Transition of a Text-Based Insulin Titration Program From a Randomized Controlled Trial Into Real-World Settings: Implementation Study.

BACKGROUND The Mobile Insulin Titration Intervention MITI program helps patients with type 2 diabetes find their correct basal insulin dose without in person care Requiring only basic cell phone technology text messages and phone calls MITI is highly accessible to patients receiving care in safety net settings MITI was shown in a randomized controlled trial RCT to be efficacious at a New York City NYC safety net clinic where patients often have challenges coming for in person care In 2016 MITI was implemented as usual care at Bellevue Hospital the site of the original RCT and at Gouverneur Health a second NYC safety net clinic under 2 different staffing models OBJECTIVE This implementation study examined MITI s transition into real world settings To understand MITI s flexibility generalizability and acceptability among patients and providers we evaluated whether MITI continued to produce positive outcomes in expanded underserved populations outside of an RCT setting METHODS Patients enrolled in MITI received weekday text messages asking for their fasting blood glucose FBG values and a weekly titration call The goal was for patients to reach their optimal insulin dose OID defined either as the dose of once daily basal insulin required to achieve either an FBG of 80 130 mg dL 4 4 7 2 mmol L or as the reaching of the maximum dose of 50 units After 12 weeks if OID was not reached the patients were asked to return to the clinic for in person care and titration MITI program outcomes clinical outcomes process outcomes and patient satisfaction were assessed RESULTS MITI was successful at both sites each with a different staffing model Providers referred 170 patients to the program 129 of whom 75 9 129 170 were eligible Of these 113 87 6 113 129 enrolled Moreover 84 1 95 113 of patients reached their OID and they did so in an average of 24 days Clinical outcomes show that mean FBG levels fell from 209 mg dL 11 6 mmol L to 141 mg dL 7 8 mmol L PUnder 001 HbA1clevels fell from 11 4 101 mmol mol to 10 0 86 mmol mol PUnder 001 Process outcomes show that 90 1 of MITI s text message prompts received a response nurses connected with patients 81 9 of weeks to provide titration instructions and 85 of attending physicians made at least one referral to the MITI program Satisfaction surveys showed that most patients felt comfortable sharing information over text and felt the texts reminded them to take their insulin check their sugar and make healthy food choices CONCLUSIONS This implementation study showed MITI to have continued success after transitioning from an RCT program into real world settings MITI showed itself to be flexible and generalizable as it easily fits into a second site staffed by general medical clinic registered nurses and remained acceptable to patients and staff who had high levels of engagement with the program