Diabetes is widespread among Southern California's Latino population, but it is particularly harmful to low income and uninsured patients, who face barriers to the sort of information and continuity of health care they need to manage the chronic condition optimally.

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. As a result, ER caregivers struggle to help diabetes patients stay healthy.

A team of researchers at the USC Department of Emergency Medicine at the 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 pocket: the mobile phone.

The researchers developed TeXT-MED (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. 

For many uninsured patients, the emergency department is the main point of contact with health care.

The goal was 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.

Examples of TeXT-MED messages that were sent to research participants.

Text-messages that trigger healthier habits

Mobile health (mHealth) text-messaging programs are being increasingly explored and endorsed by public health care authorities and private industry to help with issues from smoking cessation to mass casualty emergencies, explained TeXT-MED investigator Sanjay Arora, MD, associate professor of clinical emergency medicine at USC’s Keck School of Medicine.

Sanjay Arora, MD

"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, MD, MPH, clinical research fellow at USC’s Keck School of Medicine. "We wanted to create an affordable system that could be easily scaled to a larger population."

Elizabeth Burner, MD, MPH

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 and 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," said Burner. “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. It also provided expert advice that helped investigators conduct the necessary qualitative analysis to better understand the project's impact, and to shape future research questions, said Burner.

Katrina Kubicek, MA, assistant director of SC CTSI Community Engagement, and Marisela Robles, MS, SC CTSI community liaison, brought extensive experience and skills in conducting the focus groups that helped researchers understand qualitative dimensions of their TeXT-MED study.

View the project presentation

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," said Burner. 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 in order 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," said Arora. "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 (CTSA) network funded through the National Center for Advancing Translational Sciences (NCATS) at the NIH (Grant Number UL1TR000130). Under the mandate of “Translating Science into Solutions for Better Health,” SC CTSI provides a wide range of resources, services, funding, and education for researchers and promotes online collaboration tools such as USC Profiles.