 68.5% in five years from now. However, according to them, only a few PWD (22.9%) use diabetes apps at this time, but in five years, two out of three PWD will use diabetes apps.

Automated Insulin Delivery Systems

AID Systems were perceived by physicians as a topic that will become more important within the next five years. Currently, only 22.9% of the physicians rated it as important, and 81.5% expected it to be important in five years. DIY AID systems were perceived as positive by 56.4% of the physicians and only 15.2% perceived it as negative (28.4% neutral). Three out of four physicians (74.7%) declared that they would support PWD using a DIY AID system; 14.7% denied this question (10.6% were indecisive). Regarding the competences of physicians, only one-third (34.0%) felt competent enough to treat PWD with a DIY AID system but 41.9% felt unsure (24.1% neutral).

Telemedical Consultation

Currently, only 9.6% of the diabetologists considered the option of telemedical video consultations to be important for practical diabetes treatment, but in five years, its importance is expected to be considerably higher (47.3%). On the other hand, diabetologists estimated that only 2.3% of their patients use telemedical services currently; however, they expected that in five years 20.4% of their PWD will use video consultations.

Interoperability

Only 6.2% of the diabetologists believed that the interoperability of different devices and systems is adequate. However, many of them (33.6%) expected interoperability to improve substantially over the next five years.

Privacy Policy

The diabetologists were skeptical about the subject of data protection: only 31.5% stated that they consider the existing data protection regulations to be sufficient, while almost half of the participating physicians (44.3%) perceived that current data protection regulation is restricting them from providing digital services and solutions. This development might be due to the new general data protection regulation established in Europe and Germany recently. The participating physicians rated the probability that unauthorized parties get access to diabetes data of the PWD to 32.1%. These strong concerns are probably also reflected in the assessment that quite a few of the respondents perceived the existing data protection arrangements as insufficient.

Data Donation

An upcoming topic is the possibility of data donation. Within diabetology, plenty of data emerges which can be useful, for example, for research institutes. More than half of the physicians (52.1%) rated the opportunity for PWD to donate diabetes data to approved institutions for scientific purposes as important. When asked about donation to health insurances in return for financial benefit or without financial benefit, this number dropped to 27.4% and 8.9%, respectively. Physicians estimated that 29.9% of their PWD will donate their diabetes data over the next five years.

Discussion

Many PWD are already treated with new technologies. Of course, these numbers are higher in PW1D than PW2D, but especially, iscCGM seems to be a central topic also for PW2D. Maybe the launch of the Freestyle Libre (Abbott Diabetes Care), which was first conducted in Germany, has pushed this development. The rtCGM is used less frequently than iscCGM, primarily because of the higher costs and the need for regular calibration of rtCGM systems of some, respectively older systems.

Regarding the attitudes, the majority of diabetologists reported a positive attitude toward digitalization and new technologies in diabetology as well as toward its potential. Overall, there was greater support for the potential benefits, especially those regarding the patients, than for the potential disadvantages of digitalization and new technologies, which reflects the fundamentally positive attitude on the topic. Therefore, the basis for further developments and integrations of new technologies is established. Especially the lack of a clear reimbursement for digital services seems to be a major issue for diabetologists.

In Germany, as in most other countries, reimbursement of medical services is dependent on the time expenditure and complexity of medical services. Digital solutions are a rapidly developing new field in diabetology, which have the potential to (partially) replace existing medical services or even create new services. As usually, with such rapidly developing new technologies, there are obviously great uncertainties regarding how such digital solutions can be integrated into the existing reimbursement system or that new digital solutions will not be sufficiently reimbursed.

It also has to be stressed that though the disadvantages were rated as rather small, they have to be concerned when new technologies are developed and new digital services are created. Because the correlations of advantages to general attitude toward digitalization and new technologies in diabetology were greater than the correlations of disadvantages, it can be assumed that advantages play a greater role than disadvantages in the perception of physicians.

By asking diabetologists to rank several key topics of digitalization and new technologies in diabetology, it becomes very evident that software for glucose data analysis is a central domain. The lack of compatibility seems to have a larger impact on daily practice routines, as it is also one of the three major topics. Rank three, AIDs, is probably mainly driven by current developments and the hope and force of patients who long for AIDs in Germany.

Gaining continuous glucose data as well as software for analyzing these data is available for some years, so it is quite established in German practice routines. While AIDs on the other side are not yet established well, diabetologists expect this topic to be very important and central in a few years, where they already see the relevance of, for example, software for analyzing glucose data. Still, data protection remains a large topic in Germany and causes many issues, whereas data donation on the other side could be a more useful topic of big data.

All in all, most physicians emphasize the future importance of different topics. The prerequisite for further technological developments of the German diabetology, the positive attitude of the diabetologists, already seems to be given. However, we must bear in mind that in Germany, most PW2Ds are still treated at the primary care level. Therefore, it would be important in future research to find out the views, perceptions, and attitudes of family doctors toward new diabetes technologies and digital solutions.

The D.U.T provides a first overview of the state of digitalization of diabetology in Germany—so far, an unclear topic. About one-fifth of German practices took part in this survey to gain a representative statement about the current state of digitalization of diabetology in Germany. Nevertheless, the limitations of this survey also must be stressed. First, the data only emerges from self-report, where, for example, registry studies could deliver more reliable data about some of the investigated topics. Second, performing this study as an online survey with a random sample represents a bias, because only technically firm diabetologists are willing to take part. Third, also the topic of the survey, technology and digitalization, creates a bias, and thus only interested people are likely to participate.

Conclusion

The results of this survey show that the number of technologies used per facility is high in Germany, that is, their use has become part of everyday life. The overall attitude of diabetologists toward digitalization and adoption of technologic options for diabetes treatment is positive. The advantages experienced or attributed to this development and options appeared to be influential on how this topic is viewed. The diabetologists also rated the potential for improving diabetes therapy in the future by using such options as high. Nevertheless, they see challenges that have not yet been satisfactorily addressed. The topic of telemedicine was perceived as important; however, it is hardly been used currently. The value of digital applications in the context of prevention and diabetes training is currently not estimated to be very high. The lack of interoperability between different systems, which, for example, forces most diabetologists to use different glucose data analysis programs, remains a point of criticism.