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

Area of Science:

• Diabetes Management
• Digital Health Interventions
• Implementation Science

Background:

• The Mobile Insulin Titration Intervention (MITI) program utilizes basic cell phone technology for remote basal insulin dose adjustment in type 2 diabetes patients.
• MITI is designed for accessibility in safety-net settings, addressing challenges patients face with in-person care.
• Previous randomized controlled trials (RCTs) demonstrated MITI's efficacy in a New York City (NYC) safety-net clinic.

Purpose of the Study:

• To evaluate the implementation, flexibility, generalizability, and acceptability of the MITI program in real-world, safety-net settings.
• To assess MITI's continued effectiveness in producing positive clinical and process outcomes outside of a strict RCT framework.
• To examine patient and provider satisfaction with the MITI program during its transition to usual care.

Main Methods:

• The study involved patients receiving weekday text messages for fasting blood glucose (FBG) monitoring and weekly titration calls.
• The primary goal was to help patients reach their optimal insulin dose (OID) within 12 weeks, defined by FBG levels or a maximum dose.
• Outcomes assessed included MITI program metrics, clinical results (FBG, HbA1c), process indicators (text response rates, nurse contact), and patient satisfaction surveys.

Main Results:

• MITI was successfully implemented at two NYC safety-net clinics with different staffing models.
• A high enrollment rate (87.6%) was observed, with 84.1% of patients reaching their OID in an average of 24 days.
• Significant clinical improvements were noted: mean FBG decreased from 209 to 141 mg/dL (P<.001), and HbA1c dropped from 11.4% to 10.0% (P<.001).
• High engagement was reported, with 90.1% text response rates and 81.9% weekly nurse contact; 85% of physicians made referrals. Patients reported comfort with texting and found it helpful for medication adherence and lifestyle choices.

Conclusions:

• The MITI program demonstrated continued success and flexibility upon transitioning from an RCT to real-world implementation in safety-net settings.
• MITI proved generalizable, adapting to a new site staffed by general medical clinic-registered nurses.
• High patient and staff engagement underscored MITI's acceptability and effectiveness in improving type 2 diabetes management remotely.