Economic Evaluation of Web- versus Telephone-based Interventions to Simultaneously Increase Colorectal and Breast Cancer Screening Among Women.

Screening for colorectal and breast cancer is considered cost effective, but limited evidence exists on cost-effectiveness of screening promotion interventions that simultaneously target both cancers. Increasing Colorectal and Breast Cancer Screening (Project COBRA), a randomized controlled trial conducted in the community, examined the cost-effectiveness of an innovative tailored web-based intervention compared with tailored telephone counseling and usual care. Screening status at 6 months was obtained by participant surveys plus medical record reviews. Cost was prospectively measured from the patient and provider perspectives using time logs and project invoices. Relative efficiency of the interventions was quantified by the incremental cost-effectiveness ratios. Nonparametric bootstrapping and net benefit regression analysis were used to assess statistical uncertainty of the results. The average cost per participant to implement the Phone counseling, Web-based, and Web + Phone counseling interventions were $277, $314, and $337, respectively. Comparing Phone counseling with usual care resulted in an additional cost of $300 (95% confidence interval [CI]: $283-$320) per cancer screening test and $421 (95% CI: $400-$441) per additional person screened in the target population. Phone counseling alone was more cost-effective than the Web + Phone intervention. Web-based intervention alone was more costly but less effective than the Phone counseling. When simultaneously promoting screening for both colorectal and breast cancer the Web-based intervention was less cost-effective compared with Phone and Web + Phone strategies. The results suggest that targeting multiple cancer screening may improve the cost-effectiveness of cancer screening interventions. PREVENTION RELEVANCE: This study informs researchers, decision makers, healthcare providers, and payers about the improved cost-effectiveness of targeting multiple cancer screenings for cancer early detection programs.

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.

Effective methods for reactivating inactive blood donors: a stratified randomised controlled study.

BACKGROUND: Recruiting of sufficient numbers of donors of blood products is vital worldwide. In this study we assessed the efficacy and cost-effectiveness of telephone calls and SMS reminders for re-recruitment of inactive blood donors. METHODS: This single-centre, non-blinded, parallel randomised controlled trial in Guangzhou, China included 11,880 inactive blood donors whose last donation was between January 1 and June 30, 2014. The donors were randomly assigned to one of two intervention groups (telephone call or short message service [SMS] communications) or to a control group without intervention. SMS messages with altruistic appeal were adopted in the SMS group; in addition to altruistic appeal, reasons for deferral of blood donation were also asked in the telephone group. All participants were followed up for 1 year. The primary outcome was re-donation rate, and rates in different groups were compared by intention-to-treat (ITT) analysis and estimation of the average treatment effect on the treated (ATT). Secondary outcomes were the self-reported deterrents. Other outcomes included the re-donation interval, and the incremental cost-effectiveness ratio (ICER) of telephone calls and SMS reminders on re-recruitment. RESULTS: ITT analysis revealed no significant differences in the re-donation rate among the three groups. ATT estimations indicated that among compliers, telephone calls significantly increased re-donation compared to both SMS reminders and no intervention. Donor return behaviour was positively associated with receiving reminders successfully, being male, older age, and previous donation history. The SMS reminder prompted donors to return sooner than no reminder within 6 months, and according to ICER calculations, SMS reminders were more cost-effective than telephone calls. Donors reported time constraints as the most main causes of self-deferral in the telephone group, and altruistic appeal had a positive effect on these donors. CONCLUSIONS: Interventions to reactivate inactive blood donors can be effective, with telephone calls prompting more donors to return but at a greater cost than SMS messages. SMS reminder with altruistic appeal can urge donors to re-donate sooner within 6 months than no reminder. TRIAL REGISTRATION: NCT03366441 (Reactivation of Inactive Blood Donors). Retrospectively registered 4 December 2017.

Appointment reminders to increase uptake of HIV retesting by at-risk individuals: a randomized controlled study in Thailand.

INTRODUCTION: Frequent HIV testing of at-risk individuals is crucial to detect and treat infections early and prevent transmissions. We assessed the effect of reminders on HIV retesting uptake. METHODS: The study was conducted within a programme involving four facilities providing free-of-charge HIV, syphilis and hepatitis B and C testing and counselling in northern Thailand. Individuals found HIV negative and identified at risk by counsellors were invited to participate in a three-arm, open-label, randomized, controlled trial comparing: (a) "No Appointment & No Reminder" (control arm); (b) "No Appointment but Reminder": short message service (SMS) sent 24 weeks after the enrolment visit to remind booking an appointment, and sent again one week later if no appointment was booked; and (c) "Appointment & Reminder": appointment scheduled during the enrolment visit and SMS sent one week before appointment to ask for confirmation; if no response: single call made within one business day. The primary endpoint was a HIV retest within seven months after the enrolment visit. The cost of each reminder strategy was calculated as the sum of the following costs in United States dollars (USD): time spent by participants, counsellors and hotline staff; phone calls made; and SMS sent. The target sample size was 217 participants per arm (651 overall). RESULTS: Between April and November 2017, 651 participants were randomized. The proportion presenting for HIV retesting within seven months was 11.2% (24/215) in the control arm, versus 19.3% (42/218) in "No Appointment but Reminder" (p = 0.023) and 36.7% (80/218) in "Appointment & Reminder" (p < 0.001). Differences in proportions compared to the control arm were respectively +8.1% (95% CI: +1.4% to +14.8%) and +25.5% (+17.9% to +33.2%). The incremental cost-effectiveness ratios of "No Appointment but Reminder" and "Appointment & Reminder" compared to the control arm were respectively USD 0.05 and USD 0.14 per participant for each 5% increase in HIV retesting uptake within seven months. CONCLUSIONS: Scheduling an appointment and sending a reminder one week before was a simple, easy-to-implement and affordable intervention that significantly increased HIV retesting uptake in these at-risk individuals. The personal phone call to clients probably contributed, and also improved service efficiency.

Effect of a Smart Pill Bottle and Pharmacist Intervention on Medication Adherence in Patients with Multiple Myeloma New to Lenalidomide Therapy.

BACKGROUND: U.S. specialty drug spend is expected to reach $400 billion by 2020, with significant growth in oncology. New oral oncology approvals have allowed for more convenient outpatient administration compared with physician-administered chemotherapies; however, patients may encounter challenges with adherence when taking medications at home. Emerging medication adherence technology (MAT) attempts to provide at-home adherence support, and while one such technology, smart pill bottles (SPB), claims to improve medication adherence, few studies have formally assessed their effects. OBJECTIVES: To assess the effect of an SPB with pharmacist intervention on medication adherence in adult patients with multiple myeloma (MM) new to lenalidomide therapy (≤ 5 cycle dispenses). Secondary objectives were to evaluate treatment cycles completed, evaluate the significance of real-time pharmacist engagement (intervention group only), determine the incremental cost-effectiveness ratio (ICER), and evaluate patient satisfaction and likelihood to use an SPB. METHODS: This prospective, random assignment, single-site, and single-blinded study recruited 40 adult patients diagnosed with MM new to lenalidomide at a specialty pharmacy. Recruitment was completed January-February 2016, and the length of study was 6 months. Participants were randomized 1:1 between the intervention and control groups. The intervention group received lenalidomide in activated SPBs with light, chimes, text message reminders, and pharmacist follow-up if weekly SPB adherence rates dropped below 80%. The control group received lenalidomide in identical SPBs with all alerts deactivated. SBPs contained cellular capabilities, enabling around-the-clock data transmission and captured data upon bottle-uncapping events. Patient adherence was calculated by dividing the number of bottle-uncapping events by the total number of doses supplied for each dosing cycle. Lenalidomide cycles completed and pharmacist outreach to the same patient were counted to determine pharmacist intervention. The ICER was calculated to determine SPB cost-effectiveness, and a Likert scale survey was given to the intervention group to evaluate patient satisfaction with the full-service SPB. RESULTS: Sixteen participants in each arm completed the study; 4 patients in each arm were lost to follow-up. Median adherence was improved for the intervention group compared with the control group (median = 100% vs. 87.4%; P = 0.001). The ICER per patient percentage adherence increase was found to be $96.03. Sixty percent of patients in the intervention group who responded to the post-satisfaction survey rated the full SPB service very positively. CONCLUSIONS: In this study, SPB interventions were associated with increased medication adherence and patient satisfaction. This pilot also provides empirical data on the cost-effectiveness of adherence technology used in a specialty pharmacy oncology setting. DISCLOSURES: This study was supported by Avella Specialty Pharmacy and AdhereTech. All authors are employees of Avella; Eric Sredzinski was an option holder of Avella; and none of the Avella authors had a financial interest in AdhereTech. AdhereTech provided the SPBs and data services for the duration of this study. The authors report no other potential conflicts of interest. Interim study data were presented at the 2016 Southwestern States Residency Conference (SSRC) on June 20, 2016, in Phoenix, AZ.

Economic evaluation of the cost of different methods of retesting chlamydia positive individuals in England.

OBJECTIVES: The National Chlamydia Screening Programme (NCSP) in England opportunistically screens eligible individuals for chlamydia infection. Retesting is recommended three3 months after treatment following a positive test result, but no guidance is given on how local areas should recall individuals for retesting. Here , we compare cost estimates for different recall methods to inform the optimal delivery of retesting programmes. DESIGN: Economic evaluation. SETTING: England. METHODS: We estimated the cost of chlamydia retesting for each of the six most commonly used recall methods in 2014 based on existing cost estimates of a chlamydia screen. Proportions accepting retesting, opting for retesting by post, returning postal testing kits and retesting positive were informed by 2014 NCSP audit data. Health professionals 'sense-checked' the costs. PRIMARY AND SECONDARY OUTCOMES: Cost and adjusted cost per chlamydia retest; cost and adjusted cost per chlamydia retest positive. RESULTS: We estimated the cost of the chlamydia retest pathway, including treatment/follow-up call, to be between £45 and £70 per completed test. At the lower end, this compared favourably to the cost of a clinic-based screen. Cost per retest positive was £389-£607. After adjusting for incomplete uptake, and non-return of postal kits, the cost rose to £109-£289 per completed test (cost per retest positive: £946-£2,506). The most economical method in terms of adjusted cost per retest was no active recall as gains in retest rates with active recall did not outweigh the higher cost. Nurse-led client contact by phone was particularly uneconomical, as was sending out postal testing kits automatically. CONCLUSIONS: Retesting without active recall is more economical than more intensive methods such as recalling by phone and automatically sending out postal kits. If sending a short message service (SMS) could be automated, this could be the most economical way of delivering retesting. However, patient choice and local accessibility of services should be taken into consideration in planning.

A 4-year randomized trial comparing three outreach interventions to promote screening mammograms.

As population health has become a focus of health care payers and providers, interest has grown in mail, phone, and other forms of outreach for improving population rates of cancer screening. Translational research is needed to compare the effectiveness and cost of low- and high-intensity behavioral outreach interventions for promoting cancer screening. The purpose of the article is to compare the effectiveness in promoting biannual mammograms of three interventions delivered over 4 years to a primary care population with a high baseline mammography adherence of 83.3%. We randomized women aged 40-84 to reminder letter only (LO arm), letter + reminder call (RC arm), and two letters + counseling call (CC arm) involving tailored education and motivational interviewing. Mammography adherence (≥1 mammogram in the previous 24 months) at four time points was determined from insurance claims records. Over 4 years, 30,162 women were randomized. At the end of 4 years, adherence was highest in the RC arm (83.0%) compared with CC (80.8%) and LO (80.8%) arms (p = .03). Only 23.5% of women in the CC arm were reached and accepted full counseling. The incremental cost per additional mammogram for RC arm women was $30.45 over the LO arm cost. A simple reminder call can increase screening mammogram adherence even when baseline adherence is high. Some more complex behavioral interventions delivered by mail and phone as in this study may be less effective, due to limited participation of patients, a focus on ambivalence, lack of follow-up, and other factors.

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.

RCT of Centralized Vaccine Reminder/Recall for Adults.

INTRODUCTION: A proven, but underutilized, method to increase current low vaccination rates is reminder/recall. Centralized reminder/recall using an Immunization Information System reduces the burden of an individual practice conducting reminder/recall. The objectives were to assess the effectiveness of centralized vaccine reminder/recall on improving adult vaccination rates using Colorado's Immunization Information System. STUDY DESIGN: This study is a pragmatic RCT. SETTING/PARTICIPANTS: Denver Health patients were divided into three strata: 25,039 individuals aged 19-64 years without a high-risk condition for pneumococcal disease, 16,897 individuals aged 19-64 years with a high-risk condition, and 5,332 individuals aged ≥65 years. Data were collected from October 2015 to April 2016 and analyzed between September 2016 and June 2017. INTERVENTION: Adults aged 19-64 years without a high-risk condition who needed influenza or tetanus, diphtheria, acellular pertussis vaccine or both, and adults with a high-risk condition and adults aged ≥65 years who needed influenza, or tetanus, diphtheria, acellular pertussis, or pneumococcal vaccine, or all three vaccines were randomized to receive up to three reminder/recalls or usual care. MAIN OUTCOME MEASURES: Documentation of receipt of any needed vaccine in Immunization Information System ≤6 months after the reminder/recall was the primary outcome. A secondary outcome included implementation costs of the reminder/recall effort. A mixed effects model assessed the association between the intervention and receipt of any needed vaccine while controlling for gender, age, race, ethnicity, insurance type, and history of vaccine refusal. RESULTS: The intervention was associated with receipt of any needed vaccine in the adults aged ≥65 years population (AOR=1.15, 95% CI=1.02, 1.30), but not the other two populations. Influenza vaccine was the source of this difference, with 32.0% receiving a vaccine in intervention versus 28.6% in usual-care groups (p≤0.01). Start-up and implementation costs per person were $0.86. In the population aged ≥65 years, 29.4 patients would need to be contacted to gain one additional vaccination. CONCLUSIONS: Centralized reminder/recall was effective at increasing influenza vaccination rates in adults aged ≥65 years over a short time period, without burdening the practices, and at a reasonable cost. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT02133391.

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.

Rideshare-Based Medical Transportation for Medicaid Patients and Primary Care Show Rates: A Difference-in-Difference Analysis of a Pilot Program.

BACKGROUND: Transportation to primary care is a well-documented barrier for patients with Medicaid, despite access to non-emergency medical transportation (NEMT) benefits. Rideshare services, which offer greater convenience and lower cost, have been proposed as an NEMT alternative. OBJECTIVE: To evaluate the impact of rideshare-based medical transportation on the proportion of Medicaid patients attending scheduled primary care appointments. DESIGN: In one of two similar practices, all eligible Medicaid patients were offered rideshare-based transportation ("rideshare practice"). A difference-in-difference analytical approach using logistic regression with robust standard errors was employed to compare show rate changes between the rideshare practice and the practice where rideshare was not offered ("control practice"). PARTICIPANTS: Our study population included residents of West Philadelphia who were insured by Medicaid and were established patients at two academic general internal medicine practices located in the same building. INTERVENTION: We designed a rideshare-based transportation pilot intervention. Patients were offered the service during their reminder call 2 days before the appointment, and rides were prescheduled by research staff. Patients then called research staff to schedule their return trip home. MAIN MEASURES: We assessed the effect of offering rideshare-based transportation on appointment show rates by comparing the change in the average show rate for the rideshare practice, from the baseline period to the intervention period, with the change at the control practice. KEY RESULTS: At the control practice, the show rate declined from 60% (146/245) to 51% (34/67). At the rideshare practice, the show rate improved from 54% (72/134) to 68% (41/60). In the adjusted model, controlling for patient demographics and provider type, the odds of showing up for an appointment before and after the intervention increased 2.57 (1.10-6.00) times more in the rideshare practice than in the control practice. CONCLUSIONS: Results of this pilot program suggest that offering a rideshare-based transportation service can increase show rates to primary care for Medicaid patients.

Text4Heart II - improving medication adherence in people with heart disease: a study protocol for a randomized controlled trial.

BACKGROUND: Cardiac rehabilitation (CR) is an essential component of contemporary management for patients with coronary heart disease, including following an acute coronary syndrome (ACS). CR typically involves education and support to assist people following an ACS to make lifestyle changes and prevent subsequent events. Despite its benefits, uptake and participation in tradition CR programs is low. The use of mobile technologies (mHealth) offers the potential to improve reach, access, and delivery of CR support. We aim to determine the effectiveness and cost-effectiveness of a text-messaging intervention (Text4Heart II) to improve adherence to medication and lifestyle change in addition to usual care in people following an ACS. A second aim is to use the RE-AIM framework to inform the potential implementation of Text4Heart II within health services in New Zealand. METHODS: Text4Heart II is a two-arm, parallel, superiority randomized controlled trial conducted in two large metropolitan hospitals in Auckland, New Zealand. Three hundred and thirty participants will be randomized to either a 24-week theory- and evidence-based personalized text message program to support self-management in addition to usual CR, or usual CR alone (control). Outcomes are assessed at 6 and 12 months. The primary outcome is the proportion of participants adhering to medication at 6 months as measured by dispensed records. Secondary outcomes include medication adherence at 12 months, the proportion of participants adhering to self-reported healthy behaviors (physical activity, fruit and vegetable consumption, moderating alcohol intake and smoking status) measured using a composite health behavior score, self-reported medication adherence, cardiovascular risk factors (lipids, blood pressure), readmissions and related hospital events at 6 and 12 months. A cost-effectiveness analysis will also be conducted. Using the RE-AIM framework, we will determine uptake and sustainability of the intervention. DISCUSSION: The Text4Heart II trial will determine the effectiveness of a text-messaging intervention to improve adherence to medication and lifestyle behaviors at both 6 and 12 months. Using the RE-AIM framework this trial will provide much needed data and insight into the potential implementation of Text4Heart II. This trial addresses many limitations/criticisms of previous mHealth trials; it builds on our Text4Heart pilot trial, it is adequately powered, has sufficient duration to elicit behavior change, and the follow-up assessments (6 and 12 months) are long enough to determine the sustained effect of the intervention. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ID: ACTRN12616000422426 . Registered retrospectively on 1 April 2016.

Text messages to increase attendance to follow-up cervical cancer screening appointments among HPV-positive Tanzanian women (Connected2Care): study protocol for a randomised controlled trial.

BACKGROUND: Cervical cancer is a major health concern in Tanzania, caused by poor attendance for cervical cancer screening and follow-up of women at risk. Mobile telephone health interventions are proven effective tools to improve health behaviour in African countries. So far, no knowledge exists on how such interventions may perform in relation to cervical cancer screening in low-income settings. This study aims to assess the degree to which a Short Message Service (SMS) intervention can increase attendance at appointments among women who have tested positive for high-risk (HR) Human Papillomavirus (HPV) during cervical cancer screening. METHODS/DESIGN: Connected2Care is a non-blinded, multicentre, parallel-group, randomised controlled trial. Tanzanian women testing positive to HR HPV at inclusion are randomly assigned in an allocation ratio of 1:1 to the SMS intervention or the control group (standard care). In a period of 10 months, the intervention group will receive 15 one-directional health educative text messages and SMS reminders for their appointment. The total sample size will be 700 with 350 women in each study arm. Primary outcome is attendance rate for follow-up. Secondary objectives are cost-effectiveness, measured through incremental ratios, and knowledge of cervical cancer by a 16-item true/false scale questionnaire at baseline and follow-up. Barriers against implementing the intervention will be assessed in a mixed-methods sub-population study. DISCUSSION: This study may provide information on the potential effects, costs, and barriers in implementing an SMS intervention targeting a group of women who are followed up after testing positive for HR HPV and are, therefore, at increased risk of developing cervical cancer. This can guide decision-makers on the effective use of mobile technology in a low-income setting. Trial status: recruiting. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02509702 . Registered on 15 June 2015.

Randomized Controlled Trial of Text Message Reminders for Increasing Influenza Vaccination.

PURPOSE: Seasonal influenza vaccine is recommended and funded for groups at higher risk of serious infection, but uptake is suboptimal. We conducted a randomized controlled trial of short message service (SMS) reminders for influenza vaccination. METHODS: Six weeks after seasonal influenza vaccinations began, we identified high-risk patients who had a mobile telephone number on record at 10 practices in Western Australia. Thirty-two percent of the selected patients had already been vaccinated in the current year and were ineligible. Of the remaining 12,354 eligible patients at each practice one-half were randomly assigned to receive a vaccination reminder by SMS (intervention) and the rest received no SMS (control). Approximately 3 months after the SMS was sent (the study period), vaccination data were extracted from the patients' electronic medical records. Log-binomial regression models were used to calculate the relative risk (RR) of vaccination between the intervention and control group. RESULTS: Twelve-percent (769 of 6,177) of the intervention group and 9% (548 of 6,177) of the control group were vaccinated during the study period, a 39% relative increase attributable to the SMS (RR = 1.39; 95% CI, 1.26-1.54). For every 29 SMSs sent, costing $3.48, 1 additional high-risk patient was immunized. The greatest effect was observed for children younger than 5 years, whose parents were more than twice as likely to have their child vaccinated if they received a SMS reminder (RR = 2.43; 95% CI, 1.79-3.29). CONCLUSION: We found SMS reminders to be a modestly effective, low-cost means to increase seasonal influenza vaccine coverage among high-risk patients.

Development and rationale for a multifactorial, randomized controlled trial to test strategies to promote adherence to complex drug regimens among older adults.

BACKGROUND: Patients with chronic conditions are often responsible for self-managing complex, multi-drug regimens with minimal professional clinical support. While numerous interventions to promote and support medication adherence have been tested, most have had limited success or have been too resource-intensive for real-world implementation. OBJECTIVE: To compare the effectiveness of multiple low-cost, technology-enabled strategies, alone and in combination, for promoting medication regimen adherence among older adults. METHODS: Older, English or Spanish-speaking patients on complex drug regimens (N=1505) will be recruited from a community health system in Chicago, IL. Enrolled patients will be randomized to one of four study arms, receiving either: 1) enhanced usual care alone; 2) daily medication reminders via SMS text messages; 3) medication monitoring via a patient portal-based assessment; or 4) both SMS text message reminders and portal-based medication monitoring. The primary outcome of the study is medication adherence, which will be assessed via multiple measures at baseline, 2months, and 6months. The effect of intervention strategies on clinical markers (hemoglobin A1c, blood pressure, cholesterol level), as well as intervention fidelity and the barriers and costs of implementation will also be evaluated. CONCLUSIONS: This randomized controlled trial will evaluate the impact of various low-cost intervention strategies on adherence to complex medication regimens and will explore barriers to implementation. If the studied intervention strategies are shown to be effective, then these approaches could be effectively deployed across a diverse range of clinical settings and patient populations. CLINICAL TRIAL REGISTRATION: This trial is registered on clinicaltrials.govNCT02820753.

The effectiveness of daily SMS reminders in pharmaceutical care of older adults on improving patients' adherence to antihypertensive medication (SPPA): study protocol for a randomized controlled trial.

BACKGROUND: Despite a variety of efficient and cost-effective antihypertensive medication, hypertension remains a serious health and economic burden. High consumption of cardiovascular drugs in the Slovak Republic does result neither in better hypertension control nor in significant decrease in cardiovascular mortality. At the same time, Slovakia has alarmingly low patients' adherence to medication intake. Studies have shown the efficiency of short messaging service (SMS) reminders to improve patients' adherence and health outcomes at low costs. Since SMS is popular among Slovaks, this approach may be feasible also in Slovakia. The primary objective is to assess if daily SMS reminders of antihypertensive medication intake provided by pharmacists in addition to the standard pharmaceutical care increase the proportion of adherent older hypertensive ambulatory patients. METHODS: The SPPA trial is a pragmatic randomized parallel group (1:1) trial in 300 older hypertensive patients carried out in community pharmacies in Slovakia. Trial pharmacies will be selected from all main regions of Slovakia. Trial intervention comprises daily personalized SMS reminders of medication intake embedded into usual pharmaceutical practice. The primary outcome is a combined adherence endpoint consisting of subjective self-reported medication adherence via the eight-item Morisky Medication Adherence Scale (MMAS-8) and objective pill count rate. Secondary outcomes include: change in the MMAS-8; comparison of adherence rates using pill count; change in systolic blood pressure; and patient satisfaction. Also, direct treatment costs will be evaluated and a cost-effectiveness analysis will be carried out. DISCUSSION: The SPPA trial engages community pharmacists and mobile health (mHealth) technologies via evidence-based pharmaceutical care to efficiently and cost-effectively addresses current main healthcare challenges: high prevalence of hypertension; overconsumption of cardiovascular medicines; low adherence to medication treatment; and resulting uncontrolled blood pressure. The results may identify new possibilities and capacities in healthcare with low additional costs and high value to patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03105687 . Registered on 07 March 2017.

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.

Understanding the Financial Implications of Immunization Reminder/Recall in a Multipractice Pediatric Group.

OBJECTIVE: Immunization reminder/recall is widely recommended as an effective strategy for increasing vaccination rates. We examined the revenue generated from well-child visits scheduled as a result of reminder/recall activities implemented in a multipractice pediatric organization. METHODS: Patients aged 19 to 35 months who were due or overdue for vaccines were identified from participating practices and assigned to either standard or enhanced reminder/recall activities. Participants who received standard reminder/recall were observed for the 6-week study period, and the number of appointments in which vaccines were administered was tracked. Participants who received enhanced reminder/recall were contacted up to 3 times and received a letter followed by up to 2 phone calls. Financial information associated with appointments scheduled during the study period was obtained, and revenue was calculated for each dose of vaccine administered. Reminder/recall costs were calculated and overall revenue generated was calculated. RESULTS: We identified 3916 children who were potentially due or overdue for immunizations. After review and manual uploading of missing historical vaccines, a total of 1892 participants received the reminder/recall initiative; 942 received standard reminder/recall, and 950 received enhanced reminder/recall. One hundred eighty-two (19%) standard and 277 (29%) enhanced reminder/recall participants scheduled an appointment by the end of the study period (P < .001). After subtracting the cost of reminder/recall activities, an additional $20,066 and $20,235 were generated by standard and enhanced reminder/recall, respectively. CONCLUSIONS: We show that conducting reminder/recall is at a minimum financially neutral, and might increase revenue generated by vaccine administration.

Process evaluation of a mobile health intervention for people with diabetes in low income countries - the implementation of the TEXT4DSM study.

Introduction Evidence about mobile health (mHealth) approaches to manage diabetes shows modest effects on outcomes, but little is known about implementation variability. This is a process evaluation of an mHealth intervention to improve diabetes self-management through Short Message Service (SMS) provision in three diabetes care programmes in the Democratic Republic of Congo (DRC), Cambodia and the Philippines. Methods The intervention involved Diabetes Self-Management Support via text messages. The content and process of the intervention is based upon the core principles of diabetes self-management and behaviour theory. In each country, messages were sent by project managers to 240 participants in each country, who were randomly assigned to the intervention group. Contracts were negotiated with national phone providers and open access software was used to send the messages. Participants received a mobile phone and SIM card. We analysed data about the implementation process over a one year period. Results The mean monthly number of messages delivered to recipients' phones was 67.7% of the planned number in DRC, 92.3% in Cambodia and 83.9% in the Philippines. A telephone check revealed problems with one-third of the phones, including breakage, loss and cancelled subscriptions. The number of people reached at least once was 177 (70.0%) in DRC; 147 (60.7%) in Cambodia; five in the Philippines (2.0%). Those reached each time was 144 in DRC (56.9%), 28 (9.9%) in Cambodia, none in the Philippines. People used their phone more frequently than before the intervention. Discussion Implementation of the intervention meets constraints at every step in the process. Barriers relate to the technology, the context and the participants.