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The Mobile Insulin Titration Intervention (MITI) for Insulin Adjustment in an Urban, Low-Income Population: Randomized Controlled Trial.

Levy N, Moynihan V, Nilo A, Singer K, Bernik LS, Etiebet MA, Fang Y, Cho J, Natarajan S - J. Med. Internet Res. (2015)

Bottom Line: A significantly greater proportion of patients in the intervention arm reached their optimal insulin glargine dose than patients in the usual care arm (88%, 29/33 vs 37%, 10/27; P<.001).The intervention was feasible and patients were highly satisfied with their treatment.The intervention was cost saving in terms of time for patients, who were able to have their insulin titrated without multiple clinic appointments.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York, NY, United States.

ABSTRACT

Background: Diabetes patients are usually started on a low dose of insulin and their dose is adjusted or "titrated" according to their blood glucose levels. Insulin titration administered through face-to-face visits with a clinician can be time consuming and logistically burdensome for patients, especially those of low socioeconomic status (SES). Given the wide use of mobile phones among this population, there is the potential to use short message service (SMS) text messaging and phone calls to perform insulin titration remotely.

Objective: The goals of this pilot study were to (1) evaluate if our Mobile Insulin Titration Intervention (MITI) intervention using text messaging and phone calls was effective in helping patients reach their optimal insulin glargine dose within 12 weeks, (2) assess the feasibility of the intervention within our clinic setting and patient population, (3) collect data on the cost savings associated with the intervention, and (4) measure patient satisfaction with the intervention.

Methods: This was a pilot study evaluating an intervention for patients requiring insulin glargine titration in the outpatient medical clinic of Bellevue Hospital Center in New York City. Patients in the intervention arm received weekday SMS text messages from a health management platform requesting their fasting blood glucose values. The clinic's diabetes nurse educator monitored the texted responses on the platform website each weekday for alarm values. Once a week, the nurse reviewed the glucose values, consulted the MITI titration algorithm, and called patients to adjust their insulin dose. Patients in the usual care arm continued to receive their standard clinic care for insulin titration. The primary outcome was whether a patient reached his/her optimal insulin glargine dose within 12 weeks.

Results: A total of 61 patients consented and were randomized into the study. A significantly greater proportion of patients in the intervention arm reached their optimal insulin glargine dose than patients in the usual care arm (88%, 29/33 vs 37%, 10/27; P<.001). Patients responded to 84.3% (420/498) of the SMS text messages requesting their blood glucose values. The nurse reached patients within 2 attempts or by voicemail 91% of the time (90/99 assigned calls). When patients traveled to the clinic, they spent a median of 45 minutes (IQR 30-60) on travel and 39 minutes (IQR 30-64) waiting prior to appointments. A total of 61% (37/61) of patients had appointment copays. After participating in the study, patients in the intervention arm reported higher treatment satisfaction than those in the usual care arm.

Conclusions: MITI is an effective way to help low-SES patients reach their optimal insulin glargine dose using basic SMS text messaging and phone calls. The intervention was feasible and patients were highly satisfied with their treatment. The intervention was cost saving in terms of time for patients, who were able to have their insulin titrated without multiple clinic appointments. Similar interventions should be explored to improve care for low-SES patients managing chronic disease.

Trial registration: Clinicaltrials.gov NCT01879579; https://clinicaltrials.gov/ct2/show/NCT01879579 (Archived by WebCite at http://www.webcitation.org/6YZik33L3).

No MeSH data available.


Related in: MedlinePlus

CONSORT diagram.
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figure1: CONSORT diagram.

Mentions: Patients were recruited from June 2013 to December 2013 and May 2014 to December 2014. Follow-up data were collected until March 2015. We screened 132 patients for eligibility; 54 were ineligible and 17 declined to participate (Figure 1). A total of 61 patients consented and were randomized into the study; 33 in the MITI arm and 28 in the usual care arm. There were 36 patients who were stratified as new to insulin treatment and 25 that were having their existing insulin dose adjusted. Of these 61 patients, there were 6 patients (5 in MITI and 1 in usual care) who met inclusion criteria when screened at the time of enrollment, but were discovered to be ineligible to participate soon after they consented and were randomized. Of the 5 ineligible patients randomized to the MITI arm, 3 had prepaid mobile phones that were not able to sign up for our SMS text messaging platform, 1 was not starting insulin glargine, and 1 did not return to the clinic to complete enrollment. The ineligible patient randomized to the usual care arm phenotypically fit a type 1 diabetes diagnosis. These 6 patients did not receive the allocated intervention, but were included in the intention-to-treat analysis. No significant differences in baseline characteristics/demographics were found between the 2 study arms. Demographics of participants are shown in Table 1.


The Mobile Insulin Titration Intervention (MITI) for Insulin Adjustment in an Urban, Low-Income Population: Randomized Controlled Trial.

Levy N, Moynihan V, Nilo A, Singer K, Bernik LS, Etiebet MA, Fang Y, Cho J, Natarajan S - J. Med. Internet Res. (2015)

CONSORT diagram.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4527003&req=5

figure1: CONSORT diagram.
Mentions: Patients were recruited from June 2013 to December 2013 and May 2014 to December 2014. Follow-up data were collected until March 2015. We screened 132 patients for eligibility; 54 were ineligible and 17 declined to participate (Figure 1). A total of 61 patients consented and were randomized into the study; 33 in the MITI arm and 28 in the usual care arm. There were 36 patients who were stratified as new to insulin treatment and 25 that were having their existing insulin dose adjusted. Of these 61 patients, there were 6 patients (5 in MITI and 1 in usual care) who met inclusion criteria when screened at the time of enrollment, but were discovered to be ineligible to participate soon after they consented and were randomized. Of the 5 ineligible patients randomized to the MITI arm, 3 had prepaid mobile phones that were not able to sign up for our SMS text messaging platform, 1 was not starting insulin glargine, and 1 did not return to the clinic to complete enrollment. The ineligible patient randomized to the usual care arm phenotypically fit a type 1 diabetes diagnosis. These 6 patients did not receive the allocated intervention, but were included in the intention-to-treat analysis. No significant differences in baseline characteristics/demographics were found between the 2 study arms. Demographics of participants are shown in Table 1.

Bottom Line: A significantly greater proportion of patients in the intervention arm reached their optimal insulin glargine dose than patients in the usual care arm (88%, 29/33 vs 37%, 10/27; P<.001).The intervention was feasible and patients were highly satisfied with their treatment.The intervention was cost saving in terms of time for patients, who were able to have their insulin titrated without multiple clinic appointments.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York, NY, United States.

ABSTRACT

Background: Diabetes patients are usually started on a low dose of insulin and their dose is adjusted or "titrated" according to their blood glucose levels. Insulin titration administered through face-to-face visits with a clinician can be time consuming and logistically burdensome for patients, especially those of low socioeconomic status (SES). Given the wide use of mobile phones among this population, there is the potential to use short message service (SMS) text messaging and phone calls to perform insulin titration remotely.

Objective: The goals of this pilot study were to (1) evaluate if our Mobile Insulin Titration Intervention (MITI) intervention using text messaging and phone calls was effective in helping patients reach their optimal insulin glargine dose within 12 weeks, (2) assess the feasibility of the intervention within our clinic setting and patient population, (3) collect data on the cost savings associated with the intervention, and (4) measure patient satisfaction with the intervention.

Methods: This was a pilot study evaluating an intervention for patients requiring insulin glargine titration in the outpatient medical clinic of Bellevue Hospital Center in New York City. Patients in the intervention arm received weekday SMS text messages from a health management platform requesting their fasting blood glucose values. The clinic's diabetes nurse educator monitored the texted responses on the platform website each weekday for alarm values. Once a week, the nurse reviewed the glucose values, consulted the MITI titration algorithm, and called patients to adjust their insulin dose. Patients in the usual care arm continued to receive their standard clinic care for insulin titration. The primary outcome was whether a patient reached his/her optimal insulin glargine dose within 12 weeks.

Results: A total of 61 patients consented and were randomized into the study. A significantly greater proportion of patients in the intervention arm reached their optimal insulin glargine dose than patients in the usual care arm (88%, 29/33 vs 37%, 10/27; P<.001). Patients responded to 84.3% (420/498) of the SMS text messages requesting their blood glucose values. The nurse reached patients within 2 attempts or by voicemail 91% of the time (90/99 assigned calls). When patients traveled to the clinic, they spent a median of 45 minutes (IQR 30-60) on travel and 39 minutes (IQR 30-64) waiting prior to appointments. A total of 61% (37/61) of patients had appointment copays. After participating in the study, patients in the intervention arm reported higher treatment satisfaction than those in the usual care arm.

Conclusions: MITI is an effective way to help low-SES patients reach their optimal insulin glargine dose using basic SMS text messaging and phone calls. The intervention was feasible and patients were highly satisfied with their treatment. The intervention was cost saving in terms of time for patients, who were able to have their insulin titrated without multiple clinic appointments. Similar interventions should be explored to improve care for low-SES patients managing chronic disease.

Trial registration: Clinicaltrials.gov NCT01879579; https://clinicaltrials.gov/ct2/show/NCT01879579 (Archived by WebCite at http://www.webcitation.org/6YZik33L3).

No MeSH data available.


Related in: MedlinePlus