Description of patient questions received by clinical pharmacists in the Nudge Study.

ObjectivesThis study explored the reasons for patients’ non-adherence to cardiometabolic medications, and tested the acceptability of the interactive voice response (IVR) as a way to address these reasons, and support...

BackgroundNonadherence is a major concern in the management of chronic conditions such as hypertension, cardiovascular disease, and diabetes where patients may discontinue or interrupt their medication for a variety of reasons. Text message reminders have been used to improve adherence. However, few programs or studies have explored the benefits of text messaging with older populations and at scale. In this paper, we present a program design using tailored and interactive text messaging to improve refill rates of partially adherent or nonadherent Medicare members of a large integrated health plan.ObjectiveThe aim of this 3-month program was to gain an understanding of whether tailored interactive text message dialogues could be used to improve medication refills in Medicare patients with one or more chronic diseases.MethodsWe used the mPulse Mobile interactive text messaging solution with partially adherent and nonadherent Medicare patients (ie, over age 65 years or younger with disabilities) of Kaiser Permanente Southern California (KP), a large integrated health plan, and compared refill rates of the text messaging group (n=12,272) to a group of partially adherent or nonadherent Medicare patients at KP who did not receive text messages (nontext messaging group, n=76,068). Both groups were exposed to other forms of refill and adherence outreach including phone calls, secure emails, and robo-calls from December 2016 to February 2017.ResultsThe text messaging group and nontext messaging group were compared using an independent samples t test to test difference in group average of refill rates. There was a significant difference in medication refill rates between the 2 groups, with a 14.07 percentage points higher refill rate in the text messaging group (P<.001).ConclusionsThe results showed a strong benefit of using this text messaging solution to improve medication refill rates among Medicare patients. These findings also support using interactive text messaging as a cost-effective, convenient, and user-friendly solution for patient engagement. Program outcomes and insights can be used to enhance the design of future text-based solutions to improve health outcomes and promote adherence and long-term behavior change.

BackgroundEfficient and effective strategies for treating chronic health conditions such as hypertension are particularly needed for under-resourced clinics such as Urban Indian Health Organizations (UIHOs).ObjectiveThe objective of the Controlling Blood Pressure Trial is to assess the impact of an interactive voice response and text message (IVR-T) intervention compared with usual care among individuals with hypertension receiving care at a UIHO in Albuquerque, New Mexico. This manuscript presents the baseline characteristics of individuals enrolled in the trial and compares their characteristics with those in the hypertension registry who did not enroll in the trial.MethodsA hypertension registry developed from the clinic’s electronic health record was used for recruitment. Potentially eligible participants were contacted by letter and then by phone. Those who expressed interest completed an in-person baseline visit that included a baseline survey and blood pressure measurement using standardized procedures. Individuals randomized to the intervention group could opt to receive either automated text messages or automated phone calls in either English or Spanish. The messages include reminders of upcoming appointments at First Nations Community HealthSource, requests to reschedule recently missed appointments, monthly reminders to refill medications, and weekly motivational messages to encourage self-care, appointment keeping, and medication taking for hypertension. Individuals in the IVR-T arm could opt to nominate a care partner to also receive notices of upcoming and missed appointments. Individuals in the IVR-T arm were also offered a home blood pressure monitor. Follow-up visits will be conducted at 6 months and 12 months.ResultsOver a 9.5-month period from April 2017 to January 2018, 295 participants were enrolled from a recruitment list of 1497 individuals. The enrolled cohort had a mean age of 53 years, was 25.1% (74/295) American Indian or Alaska Native and 51.9% (153/295) Hispanic, and 39.0% (115/295) had a baseline blood pressure greater than or equal to 140/90 mmHg. Overall, the differences between those enrolled in the trial and patients with hypertension who were ineligible, those who could not be reached, or those who chose not to enroll were minimal. Enrolled individuals had a slightly lower blood pressure (129/77 mmHg vs 132/79 mmHg; P=.04 for systolic blood pressure and P=.01 for diastolic blood pressure), were more likely to self-pay for their care (26% vs 10%; P<.001), and had a more recent primary care visit (164 days vs 231 days; P<.001). The enrolled cohort reported a high prevalence of poor health, low socioeconomic status, and high levels of basic material needs.ConclusionsThe Controlling Blood Pressure Trial has successfully enrolled a representative sample of individuals receiving health care at a UIHO. Trial follow-up will conclude in February 2019.Trial RegistrationClinicalTrials.gov NCT03135405; http://clinicaltrials.gov/ct2/show/NCT03135405 (Archived by WebCite http://www.webcitation.org/76H2B4SO6)International Registered Report Identifier (IRRID)DERR1-10.2196/11794

Almost 50% of patients with cardiovascular diseases face challenges in taking medications and increased morbidity and mortality. Text messaging may impact medication refill behavior and can be delivered at scale to patients by texting mobile phones. To obtain feedback from persons with chronic conditions on the design of interactive text messages and determine language of message for making messages that can motivate patients to refill medications on time. We purposively sampled 35 English and Spanish speaking patients with at least one chronic condition from three large healthcare delivery systems to participate in N-of-1 video-based synchronous interviews. Research assistants shared ideas for theory-informed text messages with content intended to persuade patients to refill their medication. We transcribed recorded interviews and conducted a content analysis to identify strategies to employ generating a dynamic interactive text message library intended to increase medication refill. Those interviewed were of diverse age and race/ethnicity and typical of persons with multiple chronic conditions. Several participants emphasized that personally tailored and positively framed messages would be more persuasive than generic and/or negative messages. Some patients appreciated humor and messages that could evoke a sense of social support from their providers and rejected the use of emojis. Messages to remind patients to refill medications may facilitate improvements in adherence, which in turn can improve chronic care. Designing messages that are persuasive and can prompt action is feasible and should be considered given the ease with which such messages can be delivered automatically at scale.

Background: The use of text messaging is a growing trend. Usual care for follow-up with patients (no dedicated communication) has proven unreliable, and alternative communication methods may be beneficial. Introduction: The objective was to evaluate the effect of text messaging as a means of follow-up communication compared to usual care on patient satisfaction among patients discharged from the emergency department (ED). Materials and Methods: Participants completed a baseline survey about their text message usage and ED visit satisfaction. The participants completed a follow-up survey 2 weeks later. Participants randomized to text messaging received a text message at 24 h, 1 week, and 2 weeks after discharge. Control participants received usual care (typically no dedicated communication). Bivariate analyses were performed, and intent-to-treat and per protocol analyses were completed to examine follow-up satisfaction with ED communication/care. Results: A total of 802 subjects were recruited (text messaging-398 subjects, usual care-404 subjects). In the intent-to-treat analysis, text messaging subjects were not more likely to report satisfaction with follow-up communication (adjusted odds ratio [aOR] 0.90 [0.46-1.75]) or follow-up care (aOR 0.66 [0.30-1.46]) than usual care subjects. In per-protocol analysis, text messaging subjects had 2.95 (1.52-5.73) higher odds of reporting satisfaction with follow-up communication and 3.24 (1.46-7.16) higher odds of reporting satisfaction with follow-up care. Discussion: The use of text messaging for follow-up, when comparing satisfaction with follow-up communication and follow-up care after discharge, performs at least equally as well as usual follow-up. Conclusions: Text messaging is a provider time-saving and resource-conserving technology allowing health care providers to potentially reach a larger proportion of patients, making it a valuable form of follow-up communication.

Effect of lifestyle focused text messaging on risk factor modification in patients with diabetes and coronary heart disease: A sub-analysis of the TEXT ME study

Text message reminders for timely routine MMR vaccination: A randomized controlled trial

There are salient outcomes beyond A1c, including patient-reported outcomes, in the current era of diabetes interventions. The current study assessed psychosocial effects over 1 year in the Teenwork Study, an RCT utilizing text-messaging (TM) and problem solving (PS) interventions in a 2x2 factorial design, in teens with T1D. Teens ages 13-17 from 2 U.S. clinical sites were randomized to 4 groups: PS, TM, PS+TM, or usual care. The PS and PS+TM groups had quarterly intervention sessions with study staff targeting barriers and strategies to improve self-care related to BG monitoring and insulin administration. The TM and PS+TM groups received reminders to check BG levels at self-selected times from 1-4 times/day. All teens completed measures of affect around BG monitoring, depressive symptoms, self-efficacy, parent involvement in diabetes care, diabetes-specific family conflict, diabetes distress, and general quality of life at baseline and 1 year. Changes in survey scores from 0 to 12 months were analyzed by group assignment, controlling for baseline scores. The sample included 281 teens ([M±SD] age 15.0±1.3 years, T1D duration 6.6±3.8 years, 4.6±1.9 BG checks/day, A1c 8.5±1.1%). Teens were 51% male, 78% white, and 80% from 2-parent families; 64% used pump therapy. At entry, groups had similar demographic and diabetes characteristics. After 1 year, all 4 groups had a significant increase in independent care behaviors (less parent involvement) (p&amp;lt;.001). Teens in the PS+TM group had decreases in diabetes family conflict (p=.009) and diabetes distress (p=.01). There were no changes in other psychosocial measures. Increased independent self-care across groups was likely developmentally driven. Combined PS+TM reduced teen-reported diabetes family conflict and diabetes distress. Providing problem-solving skills at quarterly visits with text reminders between visits together may serve to encourage and empower teens with T1D, thus improving their psychosocial outcomes. Disclosure P.V. Commissariat: None. L. Volkening: None. D.A. Butler: None. B. Anderson: Advisory Panel; Self; Sanofi-Aventis. L.M. Laffel: Consultant; Self; Eli Lilly and Company, Novo Nordisk Inc., Sanofi US, MannKind Corporation, Roche Diagnostics Corporation, Dexcom, Inc., Insulet Corporation, AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Johnson &amp; Johnson Diabetes Institute, LLC..

A comprehensive lipid panel is recommended by guidelines to evaluate atherosclerotic cardiovascular disease risk, but uptake is low. To evaluate whether direct outreach including bulk orders with and without text messaging increases lipid screening rates. Pragmatic randomized clinical trial conducted from June 6, 2023, to September 6, 2023, at 2 primary care practices at an academic health system among patients aged 20 to 75 years with at least 1 primary care visit in the past 3 years who were overdue for lipid screening. Data analysis was performed from September 2023 to May 2024. Eligible patients were randomized in a 1:2:2 ratio to usual care (group 1), direct outreach and bulk orders (group 2), and bulk order outreach with additional text message reminders for scheduling assistance (group 3). In group 3, participants received an initial, follow-up, and reminder text message. Patients with electronic portal accounts were encouraged to schedule through them, while others received laboratory contact information. Any participant inquiries were answered either with automated responses for common questions or with study team support. Proportion of patients who completed a lipid panel within 3 months. Among the 1000 participants, the median (IQR) age was 38 (28-55) years; 470 (47.0%) were female; and 22 (2.3%) were Asian, 38 (3.9%) were Black, 32 (3.2%) were Hispanic or Latino, and 862 (88.6%) were White (race and ethnicity were based on self-reported data). At 3 months, a lipid panel was completed by 12 of 202 patients (5.9%; 95% CI, 3.4% to 10.1%) receiving usual care (group 1) vs 62 of 394 patients (15.7%; 95% CI, 12.5% to 19.7%) receiving direct outreach and bulk order (group 2), a difference of 9.8 percentage points (95% CI, 4.6 to 15.0; P = .001). The panel was completed by 73 of 404 patients (18.1%; 95% CI, 14.6% to 22.1%) receiving outreach, bulk order, and text message reminders (group 3), for a difference of 2.4 percentage points (95% CI, -3.1 to 7.8; P = .43) vs outreach with bulk order alone (group 2). At 6 months, there were no significant differences in lipid screening between either group 1 vs group 2 or group 2 vs group 3. Lipid screening among participants receiving bulk orders and outreach letters increased significantly compared with usual care at 3 months. However, there was no difference at 6 months. More than 80% of patients did not follow through with lipid screening despite the intervention, and there was no additional increase in lipid testing at 3 months among participants receiving bulk ordering and supplemental text messaging. ClinicalTrials.gov Identifier: NCT05724615.

Background: As a leading cause of morbidity and mortality, Hypertension is a pressing global concern. Adherence to antihypertensive is a cornerstone of effective antihypertensive therapy. However, suboptimal medication adherence is widespread. Mobile health technology i.e. text messaging is a promising tool that can promote medication adherence with a wide-reaching effect on population health. Aims: To critically assess the effectiveness of text-based messaging interventions for improving medication adherence among community-dwelling adults with Hypertension. Methods: Studies were identified through a detailed search of six databases by two independent reviewers: PubMed, Embase, Cochrane, PsycINFO, CINAHL and Scopus. Studies included were: (1) published in English, since 2000; (2) randomised controlled trials; (3) done on community-dwelling adults diagnosed with Primary/ Essential Hypertension; (4) utilised 1 or 2-way text messaging, tailored text messaging, interactive voice response and text-based mobile applications; and (5) with medication adherence-related outcomes. Data extraction was conducted based on the Cochrane Handbook for Systematic Reviews of Intervention, and relevant studies underwent a study appraisal using the Cochrane Risk of Bias Tool. Results: Twelve studies were included in the final review. Text-based messaging interventions exhibited a small statistically significant effect on medication adherence scores and systolic blood pressure reduction while the effect on controlled blood pressure and adherence remains uncertain. Subgroup analyses revealed having a multifaceted content on Hypertension management may be more effective than solely medication adherence content and or reminders. Significance of the study: There is limited evidence that text messaging-based interventions resulted in improved medication adherence and blood pressure control as a result of adherence. With the rise of mobile health, future studies exploring the cost effectiveness and feasibility of tailored and interactive text messaging interventions are warranted to influence the use of public health resources into the development of communication tools as a public health strategy for promoting medication adherence.

Low-income, racial/ethnic minorities are often nonadherent to diabetes medications, have uncontrolled glycemia, and have high rates of diabetes-related morbidity. Cell phones provide a viable modality to support medication adherence, but few cell phone-based interventions have been designed for low-income persons, a population with more feature phone penetration than smartphone penetration. In an effort to reach the broadest range of patients, we leveraged the voice and text messaging capabilities shared by all cell phones to design the MEssaging for Diabetes intervention. We specifically advanced and adapted an existing tailored text messaging system to include interactive voice response functionality and support the medication adherence barriers of low-income, diverse adults with type 2 diabetes mellitus. We report on the design process and feasibility testing results (i.e., technical use patterns and subjective user experiences) from patients from the target population who used the intervention in one of three user-centered design iterations. The types of challenges encountered in design were related to providing text message content with valued information and support that engages patients. The design process also highlighted the value of obtaining mixed methods data to provide insight into legitimate versus illegitimate missing data, patterns of use, and subjective user experiences. The iterative testing process and results outlined here provide a potential template for other teams seeking to design technology-based self-care support solutions for comparable patient populations.

Introduction: The Ebola vaccine Deployment, Acceptance, and Compliance (EBODAC) project was established to develop a communication and community engagement strategy, including the development of appropriate technology, to maximize Ebola vaccination impact in the targeted population both in support of clinical trials and in the broader vaccination program beyond the clinical trial. EBODAC supported the EBOVAC-Salone trial in Kambia district in Sierra Leone to ensure that the novel prime-boost vaccine regimen is well accepted and successfully used in the context of clinical trials; while also preparing to maximize the impact of the potential deployment of a future Ebola vaccination program. The Mobile Technology for Community Health (MOTECH) platform was utilized and customized to help ensure compliance with the prime-boost vaccination regimen. Its main role was to support the communications and reminders surrounding the Ebola vaccine trial through an automated message service to participants’ mobile phones as Interactive Voice Responses (IVR) and SMS (Short Message Service) messages. Methods: The study was cross-sectional and adopted qualitative and quantitative research methods. The design was constructed to provide a representation of different user segments. The sample size was not constructed to provide statistical differences or detect differences in impact among groups but was simply designed to provide insights into how study participants interacted with the technology. Eligibility criteria involved randomly selecting participants from those that: a) received IVR and SMS and didn’t miss an appointment (booster compliant), b) received IVR and SMS and missed an appointment (booster non-compliant), c) received no IVR and SMS and didn’t miss or missed an appointment (MOTECH non-user). Quantitative information was entered in well-designed data entry templates. All participants’ names were anonymized for data analysis. Results: All the respondents, (n=81) revealed liking both the IVRS and SMS messages and majority of these, 80.2% (n=65) reported that IVR was very easy to understand. Respondents 47.5% (n=45) were comfortable receiving IVR, as opposed to 35.8% (n=29) preferred both text and voice messages. It was also found that 74.1% (n=60) of the respondents who were sent visit reminder messages never missed clinic appointment and 81.5% of those that received information preferred to know how to protect themselves from the disease. Conclusion: The EBOVAC-Salone automated voice messages contributed to valuable learning about areas of improvement for the MOTECH that will be of great importance for future outbreaks and medical interventions.

BackgroundEmergency department (ED) visits can be opportunities to address uncontrolled hypertension. We sought to compare short‐term blood pressure measures between the Vanderbilt Emergency Room Bundle (VERB) intervention and usual care plus education.Methods and ResultsWe conducted a randomized trial of 206 adult patients with hypertension and elevated systolic blood pressure (SBP) presenting to 2 urban emergency departments in Tennessee, USA. The VERB intervention included educational materials, a brief motivational interview, pillbox, primary care engagement letter, pharmacy resources, and 45 days of informational and reminder text messages. The education arm received a hypertension pamphlet. After 78 participants were enrolled, text messages requested confirmation of receipt. The primary clinical outcome was 30‐day SBP. The median 30‐day SBP was 122 and 126 mm Hg in the VERB and education arms, respectively. We estimated the mean 30‐day SBP to be 3.98 mm Hg lower in the VERB arm (95% CI, −2.44 to 10.4; P=0.22). Among participants enrolled after text messages were adapted, the respective median SBPs were 121 and 130 mm Hg, and we estimated the mean 30‐day SBP to be 8.57 mm Hg lower in the VERB arm (95% CI, 0.98‒16.2; P=0.027). In this subgroup, the median response rate to VERB text messages was 56% (interquartile range, [26%‒80%]).ConclusionsThis pilot study demonstrated feasibility and found an improvement in SBP for the subgroup for whom interactive messages were featured. Future studies should evaluate the role of interactive text messaging as part of a comprehensive emergency department intervention to improve blood pressure control.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT02672787.

The widespread availability of high speed, mobile cellular telephones and other advances in communication technology have the potential to change the way that interventions for substance use disorders (SUD) are delivered and how progress is monitored. This article reviews recent research on the use of new technology to monitor progress and deliver interventions for SUD. Several studies of telephone-based interventions show positive effects, but sometimes only in certain subgroups. However, other studies produced negative results. Studies support the use of interactive voice response (IVR) and personal digital assistants (PDAs) to conduct assessments, but there is little data on whether IVR- or PDA-based interventions improve outcomes. Text messaging has received comparatively little research, but appears promising as a means to conduct assessments and deliver automated interventions. Finally, smartphone technology provides the widest range of features and interventions and the greatest flexibility, but few intervention studies that use them have been conducted.

Severe hypoglycemia is a life-threatening, iatrogenic complication of diabetes medications associated with increased risks of falls, cardiovascular events, cognitive decline, and mortality. To determine whether proactive outreach by a clinical pharmacist applying an evidence-based hypoglycemia-prevention algorithm (Hypoglycemia on a Page) would result in safer prescribing of diabetes regimens among patients with type 2 diabetes (T2D) with hypoglycemia risk. This randomized clinical trial was conducted between July 20, 2023, and January 22, 2024, with follow-up outcomes collected through January 2025. The study included adults with T2D at high risk of hypoglycemia based on a validated hypoglycemia risk tool. The trial was conducted within Kaiser Permanente Northern California, a large, integrated health care delivery system. Patients were randomized 1:1 to either a protocol-driven outreach by a clinical pharmacist (intervention) arm or a usual care (control) arm. The main outcome was the comparison of the proportion of patients who were prescribed safer (less hypoglycemia-prone) diabetes regimens, defined as discontinuation of sulfonylureas and/or rapid-acting or short-acting or mixed insulins, using an intention-to-treat analysis. From an eligible population of 1204 patients, 200 were enrolled into the clinical trial. Among these, 191 patients were in the intention-to-treat cohort (mean [SD] age, 71.3 [11.5] years; 100 females [52.4%]). The 2 study arms were similar at baseline in terms of race and ethnicity, sex, mean (SD) hemoglobin A1c (HbA1c) level (intervention: 8.0 [1.3]; control: 8.3 [1.8]), and number (percentage) of patients receiving insulin (intervention: 82 [85.4%]; control:85 [89.5%]) and sulfonylurea (intervention: 25 [26.0%]; control: 21 [22.1%]). At 6 months, patients in the intervention arm were more likely to be prescribed a safer diabetes regimen than those in the control arm (27 [28.1%] vs 15 [15.8%]; risk difference [RD], 12.3% [95% CI, 0.6% to 24.0%]). Patients in the intervention arm also experienced significantly fewer hypoglycemia-related emergency department or inpatient encounters (0 vs 5 [5.3%]; RD, -5.3% [95% CI, -11.8% to -1.3%]). There was no worsening of HbA1c control in the intervention arm compared with the control arm (47 [61.8%] vs 49 [63.6%] with HbA1c <8%; RD, -1.8% [95% CI, -17.0% to 13.5%]). In this randomized clinical trial, adding proactive, protocol-driven clinical pharmacist outreach into collaborative team-based care improved medication optimization and patient outcomes. This approach provides an evidence-based strategy for reducing the risk of developing severe hypoglycemia in individuals with T2D at high risk, enhancing patient safety, and potentially reducing overall health care cost. ClinicalTrials.gov Identifier: NCT06746714.