Accepted for/Published in: Journal of Medical Internet Research
Date Submitted: May 21, 2019
Open Peer Review Period: May 21, 2019 - May 28, 2019
Date Accepted: Jul 19, 2019
(closed for review but you can still tweet)
Automated Text Messaging with Patients in VA Specialty Clinics: A Hybrid Type 2 Effectiveness-Implementation Study
ABSTRACT
Background:
Acceptability of mobile phone text messaging, as means of asynchronous communication between healthcare systems and patients, is growing. The U.S. Department of Veterans Affairs (VA) has adopted an automated texting system (aTS). The system allows facilities to develop clinical protocols to promote patient self-management and allow clinical teams to monitor patient progress in between in-person visits.
Objective:
Guided by the Practical, Robust, Implementation and Sustainability Model (PRISM), we conducted a mixed-methods hybrid type 2 effectiveness-implementation study comparing two programs supporting implementation of an aTS protocol for medication adherence in patients with hepatitis C virus (HCV).
Methods:
Seven VA HCV specialty clinics were randomized to standard aTS implementation program versus an augmented-facilitation program. Implementation process measures included: facilitation metrics, usability and usefulness. Implementation outcomes (provider and patient use of the aTS HCV protocol) and effectiveness outcomes (medication adherence, health perceptions and behaviors, and sustained virologic response (SVR)) were measured.
Results:
Implementation Processes: Across the seven randomized clinics and 15 providers, there were 293 facilitation events using a core set of nine implementation strategies (157 events in augmented, 136 events in usual implementation). Providers found the aTS appropriate with high potential for scale-up, but not without difficulties in startup, patient selection and recruitment, and clinic workflow integration. Patients largely found the aTS easy to use and helpful, however low perceived need for self-management support contributed to high declination. Implementation Outcomes: Reach and use was modest with 197 patients approached, 71 (36%) enrolled, 50 (25%) authenticated, and 32 (16%) utilizing. In augmented-facilitation clinics, more patients actively used the aTS HCV protocol, compared with usual clinic patients (20% vs 12%). Effectiveness Outcomes: Patients who texted reported lower distress about failing HCV treatment (87% vs 53%, P=0.05) and better adherence to HCV medication (73% reporting excellent adherence versus 40%, P=0.06), although SVR did not differ by group.
Conclusions:
The aTS is a promising intervention for improving patient self-management, and augmented implementation may be needed to support patient engagement. For successful and sustained implementation, aTS will require additional implementation strategies at the clinic, provider, and also patient level (considering behavioral, social, organizational, and technical scale-up challenges). Clinical Trial: ClinicalTrials.gov Identifier: NCT03898349
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