title: The Mobile Insulin Titration Intervention (MITI) for Insulin Adjustment in an Urban, Low-Income Population: Randomized Controlled Trial.
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.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT01879579; https://clinicaltrials.gov/ct2/show/NCT01879579 (Archived by WebCite at http://www.webcitation.org/6YZik33L3).
authors.affiliation: Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York, NY, United States.
authors.forename: Natalie
authors.identifier: http://orcid.org/0000-0003-2956-5876
authors.initials: N
authors.lastname: Levy
authors.forename: Victoria
authors.identifier: http://orcid.org/0000-0002-5480-0578
authors.initials: V
authors.lastname: Moynihan
authors.forename: Annielyn
authors.identifier: http://orcid.org/0000-0001-9165-3100
authors.initials: A
authors.lastname: Nilo
authors.forename: Karyn
authors.identifier: http://orcid.org/0000-0003-1543-0962
authors.initials: K
authors.lastname: Singer
authors.forename: Lidia S
authors.identifier: http://orcid.org/0000-0003-4943-6756
authors.initials: LS
authors.lastname: Bernik
authors.forename: Mary-Ann
authors.identifier: http://orcid.org/0000-0001-7697-8759
authors.initials: MA
authors.lastname: Etiebet
authors.forename: Yixin
authors.identifier: http://orcid.org/0000-0003-0104-9140
authors.initials: Y
authors.lastname: Fang
authors.forename: James
authors.identifier: http://orcid.org/0000-0001-8037-1028
authors.initials: J
authors.lastname: Cho
authors.forename: Sundar
authors.identifier: http://orcid.org/0000-0003-1360-4324
authors.initials: S
authors.lastname: Natarajan
mesh_terms: D001786:Blood Glucose / Q000378:metabolism; D040421:Cell Phone; D002908:Chronic Disease; D003920:Diabetes Mellitus / Q000097:blood / Q000188:drug therapy* / Q000191:economics; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage* / Q000191:economics; D007328:Insulin; D000069036:Insulin Glargine / Q000008:administration & dosage* / Q000191:economics; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D010865:Pilot Projects; D017216:Telemedicine / Q000379:methods*; D060145:Text Messaging
chemical_list: D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin; D000069036:Insulin Glargine
keywords: cell phones; health care disparities; insulin, long-acting; patient-centered care; remote consultation; telemedicine; text messaging