Short Message Service Text Message Support for Weight Loss in Patients With Prediabetes: Pragmatic Trial.

BACKGROUND: To reach all 84.1 million US adults estimated to have prediabetes warrants need for low-cost and less burdensome alternatives to the National Diabetes Prevention Program (NDPP). In a previous randomized controlled trial, we demonstrated the efficacy of a 12-month short message service text message support program called SMS4PreDM amongst individuals with prediabetes. OBJECTIVE: The study aimed to evaluate the implementation and effectiveness of SMS4PreDM in a pragmatic study following dissemination in a safety net health care system. METHODS: English- and Spanish-speaking patients at risk for diabetes (eg, glycated hemoglobin 5.7-6.4) were referred by their providers and offered either NDPP classes, SMS4PreDM, or both. This analysis focuses on weight change among 285 SMS4PreDM-only participants who began the year-long intervention between October 2015 and April 2017 with accompanying pre- and postweights, as compared with 1233 usual-care control patients at risk for diabetes, who were identified from electronic health records during this time but not referred. Weight outcomes included time-related mean weight change and frequency of either ≥3% weight loss or gain. Mixed linear models adjusted for age, gender, race, ethnicity, preferred language, and baseline weight. A secondary analysis was stratified by language. We also assessed implementation factors, including retention and cost. RESULTS: SMS4PreDM participants had high retention (259 of 285 patients or 91.0% completion at 12-months, ) and a time-related mean weight loss of 1.3 pounds (SE 0.74), compared with the control group's slight mean weight gain of 0.25 pounds (SE 0.59; P=.004). Spanish-speaking SMS4PreDM participants (n=130) had a time-related mean weight loss of 1.11 pounds (SE 1.22) compared with weight gain of 0.96 pounds (SE 1.14) in Spanish-speaking controls (n=382, P<.001). English-speaking intervention participants (n=155) had a comparable time-related mean weight change (-0.89 pounds; SE 0.93) as English-speaking controls (n=828; 0.31 pounds gained; SE 0.62, P=.14). Overall, frequency of achieving ≥3% weight loss was comparable between groups (54 of 285 or 19.0% of SMS4PreDM participants [95% CI 14.8-23.9] vs 266 of 1233 or 21.6% of controls [95% CI 19.3-24.0]; P=.33). Nonetheless, more controls had ≥3% weight gain compared with intervention participants (337 of 1233 or 27.3% of controls [95% CI 24.9-29.9] vs 57 of 285 or 20.0% of SMS4PreDM participants [95% CI 16.8-25.1]; P=.01). SMS4PreDM delivery costs were US $100.92 per participant. CONCLUSIONS: Although SMS4PreDM was relatively low cost to deliver and demonstrated high retention, weight loss outcomes may not be sufficient to serve as a population health strategy.

Appointment reminders by text message in a safety net health care system: a pragmatic investigation.

INTRODUCTION: Short Message Service (SMS) appointment reminders may provide a wide-reaching, low cost approach to reducing operational inefficiencies and improving access to care. Previous studies indicate this modality may improve attendance rates, yet there is a need for large-scale, pragmatic studies that include unintended consequences and operational costs. METHODS: This pragmatic investigation was a before-after analysis that compared visit attendance outcomes among patients who opted into SMS appointment reminders with outcomes among those who declined over an 18-month evaluation period from March 25, 2013, to September 30, 2014. Eligibility in our integrated safety net health care system included age greater than 17, English or Spanish as a primary language, and a cell phone number in our scheduling system. RESULTS: 47,390 patients were invited by SMS to participate, of which 20,724 (43.7 percent) responded with 18,138 opting in (81.5 percent of respondents). Participants received SMS reminders for 77,783 scheduled visits; comparison group patients (N=72,757) were scheduled for 573,079 visits during the evaluation period. Intervention and comparison groups had, respectively, attendance rates of 72.8 percent versus 66.1 percent (p<0.001), cancellation rates of 13.2 percent versus 18.6 percent (p<0.001), and no show rates of 14.0 percent versus 15.3 percent. Patient satisfaction with text messaging ranged from 77 percent to 96 percent. Implementation challenges included a low rate of inaccurate reminders due to non-standard use of the scheduling system across clinical departments. DISCUSSION: SMS appointment reminders improve patient satisfaction and provide a low operating cost approach to reducing operational inefficiencies through improved attendance rates in an integrated safety net health care system.

Text Message Support for Weight Loss in Patients With Prediabetes: A Randomized Clinical Trial.

OBJECTIVE: Although the benefits of in-person Diabetes Prevention Program (DPP) classes for diabetes prevention have been demonstrated in trials, effectiveness in clinical practice is limited by low participation rates. This study explores whether text message support enhances weight loss in patients offered DPP classes. RESEARCH DESIGN AND METHODS: English- and Spanish-speaking patients with prediabetes (n = 163) were randomized to the control group, which only received an invitation to DPP classes as defined by the Centers for Disease Control and Prevention, or to the text message-augmented intervention group, which also received text messages adapted from the DPP curriculum for 12 months. RESULTS: Mean weight decreased 0.6 pounds (95% CI -2.7 to 1.6) in the control group and 2.6 pounds (95% CI -5.5 to 0.2) in the intervention group (P value 0.05). Three percent weight loss was achieved by 21.5% of participants in the control group (95% CI 12.5-30.6), compared with 38.5% in the intervention group (95% CI 27.7-49.3) (absolute difference 17.0%; P value 0.02). Mean glycated hemoglobin (HbA1c) increased by 0.19% or 2.1 mmol/mol (95% CI -0.1 to 0.5%) and decreased by 0.09% or 1.0 mmol/mol (95% CI -0.2 to 0.0%) in the control group and intervention participants, respectively (absolute difference 0.28%; P value 0.07). Stratification by language demonstrated a significant treatment effect in Spanish speakers but not in English speakers. CONCLUSIONS: Text message support can lead to clinically significant weight loss in patients with prediabetes. Further study assessing effect by primary language and in an operational setting is warranted.

A mobile health infrastructure to support underserved patients with chronic disease.

BACKGROUND: Chronic diseases are the global leading cause of death, but the US health system is poorly designed to support patients with chronic disease. Underserved patients report high rates of cell phone use and interest in using mobile technology for health care. A mobile health infrastructure may help transform health care delivery for underserved patients with chronic disease. PROBLEM: This study assessed the feasibility of integrating mobile health infrastructure with clinical information systems and the electronic medical record (EMR) to support patients with chronic disease through automated, bidirectional text messaging. GOALS: Three priority areas of chronic disease management were targeted. Existing self-management support was expanded, and new support for laboratory test scheduling and medication management was created. STRATEGY: Adult patients (n=135) with diabetes selected preferred content and scheduling for self-management message prompts. Outreach messages were sent to patients overdue for laboratory tests and medications. Manual review of pharmacy and laboratory outreach data was conducted for quality assurance. Focus groups were held to solicit patient perspectives. RESULTS: Patients sent over 6500 response messages with response rates of 53.7% (blood sugar), 48.8% (step counts), and 31.9% (blood pressure). Laboratory data integration was achieved, but pharmacy data gaps required ongoing manual review. Focus group participants reported improved self-management and information awareness. IMPLICATIONS: HIT was used to address dependency on visit-bound disease management in a novel, low-cost way. Use of a mobile health infrastructure was feasible. Text messaging solutions may mitigate barriers to access and enhance support for patients with chronic disease.

Nurse-run, telephone-based outreach to improve lipids in people with diabetes.

BACKGROUND: There is a need for randomized, prospective trials of case management interventions with resource utilization analyses. OBJECTIVES: To determine whether algorithm-driven telephone care by nurses improves lipid control in patients with diabetes. DESIGN: Prospective, randomized, controlled trial. PARTICIPANTS: Adults with diabetes at a federally funded community health center were randomly assigned to intervention (n = 381) or usual-care (n = 381) groups. INTERVENTIONS: Nurses independently initiated and titrated lipid therapy and promoted behavioral change through motivational interviewing and self-management techniques. Other parameters of diabetes care were addressed based on time constraints. MAIN MEASURES: The primary outcome was the proportion of patients with a low-density lipoprotein (LDL) less than 100 mg/dL. Secondary outcomes included the number of hospital admissions, total hospital charges per patient, and the proportion of patients meeting other lipid, glycemic, and blood pressure guidelines. KEY RESULTS: The percent of patients with an LDL < 100 mg/dL increased from 52.0% to 58.5% in the intervention group and decreased from 55.6% to 46.7% in the control group (P < .01). Average cost per patient to the healthcare system was less for the intervention group ($6600 vs $9033, P = .03). Intervention patients trended toward fewer hospital admissions (P = .06). The intervention did not affect glycemic and blood pressure outcomes. CONCLUSIONS: Nurses can improve lipid control in patients with diabetes in a primarily indigent population through telephone care using moderately complex algorithms, but a more targeted approach is warranted. Telephone-based outreach may decrease resource utilization, but more study is needed.

Care by cell phone: text messaging for chronic disease management.

OBJECTIVES: To assess the feasibility of engaging adults with diabetes in self management behaviors between clinic visits by using cell phone text messaging to provide blood sugar measurement prompts and appointment reminders. STUDY DESIGN: Quasi-experimental pilot among adult diabetic patients with cell phones who receive regular care at a federally qualified community health center in Denver, Colorado, which serves a population that is predominantly either uninsured (41%) or on Medicaid or Medicare (56%). METHODS: Patients (N = 47) received text message prompts over a 3-month period. Blood sugar readings were requested 3 times per week (Monday, Wednesday, and Friday). Reminders were sent 7, 3, and 1 day(s) before each scheduled appointment. Acknowledgments were returned for all patient-sent messages. Focus groups were conducted in English and Spanish with selected patients (n = 8). RESULTS: Patients of all ages were active participants. Correctly formatted responses were received for 67.3% of 1585 prompts. More than three-fourths (79%) of the cohort responded to more than 50% of their prompts. The appointment analysis was underpowered to detect significant changes in attendance. Participants reported increased social support, feelings that the program "made them accountable," and increased awareness of health information. Two-thirds (66%) of patients provided glucose readings when prompted during the study, compared with 12% at 2 preceding clinic visits. CONCLUSIONS: For certain patients, cell phone-based text messaging may enhance chronic disease management support and patient-provider communications beyond the clinic setting.

Diabetes population management by telephone visits.

INTRODUCTION: Little has been published on the impact of telephone visits on diabetes outcome performance. RESEARCH DESIGN AND METHODS: An attending and resident physician prioritized telephone visits based on glycemic, blood pressure, and lipid performance. The resident and attending panel was compared with all other diabetic patients at the clinic for baseline and end-intervention performance. RESULTS: The intervention patients had an absolute percentage of increase versus control patients of 14.9 (p<0.01), 13.9 (p<0.01), and 8.3 (p=0.01) for HbA1c <9%, low-density lipoprotein <100 mg/dL, and blood pressure <130/80 mm Hg, respectively. CONCLUSIONS: This pilot study suggests that provider-driven telephone visits may be a means for healthcare systems to improve chronic disease outcomes as they transition to new paradigms of chronic care delivery. LIMITATIONS: This study was neither randomized nor blinded, was susceptible to an interventionist effect, and did not analyze for differences in baseline medication use.

The impact of tailored diabetes registry report cards on measures of disease control: a nested randomized trial.

BACKGROUND: Most studies of diabetes self-management that show improved clinical outcome performance involve multiple, time-intensive educational sessions in a group format. Most provider performance feedback interventions do not improve intermediate outcomes, yet lack targeted, patient-level feedback. METHODS: 5,457 low-income adults with diabetes at eight federally-qualified community health centers participated in this nested randomized trial. Half of the patients received report card mailings quarterly; patients at 4 of 8 clinics received report cards at every clinic visit; and providers at 4 of 8 clinics received quarterly performance feedback with targeted patient-level data. Expert-recommended glycemic, lipid, and blood pressure outcomes were assessed. Assessment of report card utility and patient and provider satisfaction was conducted through mailed patient surveys and mid- and post-intervention provider interviews. RESULTS: Many providers and the majority of patients perceived the patient report card as being an effective tool. However, patient report card mailings did not improve process outcomes, nor did point-of-care distribution improve intermediate outcomes. Clinics with patient-level provider performance feedback achieved a greater absolute increase in the percentage of patients at target for glycemic control compared to control clinics (6.4% vs 3.8% respectively, Generalized estimating equations Standard Error 0.014, p < 0.001, CI -0.131 - -0.077). Provider reaction to performance feedback was mixed, with some citing frustration with the lack of both time and ancillary resources. CONCLUSIONS: Patient performance report cards were generally well received by patients and providers, but were not associated with improved outcomes. Targeted, patient-level feedback to providers improved glycemic performance. Provider frustration highlights the need to supplement provider outreach efforts. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00827710.