Trial to examine text message-based mHealth in emergency department patients with diabetes (TExT-MED): a randomized controlled trial.
OBJECTIVE
Increasingly, low-income inner-city patients with diabetes utilize emergency departments (EDs) for acute and chronic care. We seek to determine whether a scalable, low-cost, unidirectional, text message-based mobile health intervention (TExT-MED) improves clinical outcomes, increases healthy behaviors, and decreases ED utilization in a safety net population.


METHODS
We conducted an randomized controlled trial of 128 adult patients with poorly controlled diabetes (glycosylated hemoglobin [Hb A1C] level ≥8%) in an urban, public ED. The TExT-MED group received 2 daily text messages for 6 months in English or Spanish. The primary outcome was change in Hb A1C level. Secondary outcomes included changes in medication adherence, self-efficacy, performance of self-care tasks, quality of life, diabetes-specific knowledge, ED utilization, and patient satisfaction.


RESULTS
Hb A1C level decreased by 1.05% in the TExT-MED group compared with 0.60% in the controls (Δ0.45; 95% confidence interval [CI] -0.27 to 1.17) at 6 months. Secondary outcomes favored the TExT-MED group, with the most sizable change observed in self-reported medication adherence (as measured by the Morisky Medication Adherence Scale, an 8-point validated scale with higher scores representing better adherence), which improved from 4.5 to 5.4 in the TExT-MED group compared with a net decrease of -0.1 in the controls (Δ1.1 [95% CI 0.1 to 2.1]). Effects were larger among Spanish speakers for both medication adherence (1.1 versus -0.3; Δ1.4; 95% CI 0.2 to 2.7) and Hb A1C (-1.2% versus -0.4%) in the TExT-MED group. The proportion of patients who used emergency services trended lower in the TExT-MED group (35.9% versus 51.6%; Δ15.7%; 95% CI 9.4% to 22%). Overall, 93.6% of respondents enjoyed TExT-MED and 100% would recommend it to family/friends.


CONCLUSIONS
The TExT-MED program did not result in a statistically significant improvement in Hb A1C. However, trends toward improvement in the primary outcome of Hb A1C and other secondary outcomes, including quality of life, were observed, the most pronounced being improved medication adherence. TExT-MED also decreased ED utilization. These findings were magnified in the Spanish-speaking subgroup. Technologies such as TExT-MED represent highly scalable, low-cost, and widely accessible solutions for safety-net ED populations.
Keck School of Medicine, Department of Emergency Medicine, University of Southern California, Los Angeles, CA. Electronic address: sanjay.arora@usc.edu.
Sanjay
S
Arora
Department of Medicine, University of Southern California, Los Angeles, CA.
Anne L
AL
Peters
Keck School of Medicine, Department of Emergency Medicine, University of Southern California, Los Angeles, CA.
Elizabeth
E
Burner
Keck School of Medicine, Department of Emergency Medicine, University of Southern California, Los Angeles, CA.
Chun Nok
CN
Lam
Keck School of Medicine, Department of Emergency Medicine, University of Southern California, Los Angeles, CA.
Michael
M
Menchine
D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy / Q000523:psychology / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000706:statistics & numerical data; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D008297:Male; D055118:Medication Adherence / Q000523:psychology; D008875:Middle Aged; D017060:Patient Satisfaction; D011788:Quality of Life / Q000523:psychology; D012648:Self Care / Q000523:psychology / Q000706:statistics & numerical data; D020377:Self Efficacy; D017216:Telemedicine / Q000379:methods; D060145:Text Messaging; D016903:Drug Monitoring
D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; C517652:hemoglobin A1c protein, human