Text message reminders for improving sun protection habits: A systematic review

Background

Excessive exposure to ultraviolet radiation increases the risk of skin cancer and other conditions. SMS text reminders may be a useful tool to improve sun protection habits due to its massive reach, low cost, and accessibility.

Objective

To perform a systematic review of randomized controlled trials (RCTs) that evaluated the effects of SMS text reminders in promoting sun protection habits.

Methods

We performed a systematic search in PubMed, Central Cochrane Library, and Scopus; following the PRISMA recommendations to perform systematic reviews. We included RCTs published up to December 2018, which evaluated the benefits and harms of SMS text reminders to improve sun protection habits. Random-effects meta-analyses were performed whenever possible. The certainty of the evidence was assessed for RCTs estimates using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The study protocol was registered in PROSPERO (CRD42018091661).

Results

Five RCTs were included in this review. When pooled, the studies found no effect of SMS text reminders in “sunburn anytime during follow-up” (two studies, risk ratio: 0.93; 95% confidence interval: 0.83–1.05). Contradictory results were obtained for sunscreen use (three RCTs) and sun protection habits (two RCTs), however, they could not be meta-analyzed because outcomes were measured differently across studies. The certainty of the evidence was very low for these three outcomes according to GRADE methodology.

Conclusions

RCTs that assessed effects of SMS text reminders did not find a significant benefit on objective outcomes, such as having a sunburn, sunscreen use and composite score of sun protection habits. Since certainty of the evidence was very low, future high-quality studies are needed to reach a conclusion regarding the balance of desirable and undesirable outcomes.

Protocol registration number

PROSPERO (CRD42018091661).

Effect of student-directed solicitation of evaluation forms on the timeliness of completion by preceptors in the United States

PURPOSE

Summative evaluation forms assessing a student's clinical performance are often completed at the end of a clinical experience from a faculty preceptor. In our institution, despite the use of an electronic system, completion timeliness has been suboptimal potentially limiting our ability to monitor student progress. The aim of the present study was to determine if a student-centered approach to summative evaluation form collection at the end of a pediatrics clinical experience will enhance timeliness of completion for third year medical students at Pennsylvania State College of Medicine.

METHODS

This was a pre- and post-intervention educational quality improvement project focused on 156 (82 pre-intervention, 74 post-intervention) third year medical students at Pennsylvania State College of Medicinecompleting their four-week pediatric clerkship. Utilizing Research Electronic Data Capture (REDCap) informatics support, student-directed evaluation form solicitation was encouraged. Wilcoxon rank sum test was applied to compare pre-intervention (May 1, 2017 to March 2, 2018) and post-intervention (April 2, 2018 to December 21, 2018) percentages of forms completed before rotation midpoint.

RESULTS

Seven hundred and forty evaluation forms were submitted during the pre-intervention phase and five-hundred and seventeen were submitted during the post-intervention phase. Form completion percentage before rotation midpoint increased after implementation of student-directed solicitation (9.6% versus 39.7%, P<0.05).

CONCLUSION

Our clerkship relies on subjective summative evaluations to track student progress, employ improvement strategies, and determine criteria for advancement; however, our preceptors struggled with timely submission. Allowing students to direct the solicitation of evaluation forms enhanced the timeliness of completion at our institution and should be considered in clerkships with similar difficulties.

Optimizing Drug-Drug Interaction Alerts Using a Multidimensional Approach

OBJECTIVES

Excessive alerts are a common concern associated with clinical decision support systems that monitor drug-drug interactions (DDIs). To reduce the number of low-value interruptive DDI alerts at our hospital, we implemented an iterative, multidimensional quality improvement effort, which included an interdisciplinary advisory group, alert metrics, and measurement of perceived clinical value.

METHODS

Alert data analysis indicated that DDIs were the most common interruptive medication alert. An interdisciplinary alert advisory group was formed to provide expert advice and oversight for alert refinement and ongoing review of alert data. Alert data were categorized into drug classes and analyzed to identify DDI alerts for refinement. Refinement strategies included alert suppression and modification of alerts to be contextually aware.

RESULTS

On the basis of historical analysis of classified DDI alerts, 26 alert refinements were implemented, representing 47% of all alerts. Alert refinement efforts resulted in the following substantial decreases in the number of interruptive DDI alerts: 40% for all clinicians (22.9-14 per 100 orders) and as high as 82% for attending physicians (6.5-1.2 per 100 orders). Two patient safety events related to alert refinements were reported during the project period.

CONCLUSIONS

Our quality improvement effort refined 47% of all DDI alerts that were firing during historical analysis, significantly reduced the number of DDI alerts in a 54-week period, and established a model for sustained alert refinements.

Texting to Increase Contraceptive Initiation Among Adolescents in the Emergency Department

PURPOSE

To evaluate the feasibility and acceptability of a text messaging intervention to increase contraception among adolescent emergency department patients.

METHODS

A pilot randomized controlled trial of sexually active females aged 14-19 receiving 3 months of theory-based, unidirectional educational and motivational texts providing reproductive health information versus standardized discharge instructions. Blinded assessors measured contraception initiation via telephone follow-up and health record review at 3 months.

RESULTS

We randomized 100 eligible participants (predominantly aged 18-19, Hispanic, and with a primary provider); 88.0% had follow-up. In the intervention arm, 3/50 (6.0%) participants opted out, and 1,172/1,654 (70.9%) texts were successfully delivered; over 90% of message failures were from one mobile carrier. Most (36/41; 87.7%) in the intervention group liked and wanted future reproductive health messages. Contraception was initiated in 6/50 (12.0%) in the intervention arm and in 11/49 (22.4%) in the control arm.

CONCLUSIONS

A pregnancy prevention texting intervention was feasible and acceptable among adolescent females in the emergency department setting.

The effects of an educational meeting and subsequent computer reminders on the ordering of laboratory tests by rheumatologists: an interrupted time series analysis

OBJECTIVES

To examine the effects of an educational meeting and subsequent computer reminders on the number of ordered laboratory tests.

METHODS

Using interrupted time series analysis we assessed whether trends in the number of laboratory tests ordered by rheumatologists between September 2012 and September 2015 at the Sint Maartenskliniek (the Netherlands) changed following an educational meeting (September 2013) and the introduction of computer reminders into the Computerised Physician Order Entry System (July 2014). The analyses were done for the set of tests on which both interventions had focussed (intervention tests; complement, cryoglobulins, immunoglobins, myeloma protein) and a set of control tests unrelated to the interventions (alanine transferase, anti-cyclic citrullinated peptide, C-reactive protein, creatine, haemoglobin, leukocytes, mean corpuscular volume, rheumatoid factor and thrombocytes).

RESULTS

At the start of the study, 101 intervention tests and 7660 control tests were ordered per month by the rheumatologists. After the educational meeting, both the level and trend of ordered intervention and control tests did not change significantly. After implementation of the reminders, the level of ordered intervention tests decreased by 85.0 tests (95%-CI -133.3 to -36.8, p<0.01), the level of control tests did not change following the introduction of reminders.

CONCLUSIONS

In summary, an educational meeting alone was not effective in decreasing the number of ordered intervention tests, but the combination with computer reminders did result in a large decrease of those tests. Therefore, we recommend using computer reminders in addition to education if reduction of inappropriate test use is aimed for.

Current Trends in Electronic Medication Reminders for Self Care

Poor adherence to medication can lead to negative health outcomes and increased financial burdens. We present a literature review on electronic medication reminders used for medication adherence in self care settings, to identify current and possible future trends. A structured PubMed search based on extracted MeSH terms provided a total of 45 publications which were identified as most relevant. Three main categories of electronic solutions were identified: mobile phone reminders, in-home electronic reminder devices, and portable reminder devices.

Are patients with diabetes mellitus satisfied with technologies used to assist with diabetes management and coping?: A structured review

Modern technological devices supporting coping and management for patients with diabetes are increasingly popular and could be important healthcare tools. This review aimed to evaluate patient satisfaction and perceptions regarding these devices, examples of which include short message service reminder systems, online educational programs, and clinician-patient electronic communication. Therapy devices such as continuous glucose monitors and continuous subcutaneous insulin infusion pumps are not included in this review. Embase, Psychinfo, Medline, CINAHL, and gray literature databases were searched for "diabetes mellitus," "technical device," "patient satisfaction," and their synonyms. This review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. The search produced 1,902 studies, 26 of which were included in the review: type 1 diabetes mellitus (eight studies), type 2 diabetes mellitus (nine studies), and both (nine studies). High satisfaction was seen with almost all devices and correlated strongly with ease of use and improved diabetes management. Satisfaction was not affected by participant age, and the effect of diabetes type was not assessed. Web devices were reported as easiest to use. Increased support was valued and resulted from devices facilitating interaction with healthcare professionals (HCPs) or peers. Technical difficulties were barriers to both use and satisfaction. Overall, patients enjoyed supplementing their usual therapy with these devices. Perceived support from HCPs or peers formed an important aspect of patient satisfaction and should be considered for future interventions.

Short- and long-term effects of real-time medication monitoring with short message service (SMS) reminders for missed doses on the refill adherence of people with Type 2 diabetes: evidence from a randomized controlled trial

AIMS

To investigate short- and long-term effects of real-time monitoring medication use combined with short message service (SMS) reminders for missed doses on refill adherence to oral anti-diabetic medication.

METHODS

A randomized controlled trial with two intervention groups and one control group involving 161 participants with Type 2 diabetes with suboptimal adherence. For 6 months, participants in the SMS group (n = 56) were monitored and received SMS reminders if they missed their medication. Participants in the non-SMS group (n = 48) were only monitored. The control group (n = 57) was not exposed to any intervention. Primary outcome measure was refill adherence to oral anti-diabetic medication. Multi-level regression analyses were performed to examine intervention effects on adherence between and within groups after 1 and 2 years of follow-up.

RESULTS

At baseline, mean refill adherence was comparable between the groups. After 1 year, adherence in the SMS group was significantly higher than in the control group (79.5% vs. 64.5%; P < 0.001) and showed a significant improvement from baseline (+16.3%; P < 0.001). Mean adherence in the non-SMS group reached 73.1% (+7.3%; P < 0.05), but did not differ from the control group (P = 0.06). After 2 years, the improved adherence in the SMS group persisted and remained significantly higher than in the control group (80.4% vs. 68.4%; P < .01), contrary to the non-SMS group whose adherence approached baseline level again (65.5%).

CONCLUSIONS

This study shows the long-term effectiveness of real-time medication monitoring combined with SMS reminders in improving refill adherence. This new reminder system can strengthen the self-management of people with diabetes.

Changing clinical practice through patient specific reminders available at the time of the clinical encounter: systematic review and meta-analysis

OBJECTIVE

To synthesise current evidence for the influence on clinical behaviour of patient-specific electronically generated reminders available at the time of the clinical encounter.

DATA SOURCES

PubMed, Cochrane library of systematic reviews; Science Citation Index Expanded; Social Sciences Citation Index; ASSIA; EMBASE; CINAHL; DARE; HMIC were searched for relevant articles.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

We included controlled trials of reminder interventions if the intervention was: directed at clinician behaviour; available during the clinical encounter; computer generated (including computer generated paper-based reminders); and generated by patient-specific (rather than condition specific or drug specific) data.

STUDY APPRAISAL AND SYNTHESIS METHODS

Systematic review and meta-analysis of controlled trials published since 1970. A random effects model was used to derive a pooled odds ratio for adherence to recommended care or achievement of target outcome. Subgroups were examined based on area of care and study design. Odds ratios were derived for each sub-group. We examined the designs, settings and other features of reminders looking for factors associated with a consistent effect.

RESULTS

Altogether, 42 papers met the inclusion criteria. The studies were of variable quality and some were affected by unit of analysis errors due to a failure to account for clustering. An overall odds ratio of 1.79 [95% confidence interval 1.56, 2.05] in favour of reminders was derived. Heterogeneity was high and factors predicting effect size were difficult to identify.

LIMITATIONS

Methodological diversity added to statistical heterogeneity as an obstacle to meta-analysis. The quality of included studies was variable and in some reports procedural details were lacking.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The analysis suggests a moderate effect of electronically generated, individually tailored reminders on clinician behaviour during the clinical encounter. Future research should concentrate on identifying the features of reminder interventions most likely to result in the target behaviour.

How much does a reminder letter increase cervical screening among under-screened women in NSW?

OBJECTIVE

To evaluate a direct mail-out campaign to increase Pap screening rates in women who have not had a test in 48 months.

METHODS

Ninety thousand under-screened women were randomised to be mailed a 48-month reminder letter to have a Pap test (n=60,000), or not to be mailed a letter (n=30,000). Differences in Pap test rates were assessed by Kaplan-Meier survival analysis, by chi2 tests of significance between Pap test rates in letter versus no-letter groups, and by proportional hazards regression modelling of predictors of a Pap test with letter versus no-letter as the main study variable. T-tests were conducted on mean time to Pap test to assess whether time to Pap test was significantly different between the intervention and control groups.

RESULTS

After 90 days following each mail-out, Pap test rates in the letter group were significantly higher than in the non-letter group, by approximately two percentage points. After controlling for potential confounders, the hazard ratio of a Pap test within 90 days of a mail-out in the letter group was 1.5 compared with 1.0 in the no-letter group. Hazard ratios of having a Pap test within 90 days decreased significantly with time since last Pap test (p<0.0001); were significantly higher than 1.0 for most non-metropolitan areas of NSW compared with metropolitan areas; and increased significantly with age (p<0.0001). Pap test hazard ratios were not associated with socio-economic status of area of residence, but the hazard ratio was significantly higher than 1.0 if the reminder letter was sent after the Christmas/New Year break. No significant differences in mean time to Pap test were found between the letter and no-letter groups.

CONCLUSIONS AND IMPLICATIONS

Being sent a reminder letter is associated with higher Pap testing rates in under-screened women.

Computer-based ambulatory information systems: recent developments

This article updates the author's earlier review of some of the major computer-based ambulatory information systems and the literature evaluating their costs, benefits, effect on quality of care, and physician acceptance. The evidence suggests that computer-based information systems can increase access to clinical information, improve physician performance, enhance quality of care, and facilitate outcomes research review. In addition to presenting health information networks and clinical decision support systems such as reminder systems, drug ordering systems, and medical care management systems, the article describes applications of telemedicine and Web-based systems. It also discusses barriers to the widespread use of computer-based ambulatory information systems.

Slippage in the NHS breast screening programme: an assessment of whether a three year screening round is being achieved

BACKGROUND

The NHS breast screening programme (NHSBSP) was established in 1987 to screen women aged 50-64 every three years to achieve a significant reduction in breast cancer mortality. Ensuring that women are re-invited every three years (that is, a three year screening round is in operation) is becoming increasingly difficult as pressure on the service rises. Coverage measures the proportion of eligible women receiving a screen in the previous three years and is currently used as an NHS performance indicator, while uptake measures the proportion of invited women who attend for screening. Data for 1996/1997 for the West Midlands NHSBSP show that, although uptake among 50-64 year olds was in excess of the 70% target at 78%, coverage was 10% below this at 68%. The discrepancy between coverage and uptake is likely to in part reflect "round slippage" in which women are re-invited at three years or more from their previous screen. To investigate the extent to which slippage is occurring in the region a technique for assessing round length independently of coverage was developed.

METHODS

Records for women receiving routine recall (incident) screens between 1994 and 1997 in the West Midlands NHSBSP were examined and the time between the most recent screen and the previous screen measured in months.

FINDINGS

Of 73,785 women screened in 1996/1997, 46.3% had a round length of under three years, although 74.9% had been re-screened within 38 months of the previous screen. Overall the regional programme was estimated to have a round slippage of approximately two months.

CONCLUSIONS

The West Midlands NHSBSP operates to high standards in terms of uptake and cancer detection, but round slippage must be reduced. The lack of quantitative data with which to assess round length has hindered assessment in the past. The simple technique developed in this study will allow assessment of round length to be used routinely as the key quality assurance measure for the programme.