Text Messaging Improves Compliance With Therapy

Maria Sgambati, MD

November 16, 2010

November 16, 2010 (Washington, DC) — Can mobile technology help motivate patients to complete vaccination series? That's the question that Sarah Russell, MD, an internist at the Veterans' Affairs Medical Center in Philadelphia, Pennsylvania, and CEO of RxText, hopes to answer. "I've had a long-standing interest in underserved populations and using low-tech solutions to reach these patients. In the United States, text messaging represents an untapped opportunity in healthcare delivery."

Multidose vaccines are an ideal target for such technology, because adherence can be low and difficulties exist with traditional reminder systems, Dr. Russell said during a presentation here at the 2010 mHealth Summit. Her study, called IMPACT (Improving Patient Adherence Through Clinic-Initiated Text Messages), recently began at several ambulatory clinics in New York City and in Boston, Massachusetts.

In the intervention group, patients scheduled to receive varicella, hepatitis B, or human papillomavirus vaccination series will get text message appointment reminders the day before and the day of the appointment. Patients in the control group will receive traditional paper/mail or telephone reminders. Healthcare providers are increasingly being evaluated on quality metrics that include such measures as vaccination completion, so this will help them as well as their patients.

Although IMPACT is still accruing patients, Dr. Russell showed some preliminary data that suggest very slight improvements in appointment success and no-show rates with text messaging. But she cautions that it is too early to tell if this difference will persist or be significant.

"As a physician, I get in a room with a patient and think about the 8000 things this patient needs to help improve their health, given the ecosystem they are living in. So I tend to think less about tools and how they might help." Dr. Russell noted. "But when I step back and look at things as an entrepreneur, I begin think about tools to help fix the system."

Mobile phones can be used to help "fix the system" and get patients more engaged in their own care. "One of the things we are doing with this new technology is looking at these disease and healthcare problems that everyone else is looking at — some are fairly high-level problems — and we are looking at different ways of intervening," Julia Royall, MA, session moderator and chief of international programs at the National Institutes of Health National Library of Medicine, told Medscape Medical News. "The beauty is that these are some really simple interventions that in some cases leverage existing technology, such as mobile phones."

Such leveraging is just what is happening halfway across the globe, in Kenya, where text messaging proved to be superior to standard care in improving adherence to antiretroviral therapy (ART) in HIV patients. Richard Lester, MD, FRCPC, clinical assistant professor at the University of British Columbia, Vancouver, presented the results of his study, published online November 9 in the Lancet, showing that simple text messaging significantly improved self-reported ART adherence by 12% (62% vs 50%). ART saves lives and ART adherence is directly related to viral suppression, as measured by HIV-1 RNA load, Dr. Lester noted. But with lifelong therapy needed, ART can be very challenging for patients.

"Globally, we really need healthcare systems that are efficient and effective," Dr. Lester told the audience. "Text messaging may be something that can help improve both." In the intervention group, the word "Mambo" — which means "How are you?" in Swahili — was sent to patients who were instructed to respond within 48 hours with either "sawa" (doing well) or "shida" (having a problem). The clinician then called the patients who responded with shida or who had not responded within 2 days.

"We found that this simple message gave patients the feeling that someone cares," Dr. Lester told attendees. "The majority would like to see the program continue and would recommend it to a friend."

In the study, 84% of the 583 patients owned their own cell phone; another 16% shared a cell phone. Before setting up the study, the researchers found that more than 50% of the patients attending the HIV clinic had a cell phone, but very few of them were using them to manage their health. In Africa, cell phone technology has "leapfrogged" over the traditional landline technology that is still prominent in developed countries; less than 1% of study participants had landlines.

"Technology is just the tool; it's got to be the combination of the information and the tool to support the mission." Ms. Royall told Medscape Medical News. "In some cases, paper and pencil may still be better or more cost-efficient than newer technologies. We should use all the media we have at hand and use what works best in each situation."

The bottom line, according to Ms. Royall, is whether or not these new technologies can be applied in a way that improves health outcomes and ultimately translates into improvements in morbidity and mortality. "If we don't get to that point . . . if we aren't making a difference in lives, then even with all these nice gadgets . . . we've failed," Royall said.

Dr. Russell is CEO of RxText. Ms. Royall has disclosed no relevant financial relationships.

Lancet. Published online November 9, 2010. Abstract

2010 mHealth Summit. Presented November 10, 2010.


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