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Journal of Evidence-Based Social Work Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/webs20
Social Work and Medical Care: Electronic Reminders to Address Adherence Allison Whisenhunt
a
a
Providence Hospital Seaside, Seaside, Oregon, USA Published online: 23 May 2014.
To cite this article: Allison Whisenhunt (2014) Social Work and Medical Care: Electronic Reminders to Address Adherence, Journal of Evidence-Based Social Work, 11:3, 248-255, DOI: 10.1080/15433714.2012.759460 To link to this article: http://dx.doi.org/10.1080/15433714.2012.759460
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Evidence-Based Social Work, 11:248–255, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1543-3714 print/1543-3722 online DOI: 10.1080/15433714.2012.759460
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Social Work and Medical Care: Electronic Reminders to Address Adherence Allison Whisenhunt Providence Hospital Seaside, Seaside, Oregon, USA
Social workers are often involved with patients and families around adherence, both to clinic appointments as well as to the medication regimen. An evidence-based practice project was created and implemented to determine the efficacy of electronic reminders such as text messaging on adherence. The implications of improving adherence can positively impact the patient on an individual level as well as reduce costs and increase revenue at a systems level. Keywords: Medication adherence, electronic reminders, short message service (SMS), outpatient appointment attendance, medical appointments
Many referrals to the medical social worker are generated by a patient/family not attending clinic appointments for medical care as recommended. Reasons for clinic nonattendance have been well documented, including forgetfulness and confusion about appointment dates and times (Nelson, Berg, Bell, Leggott, & Seminario, 2011). Once barriers to clinic attendance such as transportation and health insurance coverage are addressed, it is important to identify ways patients/families can avoid any confusion about appointments as well as best remember or be reminded of the appointment. From a systems perspective, nonattendance to clinic visits also reduces the efficiency of health systems (Chen, Fang, Chen, & Dai, 2008). Patient nonattendance in the outpatient clinic can have many negative impacts such as wasted resources, less productivity of staff, and for those working in teaching medical settings patient nonattendance creates less opportunity for learning for new staff as well as students (Geraghty, Glynn, Amin, & Kinsella, 2008). For example, data on no-show rates by month for health care providers in the Division of Pulmonary Medicine at Cincinnati Children’s Hospital Medical Center for January 2009–July 2011 range from 0–42.9% (local data). Social work is also often called upon to help patients and families with adherence to taking medications. Once basic barriers have been addressed, such as access to medications, and problemsolving social factors, such as how to ensure medication adherence among various households and between school and home, there is often a need to help identify ways in which patients and families can be reminded to take their medications. The prevalence of cell-phone ownership and use has increased over time; almost every household in the United States has at least one cell phone (Krishna, Boren, & Balas, 2009) and the use of cell phones has grown in groups at risk of having lower rates of appointment attendance (Nelson Address correspondence to Allison Whisenhunt, MSW, LISW-S, Providence Hospital Seaside, PO Box 1098, Seaside, OR 97138, USA. E-mail: [email protected]
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et al., 2011). Wireless mobile technology may help remove disparities as the ownership and use of cell phones is more prevalent among those with low socioeconomic status (Krishna et al., 2009). Communication with patients and families can be challenging when there are frequently changing phone numbers and cell phone carriers (Chen et al., 2008). Local clinicians report that for some patients and families there are financial strains that limit the amount of cell phone minutes available for talking and the use of more affordable text messaging can be the only way to communicate. Utilizing the Iowa Model of Evidence-Based Practice, which provides a framework for the development of evidence-based practice in a clinical agency (Burns & Grove, 2011), the following clinical question was developed: Among pediatric patients and families, does the use of electronic reminders such as text messaging versus standard care (no electronic reminders) improve adherence to taking medication and attending outpatient appointments? OVERVIEW OF THE RESEARCH A comprehensive literature review was conducted using the following keywords: asthma, medication adherence, electronic reminders, reminder systems/cellular phone/text message/communication, office visits/ambulatory care/appointments and schedules, short message service (SMS), outpatient appointment attendance, pulmonary, cystic fibrosis, and medical appointments. Articles were identified through the following databases: PubMed, Medline, Cochrane Collaboration, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, and Google Scholar. An inquiry was sent by e-mail through Children’s Hospitals Association listserv with only one response stating that no text messaging was used at a particular institution. While there was no limit placed regarding when the article was published, all of the articles reviewed ranged from 2006– 2012 and only English-language articles were selected. Since the clinical question focused on push technology, only articles focusing on sending electronic reminders, rather than studies that included back-and-forth electronic communication, were included. As of the last literature search December 15, 2011, a total of 12 articles were found to be relevant to this clinical question. Of the articles, there were three meta-analysis or systematic reviews, five randomized controlled trials, three cohort studies, and one published expert opinion. All articles were critically appraised utilizing the evaluation system developed at Cincinnati Children’s Hospital Medical Center known as LEGEND (Let Evidence Guide Every New Decision). Tables are included in the Appendix to explain the LEGEND system (Appendix A) and to provide an overview of the literature appraised for this evidence-based practice project (Appendices B and C). RESULTS Adherence to the treatment regimen and outpatient appointments can be linked to health outcomes, such as possible improvement in quality of life, possible reduction in risk of hospitalization, and allowing for changes in medication or clarifying confusion about the treatment regimen (Guy et al., 2012). Patients who fail to attend outpatient appointments and who have had insufficient adherence to medications have experienced more adverse health outcomes, such as increased hospitalization rates as well as poor symptom management (Guy et al., 2012; Strandbygaard, Thomsen, & Backer, 2010). Compared to no appointment reminder, text message reminders increase the likelihood that patients will attend clinic appointments by 50% in both primary care and hospital outpatient clinics (Guy et al., 2012). Text messaging has been shown to be at least as effective as calls at reducing outpatient appointment nonattendance and is more cost effective (Chen et al., 2008;
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Leong et al., 2006; Koshy, Car, & Majeed, 2008; Foley & O’Neill, 2009; Geraghty et al., 2008; Ting et al., 2012; Wei, Hollin & Kachnowski, 2010). Text messaging has the potential to reach a large number of patients and families at relatively low cost (Chen et al., 2008). Information interventions through electronic media such as text messages have been shown to positively impact behavior change, including smoking cessation, weight loss, and daily vitamin consumption (Cole-Lewis & Kershaw, 2010; Krishna et al., 2009) and improved mean adherence for medication by 17.8%, 95% CI (3.2–32.3%), p D 0.019 (Strandbygaard et al., 2010). Chronic diseases requiring regular management, such as diabetes and asthma, benefit most from cell phone-based interventions (Krishna et al., 2009). In terms of age, all of the systematic reviews (Cole-Lewis & Kershaw, 2010; Guy et al., 2012; Krishna et al., 2009) and the literature review (Wei et al., 2011) included studies with the pediatric population. Many of the individual articles that were appraised were specific to the pediatric population (Geraghty et al., 2008; Nelson et al., 2009; Ting et al., 2012) and those studies looking at adult patients could be generalized to the pediatric population since in most cases the text messages are sent to the adult caregiver. A high grade of evidence was found in support of electronic reminders for both adherence to coming to outpatient appointments as well as for adherence to taking medications. Based on the evidence, the following recommendations can be made: It is strongly recommended that electronic reminders, such as text messages, be used to reduce no-show rates in the outpatient clinic. It is strongly recommended that electronic reminders, such as text messages, be used with patients and families to positively impact behavior change and improve treatment adherence. APPLICATION OF RESULTS In line with the Iowa model, the next steps involve translation of the knowledge into practice as well as evaluation of the impact of the research based change (Burns & Grove, 2011). An informal survey was given to all willing patients and families who registered for a pulmonary outpatient appointment in the month of February 2012 to determine the type of appointment reminders that are most preferred; of the 289 respondents, 44.3% said text-message appointment reminders were preferred, which was more than any other form of appointment reminder options. These survey results, combined with the effectiveness of text message reminders demonstrated in the literature, create a strong argument that the institution offers this appointment-reminder communication option. While the institution is developing a system that will provide this, a small test of change is being conducted to determine the effectiveness of text-message appointment reminders with the population of patients who are the most frequent appointment no-show offenders. This test of change can also be used to solicit feedback from patients and families about the verbiage in the text messages and the timing of the messages in relation to when the appointment is scheduled. The informal survey showed only 14.2% of respondents were interested in medication reminders, so the current implementation plan is focusing on implementing the electronic appointment reminders first. IMPLICATIONS FOR SOCIAL WORK Social workers are often involved in advocating for system changes and helping families navigate the available resources. Equipped with the knowledge of the evidence in support electronic reminders to address adherence, social workers can suggest that electronic reminders, such as text
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messaging, be offered to patients and families for both appointment reminders and medication reminders. In addition, social workers can educate patients and families about resources for electronic reminders. The use of text messaging could potentially help reduce disparities in access as the ownership of cell phones is more prevalent among those with low socioeconomic status (Krishna et al., 2009); this is also in line with the Social Work value of social justice and creating equal opportunities. It is important to assess patient/family preference for the form of communication for appointment reminders, as not everyone has a cell phone or unlimited text messaging service on their phone (Krishna et al., 2009). Members of the health care team will need to partner with patients and families to keep mobile phone numbers current (Chen et al., 2008). Text messaging can be individualized to the requested time of day for each patient, and possibly several times of day, to be most effective and meet patient and family preference (Strandbygaard et al., 2010). The other important consideration is confidentiality and how the text message is sent. Health care staff, including social workers, are advised to not send text messages to patients or family member with a personal cell phone, as this violates boundaries and can lead to confusion about how to reach staff when needed (Leong et al., 2006). Electronic messaging is a fast changing phenomenon and recommendations about this form of communication need to be revisited frequently. The National Association of Social Workers (NASW, 1999) includes standards that relate to electronic communication. For example, in relation to informed consent, standard 1.03 (e) states that: “Social workers who provide services via electronic media (such as computer, telephone, radio, and television) should inform recipients of the limitations and risks associated with such services.” For patients and families who are not connected to an agency that offers electronic reminders, Social Workers can help research and connect them to this in other ways. For instance, electronic reminders can be in the form of a daily alarm on a cell phone. There are disease-specific supports available, such as www.cffone.com that offers patients with cystic fibrosis, aged 11 years and older, with various forms of electronic support, including a text message reminder system. Other online supports, such as www.mymedschedule.com, are available for people with any diagnosis to receive text message reminders and/or email reminders about taking and/or refilling medication.
CONCLUSION In summary, there is strong evidence that the use of electronic reminders improves adherence to outpatient appointment attendance and medication adherence. Social workers play an important role in advocating that these resources be made available to patients and families. There is also a need for social workers to educate patients and families about these resources, including limitations to confidentiality.
NOTE 1. See Appendix A for meaning of bracket notation following some references.
REFERENCES1 Burns, N. & Grove, S. (2011). Understanding nursing research: Building an evidence-based practice (5th ed.). Maryland Heights, MO: Elsevier Saunders.
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Chen, Z., Fang, L., Chen, L., & Dai, H. (2008). Comparison of an SMS text messaging and phone reminder to improve attendance at a health promotion center: A randomized controlled trial. Journal of Zhejiang University SCIENCE B, 9(1), 34–38. [2a] Cole-Lewis, H., & Kershaw, T (2010). Text messaging as a tool for behavior change in disease prevention and management. Epidemiologic Reviews, 32, 56–69. [1a] Foley, J., & O’Neill, M. (2009). Use of mobile telephone short message service (SMS) as a reminder: The effect on patient attendance. European Archives of Paediatric Dentistry, 10(1), 15–18. [4a] Geraghty, M., Glynn, F., Amin, M., & Kinsella, J. (2008). Patient mobile telephone “text” reminder: A novel way to reduce non-attendance at the ENT outpatient clinic. The Journal of Laryngology & Otology, 122, 296–298. [4a] Guy, R., Hocking, J., Wand, H., Stott, S., Ali, H., & Kaldor, J. (2011). How effective are short message service reminders at increasing clinic attendance? A meta-analysis and systematic review. Health Services Research, 47, 614–632. doi: 10.1111/j.1475-6773.2011.01342.x [1a] Koshy, E., Car, J., & Majeed, A. (2008). Effectiveness of mobile-phone short message service (SMS) reminders for ophthalmology outpatient appointments: An observational study. BMC Ophthalmology, 8(9), 1–6. [4a] Krishna, S., Boren, S., & Balas, E. (2009). Healthcare via cell phones: A systematic review. Telemedicine and e-Health, 15(3), 231–240. [1b] Leong, K. C., Chen, W., Leong, K. W., Mastura, I., Mimi, O., Sheikh, M., et al. (2006). The use of text messaging to improve attendance in primary care: A randomized controlled trial. Family Practice Advance Access, 23(6), 699–705. [2b] National Association of Social Workers. (1999). Code of ethics of the National Association of Social Workers. Washington, DC: NASW Press. Nelson, T. M., Berg, J. H., Bell, J. F., Leggott, P. J., & Seminario, A. L. (2011). Assessing the effectiveness of text messages as appointment reminders in a pediatric dental setting. Journal of the American Dental Association, 142(4), 397–405. [2b] Strandbygaard, U., Thomsen, S. F., & Backer, V. (2010). A daily SMS reminder increases adherence to asthma treatment: A three-month follow-up study. Respiratory Medicine, 104(2), 166–171. [2a] Ting, T. V., Kudalkar, D., Nelson, S., Cortina, S., Pendi, J., Budhani, S., et al. (2012). Usefulness of cellular text messaging (CMTR) for improving adherence among adolescents and young adults with systemic lupus erythematosus. The Journal of Rheumatology, 39(1), 174–179. [2a] Wei, J., Hollin, I., & Kachnowski, S. (2011). A review of the use of mobile phone text messaging in clinical and healthy behavior interventions. Journal of Telemedicine and Telecare, 17, 41–48. [5a]
APPENDIX A LEGEND System Overview Quality Level 1a or 1b 2a or 2b 3a or 3b 4a or 4b 5a or 5b 5
Definition Systematic review, meta-analysis, or meta-synthesis of multiple studies Best study design for domain Fair study design for domain Weak study design for domain General review, expert opinion, case report, consensus report, or guideline Local consensus
a D good quality study; b D lesser quality study.
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Systematic review To assess the effectiveness of short message service (SMS) reminders at increasing appointment attendance Systematic review, populations varied healthy, diabetic, asthmatic, obese, smokers
Guy et al. (2012)
Systematic review
RCT Included: Patients with cSLE between 13–25 yrs old with unlimited texting; for hydroxychloroquine (HCQ), patients had the diagnosis at least 6 months Excluded: Patients with active neuropsychiatric SLE symptoms, patients with other chronic diseases
Krishna Boren, & Balas (2009)
Ting et al. (2012)
Cole-Lewis & Kershaw (2010)
Research Design and Sample
Citation
Randomized control trials (RCT; 20 of 25 were RCT’s) or controlled studies that evaluated delivery of health information or educational intervention with cell phone or text messaging and measured change in process of care or health outcomes
Adherence to clinic visit defined as patient seen within 1 week of a 1-month follow-up recommendation; 2 weeks within a 2-month follow-up recommendation; and 3 weeks for a 3-month follow-up recommendation. Medication adherence measured by: patient self report inventory (MASRI) at each visit, whole blood levels of HCQ, and pharmacy refill info Clinic attendance info extracted from computer system (databases and electronic medical record)
Cellular text messaging reminders (CTMR) sent 7-, 3-, and 1-day text message appointment reminder, Medication reminders sent daily at patient preference of time of day; twice a day if applicable
Health behavior & outcomes
Attendance at clinic appointment
Dependent Variable, Outcome
Text messaging/cell phone interventions
Text messaging as main intervention
SMS message versus no appointment reminder
Independent Variable, Intervention
APPENDIX B Evidence Synthesis Results Use of SMS reminders increases the likelihood of attendance at clinic appointments by 50% compared to no appointment reminder Text messaging is a useful tool for behavior change interventions. Several studies of medication adherence interventions show the benefits of medication reminders and when coupled with evidence of the benefits of mobile phones as an inexpensive, personal, efficient, and widely accessible way to intervene on health provides a very strong rationale for extending research on text messaging to medication adherence. Information and education interventions delivered through wireless mobile technology resulted in both clinical and process improvements in the majority of the studies (60%). Chronic diseases (e.g., asthma) requiring regular management benefited the most from the cell-phone interventions. CTMR is an inexpensive and rapidly receivable method of communication and could be a potentially useful method of improving clinic visit adherence (results were statistically significant); CTMR did not appear to be effective for improving med adherence
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(continued )
2a
1b
1a
1a
Level of Evidence a
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Literature review
Wei Hollin, & Kachnowski (2010)
to information in Appendix A.
RCT Inclusion: All dental clinic patients from May 1, 2009–November 30, 2009 (survey determined eligibility) Exclusion: Those who did not complete the survey and patients scheduled for oral conscious sedation or anesthesia
Nelson et al. (2011)
a Corresponds
RCT between 18–45 years of age with diagnosis of asthma based on clinical history and daily symptoms, positive methacholine challenge test with positive methacholine challenge test (PD(20); 4 mol) Excluded: Medical co-morbidities and a smoking history of more than 10 pack years
Research Design and Sample
Strandbygaard Thomsen, & Backer. (2010)
Citation
Text message
Daily SMS text at 10:00 am for 8 weeks vs. control group with no SMS text, SMS sent to intervention group at 10:00 am; overall this was received positively, though the time of day was not favorable to the group. Both groups received teaching about importance of ICS and proper inhaler technique Text-message reminder vs. voice reminder (control group) sent 48 hours before appointment to caregiver of pediatric dental patient
Independent Variable, Intervention
Divided by focus: medication adherence, clinical care management, and preventative behavior
Show rate vs. no-show rate Cancelation counted as show Voice reminder D 3 calls and if no answer then a message. Only one appointment was used, even if the patient had more during the study period. Also asked about preference for what type of reminder
Primary outcome was mean adherence rate to asthma treatment; secondary outcomes were reimbursement of asthma medication and change in exhaled nitric oxide levels, lung function, and airway responsiveness
Dependent Variable, Outcome
APPENDIX B (Continued ) Results
No significant findings. SMS reminders were not as effective as voice reminders; those who had the text message were 2.12 less likely to attend the dental appointments than those who got the voice-mail reminders; more participants said they would prefer voice reminder rather than text (41% vs. 27%) Text messaging has been shown to be more cost-effective than calls in improving outpatient appointment attendance it shows promise in improving adherence especially for chronically ill patients
A daily SMS reminder did have a significant effect on adherence to asthma treatment Those receiving SMS text were 17.8% more adherent (was statistically significant) No statistically significant difference in secondary outcomes.
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5a
2b
2a
Level of Evidence a
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Cross sectional Demographic Variables: Patients scheduled for outpatient pediatric dentistry appointment in October 2007 who had mobile-phone contact details as well as a historical control group who had appointments in October 2006 and had mobile-phone details Cross-sectional, retrospective Demographic Variables: Ear, Nose, & Throat outpatient clinic patients
Randomized control trial (RCT) Demographic variables: Adults, median age about 50 years, who had an appointment scheduled between 72 hour–2 months from recruitment date (April 2007–May 2007) and provided mobile phone number Multicenter, 3-arm RCT Demographic Variables: One quarter were caregivers of patients; mean age about 38 years, mix of preventative care and chronic illness Patients with a follow-up appointment between 48 hours–3 months from the recruitment date. The patient or their caregiver had a mobile phone with text messaging function. Cross sectional; pilot study Demographic Variables: All new visit patients in the time period; divided by mobile-phone information status to intervention and control groups Data from between April–Sept 2006
Research Design and Sample
a Corresponds to information in Appendix A.
Geraghty et al. (2008)
Foley & O’Neill (2009)
Koshy, Car, & Majeed (2008)
Leong et al. (2006) Family practice, August 17, 2006
Chen et al. (2008)
Citation
Text message reminder for appointment vs. control group
SMS text 24 hr prior to appointment vs. historical control group for October 2006
Reduction in nonattendance
Appointment attendance
Appointment attendance
Clinic attendance on the day the appointment was originally scheduled
Text message reminder vs. phone call reminder vs. no reminder
Automated text sent; control group received no reminder
Appointment attendance and cost analysis of text vs. phone
Dependent Variable Outcome (Measure)
Text message reminder vs. phone call reminder vs. no reminder (control)
Independent Variable Intervention (Measure)
The use of SMS reminders reduced nonattendance compared to no reminder and was more cost effective than other traditional reminders. Patients who received a text-message reminder were 38% less likely to be non-attenders (statistically significant) Those who receieved text-message reminders were also 26% more likely to cancel their appointments (though this was not statistically significant) Number needed to text to prevent one appointment nonattendance is 14 SMS reminders led to 6.9% absolute reduction and 38% relative reduction in nonattendance rates Sending text messages to patients 24 hr prior to appointment resulted in a relative reduction in nonattendance by over 50% comparing data from 2006–2007. 23.9% failed appointment in 2006 compared to 10.4% in 2007 Cancellation rate in 2007 also greater though not statistically significant Cost info: Each text was .065 per text Total text cost was e30. Nonattendance at outpatient clinic was estimated to cost 65 per incident People were 1.5 times more likely to come to appointment with text-message reminder Text-message group was about 22% nonattendance, control group was about 33% nonattendance. Text message reminder system decreased nonattendance and was more cost effective than telephone reminders
The attendance rate of the text messaging group was significantly higher than that of the control group, but there was no difference between the text-messaging group and the mobile-phone group. The text-messaging system cost less than half of the mobile-phone reminder per attendance. Text message vs. control and mobile phone vs. control showed statistical significance with improving appointment attendance, but were not statistically significant compared to each other. Texting was half the cost of calls.
The attendance rates were 80.5% control, 87.5% SMS, 88.3% telephone Cost effectiveness analysis showed cost was significantly less for SMS group vs. phone group (0.31 Yuan vs. 0.48 Yuan)
Significant Results Statistical & Clinical
APPENDIX C Articles Included in Systematic Reviews that Looked at the Cost Effectiveness of Text Messaging
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4a
4a
4a
2b
2a
Level of Evidence a
Journal of Evidence-Based Social Work Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/webs20
Social Work and Medical Care: Electronic Reminders to Address Adherence Allison Whisenhunt
a
a
Providence Hospital Seaside, Seaside, Oregon, USA Published online: 23 May 2014.
To cite this article: Allison Whisenhunt (2014) Social Work and Medical Care: Electronic Reminders to Address Adherence, Journal of Evidence-Based Social Work, 11:3, 248-255, DOI: 10.1080/15433714.2012.759460 To link to this article: http://dx.doi.org/10.1080/15433714.2012.759460
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Evidence-Based Social Work, 11:248–255, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1543-3714 print/1543-3722 online DOI: 10.1080/15433714.2012.759460
Downloaded by [University of Newcastle (Australia)] at 14:08 25 August 2014
Social Work and Medical Care: Electronic Reminders to Address Adherence Allison Whisenhunt Providence Hospital Seaside, Seaside, Oregon, USA
Social workers are often involved with patients and families around adherence, both to clinic appointments as well as to the medication regimen. An evidence-based practice project was created and implemented to determine the efficacy of electronic reminders such as text messaging on adherence. The implications of improving adherence can positively impact the patient on an individual level as well as reduce costs and increase revenue at a systems level. Keywords: Medication adherence, electronic reminders, short message service (SMS), outpatient appointment attendance, medical appointments
Many referrals to the medical social worker are generated by a patient/family not attending clinic appointments for medical care as recommended. Reasons for clinic nonattendance have been well documented, including forgetfulness and confusion about appointment dates and times (Nelson, Berg, Bell, Leggott, & Seminario, 2011). Once barriers to clinic attendance such as transportation and health insurance coverage are addressed, it is important to identify ways patients/families can avoid any confusion about appointments as well as best remember or be reminded of the appointment. From a systems perspective, nonattendance to clinic visits also reduces the efficiency of health systems (Chen, Fang, Chen, & Dai, 2008). Patient nonattendance in the outpatient clinic can have many negative impacts such as wasted resources, less productivity of staff, and for those working in teaching medical settings patient nonattendance creates less opportunity for learning for new staff as well as students (Geraghty, Glynn, Amin, & Kinsella, 2008). For example, data on no-show rates by month for health care providers in the Division of Pulmonary Medicine at Cincinnati Children’s Hospital Medical Center for January 2009–July 2011 range from 0–42.9% (local data). Social work is also often called upon to help patients and families with adherence to taking medications. Once basic barriers have been addressed, such as access to medications, and problemsolving social factors, such as how to ensure medication adherence among various households and between school and home, there is often a need to help identify ways in which patients and families can be reminded to take their medications. The prevalence of cell-phone ownership and use has increased over time; almost every household in the United States has at least one cell phone (Krishna, Boren, & Balas, 2009) and the use of cell phones has grown in groups at risk of having lower rates of appointment attendance (Nelson Address correspondence to Allison Whisenhunt, MSW, LISW-S, Providence Hospital Seaside, PO Box 1098, Seaside, OR 97138, USA. E-mail: [email protected]
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et al., 2011). Wireless mobile technology may help remove disparities as the ownership and use of cell phones is more prevalent among those with low socioeconomic status (Krishna et al., 2009). Communication with patients and families can be challenging when there are frequently changing phone numbers and cell phone carriers (Chen et al., 2008). Local clinicians report that for some patients and families there are financial strains that limit the amount of cell phone minutes available for talking and the use of more affordable text messaging can be the only way to communicate. Utilizing the Iowa Model of Evidence-Based Practice, which provides a framework for the development of evidence-based practice in a clinical agency (Burns & Grove, 2011), the following clinical question was developed: Among pediatric patients and families, does the use of electronic reminders such as text messaging versus standard care (no electronic reminders) improve adherence to taking medication and attending outpatient appointments? OVERVIEW OF THE RESEARCH A comprehensive literature review was conducted using the following keywords: asthma, medication adherence, electronic reminders, reminder systems/cellular phone/text message/communication, office visits/ambulatory care/appointments and schedules, short message service (SMS), outpatient appointment attendance, pulmonary, cystic fibrosis, and medical appointments. Articles were identified through the following databases: PubMed, Medline, Cochrane Collaboration, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, and Google Scholar. An inquiry was sent by e-mail through Children’s Hospitals Association listserv with only one response stating that no text messaging was used at a particular institution. While there was no limit placed regarding when the article was published, all of the articles reviewed ranged from 2006– 2012 and only English-language articles were selected. Since the clinical question focused on push technology, only articles focusing on sending electronic reminders, rather than studies that included back-and-forth electronic communication, were included. As of the last literature search December 15, 2011, a total of 12 articles were found to be relevant to this clinical question. Of the articles, there were three meta-analysis or systematic reviews, five randomized controlled trials, three cohort studies, and one published expert opinion. All articles were critically appraised utilizing the evaluation system developed at Cincinnati Children’s Hospital Medical Center known as LEGEND (Let Evidence Guide Every New Decision). Tables are included in the Appendix to explain the LEGEND system (Appendix A) and to provide an overview of the literature appraised for this evidence-based practice project (Appendices B and C). RESULTS Adherence to the treatment regimen and outpatient appointments can be linked to health outcomes, such as possible improvement in quality of life, possible reduction in risk of hospitalization, and allowing for changes in medication or clarifying confusion about the treatment regimen (Guy et al., 2012). Patients who fail to attend outpatient appointments and who have had insufficient adherence to medications have experienced more adverse health outcomes, such as increased hospitalization rates as well as poor symptom management (Guy et al., 2012; Strandbygaard, Thomsen, & Backer, 2010). Compared to no appointment reminder, text message reminders increase the likelihood that patients will attend clinic appointments by 50% in both primary care and hospital outpatient clinics (Guy et al., 2012). Text messaging has been shown to be at least as effective as calls at reducing outpatient appointment nonattendance and is more cost effective (Chen et al., 2008;
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Leong et al., 2006; Koshy, Car, & Majeed, 2008; Foley & O’Neill, 2009; Geraghty et al., 2008; Ting et al., 2012; Wei, Hollin & Kachnowski, 2010). Text messaging has the potential to reach a large number of patients and families at relatively low cost (Chen et al., 2008). Information interventions through electronic media such as text messages have been shown to positively impact behavior change, including smoking cessation, weight loss, and daily vitamin consumption (Cole-Lewis & Kershaw, 2010; Krishna et al., 2009) and improved mean adherence for medication by 17.8%, 95% CI (3.2–32.3%), p D 0.019 (Strandbygaard et al., 2010). Chronic diseases requiring regular management, such as diabetes and asthma, benefit most from cell phone-based interventions (Krishna et al., 2009). In terms of age, all of the systematic reviews (Cole-Lewis & Kershaw, 2010; Guy et al., 2012; Krishna et al., 2009) and the literature review (Wei et al., 2011) included studies with the pediatric population. Many of the individual articles that were appraised were specific to the pediatric population (Geraghty et al., 2008; Nelson et al., 2009; Ting et al., 2012) and those studies looking at adult patients could be generalized to the pediatric population since in most cases the text messages are sent to the adult caregiver. A high grade of evidence was found in support of electronic reminders for both adherence to coming to outpatient appointments as well as for adherence to taking medications. Based on the evidence, the following recommendations can be made: It is strongly recommended that electronic reminders, such as text messages, be used to reduce no-show rates in the outpatient clinic. It is strongly recommended that electronic reminders, such as text messages, be used with patients and families to positively impact behavior change and improve treatment adherence. APPLICATION OF RESULTS In line with the Iowa model, the next steps involve translation of the knowledge into practice as well as evaluation of the impact of the research based change (Burns & Grove, 2011). An informal survey was given to all willing patients and families who registered for a pulmonary outpatient appointment in the month of February 2012 to determine the type of appointment reminders that are most preferred; of the 289 respondents, 44.3% said text-message appointment reminders were preferred, which was more than any other form of appointment reminder options. These survey results, combined with the effectiveness of text message reminders demonstrated in the literature, create a strong argument that the institution offers this appointment-reminder communication option. While the institution is developing a system that will provide this, a small test of change is being conducted to determine the effectiveness of text-message appointment reminders with the population of patients who are the most frequent appointment no-show offenders. This test of change can also be used to solicit feedback from patients and families about the verbiage in the text messages and the timing of the messages in relation to when the appointment is scheduled. The informal survey showed only 14.2% of respondents were interested in medication reminders, so the current implementation plan is focusing on implementing the electronic appointment reminders first. IMPLICATIONS FOR SOCIAL WORK Social workers are often involved in advocating for system changes and helping families navigate the available resources. Equipped with the knowledge of the evidence in support electronic reminders to address adherence, social workers can suggest that electronic reminders, such as text
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messaging, be offered to patients and families for both appointment reminders and medication reminders. In addition, social workers can educate patients and families about resources for electronic reminders. The use of text messaging could potentially help reduce disparities in access as the ownership of cell phones is more prevalent among those with low socioeconomic status (Krishna et al., 2009); this is also in line with the Social Work value of social justice and creating equal opportunities. It is important to assess patient/family preference for the form of communication for appointment reminders, as not everyone has a cell phone or unlimited text messaging service on their phone (Krishna et al., 2009). Members of the health care team will need to partner with patients and families to keep mobile phone numbers current (Chen et al., 2008). Text messaging can be individualized to the requested time of day for each patient, and possibly several times of day, to be most effective and meet patient and family preference (Strandbygaard et al., 2010). The other important consideration is confidentiality and how the text message is sent. Health care staff, including social workers, are advised to not send text messages to patients or family member with a personal cell phone, as this violates boundaries and can lead to confusion about how to reach staff when needed (Leong et al., 2006). Electronic messaging is a fast changing phenomenon and recommendations about this form of communication need to be revisited frequently. The National Association of Social Workers (NASW, 1999) includes standards that relate to electronic communication. For example, in relation to informed consent, standard 1.03 (e) states that: “Social workers who provide services via electronic media (such as computer, telephone, radio, and television) should inform recipients of the limitations and risks associated with such services.” For patients and families who are not connected to an agency that offers electronic reminders, Social Workers can help research and connect them to this in other ways. For instance, electronic reminders can be in the form of a daily alarm on a cell phone. There are disease-specific supports available, such as www.cffone.com that offers patients with cystic fibrosis, aged 11 years and older, with various forms of electronic support, including a text message reminder system. Other online supports, such as www.mymedschedule.com, are available for people with any diagnosis to receive text message reminders and/or email reminders about taking and/or refilling medication.
CONCLUSION In summary, there is strong evidence that the use of electronic reminders improves adherence to outpatient appointment attendance and medication adherence. Social workers play an important role in advocating that these resources be made available to patients and families. There is also a need for social workers to educate patients and families about these resources, including limitations to confidentiality.
NOTE 1. See Appendix A for meaning of bracket notation following some references.
REFERENCES1 Burns, N. & Grove, S. (2011). Understanding nursing research: Building an evidence-based practice (5th ed.). Maryland Heights, MO: Elsevier Saunders.
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Chen, Z., Fang, L., Chen, L., & Dai, H. (2008). Comparison of an SMS text messaging and phone reminder to improve attendance at a health promotion center: A randomized controlled trial. Journal of Zhejiang University SCIENCE B, 9(1), 34–38. [2a] Cole-Lewis, H., & Kershaw, T (2010). Text messaging as a tool for behavior change in disease prevention and management. Epidemiologic Reviews, 32, 56–69. [1a] Foley, J., & O’Neill, M. (2009). Use of mobile telephone short message service (SMS) as a reminder: The effect on patient attendance. European Archives of Paediatric Dentistry, 10(1), 15–18. [4a] Geraghty, M., Glynn, F., Amin, M., & Kinsella, J. (2008). Patient mobile telephone “text” reminder: A novel way to reduce non-attendance at the ENT outpatient clinic. The Journal of Laryngology & Otology, 122, 296–298. [4a] Guy, R., Hocking, J., Wand, H., Stott, S., Ali, H., & Kaldor, J. (2011). How effective are short message service reminders at increasing clinic attendance? A meta-analysis and systematic review. Health Services Research, 47, 614–632. doi: 10.1111/j.1475-6773.2011.01342.x [1a] Koshy, E., Car, J., & Majeed, A. (2008). Effectiveness of mobile-phone short message service (SMS) reminders for ophthalmology outpatient appointments: An observational study. BMC Ophthalmology, 8(9), 1–6. [4a] Krishna, S., Boren, S., & Balas, E. (2009). Healthcare via cell phones: A systematic review. Telemedicine and e-Health, 15(3), 231–240. [1b] Leong, K. C., Chen, W., Leong, K. W., Mastura, I., Mimi, O., Sheikh, M., et al. (2006). The use of text messaging to improve attendance in primary care: A randomized controlled trial. Family Practice Advance Access, 23(6), 699–705. [2b] National Association of Social Workers. (1999). Code of ethics of the National Association of Social Workers. Washington, DC: NASW Press. Nelson, T. M., Berg, J. H., Bell, J. F., Leggott, P. J., & Seminario, A. L. (2011). Assessing the effectiveness of text messages as appointment reminders in a pediatric dental setting. Journal of the American Dental Association, 142(4), 397–405. [2b] Strandbygaard, U., Thomsen, S. F., & Backer, V. (2010). A daily SMS reminder increases adherence to asthma treatment: A three-month follow-up study. Respiratory Medicine, 104(2), 166–171. [2a] Ting, T. V., Kudalkar, D., Nelson, S., Cortina, S., Pendi, J., Budhani, S., et al. (2012). Usefulness of cellular text messaging (CMTR) for improving adherence among adolescents and young adults with systemic lupus erythematosus. The Journal of Rheumatology, 39(1), 174–179. [2a] Wei, J., Hollin, I., & Kachnowski, S. (2011). A review of the use of mobile phone text messaging in clinical and healthy behavior interventions. Journal of Telemedicine and Telecare, 17, 41–48. [5a]
APPENDIX A LEGEND System Overview Quality Level 1a or 1b 2a or 2b 3a or 3b 4a or 4b 5a or 5b 5
Definition Systematic review, meta-analysis, or meta-synthesis of multiple studies Best study design for domain Fair study design for domain Weak study design for domain General review, expert opinion, case report, consensus report, or guideline Local consensus
a D good quality study; b D lesser quality study.
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Systematic review To assess the effectiveness of short message service (SMS) reminders at increasing appointment attendance Systematic review, populations varied healthy, diabetic, asthmatic, obese, smokers
Guy et al. (2012)
Systematic review
RCT Included: Patients with cSLE between 13–25 yrs old with unlimited texting; for hydroxychloroquine (HCQ), patients had the diagnosis at least 6 months Excluded: Patients with active neuropsychiatric SLE symptoms, patients with other chronic diseases
Krishna Boren, & Balas (2009)
Ting et al. (2012)
Cole-Lewis & Kershaw (2010)
Research Design and Sample
Citation
Randomized control trials (RCT; 20 of 25 were RCT’s) or controlled studies that evaluated delivery of health information or educational intervention with cell phone or text messaging and measured change in process of care or health outcomes
Adherence to clinic visit defined as patient seen within 1 week of a 1-month follow-up recommendation; 2 weeks within a 2-month follow-up recommendation; and 3 weeks for a 3-month follow-up recommendation. Medication adherence measured by: patient self report inventory (MASRI) at each visit, whole blood levels of HCQ, and pharmacy refill info Clinic attendance info extracted from computer system (databases and electronic medical record)
Cellular text messaging reminders (CTMR) sent 7-, 3-, and 1-day text message appointment reminder, Medication reminders sent daily at patient preference of time of day; twice a day if applicable
Health behavior & outcomes
Attendance at clinic appointment
Dependent Variable, Outcome
Text messaging/cell phone interventions
Text messaging as main intervention
SMS message versus no appointment reminder
Independent Variable, Intervention
APPENDIX B Evidence Synthesis Results Use of SMS reminders increases the likelihood of attendance at clinic appointments by 50% compared to no appointment reminder Text messaging is a useful tool for behavior change interventions. Several studies of medication adherence interventions show the benefits of medication reminders and when coupled with evidence of the benefits of mobile phones as an inexpensive, personal, efficient, and widely accessible way to intervene on health provides a very strong rationale for extending research on text messaging to medication adherence. Information and education interventions delivered through wireless mobile technology resulted in both clinical and process improvements in the majority of the studies (60%). Chronic diseases (e.g., asthma) requiring regular management benefited the most from the cell-phone interventions. CTMR is an inexpensive and rapidly receivable method of communication and could be a potentially useful method of improving clinic visit adherence (results were statistically significant); CTMR did not appear to be effective for improving med adherence
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(continued )
2a
1b
1a
1a
Level of Evidence a
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Literature review
Wei Hollin, & Kachnowski (2010)
to information in Appendix A.
RCT Inclusion: All dental clinic patients from May 1, 2009–November 30, 2009 (survey determined eligibility) Exclusion: Those who did not complete the survey and patients scheduled for oral conscious sedation or anesthesia
Nelson et al. (2011)
a Corresponds
RCT between 18–45 years of age with diagnosis of asthma based on clinical history and daily symptoms, positive methacholine challenge test with positive methacholine challenge test (PD(20); 4 mol) Excluded: Medical co-morbidities and a smoking history of more than 10 pack years
Research Design and Sample
Strandbygaard Thomsen, & Backer. (2010)
Citation
Text message
Daily SMS text at 10:00 am for 8 weeks vs. control group with no SMS text, SMS sent to intervention group at 10:00 am; overall this was received positively, though the time of day was not favorable to the group. Both groups received teaching about importance of ICS and proper inhaler technique Text-message reminder vs. voice reminder (control group) sent 48 hours before appointment to caregiver of pediatric dental patient
Independent Variable, Intervention
Divided by focus: medication adherence, clinical care management, and preventative behavior
Show rate vs. no-show rate Cancelation counted as show Voice reminder D 3 calls and if no answer then a message. Only one appointment was used, even if the patient had more during the study period. Also asked about preference for what type of reminder
Primary outcome was mean adherence rate to asthma treatment; secondary outcomes were reimbursement of asthma medication and change in exhaled nitric oxide levels, lung function, and airway responsiveness
Dependent Variable, Outcome
APPENDIX B (Continued ) Results
No significant findings. SMS reminders were not as effective as voice reminders; those who had the text message were 2.12 less likely to attend the dental appointments than those who got the voice-mail reminders; more participants said they would prefer voice reminder rather than text (41% vs. 27%) Text messaging has been shown to be more cost-effective than calls in improving outpatient appointment attendance it shows promise in improving adherence especially for chronically ill patients
A daily SMS reminder did have a significant effect on adherence to asthma treatment Those receiving SMS text were 17.8% more adherent (was statistically significant) No statistically significant difference in secondary outcomes.
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5a
2b
2a
Level of Evidence a
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Cross sectional Demographic Variables: Patients scheduled for outpatient pediatric dentistry appointment in October 2007 who had mobile-phone contact details as well as a historical control group who had appointments in October 2006 and had mobile-phone details Cross-sectional, retrospective Demographic Variables: Ear, Nose, & Throat outpatient clinic patients
Randomized control trial (RCT) Demographic variables: Adults, median age about 50 years, who had an appointment scheduled between 72 hour–2 months from recruitment date (April 2007–May 2007) and provided mobile phone number Multicenter, 3-arm RCT Demographic Variables: One quarter were caregivers of patients; mean age about 38 years, mix of preventative care and chronic illness Patients with a follow-up appointment between 48 hours–3 months from the recruitment date. The patient or their caregiver had a mobile phone with text messaging function. Cross sectional; pilot study Demographic Variables: All new visit patients in the time period; divided by mobile-phone information status to intervention and control groups Data from between April–Sept 2006
Research Design and Sample
a Corresponds to information in Appendix A.
Geraghty et al. (2008)
Foley & O’Neill (2009)
Koshy, Car, & Majeed (2008)
Leong et al. (2006) Family practice, August 17, 2006
Chen et al. (2008)
Citation
Text message reminder for appointment vs. control group
SMS text 24 hr prior to appointment vs. historical control group for October 2006
Reduction in nonattendance
Appointment attendance
Appointment attendance
Clinic attendance on the day the appointment was originally scheduled
Text message reminder vs. phone call reminder vs. no reminder
Automated text sent; control group received no reminder
Appointment attendance and cost analysis of text vs. phone
Dependent Variable Outcome (Measure)
Text message reminder vs. phone call reminder vs. no reminder (control)
Independent Variable Intervention (Measure)
The use of SMS reminders reduced nonattendance compared to no reminder and was more cost effective than other traditional reminders. Patients who received a text-message reminder were 38% less likely to be non-attenders (statistically significant) Those who receieved text-message reminders were also 26% more likely to cancel their appointments (though this was not statistically significant) Number needed to text to prevent one appointment nonattendance is 14 SMS reminders led to 6.9% absolute reduction and 38% relative reduction in nonattendance rates Sending text messages to patients 24 hr prior to appointment resulted in a relative reduction in nonattendance by over 50% comparing data from 2006–2007. 23.9% failed appointment in 2006 compared to 10.4% in 2007 Cancellation rate in 2007 also greater though not statistically significant Cost info: Each text was .065 per text Total text cost was e30. Nonattendance at outpatient clinic was estimated to cost 65 per incident People were 1.5 times more likely to come to appointment with text-message reminder Text-message group was about 22% nonattendance, control group was about 33% nonattendance. Text message reminder system decreased nonattendance and was more cost effective than telephone reminders
The attendance rate of the text messaging group was significantly higher than that of the control group, but there was no difference between the text-messaging group and the mobile-phone group. The text-messaging system cost less than half of the mobile-phone reminder per attendance. Text message vs. control and mobile phone vs. control showed statistical significance with improving appointment attendance, but were not statistically significant compared to each other. Texting was half the cost of calls.
The attendance rates were 80.5% control, 87.5% SMS, 88.3% telephone Cost effectiveness analysis showed cost was significantly less for SMS group vs. phone group (0.31 Yuan vs. 0.48 Yuan)
Significant Results Statistical & Clinical
APPENDIX C Articles Included in Systematic Reviews that Looked at the Cost Effectiveness of Text Messaging
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4a
4a
4a
2b
2a
Level of Evidence a
