J Nurs Care Qual Vol. 21, No. 3, pp. 266271 c 2006 Lippincott Williams & Wilkins, Inc.

Impact of a Nurse Short Message Service Intervention for Patients With Diabetes
Hee-Seung Kim, PhD, RN; Nam-Cho Kim, PhD, RN; Sung-Hee Ahn, PhD, RN
The purpose of this study was to investigate the effect of a nurse short message service by cellular phone and the Internet on glycosylated hemoglobin (HbA1 c) levels and adherence to diabetes control recommendations. The patients with diabetes were asked to input their blood glucose levels every day by cellular phone or the Internet. Optimal recommendations were sent weekly to each patient by short message service. After 12 weeks, the patients had a mean decrease of 1.1% in HbA1 c level and an increase in diabetic medication taking, 30 minutes of physical exercise, and foot care adherence. Key words: adherence, cellular phone, diabetes, glycosylated hemoglobin, short message service, tele-health

IABETES is a chronic disease requiring lifelong medical and nursing intervention and lifestyle adjustment.1 The prevalence of diabetes mellitus is 8% to 10% in the Korean community, and more than 95% of patients have type 2 diabetes mellitus.2 Many Korean people with diabetes do not adhere to health regimens except for visiting a physician 3 to 4 times per year.3 Only 8.2% of people with diabetes adhere to self-monitoring of blood glucose levels.4 Adherence has the largest effect on hyperglycemia.5 The term adherence might imply a more holistic view about self-care than compliance because it places the patient in a central position.6 Studies on adherence in patients with diabetes indicate that lack of knowledge and management skills are the

From the College of Nursing, The Catholic University, Seoul, Korea. This work was supported by the Korea Research Grant funded by the Korean Government (MOEHRD) (KRF2005-015-E00232). Corresponding author: Hee-Seung Kim, PhD, RN, College of Nursing, The Catholic University, 505 Banpodong, Socho-gu, Seoul 137-701, South Korea (e-mail: hees@catholic.ac.kr). Accepted for publication: September 7, 2005

main contributing factors to nonadherence.7 Therefore, various strategies for diabetes management, such as flow sheets and reminder cards, have been designed to improve the adherence of patients with diabetes.8,9 Although a nurse telephone intervention could improve glycosylated hemoglobin (HbA1 c) levels and adherence to diet and blood glucose testing, it was time-consuming.10 Recently, computer-based or electronic management systems have been reported for improvement of HbA1 c levels.11,12 However, there are financial barriers to use of these systems for providing diabetes care in the community.13,14 New delivery systems that can provide recommendations and prescriptions for patients with diabetes at the right time and accommodate for patients behavioral changes are needed. The Internet has established itself as a worldwide communication system that allows a person to contact other people anywhere and at any time to exchange information online. Most Koreans use the Internet and cellular phones. To develop a more efficient delivery system for diabetes care, our research team designed a new model of diabetes management system using cellular phones and wire Internet. By using this technology, a patient with diabetes

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Impact of a Nurse Short Message Service Intervention for Patients With Diabetes can contact a nurse online at any time, be provided with information, and receive suitable recommendations from the nurse at any location. In an earlier study, we evaluated whether a nurse intervention using short message service by cellular phone and wire Internet would improve fasting plasma glucose, 2-hour postprandial blood glucose, and serum lipid levels and care satisfaction in patients with type 2 diabetes.15 No research has been done to test the direct effects of an Internet-based system on controlling HbA1 c levels and adherence to treatment recommendations in people with type 2 diabetes mellitus. The present study evaluated whether an intervention using a nurse short message service (SMS) by cellular phone and the Internet could improve HbA1 c levels and adherence to treatment control recommendations in people with type 2 diabetes mellitus. METHODS Participants Participants were recruited from the endocrinology outpatient department of tertiary care hospital located in an urban area of South Korea. All participants in this study had Internet access in their homes and were 30 years of age or older. The hospital is a university-affiliated medical center with 800 beds. The data were collected from January 2003 to March 2004. Diabetes was diagnosed according to the American Diabetes Association (ADA) criteria.16 The selection criteria required that participants were adults, able to perform blood glucose self-testing and selfinjection of medication, able to input data at the Web site, and have their own cellular phone. Patients were excluded if they had a clinical history of heart failure, hepatic dysfunction, renal insufficiency with a creatinine level higher than 1.5 mg/dL, or had been using insulin pumps. Patients who were offered any information on diabetes care from a specific Web site were also excluded. A total of 45 patients met the above criteria and agreed to participate. Only 33 sub-

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jects completed the entire study. Twelve subjects did not record their glucose levels for more than 4 weeks on the Web site (http://www.biodang.com). Intervention The goal of the intervention was to maintain blood glucose level at a normal range (HbA1 c < 7%). Before the intervention, each patient was instructed for 30 minutes by the researcher on how to input data at the Web site. Patients contacted our Web site and logged in whenever it was convenient for them. They then sent their self-monitored blood glucose levels and drug information, including the types and dosage of insulin and oral antidiabetic medication that they used for diabetes control. The researcher could view the information on each patient, including the blood glucose levels, medications, and details of some events provided by the patient. In addition to this information, a nurse also could view basic personal history including background information, family history, smoking habits, body mass index, blood pressure, and baseline laboratory data. After integrating the above information, the nurse sent weekly optimal re- commendations to each patient by SMS using cellular phone and wire Internet. Short message service is based on a text message. The researcher provided the intervention for 12 weeks. The 12 weeks of intervention consisted of continuous education and reinforcement of diet, exercise, medication adjustment, and frequent self-monitoring of blood glucose levels. The researcher followed a protocol approved by the physician after reviewing the blood glucose log and discussing glucose values with the patients. All oral hypoglycemic agent or insulin adjustments were communicated to the subjects physicians. If a patient did not forward a blood glucose level for more than 1 week, a warning message was sent. If, despite warning messages, individuals had not recorded glucose levels for more than 4 consecutive weeks, they were withdrawn from the intervention group.

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JOURNAL OF NURSING CARE QUALITY/JULYSEPTEMBER 2006 A paired t test was used for comparison of differences between pretest and posttest values in the group. RESULTS Sociodemographic and clinical findings The characteristics of the participants are shown in Table 1. The mean age of the intervention group was 43.5 years. Slightly more than half (57.6%) of the group were women. The mean body mass index was 24.3 kg/m2 . The mean systolic and diastolic blood pressure were 117.2 and 78.9 mmHg, respectively. The mean duration of diabetes was 5.6 years. The mean HbA1 c was 8.1%, and the mean fasting blood glucose level was 164.9 mg/dL. Subjects adhered to their diet a mean of 3.8 days per week. Participants exercised 30 minutes a day for only 2.5 days per week. Subjects adhered to their diabetic medication taking a mean of 4.8 days and foot care 4.9 days per week. Glycosylated hemoglobin There was a significant mean change in glycosylated hemoglobin (HbA1 c) for the group (P = .006), with a mean change of 1.1 (8.1% at posttest minus 7.0% at pretest) (Table 2). Subjects had improved HbA1 c levels at the end of study compared with the enrollment. Adherence Thirty minutes of physical exercise (P = .036), diabetic medication taking (P = .032), and foot care (P = .030) adherence improved at posttest compared with that at pretest. At posttest, patients had a mean increase of about 1 day per week in 30 minutes of physical exercise adherence compared with the pretest. Diabetic medication taking adherence increased 1.1 days per week at posttest compared to pretest. At posttest, patients had a mean increase of 1.1 days per week in foot care adherence. There was no significant difference in diet adherence (Table 2). Limitations Participants were recruited from the endocrinology outpatient department of a

Procedure and measures A quasi-experimental, 1-group, pretest and posttest design was used in this study. Before the SMS intervention, demographic variables, HbA1 c levels, and diabetes adherence were measured as pretest data. The HbA1 c and diabetes adherence were measured again 12 weeks later. The HbA1 c level was determined by a high-performance liquid chromatography technique using Variant II (Bio-Rad, Hercules, Calif). The Variant II was calibrated weekly and used for all participants. Self-reported adherence was measured by a diabetes self-care activities measure.17 It included 4 items, namely diabetic medication taking, diabetic diet, 30 minutes of physical exercise, and foot care. The diabetic medication question was, How many of the last seven days, did you take your recommended diabetic medication? The diabetic diet question was: How many days did you follow your recommended diet over the past 7 days? The physical exercise question asked how many of the past 7 days did patients do at least 30 minutes of physical exercise or walking, and the foot care question was, How many of the past 7 days did you check your feet for cuts and sores? The content validity of the questionnaire was verified by 2 endocrinologists, 1 diabetes educator, and 3 nurses with a masters degree or a PhD. The Cronbach reliability of this study sample was .87. Ethical considerations The Medical Research Ethics Committee of the university hospital approved the research protocol. Written consents were obtained from those who agreed to participate. Anonymity and confidentiality were guaranteed to participants. All participants used their identification and password to log on to the Web site, and only the researcher had access to the participants information. Data analyses The data were analyzed by the SAS (version 6.12, SAS institute, Cary, NC) program.

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Table 1. Sociodemographic and clinical characteristics of study participants at enrollment

Characteristics Age, y Gender Male/female Body mass index, kg/m2 Systolic blood pressure, mmHg Diastolic blood pressure, mmHg Duration of diabetes, y Glycosylated hemoglobin, % Fasting blood glucose, mg/dL Treatment method Diet only Oral hypoglycemic agent Insulin Oral hypoglycemic agent + insulin Adherence, d/wk Diabetic diet 30-minute physical exercise Diabetic medication taking Foot care M SD/n (%) 43.5 12.6 14 (42.4)/19 (57.6) 24.3 3.7 117.2 13.5 78.9 9.0 5.6 5.7 8.1 2.1 164.9 43.6 3 (9.1) 16 (48.5) 11 (33.3) 3 (9.1) 3.8 2.8 2.5 2.2 4.8 2.6 4.9 3.0

= 33

tertiary care hospital in an urban area of South Korea. They were unlikely to represent all Korean people with diabetes, which influences the generalizability of the results. Participants could either complete the adherence questionnaire themselves or respond to the items read out by the researcher. Selfreport of the adherence questionnaire may have biased the results. Using both methods

to collect adherence scores may also have reduced the internal validity of the study. The study did not have a comparison group. Although this study demonstrated that the SMS intervention could reduce HbA1 c levels remarkably during a short-term period of 12 weeks, the long-term effectiveness remains to be determined. To further the development, more trials and studies are needed.

Table 2. Effect of intervention on glycosylated hemoglobin and adherence

Difference (posttest--pretest) 1.1 2.1 0.8 1.8 0.9 2.0 1.1 1.9 1.1 2.2

Variables Glycosylated hemoglobin, % Adherence Diabetic diet, d/wk 30-minute physical exercise, d/wk Diabetic medication taking, d/wk Foot care, d/wk

Pretest 8.1 2.1 3.8 2.8 2.5 2.2 4.8 2.6 4.9 3.0

Posttest 7.0 1.1 3.0 2.7 3.4 2.2 5.9 1.9 6.0 2.3

t 2.89 1.44 2.22 2.36 2.33

P .006 .182 .036 .032 .030

Data

are mean SD.

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JOURNAL OF NURSING CARE QUALITY/JULYSEPTEMBER 2006 increase in diet adherence than the control group.10 It is unclear which factors might account for the difference. The mean age of participants in the 2 studies was different: 59.7 for the telephone intervention group and 43.5 for the SMS intervention group. Patients in the SMS intervention group may be less likely to change their dietary habits when eating at work. In this study, the 30 minutes of physical exercise adherence increased after 12 weeks. It seems that the SMS intervention was effective for exercise adherence. Adherence to taking diabetic medications increased after 12 weeks. In Hong Kong, adherence to taking oral hypoglycemic medications was the highest in a cross-sectional study.22 Foot care adherence increased after the SMS intervention. Patients in the automated telephone disease management, with the telephone nurse group, had an increase of foot inspection adherence during the 1-year study period.23 The number of foot examinations significantly increased in patients whose providers used the diabetes electronic management system.11 The educational intervention appeared to have a positive effect on patient foot care adherence. Overall, the findings suggested that the SMS intervention improved HbA1 c level and adherence to diabetic medication taking, physical exercise, and foot care. Patients with diabetes wanted more frequent contact with their healthcare providers for managing the disease. By using this Web-based patient management system, patients can contact their physicians, nurses, and dietitians whenever they want to.

DISCUSSION A near-normal glycemic control reduces the development and progression of microvascular and neuropathic complications by approximately 50% in type 2 diabetes mellitus.18,19 The ADA has recommended that all persons with diabetes should attempt to achieve near normalization of blood glucose levels.20 Epidemiological analysis of the United Kingdom Prospective Diabetes Study Group data showed a continuous relationship between the risk of microvascular complications and hyperglycemia, such that for every percentage point decrease in HbA1 c, there was a 35% reduction in the risk for microvascular complication.21 The goal of this studys intervention was to keep blood glucose concentrations close to the normal range. This study revealed that an SMS intervention by a nurse could improve HbA1 c in patients with type 2 diabetes mellitus. In the study, the HbA1 c level decreased 1.1 percentage points after 12 weeks. In a prior randomized trial, the effect of nurse telephone calls on HbA1 c levels was evaluated.10 After 12 weeks, patients in the telephone intervention group had a mean decrease of 1.2% in HbA1 c levels. Therefore, mean end-point HbA1 c levels in the intervention groups of the 2 studies were essentially the same. However, the telephone intervention nurse spent more time and money with patients than the SMS intervention nurse. There was no significant difference in diabetic diet adherence pretest and posttest. However, in our prior randomized trial, the telephone intervention group had a greater
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