Text message program improves outcomes, decreases ED utilization among ED patients with poorly controlled diabetes
Leverage mobile phones to reach disadvantaged patients with limited access to primary care
Emergency providers are generally not trained or well-positioned to provide chronic care management to patients. However, they often must deal with the consequences of poorly managed chronic diseases when patients present with urgent or emergent complications. It's a frustrating situation, especially when the same patients keep coming back to the ED for problems that could have been prevented through better management of their chronic diseases.
Emergency providers who commonly serve disadvantaged populations are especially familiar with the medical consequences of uncontrolled diabetes. "We see the implications of this on every shift," explains Sanjay Arora, MD, an associate professor of emergency medicine at the Keck School of Medicine at the University of Southern California in Los Angeles. "We have people coming in with highly avoidable complications such as diabetic feet, amputations, and blindness, which, with any kind of regular primary care, could have been avoided."
Many of the patients who present to the ED with these problems lack access to primary care either because of financial or time constraints, says Arora. "When the clinics are open, they are working, which prompts them to come to the ED seeking care that we are not really equipped to provide," he says. "We see everyone regardless of insurance status, but the flip side of that is that we can't be expected to do everything. We can't provide primary care, we can't provide education. It is not because we don't want to. It is just that we don't have the time."
Deliver education via text
To get around the problem, Arora and colleagues decided to test the impact of a program that delivered at least some of this important disease management information to patients via a series of automated mobile text messages (mHealth) transmitted over a six-month period. The program, called TExT-MED (Trial to Examine Text Message Based mHealth in ED Patients with Diabetes) included daily messages that were either motivational or instructional.1
For example, a text message might tell patients that controlling their blood glucose, blood pressure, and cholesterol can lead to a longer life, or the message might instruct patients to eat more fruits, vegetables, beans, and whole grains, and to consume less salt and fat. The program also included three medication reminders per week, and there were two so-called healthy living challenges sent to patients each week. These might instruct patients to avoid drinking any soda or juice that day or to examine food labels to find a snack that contains fewer than 100 calories. In addition, patients received two trivia questions per week, derived from the National Diabetes Education Program materials. Answers to the trivia questions were disseminated via text message one hour following the questions.
"The thought behind this was let's try picking a technology that we know all of these patients have and are comfortable with and try to teach them the things that we would all like to teach them, but don't have the time to do," says Arora. "We thought we could do it equally well via an automated text-messaging program that wouldn't take up any of the physician's time."
The program, which was developed by four physicians and two certified diabetes educators, was prepared in both English and Spanish versions. The stated goals of the effort were to improve glycemic control, promote self-care behaviors, and to augment self-efficacy.
Because this was a randomized, controlled trial, research assistants were on hand in the ED at the test site: Los Angeles County Hospital at the University of Southern California, a large safety-net facility, serving more than 170,000 low-income patients each year. The research assistants tested the baseline knowledge of study participants, and they assessed their quality of life and level of self-care. They also had to obtain informed consent, so there was a process in place to get patients enrolled.
However, Arora notes that in the real world, engaging patients in this type of program could be as simple as having a poster on the wall explaining the program, or handing patients a piece of paper with a phone number they can call to activate the text-messaging program. "Our research has shown that even in low-income populations, the vast majority of patients are already on unlimited text messaging plans," he says.
Further, Arora notes that automated mobile health interventions of this nature tend to be very inexpensive if they are done on a large scale. "We are talking pennies per message, which is a very small charge," he adds. "What we have here is a very hard-working and considerate Latino population who suffer a disproportionate burden of diabetes. They have twice as much diabetes as their white counterparts, and so it just seemed morally like a good thing to do for our patients."
Consider culture, understanding
Researchers identified a total of 128 patients to participate in the trial. They all had glycosylated hemoglobin (Hb A1c) levels that were equal to or greater than 8% — an indication of poorly controlled diabetes. Patients randomized to the control group received usual care, and patients randomized to the treatment group received usual care plus the daily text messages sent to their mobile phones. The messages were delivered in either English or Spanish, depending on the patient's preference.
At six months, the researchers report that Hb A1c levels decreased by 1.05% in the intervention group compared to 0.60% in the control group. Further, self-reported medication adherence improved from 4.5 to 5.4 (as measured on an 8 point scale) in the intervention group versus a decrease of 0.1 in the control group.
The text messages also appeared to have an impact on ED utilization. The researchers note that during the six-month study period, 35.9% of patients in the intervention group presented to the ED for care, as compared to 51.6% of patients in the control group.
Interestingly, the magnitude of improvement on all of these outcomes was greater among Latinos than patients of other ethnicities — a finding that does not surprise Arora. "They tend to be the ones who are most disenfranchised in our system because of cultural discordance and language discordance with providers," he says. "This [program] was all culturally competent. We put it through multiple iterations of focus groups, and worked with the local community to make sure that the standard version of this was on point — they would get it, they would relate to it, and they would understand it. I don't think they ever received much education like this before."
Engage family, friends
Since the trial, the intellectual property rights to the TExT-MED program have been purchased from the University of Southern California by Nashville, TN-based Agile Health, LLC, which is further developing the approach. The program now includes more messages and more personalization, explains Arora. "It also has some more advanced keyword functionality where there can be some automated interaction between the program and the patient," he says. "It is enhancing that feeling of physician-patient contact without actually having the physician involved, which is what makes the program so scalable."
Further, Arora and colleagues have just commenced a second trial, testing the impact of another text-messaging program that is designed for the friends and family of patients with diabetes.
"We are going to be giving diabetic patients the same TExT-Med curriculum, but then also having them identify a family member, friend, or someone in their social network who they think will have the biggest impact on their health," says Arora. "These people won't get the same messages, but they will get mirrored messages tailored to help them encourage their brother, sister, father, or friend to take their medicines today or help them go for a walk, so it is involving the family."
Arora emphasizes that the text-messaging programs are not trying to be a surrogate physician or to offer any kind of medical advice. Rather, the goal is to put diabetes and medical care on the radar screen of people who are typically more concerned with keeping their jobs and bringing home a paycheck, he says. "It is to get their heads continually focused on [the fact] that this [disease] isn't going away, they need to deal with it, and it needs to move up on the ladder [of priorities]," observes Arora. "Then eventually, hopefully, they will get into primary care and they won't need the program anymore."
- Arora S, Peters A, Burner E, et al. Trial to Examine Text Message-based mHealth in Emergency Department patients with diabetes (TExT-MED): A randomized controlled trial. Ann Emerg Med. 2013 Nov 5. [Epub ahead of print].
- Sanjay Arora, MD, Associate Professor, Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA. E-mail: firstname.lastname@example.org.