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In busy ED, text message program can reach sickest patients with diabetes
SAN FRANCISCO — The ED is a novel location to find some of the sickest patients in need of diabetes care, and a simple mobile health intervention using text messaging can serve as way to bridge the gap between a patient’s urgent visit and finding stable health care, according to a speaker at the American Diabetes Association Scientific Sessions.
“One of the unique things about the emergency department is this may be the only place some of these patients touch the health care system,” Sanjay Arora, MD, vice chair for research and scholarship and associate professor of emergency medicine at the Keck School of Medicine at the University of Southern California and LA County Hospital, said during a presentation. “They [may not] have doctors. If you base your interventions or your programs only in outpatient clinics, you’re going to miss a big portion of the population who really need that help.”
People with diabetes often come to the ED for non-emergencies for several reasons, Arora said. Often, there are barriers to outpatient care for people who work nontraditional hours, lack transportation or do not speak English. Still others seek medical help only when symptoms for a perhaps long-standing illness become difficult to manage, Arora said.
All of this, Arora said, creates a problem: The ED is open 24/7 and often has bilingual staff members, but it also has fixed costs, overcrowding and providers who are limited by training and time. LA County Hospital, he noted, is the busiest ED in the nation, serving 500 patients daily as the flagship of the safety net system in Los Angeles.
“We are a group of providers who would love to be able to help these people who come seeking care, but we just can’t,” Arora said. “We don’t have the time, and we don’t have the training to do it. Importantly, the ED does serve as a very novel location to be thinking about defined patients in need of care.”
The ED is a place where providers will encounter high-risk populations in need of activation and engagement, who are often resource-poor, Arora said.
“They are at a perfect moment to actually enact change,” Arora said. “They are having a health crisis. They are thinking about their health, and that is why they are at the emergency department. We should be using that moment to bridge the gap between their urgent visit and a more stable, long-term outpatient experience.”
Solutions must be pragmatic and scalable, Arora said. An ED simply does not have the available space for providers to spend 1 hour or more going over insulin dosing procedures with multiple patients on a daily basis.
Text message-based intervention
To better reach these patients, Arora and colleagues opted to make use of a personal mobile device to enact a text-based intervention — TExT-MED, a unidirectional program that was fully automated and free with a bilingual program. The researchers first conducted focus groups with the target population of people with type 2 diabetes visiting the ED and solicited expert feedback from diabetes educators and endocrinologists.
“For example, when we did some knowledge surveys, we found that 85% of our patients didn’t know what the symptoms of hypoglycemia were,” Arora said. “We figured it was important to [include] hypoglycemia education.”
Arora and colleagues analyzed data from 128 patients with newly diagnosed type 2 diabetes and an HbA1c of at least 8%, recruited from the ED of LA County Hospital (mean age, 50 years; 64% women; 87% Hispanic; 72% Spanish-speaking; mean HbA1c, 10.1%). Patients assigned to the intervention group (n = 64) received two tailored text messages per day for 6 months; controls (n = 64) received the same information in the form of an educational pamphlet. The intervention included four different message types: challenges (“Eat only fruits and vegetables for one meal today.”), motivational (“Diabetes is serious, but you can learn to manage it.”), trivia (“Eating too much sugar is a cause of diabetes. A. True or B. False”) and medication reminders.
At 6 months, the researchers observed greater improvements in HbA1c in the intervention group vs. controls (mean decrease, –1.05% vs. –0.6%), as well as improved medication adherence, and trends toward improvement in quality of life and self-efficacy measures that did not rise to significance. The researchers also observed a 20% reduction in ED utilization among those assigned to the text message group, Arora said. In surveys after the intervention, most patients said receiving two text messages per day was adequate, Arora said, noting that most said they felt that receiving three messages per day was too many.
The program has since been commercialized by Agile Health, and more than 10,000 patients are now enrolled in the text-based intervention, according to Arora. Internal findings reported by Agile Health were similar to data reported during the study, he said. Additionally, new data showed a 44% increase in patients working with a case manager without adding more personnel, Arora said.
Driving outpatient care
Arora said a secondary module, called TExT-MED-FANS, designed for friends and family support persons, is now in the randomized controlled trial phase. The new intervention leverages the success of TExT-MED by augmenting the program with a social supporter that each patient can select from his or her own support system. Patients and their support persons receive similar health-related text messages, synchronized by time and content. The study, which includes 166 patients with type 2 diabetes recruited from the ED, is expected to be completed in December.
“The purpose of the text message program is not to replace outpatient care or a health care system navigator,” Arora said during a question and answer session after the presentation. “It is meant to augment those things. It is meant to get it in the patient’s mind that this is something they need to be thinking about every single day, twice a day. It is meant to drive outpatient care, not in any way replace it.” – by Regina Schaffer
Reference:
Arora S. Improving quality of care and safety in the inpatient setting. Presented at: American Diabetes Association 79th Scientific Sessions; June 7-11, 2019; San Francisco.
Disclosure: Arora reports he serves as a consultant for Agile Health.