Randomized Clinical Trial of BidirectionalText Messaging to Improve Adherence toRecommended Lipid Testing
Laura-Mae Baldwin, MD, MPH
Caitlin Morrison, MPH
Nick Anderson, PhD
Kelly Edwards, PhD, MA
Jeff Green
Jonathan Griffin, MD, MHA
William Reiter, MD, FACP
Cleary Waldren, MS
A collaboration between the University of Washington Department of FamilyMedicine, the Institute of Translational Health Sciences, Northwest EHRCollaborative (Anaconda, MT), and a multidisciplinary group practice In rural MT.
Acknowledgements
•Chris Miller, Lalitha Ramesh – IT Support
•Anthony Beaver, Brenda Benefiet, MitchellMarrujo - Patient Contact
Acknowledgements
•This research was funded by the Office of theNational Coordinator for Health InformationTechnology (Award Number 10775336) and by theNorthwest EHR Collaborative.
•The content is solely the responsibility of the authorsand does not necessarily represent the official viewsof the Office of the National Coordinator for HealthInformation Technology.
Background
•Increasing alliance of technology and healthcare
•EHR most prevalent technology that isincreasing the ability to record and monitorcare
Background
•Patients simultaneously are adopting technologies thatmay have health applications
•Mobile phone saturation is one of the most dramatic –85% of adults have a cell phone *
–95% ages 18-34
–92% ages 35-46
–86% ages 47-56
–84% ages 57-65
–68% ages 66-74
–48% ages 75+
*Source: Zickuhr, Kathryn. Generations and their gadgets. Pew Internet & American Life Project, February 3, 2011,http://pewinternet.org/Reports/2011/Generations-and-gadgets.aspxaccessed on June 5, 2013.
Study Questions
•Can patient text messaging reminders improveadherence to recommended care?
•Will patients participate in bidirectional patient-provider text messaging?
•How do patients feel about bidirectional textmessaging with their medical providers?
Recommended Care: Lipid Testing
•Lipid testing among patients who require ongoingmonitoring:
–Diabetes Mellitus
–Ischemic Vascular Disease
–Coronary Artery Disease
–Hyperlipidemia
•PQRS and NCQA measure important to themedical group
Research
Research
Clinical Care
Clinical Care
Organizational Structure
NWEHR
NWEHR
MedicalGroup
MedicalGroup
UWResearch
UWResearch
UWInformatics
UWInformatics
BAA
IRB
Methods
Pilot randomized controlled trial
•Identified study population
•Randomized to intervention and control groups
•Applied intervention for specified time
•Compared study groups
Study Population
•18 to 75 years old and assigned to one of twophysicians’ practices
•At least one face to face visit with a medical provider(MD, DO, NP, PA) in the Medical Group in the prior 12months.
•Diagnosis of Diabetes Mellitus (DM), Ischemic VascularDisease (IVD), Coronary Artery Disease (CAD)
•Diagnosis of Hyperlipidemia (HLD) and no DM, IVD,CAD
Eligible for Reminder Text Message
IF:
•No LDL in the past 12 months
OR
•No LDL in the past 3 months
AND:
–The latest LDL between 3 and 12 months prior is >100 forpatients with a diagnosis of DM, IVD, or CAD.
–The latest LDL between 3 and 12 months prior is >130 forpatients with a diagnosis of HLD.
Methods
•Called eligible patients to determine whether they had acell phone, and were willing to accept text messaging fromthe practice. At the call, recorded current cell phonenumber.
•Randomized half of group to receive text messagereminders about lipid testing
•Sent up to 3 text message reminders 30 days apart
•Interviewed intervention group on experience with textmessaging after 2nd text message reminder sent
Text Message
“You are due for a cholesterol test. Reply 1for YES, I will go to <MEDICAL GROUPNAME>’s lab this week, open 7:30-6 M-F.Reply 2 for NO. Fasting not needed.”
Project Timeline
•Text #1 – April 1, 2013
•Text #2 – April 29, 2013
•Research interviews conducted
•Text #3 – May 28, 2013
•End of observation period –June 25, 2013
Outcomes of Interest
1.Adherence to recommended testing
2.Patient response to text messages
3. Patient experience of text messaging as amethod for screening reminders
Enrollment Chart
248
Overdue for LDL basedon EHR data
248
Overdue for LDL basedon EHR data
71
Ineligible or declined
71
Ineligible or declined
112
Not reached after 3recruitment calls
112
Not reached after 3recruitment calls
65
Eligible – had cellphone, willing toparticipate
65
Eligible – had cellphone, willing toparticipate
4
Received LDL prior tointervention
4
Received LDL prior tointervention
61
Eligible – andrandomized
61
Eligible – andrandomized
26
Refused
26
Refused
45
Ineligible (no cell phone,no text plan, differentprimary physician)
45
Ineligible (no cell phone,no text plan, differentprimary physician)
Study Groups
28
Received up to 3text messages
28
Received up to 3text messages
61
Eligible andrandomized
61
Eligible andrandomized
31
Randomized to textmessage group
31
Randomized to textmessage group
30
Randomized to controlgroup
30
Randomized to controlgroup
1
Refused after firsttext message
1
Refused after firsttext message
2
Duplicate phonenumber –only onetext message
2
Duplicate phonenumber –only onetext message
3
Duplicate phonenumber – only onetext message
3
Duplicate phonenumber – only onetext message
Patient Characteristics
n = 61
% age 55 and older
49.2%
% female
32.8%
% with a Wellness Visit in the last 12months
24.6%
Mean (SD) # ambulatory visits inprevious year
4.0 (2.8)
Chronic Disease Status
Adherence to Recommended Testing
Persons whocame in forLDL testing
Month#1
%
Month#2
%
Month#3
%
TotalOverall
%
Intervention
(N=31)
7
(n=31)
22.6%
2
(n=24)
8.3%
2
(n=22)
9.1%
11
35.4%
Control
(N=30)
2
(n=30)
6.7%
4
(n=28)
14.3%
3
(n=24)
12.5%
9
30.0%
AdjustedRelativeRisk (CIs)
4.96
(1.08-11.35)
1.42,(0.61-2.39)
Response Rate to Text Messages
Responded to messages
Participants (n=28)
Percent
Never responded
9
32.1%
Ever responded
19
67.9%
First only
8
28.6%
Second only
1
3.6%
Third only
2
7.1%
First and second only
4
14.3%
First and third only
2
7.1%
Second and third only
1
3.6%
All messages
1
3.6%
How Patients Responded to Text Messages
Response Type by Message
Persons who responded
Percent of responses
Message 1
N = 15
Yes
6
40.0%
No
6
40.0%
Other
3
20.0%
Message 2
N = 7
Yes
3
42.9%
No
2
28.6%
Other
2
28.6%
Message 3
N = 6
Yes
1
16.7%
No
5
83.3%
Other
0
0.0%
“Other” responses
•Who is this for?
•I already had the above test done prior toseeing Dr. XXXXX in early March of this year.
•I also need to get a PSA test for {anotherprovider}. I will waite and coordinate into onelab visit.
•Already had one!
•.
“Yes” / “No” with more information
•2. I will use the state clinic for lab tests.
•1 / …
•Not sure who is requesting or if you aremeaninh / 2 i will call you
Patient Experience with Text Messaging
•Invited the 28 individuals who received textmessage reminders to participate in a briefinterview about their experience
•$10 incentive for participating
•11/28 agreed to participate
•8/11 were reached for the interview
Patient Experience with Text Messaging
<MEDICAL GROUP NAME> is trying to find ways that help people getthe health care they need. A little over 5 weeks ago, <MEDICALGROUP NAME> sent you the first text message with a reminder toget a cholesterol test. Do you remember getting this text message?
What did you think about getting a reminder like this via textmessage?
•7 of 8 thought text messaging was a positive experience
•1 of 8 remembered receiving the message, but did notregularly text, so did not successfully retrieve the message
Patient Comments about Text Messaging
“Text is an easy way to communicate and can also beautomated.”
“I think it’s a good idea, people make appointmentsand it helps to recall when to do….It would be helpful ifthere are extenuating circumstances, like mine, toinclude a phone number.”
Patient Experience with Text Messaging
•Of the 7 interviewees who received the textmessage:
–3 came in for testing
•2 noted that the second message prompted them tocome in
–The 4 who did not come had the test done withanother doctor (n=1), were waiting to test at theirannual appointment (n=1), or did not think theywere due (n=2)
Patient Experience with Text Messaging
How concerned are you, if at all, about theprivacy of your health information in textmessages?
–5 did not want actual health informationcommunicated in accessible formats
–1 had no concern
–1 person was very concerned
–1 person did not know
There are many ways to get health reminderslike this – phone, text message, postal mail,email. What do you think about getting ahealth reminder via text message compared tothese other ways?
Method Preferred
Participants (n=8)
Text
2
Email
2
Text or email
1
Text, email or phone
1
Mail
1
Phone
1
Main Findings
•A first text message reminder significantly increasedLDL testing among rural patients overdue for this test.
•After three months, patients with no text messagereminders nearly “caught up” with LDL testingcompared with patient who had received reminders.
•This pilot study had a small sample size, so a largerstudy is needed.
Main Findings
•A majority of patients engaged in textmessaging with their provider (67.9%)
•The minority of those who text messaged backsaid they would be coming in for their LDLtests
–40% after message 1
–42.9% after message 2
–16.7% after message 3
Main Findings
•Most patients had a positive experience withtext message reminders, but did not wanthealth information transmitted by textmessage.
•Half of those interviewed rated text messagingas a preferred method for getting healthreminders, others preferred other methods (e-mail, phone, postal mail)
Limitations
•Excluded adults over 75 years of age
•Small sample size
•Special procedures gathered cell phonenumbers – not always available
Conclusions
•Text message reminders may result inclinically meaningful improvements inadherence to recommended laboratorymonitoring
Conclusions
•In this study, the greatest testing effect wasafter the first text message.
•Some of those who came in for LDL testingafter the first text message may have beentested within a few months anyway.
•Though not statistically significant, moreindividuals who received text messages didget LDL testing after 3 months.
Conclusions
•Given this study’s findings, among 1000 patientsneeding an LDL test, the number tested within 3months would be:
–354 if reminded by text message
–300 if not reminded
•Over 50 more patients would come in fortesting.
Conclusions
•Patients have a positive experience with textmessaging
•Patients will use text messaging to relayadditional information
Next Steps
•Testing text message reminders in a largerstudy population
•Better understanding of patient concerns andlimits regarding health care applications thatuse mobile technology
For more information,contact:Laura-Mae Baldwinlmb@uw.eduCaitlin Morrisoncm46@uw.edu