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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

Number of patients who reached optimal insulin dose within 12 weeks. Note: for patients that did not reach optimal dose, 3 of 4 patients in the MITI arm and 1 of 17 in the usual care arm did not receive the allocated intervention.
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figure2: Number of patients who reached optimal insulin dose within 12 weeks. Note: for patients that did not reach optimal dose, 3 of 4 patients in the MITI arm and 1 of 17 in the usual care arm did not receive the allocated intervention.

Mentions: The primary outcome was the number of patients that reached their optimal insulin glargine dose within 12 weeks. In the MITI arm, 29 of 33 patients (88%, 95% CI 72%-97%) reached their optimal dose. Of the 29 patients who met optimal dose, 27 did so by achieving a fasting blood glucose value between 80 and 130 mg/dL (inclusive). Two patients reached the maximum dose that could be safely administered. In the usual care arm, 10 of 27 patients (37%, 95% CI 19%-58%) reached their optimal dose (Figure 2). Of the 10 patients in the usual care arm that reached their optimal dose, 9 did so by achieving a fasting blood glucose between 80 and 130 mg/dL. One patient met this goal by reaching the maximum dose that could safely be administered. The primary outcome could not be measured for one usual care patient who discontinued insulin glargine early due to a possible allergic reaction. The MITI arm had a significantly greater proportion of patients reach their optimal insulin glargine dose (OR 12.3, 95% CI 3.3-45.4, P<.001).


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)

Number of patients who reached optimal insulin dose within 12 weeks. Note: for patients that did not reach optimal dose, 3 of 4 patients in the MITI arm and 1 of 17 in the usual care arm did not receive the allocated intervention.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

figure2: Number of patients who reached optimal insulin dose within 12 weeks. Note: for patients that did not reach optimal dose, 3 of 4 patients in the MITI arm and 1 of 17 in the usual care arm did not receive the allocated intervention.
Mentions: The primary outcome was the number of patients that reached their optimal insulin glargine dose within 12 weeks. In the MITI arm, 29 of 33 patients (88%, 95% CI 72%-97%) reached their optimal dose. Of the 29 patients who met optimal dose, 27 did so by achieving a fasting blood glucose value between 80 and 130 mg/dL (inclusive). Two patients reached the maximum dose that could be safely administered. In the usual care arm, 10 of 27 patients (37%, 95% CI 19%-58%) reached their optimal dose (Figure 2). Of the 10 patients in the usual care arm that reached their optimal dose, 9 did so by achieving a fasting blood glucose between 80 and 130 mg/dL. One patient met this goal by reaching the maximum dose that could safely be administered. The primary outcome could not be measured for one usual care patient who discontinued insulin glargine early due to a possible allergic reaction. The MITI arm had a significantly greater proportion of patients reach their optimal insulin glargine dose (OR 12.3, 95% CI 3.3-45.4, P<.001).

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