A team of researchers in the Department of Emergency Medicine at Los Angeles County+USC Medical Center is exploring ways in which they can connect with their diabetes patients through the one piece of technology nearly everyone has in their pockets: cellphones.
The researchers developed TeXT-MED, or Trial to Examine Text Message for Emergency Department Patients with Diabetes, a six-month study that examined the impact of a “mobile health” intervention on the diabetes management of low-income and mostly uninsured inner-city Latinos.
The study aimed to help patients overcome obstacles of language, culture and access in order to activate lifestyle changes that promote better long-term health, with fewer of the potentially devastating complications diabetes can cause, such as eye problems and blindness, foot pain and amputation, kidney disease, and stroke.
Diabetes is widespread among Southern California’s Latino population, but it’s particularly harmful to low-income and uninsured patients, who face barriers to the sort of information and continuity of health care that is necessary to optimally manage the chronic condition.
For many of these uninsured patients, the emergency department is the main point of contact with health care. However, hospital emergency departments are designed to handle emergencies and acute problems — not chronic conditions. Consequently, these caregivers struggle to help diabetes patients stay healthy.
Text messages that trigger healthier habits
Public health care authorities and private industry professionals are increasingly exploring and endorsing mobile health text-messaging programs to help with issues ranging from smoking cessation to mass casualty emergencies, according to TeXT-MED investigator Sanjay Arora, associate professor of clinical emergency medicine at the Keck School of Medicine of USC.
In the study, researchers regularly sent patients text messages about food and diet, medication adherence, weight control, exercise and mental outlook — the cornerstones of successful diabetes management.
For example, some messages suggested that patients have a salad for lunch, go on a walk or read food labels to make healthier choices at the supermarket. Other messages were reminders to fill a prescription or to check blood sugar levels. Some took the form of quizzes and trivia about diabetes, while others had to do with family and friends, suggesting, for example, that patients tell someone close that they loved them.
“Our plan was to identify the things that everyone with diabetes should be doing for themselves that don’t require the involvement of doctors or nurses in the emergency room,” said co-principal investigator Elizabeth Burner, clinical research fellow at the Keck School. “We wanted to create an affordable system that could be easily scaled to a larger population.”
Looking beyond the numbers
The TeXT-MED study measured parameters such as blood sugar levels, weight and medication adherence. It also looked at patients’ eating and exercise habits as well as their visits to clinics — rather than the emergency department — for ongoing primary care.
Such quantifiable data provided basic insight into the impact of the text messages on patients, but researchers also explored other equally important qualitative dimensions of their experience.
“We got a lot of numbers, but numbers don’t always tell the whole story,” Burner said. “We needed to better understand the actual experiences patients were having.”
The Southern California Clinical and Translational Science Institute (SC CTSI) provided pilot funding to support the TeXT-MED study. In addition, Katrina Kubicek, assistant director of SC CTSI Community Engagement, and Marisela Robles, the institute’s community liaison, conducted focus groups that helped researchers understand qualitative dimensions of their TeXT-MED study.
Learning from research participants
The qualitative analysis revealed that one of TeXT-MED’s most important benefits was supporting adherence to drug regimens. The messages were particularly effective in encouraging patients to keep their drug prescriptions filled and up to date, as well as to take them on schedule.
For their next study, the investigators want to further personalize the TeXT-MED messages, an idea suggested by the participants during the focus groups.
“Patients wanted to receive messages that were tied to them and their specific condition,” Burner said.
For example, if a patient had previously lost a foot due to their diabetes, exercise-related messages could be customized for their abilities.
Another research direction that came out of the focus groups is to include family and friends in the text-messaging program to create a stronger support group for the diabetes patient.
“Our biggest goal is to activate the patient to take that first step and start doing things for their health that they haven’t done before,” Arora said. “The home run for projects like this is to get patients to understand that the emergency department is not the best place to manage their diabetes and to see a primary care doctor regularly.”
SC CTSI is part of the 60-member Clinical and Translational Science Awards network funded through the National Center for Advancing Translational Sciences at the National Institutes of Health (grant UL1TR000130). Under the mandate of “Translating Science into Solutions for Better Health,” SC CTSI provides a wide range of services, funding and education for researchers and promotes online collaboration tools such as USC Health Sciences Profiles.