Positive exploitation of the exponential growth and development seen in the information and communication technology (ICT) sector in the last decade has provided novel solutions to operational challenges such as overcrowding and staff shortages within the health care arena. Telemedicine has emerged as one such advancement and has seen rapid diffusion for the management of chronic diseases in particular. Diabetes is one such condition that has proven to be readily adaptable to self-management and remote monitoring.

Mobile health (mHealth) is a facet of telemedicine focusing on the use of mobile phone technology to facilitate exchange of health information between the patient and the caregiver. Increasingly, apps downloaded by the patient-user to personal handheld smart devices, such as phones or tablets, are used as data-capturing tools, conduits to share and exchange health information, and repositories of disease-specific information and education [1]. There are an estimated 3.8 million smartphone users in Ireland, representing an increase of 16.8% since 2018. Smartphone penetration rates Europewide reflect this trend, with projected ownership rates of 87%, 92%, and 94% by 2025 in France, Germany, and the United Kingdom, respectively [2].

This review sought to evaluate the smartphone apps that have been developed for gestational diabetes mellitus (GDM) to promote patient-centered care through the surveillance of markers of glycemic control, such as blood glucose levels, diet, exercise, and weight management. mHealth promotes a precision medicine model of care by maintaining channels of communication between patients and their health care professional while focusing the onus of disease management on the patients themselves. Such responsibility has been shown to foster improved patient compliance and satisfaction levels and represents an exciting new chapter in GDM care [3]. Demonstration of improved glycemic control has been shown from use of smartphone app–based interventions for adults with type 2 diabetes mellitus [4]. Treatment strategies for GDM and type 2 diabetes mellitus are similar, encompassing medical nutrition therapy, lifestyle modifications, and self-assessment of daily blood glucose levels, such that the patient with GDM is perfectly poised to benefit from app-assisted care.

Previous reviews have examined mHealth in the context of all types of diabetes rather than a specific focus on GDM [5]. Leblalta et al [6] addressed all digital health interventions available to support women with GDM, including models of web-based care that have arguably become outdated. We sought to refine this existing knowledge by exploring further and assessing the surveillance strategies and capabilities afforded by smartphone apps for women with GDM.

The electronic database search yielded 954 results. Subsequent removal of duplicates resulted in 714 articles for title and abstract screening. A further 597 references were then excluded, as they did not meet the inclusion criteria. The remaining 117 articles were subject to full-text screening. An additional 5 studies obtained following forward citation searching were also screened by full-text review. This process resulted in the exclusion of 105 articles. Excluded studies included those describing the use of mobile phone technology without specific use of a smartphone app, descriptions of software and technological architecture development, and studies relating solely to web-based interventions (Textbox 1). Ultimately, 17 articles were included in the final review.

There were 17 studies included in this review, the characteristics of which are represented in Table 2. The included studies were published between 2010 and 2022, with the majority (16/17, 94%) published during or since 2018. The studies were conducted across 11 countries, with 7 from Asia, 6 from Europe, 3 from Australia, and 1 from the United States. There were 10 randomized controlled trials (RCTs), 5 pilot intervention studies, 1 qualitative study, and 1 case series. The number of participants ranged from 4 participants in the case series to 340 in the largest of the RCTs (mean 111; median 100).

This scoping review provides a comprehensive overview of the availability and functionality of smartphone apps capable of the generating remote feedback in the surveillance of women with GDM. We have noted that app-assisted care is noninferior to standard clinic-based care in terms of glycemic treatment targets, and in fact, half the reviewed studies identified an improvement in overall glycemic control [10-12,15,20-24]. Such evidence demonstrates the feasibility of adopting app-assisted health care for GDM.

If the adoption and diffusion of app-assisted platforms as a viable aspect of surveillance are to be successful, patient and staff satisfaction and acceptability levels must be high. Continued use of novel solutions in health care management, such as smartphone apps, requires accessible, easily interpretable, and aesthetically pleasing interfaces. Additionally, behavioral intention has been highlighted as a significant determinant of ongoing health technology use and engagement by the patient [27]. Other factors that should be taken into consideration in the development and dissemination stage of artificial intelligence–assisted technologies are personal innovativeness or the willingness to engage in a new health solution as well as performance and effort expectancy [27-29]. In this review, we have shown that over half of the reviewed studies (10/17, 58 %) did not seek to assess patient or staff satisfaction levels, although we acknowledge that secondary analyses might have explored these themes. Three studies did assess patient compliance with the mandated monitoring schedule and thus satisfaction can be inferred, although not proven, from continued usage behavior in these studies [10,15,24]. Where satisfaction was assessed, all studies reported positive experiential expressions from the app-using groups [9,16-19,22]. Such expressions included reassurance that blood glucose levels were being reviewed frequently, and often in real time, by the obstetric diabetes team and feelings of self-efficacy, autonomy, and convenience. Satisfaction among staff users of the app-linked technologies was only assessed in 3 studies. Effective and time-efficient management was the most commonly identified theme. Ensuring collaboration and endorsement between all stakeholders in a novel ICT-based health intervention is crucial to its success. Cognitive trust has been found to be an impacting factor on the behavioral intentions of physicians’ use and endorsement of app-assisted health care [30]. Robust RCTs prior to mass product circulation will contribute to allaying trust concerns with the technology.

The impact of resource utilization and economic benefit have been promoted as hugely beneficial effects of telemedicine, and by extension, so have mHealth management strategies [31,32]. These themes were only explored in 5 of the studies [8-10,16,18]. A statistically significant reduction in resource use by app-using women was noted by one study, and this reduction resulted in an overall cost saving for the hospital [16]. An analysis by another study, however, did not report significant cost savings [9]. Finally, one study reported an increase in the number of low-utility clinic visits among app users compared with a historical control group [18]. This may be a result of increased compliance with self-monitoring leading to a greater numbers of hyperglycemic episodes that need to be evaluated. This particular study did not offer feedback relating to uploaded glycemic indices or lifestyle patterns, and addition of these capabilities to the app technology would likely have an impact on requirement for in-person hospital review. Such considerations should be given due attention during early iterations of the app development phase.

The evidence collated in this review demonstrates achievement of equivalent or improved glycemic control, confirms noninferior maternal and neonatal outcomes, and highlights the potential for reduced resource utilization and economic efficiency among women availing of app-assisted health care delivery for GDM. The transition towards incorporation of mHealth technologies such as smartphone apps has been welcomed by women with GDM who have shown high levels of satisfaction with a self-monitored remote management strategy. Key to the success of such smartphone apps is the maintenance of communication between the patient and her obstetric diabetes team. To optimize this alliance, a bidirectional communication strategy, as described in 8 of the studies in this review, would likely help to obviate the requirement for many women with well-controlled GDM to attend the hospital for in-person review without impacting on their sense of team involvement or hospital oversight. The resource implications of such a strategy are not limited to the hospital infrastructure alone, with benefits envisaged for the patient through the potential avoidance of financial and time constraints associated with frequent hospital attendances.

Given the rapid expansion of the telehealth sector, this review of app-assisted health care facilitating remote feedback in the setting of GDM is timely and judicious. However, to allow for comprehensive knowledge acquisition of the potential benefits and drawbacks of telemedicine and mHealth management of GDM, further research is still required. For instance, only 1 study in this review adapted a smartphone app for a culturally diverse audience [13]. In an era of great ethnic diversity within populations, absence of such a feature could be an exclusory factor. Further, patients who are willing to partake in research studies are more likely to be health and eHealth literate which may introduce bias into the study cohorts. Finally, the impact of app-assisted health care and remote surveillance needs robust health economic assessments to enable the refinement of existing technology such that app-assisted systems can viably become integrated into routine medical practice.