Effect of reminder letters after health checkups on the consultation behavior of participants with possible hypertension, hyperglycemia, and dyslipidemia: A retrospective cohort study using administrative claims data in Japan.

OBJECTIVES: Prevention of and early treatment for noncommunicable diseases such as hypertension, hyperglycemia, and dyslipidemia are important, as these diseases are asymptomatic in early stages but can lead to critical conditions such as macro- and microvascular disorders later on. While screening is conducted worldwide, low rates of hospital visits after screening is a common issue. We aimed to investigate the effect of reminder letters on the consultation behavior of screened participants. METHODS: We used administrative claims data from a database managed by JMDC Inc for participants of health checkups in 2014, 2015, 2016, and 2017, who belonged to a health insurance society. Reminder letters were sent regularly 6 months after checkups to improve participant consultation behavior. Participants who screened positive for hypertension, hyperglycemia, and dyslipidemia, and who were not taking medication for any of these diseases at the time of health checkups, were included in the analyses. RESULTS: A total of 1739 participants in 2014, 1693 in 2015, 2002 in 2016, and 2144 in 2017 were included in the analysis for hypertension. The cumulative proportion of hospital visits gradually increased over the course of 12 months after checkups in all years. After 2015, spikes, albeit very small ones, were observed at 6 months after checkups in accordance with the timing of reminder letters. Similar trends were observed for hyperglycemia and dyslipidemia. CONCLUSIONS: Sending reminder letters is a potentially effective approach to increase hospital visits, but further improvements (ie, multiple reminders) may be necessary to affect enhancements in participant consultation behavior.

Short Message Service reminders reduce outpatient colonoscopy nonattendance rate: A randomized controlled study.

BACKGROUND AND AIM: Nonattendance of outpatient colonoscopy leads to inefficient use of health-care resources. We aimed to study the effectiveness of using Short Message Service (SMS) reminder prior in patients scheduled for outpatient colonoscopy on their nonattendance rate. METHODS: Patients who scheduled for an outpatient colonoscopy and had access of SMS were recruited from three clinics in Hong Kong. Patients were randomized to SMS group and standard care (SC) group. All patients were given a written appointment slip on the booking date. In addition, patients in the SMS group received an SMS reminder 7-10 days before their colonoscopy appointment. Patients' demographics, attendance, colonoscopy completion, and bowel preparation quality were recorded. Logistic regression was performed to identify predictors of nonattendance. RESULTS: From November 2013 to October 2019, a total of 2225 eligible patients were recruited. A total of 1079 patients were allocated to the SMS group and 1146 to the SC group. The nonattendance rate of patients in the SMS group was significantly lower than that in the SC group (8.9% vs 11.9%, P = 0.022). There were no significant differences in their baseline characteristics and colonoscopy completion rate and bowel preparation quality. A trend towards a higher rate of adequate bowel preparation was observed in the SMS group when compared with the SC group (69.9% vs 65.8%, P = 0.053). Independent predictors for nonattendance included younger age, underprivilege, and existing diabetes. CONCLUSIONS: An SMS reminder for outpatient colonoscopy is effective in reducing the nonattendance rate and may potentially improve the bowel preparation quality.

Computerized Capability of Office-Based Physicians to Identify Patients Who Need Preventive or Follow-up Care - United States, 2017.

Preventive care or follow-up care have the potential to improve health outcomes, reduce disease in the population, and decrease health care costs in the long-term (1). Approximately one half of persons in the United States receive general recommended preventive services (2,3). Missed physician appointments can hinder the receipt of needed health care (4). With electronic health record (EHR) systems able to improve interaction and communication between patients and providers (5), electronic reminders are used to decrease missed care. These reminders can improve various types of preventive and follow-up care, such as immunizations (6) and cancer screening (7); however, computerized capability must exist to make use of these reminders. To examine this capability among U.S. office-based physicians, data from the National Electronic Health Records Survey (NEHRS) for 2017, the most recent data available, were analyzed. An estimated 64.7% of office-based physicians had computerized capability to identify patients who were due for preventive or follow-up care, with 72.9% of primary care physicians and 71.4% of physicians with an EHR system having this capability compared with surgeons (54.8%), nonprimary care physicians (58.5%), and physicians without an EHR system (23.4%). Having an EHR system is associated with the ability to send electronic reminders to increase receipt of preventive or follow-up care, which has been shown to improve patient health outcomes (8).

Assessing the use of cell phones to monitor health and nutrition interventions: Evidence from rural Guatemala.

In-person (face-to-face) data collection methods offer many advantages but can also be time-consuming and expensive, particularly in areas of difficult access. We take advantage of the increasing mobile phone penetration rate in rural areas to evaluate the feasibility of using cell phones to monitor the provision of key health and nutrition interventions linked to the first 1,000 days of life, a critical period of growth and development. We examine response rates to calendarized text messages (SMS) and phone calls sent to 1,542 households over a period of four months. These households have children under two years old and pregnant women and are located across randomly selected communities in Quiche, Guatemala. We find that the overall (valid) response rate to phone calls is over 5 times higher than to text messages (75.8% versus 14.4%). We also test whether simple SMS reminders improve the timely reception of health services but do not find any effects in this regard. Language, education, and age appear to be major barriers to respond to text messages as opposed to phone calls, and the rate of response is not correlated with a household's geographic location (accessibility). Moreover, response veracity is high, with an 84-91% match between household responses and administrative records. The costs per monitored intervention are around 1.12 US dollars using text messages and 85 cents making phone calls, with the costs per effective answer showing a starker contrast, at 7.76 and 1.12 US dollars, respectively. Our findings indicate that mobile phone calls can be an effective, low-cost tool to collect reliable information remotely and in real time. In the current context, where in-person contact with households is not possible due to the COVID-19 crisis, phone calls can be a valuable instrument for collecting information, monitoring development interventions, or implementing brief surveys.

The use of WhatsApp group messaging in the coordination of measles supplemental immunization activity in Cross Rivers State, Nigeria, 2018.

INTRODUCTION: Cross Rivers State, in southern Nigeria, conducted measles Supplemental Immunization Activities (SIAs) in 2 phases from 2 -15 March, 2018. The SIAs coordination was led by the State technical coordination committee. A total of 90 supervisors from the national and subnational levels, including consultants were deployed to support the SIAs. The instant messaging service - WhatsApp was utilized to help in the communication and coordination among the State and field teams. METHODS: We reviewed the chat logs from the WhatsApp group exchanges made between 28 February 2018 and 31 March 2018. Thematic content analysis was done. RESULTS: A total of 653 WhatsApp messages were posted among the 55 group members during the study period, including text messages and media content. Eleven percent of the posts related to monitoring processes and data sharing, while posts related to vaccine logistics and waste management made up about 6% of the total. Overall coordination and deployment was covered in 6% of the posts. Forty percent of the media content showed vaccination service delivery and SIAs launching events or monitoring meetings in various areas. The coordination team used WhatsApp to send reminders to the field staff about data sharing, vaccine and waste management, as well as feedback on coverage and completeness of data sharing. The WhatsApp group discussions did not include most of the logistical and hesitancy challenges documented in the State SIAs technical report. CONCLUSION: We recommend focusing group discussions on instant messaging platforms so that they can be used for problem solving and sharing best practices, integrating it with other supervisory processes and tools, as well as providing feedback based on processed data from the field.

Two-Way Clinical Messaging in a CML Specialty Pharmacy Service Model.

BACKGROUND: Adherence to treatment is correlated with treatment success in chronic myeloid leukemia (CML). CVS Specialty explored novel methods to improve adherence in this population to ensure optimal adherence and lower the risk of unsuccessful treatment. One novel program explored involved an interactive 2-way clinical messaging technology that coaches patients with adherence and knowledge about taking their treatment and managing their conditions. Clinical secure messaging is a 2-way messaging program distinct from the 1-way refill reminders and order status messages that patients were receiving if opted into the messaging program. OBJECTIVE: To assess the effect on adherence of 2-way clinical messaging in a CML population treated with tyrosine kinase inhibitors (TKIs) compared with patients enrolled in 1-way refill reminders. METHODS: A retrospective cohort study was conducted using prescription claims data. Patients new to TKI therapy and enrolled in at least 1-way messaging were identified and divided into control and study cohorts based on clinical messaging enrollment status. Participants were followed for 365 days after their first fill. Adherence outcomes were defined by medication possession ratio (MPR), length of therapy, first fill drop-off rate, and gap days between refills. Optimal adherence was defined as an MPR ≥ 85%. RESULTS: Patients receiving clinical messaging had on average a 7.64% higher MPR score (MPR: 73.94% vs. 66.30%) compared with the control arm (P = 0.0063). This translates to 22% more patients being optimally adherent while exposed to clinical messaging (P = 0.022). Patients in the exposed group had a mean 32-day increase in average length of therapy compared with the control group (243 days vs. 275 days, P = 0.0043), potentially driving an increase in adherence. Additional drivers included a 5.4 percentage point reduction in first fill drop-off rates (4.66% vs. 10.04%, P = 0.0149). Persistency after 12 months was similar between the study arms (41%). CONCLUSIONS: Two-way clinical messaging positively affected adherence outcomes in a CML population. This effect was in addition to 1-way refill reminders and order status messages. The nature of the clinical content encourages further investigation into this novel execution of adherence coaching and counseling through a digital platform. DISCLOSURES: Funding for this research was provided by CVS Health. The sponsor was involved at all stages of the study's conduct and reporting. Sawicki and Friend are employed by CVS Health. The other authors were employed by CVS at the time of this study. The authors have nothing more to disclose. Posters based on this work were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2016; April 19-22, 2016; San Francisco, CA, and AMCP Nexus 2016; October 3-6, 2016; National Harbor, MD.

Mailed FIT (fecal immunochemical test), navigation or patient reminders? Using microsimulation to inform selection of interventions to increase colorectal cancer screening in Medicaid enrollees.

Colorectal cancer (CRC) can be effectively prevented or detected with guideline concordant screening, yet Medicaid enrollees experience disparities. We used microsimulation to project CRC screening patterns, CRC cases averted, and life-years gained in the population of 68,077 Oregon Medicaid enrollees 50-64 over a five year period starting in January 2019. The simulation estimated the cost-effectiveness of five intervention scenarios - academic detailing plus provider audit and feedback (Detailing+), patient reminders (Reminders), mailing a Fecal Immunochemical Test (FIT) directly to the patient's home (Mailed FIT), patient navigation (Navigation), and mailed FIT with Navigation (Mailed FIT + Navigation) - compared to usual care. Each intervention scenario raised CRC screening rates compared to usual care, with improvements as high as 11.6 percentage points (Mailed FIT + Navigation) and as low as 2.5 percentage points (Reminders) after one year. Compared to usual care, Mailed FIT + Navigation would raise CRC screening rates 20.2 percentage points after five years - averting nearly 77 cancer cases (a reduction of 113 per 100,000) and exceeding national screening targets. Over a five year period, Reminders, Mailed FIT and Mailed FIT + Navigation were expected to be cost effective if stakeholders were willing to pay $230 or less per additional year up-to-date (at a cost of $22, $59, and $227 respectively), whereas Detailing+ and Navigation were more costly for the same benefits. To approach national CRC screening targets, health system stakeholders are encouraged to implement Mailed FIT with or without Navigation and Reminders.

Relevance of a Toll-Free Call Service Using an Interactive Voice Server to Strengthen Health System Governance and Responsiveness in Burkina Faso.

BACKGROUND: In Africa, health systems are poorly accessible, inequitable, and unresponsive. People rarely have either the confidence or the opportunity to express their opinions. In Burkina Faso, there is a political will to improve governance and responsiveness to create a more relevant and equitable health system. Given their development in Africa, information and communication technologies (ICTs) offer opportunities in this area. METHODS: This article presents the results of an evaluation of a toll-free call service coupled with an interactive voice server (TF-IVS) tested in Ouagadougou, Burkina Faso, to assess its relevance for improving health systems governance. The approach consisted of a 2-phased action research project to test 2 technologies: recorded messages and touch keypad. Using a concurrent mixed approach, we assessed the technological, social, and instrumental relevance of the service. RESULTS: The call service is available everywhere, 24 hours per day, seven days per week. The equipment and its physical location were not adequately protected against technological hazards. Of the 278 days of operation, 49 were non-functional. In 8 months, there were 13 877 calls, which demonstrated the popularity of ICTs and the ease of access to telephone networks and mobile technologies. The TF-IVS was free, anonymous, and multilingual, which fostered the expression of public opinion. However, cultural context (religion, ethnic culture) and fear of reprisals may have had a negative influence. In the end, questions remained regarding people's capacity to use this innovative service. In the first trial, 49% of callers recorded their message and in the second, 48%. Touch key technology appeared more relevant for automated and real-time data collection and analysis, but there was no comprehensive strategy for translating the information collected into a response from healthcare actors or the government. CONCLUSION: This study showed the relevance and feasibility of implementing a TF-IVS to strengthen health system responsiveness in one of the world's poorest countries. Public opinion expressed through data collected in real-time is helpful for improving system responsiveness to meet care needs and enhance equity. However, the strategy for developing this tool must take into account the implementation context and the activities needed to influence the mechanisms of social responsibility (eg, information provision, citizen action, and state response).

Automated Text Message Reminders Improve Radiation Therapy Compliance.

PURPOSE: Protraction of radiation therapy courses can lead to lower cancer control and cancer-specific survival rates. The requirement for daily, consecutive radiation treatments coupled with the complexities of multimodality cancer care and quality assurance can occasionally lead to missed patient appointments or clinical inefficiency. To determine whether an automated text messaging (short message service [SMs]) platform could improve patient compliance with scheduled radiation therapy delivery, we created an automated SMS platform to send daily reminders of radiation therapy appointments. METHODS AND MATERIALS: An automated SMS text messaging program was used from July 2016 to January 2017 to deliver daily appointment time reminders to patients on an elective basis. Automated text messages were sent 2 hours before treatment appointments with appointment-specific information. We analyzed for compliance with radiation therapy appointments for patients who elected to receive SMS reminders versus those who did not. RESULTS: Multivariate analysis of >37,000 encounters involving ∼3400 patients demonstrated that of the factors considered, nonreceipt of SMS appointment reminders had a strong association with 15- to 60-minute tardiness (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.13-1.38; P < .0001), >60-minute tardiness (OR, 1.56; 95% CI, 1.34-1.82; P < .0001) and no-shows (OR, 6.77; 95% CI, 5.45-8.41; P < .0001). Other demographic factors associated with decreased compliance included being early in a radiation therapy course, having an appointment earlier in the day, younger age, and male sex. Receipt of an SMS message did not correlate with overall treatment package time. CONCLUSIONS: Receipt of text messages correlates with compliance for radiation therapy appointments. Prospective randomized trials would be required to determine conclusively whether SMS is an effective intervention for improving compliance in populations at risk for being late to or missing radiation therapy appointments.

Barriers to a software reminder system for risk assessment of stroke in atrial fibrillation: a process evaluation of a cluster randomised trial in general practice.

BACKGROUND: Oral anticoagulants reduce the risk of stroke in patients with atrial fibrillation (AF), but are underused. AURAS-AF (AUtomated Risk Assessment for Stroke in AF) is a software tool designed to identify eligible patients and promote discussions within consultations about initiating anticoagulants. AIM: To investigate the implementation of the software in UK general practice. DESIGN AND SETTING: Process evaluation involving 23 practices randomly allocated to use AURAS-AF during a cluster randomised trial. METHOD: An initial invitation to discuss anticoagulation was followed by screen reminders appearing during consultations until a decision had been made. The reminders required responses, giving reasons for cases where an anticoagulant was not initiated. Qualitative interviews with clinicians and patients explored acceptability and usability. RESULTS: In a sample of 476 patients eligible for the invitation letter, only 159 (33.4%) were considered suitable for invitation by their GPs. Reasons given were frequently based on frailty, and risk of falls or haemorrhage. Of those invited, 35 (22%) started an anticoagulant (7.4% of those originally identified). A total of 1695 main-screen reminders occurred in 940 patients. In 883 instances, the decision was taken not to initiate and a range of reasons offered. Interviews with 15 patients and seven clinicians indicated that the intervention was acceptable, though the issue of disruptive screen reminders was raised. CONCLUSION: Automated risk assessment for stroke in atrial fibrillation and prompting during consultations are feasible and generally acceptable, but did not overcome concerns about frailty and risk of haemorrhage as barriers to anticoagulant uptake.

Evaluation of patient-focused interventions to promote colorectal cancer screening among new york state medicaid managed care patients.

BACKGROUND: The objective of this study was to evaluate an ongoing initiative to improve colorectal cancer (CRC) screening uptake in the New York State (NYS) Medicaid managed care population. METHODS: Patients aged 50 to 75 years who were not up to date with CRC screening and resided in 2 NYS regions were randomly assigned to 1 of 3 cohorts: no mailed reminder, mailed reminder, and mailed reminder + incentive (in the form of a $25 cash card). Screening prevalence and the costs of the intervention were summarized. RESULTS: In total, 7123 individuals in the Adirondack Region and 10,943 in the Central Region (including the Syracuse metropolitan area) were included. Screening prevalence in the Adirondack Region was 7.2% in the mailed reminder + incentive cohort, 7.0% in the mailed reminder cohort, and 5.8% in the no mailed reminder cohort. In the Central Region, screening prevalence was 7.2% in the mailed reminder cohort, 6.9% in the mailed reminder + incentive cohort, and 6.5% in the no mailed reminder cohort. The cost of implementing interventions in the Central Region was approximately 53% lower than in the Adirondack Region. CONCLUSIONS: Screening uptake was low and did not differ significantly across the 2 regions or within the 3 cohorts. The incentive payment and mailed reminder did not appear to be effective in increasing CRC screening. The total cost of implementation was lower in the Central Region because of efficiencies generated from lessons learned during the first round of implementation in the Adirondack Region. More varied multicomponent interventions may be required to facilitate the completion of CRC screening among Medicaid beneficiaries.

Colorectal cancer screening interventions in 2 health care systems serving disadvantaged populations: Screening uptake and cost-effectiveness.

BACKGROUND: The objectives of the current study were to assess changes in colorectal cancer (CRC) screening uptake and the cost-effectiveness of implementing multiple evidence-based interventions (EBIs). EBIs were implemented at 2 federally qualified health centers that participated in the Colorado Department of Public Health and Environment's Clinic Quality Improvement for Population Health initiative. METHODS: Interventions included patient and provider reminder systems (health system 1), provider assessment and feedback (health systems 1 and 2), and numerous support activities (health systems 1 and 2). The authors evaluated health system 1 from July 2013 to June 2015 and health system 2 from July 2014 to June 2017. Evaluation measures included annual CRC screening uptake, EBIs implemented, funds received and expended by each health system to implement EBIs, and intervention costs to the Colorado Department of Public Health and Environment and health systems. RESULTS: CRC screening uptake increased by 18 percentage points in health system 1 and 10 percentage points in health system 2. The improvements in CRC screening uptake, not including the cost of the screening tests, were obtained at an added cost ranging from $24 to $29 per person screened. CONCLUSIONS: In both health systems, the multicomponent interventions implemented likely resulted in improvements in CRC screening. The results suggest that significant increases in CRC screening uptake can be achieved in federally qualified health centers when appropriate technical support and health system commitment are present. The cost estimates of the multicomponent interventions suggest that these interventions and support activities can be implemented in a cost-effective manner.

Dramatic Reduction in Hospital-Acquired Pressure Injuries Using a Pink Paper Reminder System.

OBJECTIVE: The goal of this quality improvement project was to reduce the number of hospital-acquired pressure injuries (HAPIs) by flagging extremely high-risk patients with a pink paper reminder system and implementing a pressure injury prevention order set. METHODS: The pink paper reminder system is an innovative, cost-neutral, simple approach to identify patients at highest risk of pressure injury development who meet specific criteria. There are 2 steps to this intervention. First, study authors developed a new risk assessment tool, the pink paper criteria. When a patient met the specified criteria, a pink piece of paper titled "SKIN AT RISK" in a large font was hung at the head of his/her bed to reinforce preventive strategies. Next, a set of pressure injury preventive measures was ordered. PATIENTS: This quality improvement project included all adult hospitalized patients of all specialties based in 2 Kaiser Permanente hospitals. RESULTS: There was a 67% reduction in HAPI incidences following the initiation of the pink paper reminder system, from a mean rate of 1.2 to 0.4 incidence of HAPIs per 1000 patient-days measured over 4 years. CONCLUSIONS: Identifying and flagging patients who are at extremely high risk of pressure injuries and implementing an order set of pressure injury preventive measures dramatically reduced the rate of HAPIs per 1000 patient-days.

Response patterns and intra-dyadic factors related to compliance with ecological momentary assessment among mothers and children.

Ecological momentary assessment (EMA) is a real-time sampling strategy that may address limitations in health research, such as the inability to examine how processes unfold on a daily basis. However, EMA studies are prone to limited data availability due to difficulties in implementing sophisticated protocols and systematic non-compliance with prompts, resulting in biased estimates and limited statistical power. The objectives of this study were to describe the availability of data, to examine response patterns, and to analyze factors related to EMA prompt compliance in a dyadic EMA study with mothers and children. Participants (N = 404) each received up to eight EMA prompts (i.e., audible pings) per day for a total of 7 days. Each EMA survey consisted of items assessing affect, perceived stress, and social context. Participants responded to approximately 80% (range: 3.4%-100%) of prompted EMA surveys, and completed 92.6% of surveys once started. Mothers and children identifying as Hispanic, as well as mothers in lower-income households, were less likely to comply with any given EMA prompt. Participant dyads were more likely to comply with prompts when they were together. Understanding factors related to systematic EMA prompt non-compliance is an important step to reduce the likelihood of biased estimates and improve statistical power. Socioeconomic factors may impede mothers' compliance with EMA protocols. Furthermore, mothers' presence and involvement may enhance children's compliance with EMA protocols.

Effect of Electronic Reminders, Financial Incentives, and Social Support on Outcomes After Myocardial Infarction: The HeartStrong Randomized Clinical Trial.

Importance: Adherence to medications prescribed after acute myocardial infarction (AMI) is low. Wireless technology and behavioral economic approaches have shown promise in improving health behaviors. Objective: To determine whether a system of medication reminders using financial incentives and social support delays subsequent vascular events in patients following AMI compared with usual care. Design, Setting, and Participants: Two-arm, randomized clinical trial with a 12-month intervention conducted from 2013 through 2016. Investigators were blinded to study group, but participants were not. Design was a health plan-intermediated intervention for members of several health plans. We recruited 1509 participants from 7179 contacted AMI survivors (insured with 5 large US insurers nationally or with Medicare fee-for-service at the University of Pennsylvania Health System). Patients aged 18 to 80 years were eligible if currently prescribed at least 2 of 4 study medications (statin, aspirin, ß-blocker, antiplatelet agent), and were hospital inpatients for 1 to 180 days and discharged home with a principal diagnosis of AMI. Interventions: Patients were randomized 2:1 to an intervention using electronic pill bottles combined with lottery incentives and social support for medication adherence (1003 patients), or to usual care (506 patients). Main Outcomes and Measures: Primary outcome was time to first vascular rehospitalization or death. Secondary outcomes were time to first all-cause rehospitalization, total number of repeated hospitalizations, medication adherence, and total medical costs. Results: A total of 35.5% of participants were female (n = 536); mean (SD) age was 61.0 (10.3) years. There were no statistically significant differences between study arms in time to first rehospitalization for a vascular event or death (hazard ratio, 1.04; 95% CI, 0.71 to 1.52; P = .84), time to first all-cause rehospitalization (hazard ratio, 0.89; 95% CI, 0.73 to 1.09; P = .27), or total number of repeated hospitalizations (hazard ratio, 0.94; 95% CI, 0.60 to 1.48; P = .79). Mean (SD) medication adherence did not differ between control (0.42 [0.39]) and intervention (0.46 [0.39]) (difference, 0.04; 95% CI, -0.01 to 0.09; P = .10). Mean (SD) medical costs in 12 months following enrollment did not differ between control ($29 811 [$74 850]) and intervention ($24 038 [$66 915]) (difference, -$5773; 95% CI, -$13 682 to $2137; P = .15). Conclusions and Relevance: A compound intervention integrating wireless pill bottles, lottery-based incentives, and social support did not significantly improve medication adherence or vascular readmission outcomes for AMI survivors. Trial Registration: clinicaltrials.gov Identifier: NCT01800201.

Mobile phone-delivered reminders and incentives to improve childhood immunisation coverage and timeliness in Kenya (M-SIMU): a cluster randomised controlled trial.

BACKGROUND: As mobile phone access continues to expand globally, opportunities exist to leverage these technologies to support demand for immunisation services and improve vaccine coverage. We aimed to assess whether short message service (SMS) reminders and monetary incentives can improve immunisation uptake in Kenya. METHODS: In this cluster-randomised controlled trial, villages were randomly and evenly allocated to four groups: control, SMS only, SMS plus a 75 Kenya Shilling (KES) incentive, and SMS plus 200 KES (85 KES = USD$1). Caregivers were eligible if they had a child younger than 5 weeks who had not yet received a first dose of pentavalent vaccine. Participants in the intervention groups received SMS reminders before scheduled pentavalent and measles immunisation visits. Participants in incentive groups, additionally, received money if their child was timely immunised (immunisation within 2 weeks of the due date). Caregivers and interviewers were not masked. The proportion of fully immunised children (receiving BCG, three doses of polio vaccine, three doses of pentavalent vaccine, and measles vaccine) by 12 months of age constituted the primary outcome and was analysed with log-binomial regression and General Estimating Equations to account for correlation within clusters. This trial is registered with ClinicalTrials.gov, number NCT01878435. FINDINGS: Between Oct 14, 2013, and Oct 17, 2014, we enrolled 2018 caregivers and their infants from 152 villages into the following four groups: control (n=489), SMS only (n=476), SMS plus 75 KES (n=562), and SMS plus 200 KES (n=491). Overall, 1375 (86%) of 1600 children who were successfully followed up achieved the primary outcome, full immunisation by 12 months of age (296 [82%] of 360 control participants, 332 [86%] of 388 SMS only participants, 383 [86%] of 446 SMS plus 75 KES participants, and 364 [90%] of 406 SMS plus 200 KES participants). Children in the SMS plus 200 KES group were significantly more likely to achieve full immunisation at 12 months of age (relative risk 1·09, 95% CI 1·02-1·16, p=0·014) than children in the control group. INTERPRETATION: In a setting with high baseline immunisation coverage levels, SMS reminders coupled with incentives significantly improved immunisation coverage and timeliness. Given that global immunisation coverage levels have stagnated around 85%, the use of incentives might be one option to reach the remaining 15%. FUNDING: Bill & Melinda Gates Foundation.

Survey of vaccination knowledge and acceptance among adults admitted to an urban emergency department.

BACKGROUND: Adult vaccination rates in the United States have fallen below national target levels and may be exacerbated by lack of access to a primary care physician. We assessed patient knowledge of and attitudes towards vaccines in an urban emergency department population and analyzed the feasibility of using this setting as a vaccine delivery site from a patient perspective. METHODS: In-person interviewers administered surveys to 250 adult patients presenting to the Detroit Receiving Hospital emergency department in Detroit, Michigan. Respondents were asked about vaccination status, preferences, and willingness to accept vaccination reminders via text messaging. Odds ratios and 95% Wald confidence intervals assessing differences between vaccinated and non-vaccinated individuals were generated with univariate logistic regression. RESULTS: Vaccinated adults were more likely to have a primary care provider than non-vaccinated adults (OR 1.94, 95% CI: 1.09-3.45). Non-vaccinated adults were significantly more likely to have unvaccinated adult relatives (OR8.64, 95% CI: 4.10-18.22). Nearly all respondents used a cell phone, and 75.8% of unvaccinated adults were willing to receive text messages reminders about vaccines. CONCLUSIONS: Although less likely to have a primary care access point than vaccinated participants, non-vaccinated respondents reported interest in receiving vaccinations. Emergency departments could serve as vaccination hubs for patients and unvaccinated accompanying family members. Text message reminders offer a potential source of additional vaccine prompts and education.

Lead Time to Appointment and No-Show Rates for New and Follow-up Patients in an Ambulatory Clinic.

High rates of no-shows in outpatient clinics are problematic for revenue and for quality of patient care. Longer lead time to appointment has variably been implicated as a risk factor for no-shows, but the evidence within pediatric clinics is inconclusive. The goal of this study was to estimate no-show rates and test for association between appointment lead time and no-show rates for new and follow-up patients. Analyses included 534 new and 1920 follow-up patients from pulmonology and gastroenterology clinics at a freestanding children's hospital. The overall rate of no-shows was lower for visits scheduled within 0 to 30 days compared with 30 days or more (23% compared with 47%, P < .0001). Patient type significantly modified the association of appointment lead time; the rate of no-shows was higher (30%) among new patients compared with (21%) follow-up patients with appointments scheduled within 30 days (P = .004). For appointments scheduled 30 or more days' lead time, no-show rates were statistically similar for new patients (46%) and follow-up patients (0.48%). Time to appointment is a risk factor associated with no-shows, and further study is needed to identify and implement effective approaches to reduce appointment lead time, especially for new patients in pediatric subspecialties.

Patient preferences and access to text messaging for health care reminders in a safety-net setting.

INTRODUCTION: Text messaging may be an effective method for providing health care reminders to patients. We aimed to understand patient access to and preferences for receiving health-related reminders via text message among patients receiving care in safety-net hospitals. MATERIALS AND METHODS: We conducted face-to-face surveys with 793 patients seeking care in three hospital emergency departments at a large safety-net institution and determined clinical and demographic predictors of preferences for text messaging for health care reminders. RESULTS: 95% of respondents reported having daily access to text messaging. Text messaging was preferred over e-mail, phone, and letters for communication. 78% of respondents wanted to receive appointment reminders, 56% wanted expiring insurance reminders, and 36% wanted reminders to take their medications. We found no clinical predictors but did find some demographic predictors-including age, ethnicity, insurance status, and income-of wanting text message reminders. DISCUSSION: In our convenience sample of safety-net patients, text messaging is an accessible, acceptable, and patient-preferred modality for receiving health care reminders. Text messaging may be a promising patient-centered approach for providing health care and insurance reminders to patients seeking care at safety-net institutions.