The Use of SMS Text Messaging to Improve the Hospital-to-Community Transition in Patients With Acute Coronary Syndrome (Txt2Prevent): Results From a Pilot Randomized Controlled Trial.

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of hospital admission in North America. Many patients with ACS experience challenges after discharge that impact their clinical outcomes and psychosocial well-being. SMS text messaging has the potential to provide support to patients during this postdischarge period. OBJECTIVE: This study pilot tested a 60-day SMS text messaging intervention (Txt2Prevent) for patients with ACS. The primary objective was to compare self-management domains between usual care and usual care plus Txt2Prevent. The secondary objectives were to compare medication adherence, health-related quality of life, self-efficacy, and health care resource use between groups. The third objective was to assess the feasibility of the study protocol and the acceptability of the intervention. METHODS: This was a randomized controlled trial with blinding of outcome assessors. We recruited 76 patients with ACS from St. Paul's Hospital in Vancouver, Canada, and randomized them to 1 of 2 groups within 7 days of discharge. The Txt2Prevent program included automated 1-way SMS text messages about follow-up care, self-management, and healthy living. Data were collected during the index admission and at 60 days after randomization. The primary outcome was measured with the Health Education Impact Questionnaire (heiQ). Other outcomes included the EQ-5D-5L, EQ-5D-5L Visual Analog Scale, a modified Sullivan Cardiac Self-Efficacy Scale, and Morisky Medication Adherence Scale scores, and self-reported health care resource use. Analyses of covariance were used to test the effect of group assignment on follow-up scores (controlling for baseline) and were considered exploratory in nature. Feasibility was assessed with descriptive characteristics of the study protocol. Acceptability was assessed with 2 survey questions and semistructured interviews. RESULTS: There were no statistically significant differences between the groups for the heiQ domains (adjusted mean difference [Txt2Prevent minus usual care] for each domain-Health-directed activity: -0.13, 95% CI -0.39 to 0.13, P=.31; Positive and active engagement in life: 0.03, 95% CI -0.19 to 0.25, P=.76; Emotional distress: 0.04, 95% CI -0.22 to 0.29, P=.77; Self-monitoring and insight: -0.14, 95% CI -0.33 to 0.05, P=.15; Constructive attitudes and approaches: -0.10, 95% CI -0.36 to 0.17, P=.47; Skill technique and acquisition: 0.05, 95% CI -0.18 to 0.27, P=.69; Social integration and support: -0.12, 95% CI -0.34 to 0.10, P=.27; and Health services navigation: -0.05, 95% CI -0.29 to 0.19, P=.69). For the secondary outcomes, there were no statistically significant differences in adjusted analyses except in 1 self-efficacy domain (Total plus), where the Txt2Prevent group had lower scores (mean difference -0.36, 95% CI -0.66 to -0.50, P=.03). The study protocol was feasible, but recruitment took longer than expected. Over 90% (29/31 [94%]) of participants reported they were satisfied with the program. CONCLUSIONS: The Txt2Prevent study was feasible to implement; however, although exploratory, there were no differences between the 2 groups in adjusted analyses except for 1 self-efficacy domain. As the intervention appeared acceptable, there is potential in using SMS text messages in this context. The design of the intervention may need to be reconsidered to have more impact on outcome measures. TRIAL REGISTRATION: ClinicalTrials.gov NCT02336919; https://clinicaltrials.gov/ct2/show/NCT02336919. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.6968.

Surveiller l'observance des médicaments : les conséquences pour les patients et les dispensateurs de soins.

La non-observance des médicaments est un enjeu mondial primordial qui peut être responsable de résultats cliniques indésirables chez les patients et accroître les coûts pour le système de santé. Un processus facilitant la transmission d'avis de non-observance violerait-il l'autonomie individuelle ou les attentes en matière de confidentialité? En revanche, les patients qui ne prennent pas leurs médicaments se rendent peut-être à risque sans le savoir et sans que les prescripteurs en soient informés et puissent intervenir. Avec l'avènement des méthodes électroniques de surveillance de l'observance des médicaments, un nouveau niveau de complexité s'ajoute à ce dilemme éthique. Les auteurs présentent deux scénarios observés en clinique, qui reflètent des situations courantes au sein du système de santé canadien.

Medication adherence monitoring: implications for patients and providers.

Non-adherence to medication is a key worldwide issue and can lead to adverse patient outcomes and increased health system costs. Would a process facilitating notification of non-adherence infringe upon the autonomy of individuals or breach expectations of privacy? In contrast, patients who are not taking their medication could unknowingly be putting themselves at risk and all the while prescribers are unaware and without the opportunity to intervene. With the advent of electronic methods of medication adherence monitoring, this ethical dilemma now involves a new layer of complexity. We present two scenarios encountered in clinical practice that reflect issues occurring regularly in the Canadian healthcare system.

The Use of Text Messaging to Improve the Hospital-to-Community Transition in Acute Coronary Syndrome Patients (Txt2Prevent): Intervention Development and Pilot Randomized Controlled Trial Protocol.

BACKGROUND: Acute coronary syndrome, including acute myocardial infarction (AMI), is one of the leading causes for hospitalization, with AMI 30-day readmission rates around 20%. Supporting patient information needs and increasing adherence to recommended self-management behaviors during transition from hospital to home has the potential to improve patient outcomes. Text messages have been effective in other interventions and may be suitable to provide support to patients during this transition period. OBJECTIVE: The goal of this study is to pilot test a text messaging intervention program (Txt2Prevent) that supports acute coronary syndrome patients for 60 days postdischarge. The primary objective is to compare self-management, as measured by the Health Education Impact Questionnaire, between patients receiving only usual care versus those who receive usual care plus the Txt2Prevent intervention. The secondary objectives are to compare medication adherence, health-related quality of life, self-efficacy, health care resource use (and associated costs), all-cause and cardiovascular disease (CVD) readmission, and all-cause and CVD mortality rates between the 2 groups. The third objective is to assess acceptability of the text messaging intervention and feasibility of the study protocol. METHODS: This is a randomized controlled trial with blinding of outcome assessors. The Txt2Prevent program includes automated text messages to patients about standard follow-up care, general self-management, and healthy living. The content of the text messages was informed by and developed based on interviews with patients, discharge materials, theoretical domains of behavior, and a clinical advisory group composed of patients, clinicians, and researchers. We will recruit 76 consecutive cardiac in-patients with acute coronary syndrome who are treated with either medical management or percutaneous coronary intervention from a hospital in Vancouver, Canada. RESULTS: Assessments at baseline will include measures for demographic information, self-management, health-related quality of life, and self-efficacy. Assessments at follow-up will include medication adherence, readmissions, health care resource use, and mortality in addition to the reassessment of baseline measures. Baseline assessments are done in-person while follow-up assessments are completed through a combination of mailed packages and phone calls. Semistructured interviews with participants will also be performed to better understand participant experiences managing their condition and with the text messages. CONCLUSIONS: This study will determine preliminary efficacy, feasibility, and acceptability of the Txt2Prevent program to support acute coronary syndrome patients in the transition to home following hospital discharge. The results of this study will be used to inform a larger trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT02336919; https://clinicaltrials.gov/ct2/show/NCT02336919 (Archived by WebCite at http://www.webcitation.org/6qMjEqo6O).

Use and Maturity of Electronic Patient Portals.

This paper focuses on the adoption of electronic patient portals aimed at providing consumers with access to their own health records along with added functions aimed to improving convenience and access to care. A variety of Canadian patient portal implementations were analysed with evidence supplemented from international examples. Measures of adoption focused on active users and frequency of access. New portal implementations can achieve adoption at a rate of 5-10% of the overall population per year with larger, jurisdiction-wide deployments growing at a slower rate than smaller, more targeted deployments.

Measuring interoperable EHR adoption and maturity: a Canadian example.

BACKGROUND: An interoperable electronic health record is a secure consolidated record of an individual's health history and care, designed to facilitate authorized information sharing across the care continuum.  Each Canadian province and territory has implemented such a system and for all, measuring adoption is essential to understanding progress and optimizing use in order to realize intended benefits. RESULTS: About 250,000 health professionals-approximately half of Canada's anticipated potential physician, nurse, pharmacist, and administrative users-indicated that they electronically access data, such as those found in provincial/territorial lab or drug information systems, in 2015.  Trends suggest further growth as maturity of use increases. CONCLUSIONS: There is strong interest in health information exchange through the iEHR in Canada, and continued growth in adoption is expected. Central to managing the evolution of digital health is access to robust data about who is using solutions, how they are used, where and when.  Stakeholders such as government, program leads, and health system administrators must critically assess progress and achievement of benefits, to inform future strategic and operational decisions.

Scaling up the use of remote patient monitoring in Canada.

Evidence supporting the use of remote patient monitoring (RPM) as a cost-effective means of keeping patients from being re-admitted to hospitals or making repeated emergency department visits is growing, especially for the treatment of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). A recent study funded by Canada Health Infoway, titled Connecting Patients with Providers: A Pan-Canadian Study on Remote Patient Monitoring, aimed to assess the current state of RPM solutions; to examine the evidence for patient and health system benefits achieved both in Canada and internationally; and to determine the critical success factors needed to support further investment and scaling-up of RPM solutions across the Canadian health care system. Break-even analysis of four different implementations reviewed in this study demonstrated that RPM programs can be viable and sustainable for large and small jurisdictions; however, more evidence is needed with regards to a number of potential applications for RPM beyond the management of COPD and CHF.

Valuing national effects of digital health investments: an applied method.

This paper describes an approach which has been applied to value national outcomes of investments by federal, provincial and territorial governments, clinicians and healthcare organizations in digital health. Hypotheses are used to develop a model, which is revised and populated based upon the available evidence. Quantitative national estimates and qualitative findings are produced and validated through structured peer review processes. This methodology has applied in four studies since 2008.