SummaryThe University of Washington Physician's Network, a group of nine neighborhood clinics in the Seattle area, developed a wireless, pager-based messaging system to send a set of daily messages to patients with diabetes that were intended to help them better manage their condition. An evaluation of the initiative via a small randomized controlled trial found that it had no impact on blood glucose levels, although blood pressure (considered a marker of positive behavioral change that shows up more quickly than hemoglobin A1c level changes) improved, and users of the system believed that their health care was better than did a control group of similar patients.
Developing OrganizationsUniversity of Washington Physician's Network, Seattle
See footnote 1.
Date First Implemented2001
Problem AddressedEven though diabetes is a chronic condition affecting millions of Americans, very few individuals with diabetes receive regular support in managing their condition.
- Effective management of this condition requires patients and their providers to periodically monitor their blood glucose (hemoglobin A1c or HbA1c) levels and other health status markers and to make adjustments in their insulin and/or behaviors (e.g., diet, exercise).
- This wireless messaging system was intended to be a low-cost, efficient means of facilitating patient–provider communication that supports patient self-management of diabetes.
Description of the Innovative ActivityPatients with diabetes are given a two-way pager that can send and receive short text messages. Patients choose the content, frequency, and timing of the messages they receive, and can also reply to messages as they wish. When appropriate, providers respond to patient queries via pager and/or by phone. Key elements of the program are described below:
- Inclusion criteria: Inclusion criteria were type 1 and type 2 diabetes patients with HbA1c values between 8 and 9.4 percent.
- Offering the pager to patients: Eligible adult patients receive a letter from their physician with a response card, and those who do not respond to this letter are contacted by phone to see if they want to participate. Patients who wish to participate are interviewed briefly and complete a screening questionnaire to ensure that they meet the inclusion criteria.
- Customized messages through the pager system: Each patient receives a two-way alphanumeric pager that sends and receives short text messages, displaying four lines at a time. Participants are given instructions on how to use the device, and then are asked their preferences for the kinds of automated messages they want to receive, and how often and what time of day they wish to receive them. Patients chose to receive up to 10 unique messages per day with an average of 3.2 messages per day. Messages cover the following topics:
- Appointment reminders (13 percent of patients chose to get these reminders)
- Medication reminders (54 percent)
- Blood glucose testing reminders (67 percent)
- Exercise reinforcement (42 percent)
- Dietary and meal time reinforcement (50 percent)
- Laboratory results reporting (4 percent)
- Customized reminders (21 percent), including general reminders to drink water and time-of-day reminders to trigger appropriate action such as taking medication or eating
- Patient response: Although most messages elicited no response, patients have the option of contacting their physician's office through the pager. A forwarding system routes "unexpected" (i.e., nonautomated) patient responses to an individual who monitors the system. This individual responds to patients via pager and/or phone call. Of the 12,000 messages sent out during the evaluation period, there were 114 "noncanned" responses from patients, 16 of which required nonurgent action by the physician clinic (e.g., a request to change messages/times, request for an appointment).
ResultsA small randomized controlled trial comparing 25 patients with a pager to 25 comparable patients in a control group found that the wireless messaging system had no apparent impact on HbA1c levels. The percentage of hypertensive patients did, however, fall significantly in the intervention group (with no such drop in the control group), and users of the system believe that it enhanced the quality of care.
- No impact on HbA1c: Both the control and intervention group achieved a modest (not statistically significant) decline in HbA1c levels (8.3 to 8.2 percent for those with pagers, and 8.2 to 7.9 percent for the control group).
- Reduction in blood pressure: The percentage of hypertensive patients fell from 64 to 38 percent, compared with a slight increase in the control group. This significant health improvement is likely the result of positive behavioral changes spurred by the messaging system; the researchers note that blood pressure is likely to change more quickly than HbA1c levels, which often take longer than 3 to 6 months (the length of the study period) to affect.
- Positive patient perceptions on quality: Patients using the pager believed that the quality of their health care improved during the study period. No such increase in perceived quality was seen in the control group. Survey results suggest that patients found the messages to be comforting, convenient, and useful; the messages also made patients feel more cared for by their providers. Roughly two-thirds (68 percent) of patients wanted to continue using the pager after the study period ended.
- No impact on HbA1c, but other benefits: The wireless messaging system had no short-term effect on HbA1c levels; reducing these levels was the main purpose of the intervention, but the system did make patients perceive higher quality of care and had a positive impact on blood pressure.
- Few administrative costs: The system had no significant impact on the administrative workload of clinic staff.
- Easy to reach patients: The system proved to be an effective, efficient means of reaching patients in a timely manner, thus reinforcing adherence to an appropriate care plan, and allowing for the tailoring of that plan between physician visits.
- Potential for real-time monitoring: This system could potentially be adapted to allow for real-time monitoring of key indicators, such as a patient's pain score, weight, and blood glucose levels.
- Some limitations and needed refinements: The pager did not work satisfactorily at all locations (e.g., rural areas), and there were some problems with mistimed messages due to patients traveling to new time zones. The system should be refined to allow for easy time zone adjustments.
- Customized messaging is preferable: The researchers found that patients did not want a fully structured regimen of reminders of everything that they had to do; rather, they preferred to receive reminders only about the care issues they found difficult; thus, in any refinements to this project, patients should be allowed to choose which messages they would like to receive and how often they want to receive them.
- Automatic reminder concept is independent of the technology used: Although use of pagers is no longer prevalent, the concept of an automatic reminder system for patients with chronic diseases can be applied to other personal communication technologies, such as cell phones and e-mail systems.
Contact the InnovatorMichael G. Leu, MD, MS
Children's Hospital & Regional Medical Center
4800 Sand Point Way NE, M1-12
Seattle, WA 98145-5020
Innovator DisclosuresDr. Leu has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesLeu MG, Norris TE, Hummel J, et al. A randomized, controlled trial of an automated wireless messaging system for diabetes. Diabetes Technol Ther. 2005;7(5):710-17. [PubMed]
1 This research was supported by funding from the American Diabetes Association, by the Warren G. Magnuson Institute for Biomedical Research and Health Professional Training, and by an Alpha Omega Alpha Student Research Fellowship. Thank you to Dr. Jeff Hummel, Dr. Peter Dunbar, Dr. Peter Tarczy-Hornoch, Dr. Harold Goldberg, and Dr. Irl Hirsch for their assistance in thinking about electronic chronic disease management and about potential research study designs, and to Wai Man Ip for his assistance in developing the system. We would like to thank our families for their ongoing support.
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Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 18, 2014.
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