What Livongo Success May Mean for Digital Health and Chronic Disease Managment
Livongo Research Review
What is their story?
Livongo has been on my radar for some time, but only recently have I seen a number of publications from them that made me pause and consider what impact they will have on patient care. This could be due to Livongos potential upcoming IPO, and their attempt to boost recognization of their brand. In any event, I want to touch upon two areas that I think are worth digging into, including Livongos impact on blood pressure management and diabetes.
What is Livongo?
For those unfamiliar with Livongo, they are essentially a new digital health company focused on the utilization of wearables and digital coaching to help manage chronic conditions. They will send members a package including items like a Bluetooth blood pressure cuff or blood glucose monitor, which then collects data and syncs with their app. The platform will also send notifications and tips for the patient about what they can do to help manage their condition, and give feedback on good work. In a way, it's a digital coach and is similar to some other platforms like Omada Health.
Why are these platforms popular now?
Well, a lot of digital health has been focused on the use case of integrating sensors and apps and other software to help nudge patients to make healthy behavior changes. My favorite area is medication adherence, such as paying to take the drug or feedback to family members when nonadherence is noted for example. Not everyone can have a personal coach, and creating some software that follows current guidelines and best practices to advise patients on healthy behaviors isn't hard at this point. In fact, digital health offers a good opportunity to scale up these features for patients that we just don't have the resources currently in place for. So health plans and payors are quickly taking notice of these platforms as a form of intermediary health tool for their members. The obvious mechanic gives this to newly diagnosed patients with a chronic condition (e.g., DM, HTN) that we know can cost a significant amount of money if not properly managed, and if they fail with the digital tool, then refer them to in-person visits or upscale their personal treatment plan. I would be the first person to argue that there are many 'healthy adherers' out there that probably do not need as many in-person touch points for their management compared to others, but it is definitely hard to figure out and technology luckily offers that ability.
Whats the data show so far?
Well, as I mentioned, Livongo has some interesting data coming out. However, I would argue they are really pushing the diabetic track at this time. Interestingly, Jodi Pulizzi, RN, Director of Content for Livongo is on the task force for the 2017 National Standards for Diabetes Self-Management Education and Support. I would argue that it can be expected that Livongo (and others) want to see standards and guidelines steadily adopt a language incorporating telehealth and digital health ingress into current standard clinical practice.
Hypertension Focused Research
Recently, at the American College of Cardiology 2019 meeting, they presented a poster titled "REMOTE MONITORING OF BLOOD PRESSURE IN T2D POPULATION DECREASES SYSTOLIC BLOOD PRESSURE AT 6 WEEKS: A PILOT STUDY," with an accompanying interview with ACC staff. Essentially, the pilot study looked at 276 members of six self-insured employer clients (after inviting 700 to participate). They were giving a Bluetooth BP device, and education on HTN management and offered a health coach. The study saw after 6 weeks of monitoring and engagement with the intervention, a decrease of 11.2 [15.6] / 5.18 [10.1] mmHg (p=0.004) along with the addition of 13 new medications for the participants.
Interestingly, when looking at the data here and the interview, there still seemed to be a population of members who didn't reach their target BP level, though overall the success seemed good. I will revisit this point at the end.
Diabetes Focused Research
Livongo has done more research on this condition, with several publications worth identifying:
"Use of a Connected Glucose Meter and Certified Diabetes Educator Coaching to Decrease the Likelihood of Abnormal Blood Glucose Excursions: The Livongo for Diabetes Program (2017)." - This study more or less set up the premise of the Livongo platform and looked at enrolled members from October 2014 to December 2015. Data collected from 4544 participants demonstrated a reduced rate of hypoglycemia and hyperglycemia with the use of remote BG tracking and health coach intervention. The obvious implication is the reduced rate of ER visits for plans with patients with recurrent hypoglycemia events.
"Remote Lifestyle Coaching Plus a Connected Glucose Meter with Certified Diabetes Educator Support Improves Glucose and Weight Loss for People with Type 2 Diabetes (2018)." - In this study, 330 adults received a two-way messaging glucose meter, test strips and access to a DM educator/coach. Randomization occurred with 4 groups, no intervention, a connected scale added on, a connected scale and light coaching, and a connected scale and intense coaching over the course of 12-weeks. Interestingly, all groups saw an improvement in BG, though higher with intensive coaching (but incurring 5.5X costs).
"Reduced medical spending associated with increased use of a remote diabetes management program and lower mean blood glucose values (2019)." - The most recent study in conjunction with Eli Lilly (who I have mentioned before as getting into the digital health space significantly) which evaluated costs affiliated with remote digital DM management. It was a retrospective study of medical claims data and BG data and compared 2261 participants in Livongo with 8741 nonmembers. Costs comparison of medical spending between those with well-controlled and poorly controlled DM was conducted using their analytical methods. Interestingly, this economical study demonstrated an overall reduction of costs for patients enrolled in the Livongo platform compared with non-participants.
Other Studies - ClinicalTrials.gov has two other studies listed, including integrating the Livongo platform with remote monitoring by the patients care team and track changes with A1c, and other study evaluating the Livongo platform versus blood glucose tracking using the iHealth Glucose Meter (which I find rather interesting).
What are the takeaway points from these studies?
Let me preface this by saying I honestly believe that what Livongo, Omada, and others are doing will likely be the future of care. They have shown that some participants can benefit extremely well from their platform and meet objectively measured goals for chronic disease management in DM an HTN. In the realm of Evidence-Based Medicine (EBM), we see disease-oriented endpoints (DOE) being met, but the shortcoming of patient-oriented evidence that matters (POEM) is missing. I would chalk this up to the length of the studies being run as short-term and hard to determine whether Livongos platform leads to a reduction of macrovascular (heart attacks) and microvascular (kidney issues, etc) complications. After all, even the FDA has put more pressure on pharma to show that medications lead to more than a drop in BG or A1c and need to demonstrate appreciable patient outcomes that matter.
However, the fact that these disease endpoints are being met is enough I say to get the platforms more credence for utilization. Let further RCT and RWE studies investigate longterm impacts. I would hypothesize that we would see a reduction in patients.
Nonetheless, there are patients who are not meeting their endpoints in some of these mentioned studies. And I think these have some serious implications for the pharmacy space.
What Livongo and Similar Companies could mean for pharmacy
Several items I would identify for those in the pharmacy industry to consider when looking at these platforms:
Retail Pharmacy Uptake - Why pay pharmacists to offer counseling services when companies like CVS with their expansion with healthhubs could just partner with Livongo and recommend their service? Cost wise, maybe a reduction and expand access for patients to care
A gap in Care Start-ups - Other companies may have an opportunity here, albeit small, where they try to create a company that can address remote patient management of patients that do not succeed with health coaching alone and bill for RPM and manage therapy remotely. This has been done, but no company I am aware of is making it a business. In all honesty, it is costly having a staff (maybe and Uber mechanisms like companies like RO and Hims and Nurx?) and liability and monitoring and licensing concerns related to telehealth. But...
These companies could expand care - Livongo could also aim to eventually do the same thing internally and bring on pharmacists or mid-level practitioners to do the same thing and outpace any new start-up if they want to or see it as a threat.
Well, that concludes by dive into Livongo and hope you found it interesting, please feel free to leave comments!