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Mehta SJ, Rhodes C, Linn KA, Reitz C, McDonald C, Okorie E, Williams K, Resnick D, Arostegui A, McAuliffe T, Wollack C, Snider CK, Peifer MK, Weinstein SP. Behavioral Interventions to Improve Breast Cancer Screening Outreach: Two Randomized Clinical Trials. JAMA Intern Med 2024:2818196. [PMID: 38709509 DOI: 10.1001/jamainternmed.2024.0495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Importance Despite public health efforts, breast cancer screening rates remain below national goals. Objective To evaluate whether bulk ordering, text messaging, and clinician endorsement increase breast cancer screening rates. Design, Setting, and Participants Two concurrent, pragmatic, randomized clinical trials, each with a 2-by-2 factorial design, were conducted between October 25, 2021, and April 25, 2022, in 2 primary care regions of an academic health system. The trials included women aged 40 to 74 years with at least 1 primary care visit in the past 2 years who were eligible for breast cancer screening. Interventions Patients in trial A were randomized in a 1:1 ratio to receive a signed bulk order for mammogram or no order; in a factorial design, patients were concurrently randomized in a 1:1 ratio to receive or not receive text message reminders. Patients in trial B were randomized in a 1:1 ratio to receive a message signed by their primary care clinician (clinician endorsement) or from the organization (standard messaging); in a factorial design, patients were concurrently randomized in a 1:1 ratio to receive or not receive text message reminders. Main Outcomes and Measures The primary outcome was the proportion of patients who completed a screening mammogram within 3 months. Results Among 24 632 patients included, the mean (SD) age was 60.4 (7.5) years. In trial A, at 3 months, 15.4% (95% CI, 14.6%-16.1%) of patients in the bulk order arm and 12.7% (95% CI, 12.1%-13.4%) in the no order arm completed a mammogram, showing a significant increase (absolute difference, 2.7%; 95% CI, 1.6%-3.6%; P < .001). In the text messaging comparison arms, 15.1% (95% CI, 14.3%-15.8%) of patients receiving a text message completed a mammogram compared with 13.0% (95% CI, 12.4%-13.7%) of those in the no text messaging arm, a significant increase (absolute difference of 2.1%; 95% CI, 1.0%-3.0%; P < .001). In trial B, at 3 months, 12.5% (95% CI, 11.3%-13.7%) of patients in the clinician endorsement arm completed a mammogram compared with 11.4% (95% CI, 10.3%-12.5%) of those in the standard messaging arm, which was not significant (absolute difference, 1.1%; 95% CI, -0.5% to 2.7%; P = .18). In the text messaging comparison arms, 13.2% (95% CI, 12.0%-14.4%) of patients receiving a text message completed a mammogram compared with 10.7% (95% CI, 9.7%-11.8%) of those in the no text messaging arm, a significant increase (absolute difference, 2.5%; 95% CI, 0.8%-4.0%; P = .003). Conclusions and Relevance These findings show that text messaging women after initial breast cancer screening outreach via either electronic portal or mailings, as well as bulk ordering with or without text messaging, can increase mammogram completion rates. Trial Registration ClinicalTrials.gov Identifier: NCT05089903.
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Affiliation(s)
- Shivan J Mehta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Corinne Rhodes
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine, University of Pennsylvania, Philadelphia
| | - Kristin A Linn
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Catherine Reitz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Caitlin McDonald
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Evelyn Okorie
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Keyirah Williams
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - David Resnick
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | | | - Timothy McAuliffe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Colin Wollack
- Penn Medicine, University of Pennsylvania, Philadelphia
| | | | - MaryAnne K Peifer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine, University of Pennsylvania, Philadelphia
| | - Susan P Weinstein
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Gleriano JS, Krein C, Chaves LDP. Aspects that facilitate access to care for viral hepatitis: An evaluative research. SAO PAULO MED J 2024; 142:e2023078. [PMID: 38477774 DOI: 10.1590/1516-3180.2023.0078.r1.29112023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 11/29/2023] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Viral hepatitis is a major public health concern worldwide. OBJECTIVES This study aimed to analyze the factors that facilitate access to care for viral hepatitis. DESIGN AND SETTING Using a sequential mixed method, this evaluation research was conducted in the state of Mato Grosso, Brazil. METHODS Mapping of references and selection of regions were made based on the quantity and heterogeneity of services. The stakeholders, including the managers of the State Department of Health and professionals from reference services, were identified. Nine semi-structured interviews were conducted using content analysis and discussions guided by the dimensions of the analysis model of universal access to health services. RESULTS In the political dimension, decentralizing services and adhering to the Intermunicipal Health Consortium are highly encouraged. In the economic-social dimension, a commitment exists to allocate public funds for the expansion of referral services and subsidies to support users in their travel for appointments, medications, and examinations. In the organizational dimension, the availability of inputs for testing, definition of user flow, ease of scheduling appointments, coordination by primary care in testing, collaboration following the guidelines and protocols, and engagement in extramural activities are guaranteed. In the technical dimension, professionals actively commit to the service and offer different opening hours, guarantee the presence of an infectious physician, expand training opportunities, and establish intersectoral partnerships. In the symbolic dimension, professionals actively listen to the experiences of users throughout their care trajectory and demonstrate empathy. CONCLUSIONS The results are crucial for improving comprehensiveness, but necessitate managerial efforts to enhance regional governance.
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Affiliation(s)
- Josué Souza Gleriano
- PhD. Nurse, Adjunct Professor, Department of Nursing, Faculty of Agricultural, Biological, Engineering and Health Sciences, Universidade do Estado de Mato Grosso (UNEMAT), Tangará da Serra (MT), Brazil
| | - Carlise Krein
- Msc. Nurse, Department of General and Specialized Nursing, Ribeirão Preto School of Nursing, Universidade de São Paulo (USP), Ribeirão Preto (SP), Brazil
| | - Lucieli Dias Pedreschi Chaves
- PhD. Nurse, Associate Professor, Department of General and Specialized Nursing, Ribeirão Preto School of Nursing, Universidade de São Paulo (USP), Ribeirão Preto (SP), Brazil
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Waddell KJ, Goel K, Park SH, Linn KA, Navathe AS, Liao JM, McDonald C, Reitz C, Moore J, Hyland S, Mehta SJ. Association of Electronic Self-Scheduling and Screening Mammogram Completion. Am J Prev Med 2024; 66:399-407. [PMID: 38085196 PMCID: PMC10922640 DOI: 10.1016/j.amepre.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/02/2023] [Accepted: 11/02/2023] [Indexed: 01/29/2024]
Abstract
INTRODUCTION The purpose of this study was to evaluate if an electronic health record (EHR) self-scheduling function was associated with changes in mammogram completion for primary care patients who were eligible for a screening mammogram using U.S. Preventive Service Task Force recommendations. METHODS This was a retrospective cohort study (September 1, 2014-August 31, 2019, analyses completed in 2022) using a difference-in-differences design to examine mammogram completion before versus after the implementation of self-scheduling. The difference-in-differences estimate was the interaction between time (pre-versus post-implementation) and group (active EHR patient portal versus inactive EHR patient portal). The primary outcome was mammogram completion among all eligible patients, with completion defined as receiving a mammogram within 6 months post-visit. The secondary outcome was mammogram completion among patients who received a clinician order during their visit. RESULTS The primary analysis included 35,257 patient visits. The overall mammogram completion rate in the pre-period was 22.2% and 49.7% in the post-period. EHR self-scheduling was significantly associated with increased mammogram completion among those with an active EHR portal, relative to patients with an inactive portal (adjusted difference 13.2 percentage points [95% CI 10.6-15.8]). For patients who received a clinician mammogram order at their eligible visit, self-scheduling was significantly associated with increased mammogram completion among patients with an active EHR portal account (adjusted difference 14.7 percentage points, [95% CI 10.9-18.5]). CONCLUSIONS EHR-based self-scheduling was associated with a significant increase in mammogram completion among primary care patients. Self-scheduling can be a low-cost, scalable function for increasing preventive cancer screenings.
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Affiliation(s)
- Kimberly J Waddell
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Cresencz VA Medical Center, Philadelphia, PA.
| | - Keshav Goel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sae-Hwan Park
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Kristin A Linn
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Amol S Navathe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Cresencz VA Medical Center, Philadelphia, PA
| | - Joshua M Liao
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Medicine, University of Washington, Seattle, WA
| | - Caitlin McDonald
- Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia, PA
| | - Catherine Reitz
- Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia, PA
| | - Jake Moore
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Steve Hyland
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Shivan J Mehta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia, PA
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Mehta SJ, McDonald C, Reitz C, Kastuar S, Snider CK, Okorie E, McNelis K, Shaikh H, Cook TS, Goldberg DS, Rothstein K. A randomized trial of mailed outreach with behavioral economic interventions to improve liver cancer surveillance. Hepatol Commun 2024; 8:e0349. [PMID: 38099859 PMCID: PMC10727671 DOI: 10.1097/hc9.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Surveillance rates for HCC remain limited in patients with cirrhosis. We evaluated whether opt-out mailed outreach increased uptake with or without a $20 unconditional incentive. METHODS This was a pragmatic randomized controlled trial in an urban academic health system including adult patients with cirrhosis or advanced fibrosis, at least 1 visit to a specialty practice in the past 2 years and no surveillance in the last 7 months. Patients were randomized in a 1:2:2 ratio to (1) usual care, (2) a mailed letter with a signed order for an ultrasound, or (3) a mailed letter with an order and a $20 unconditional incentive. The main outcome was the proportion with completion of ultrasound within 6 months. RESULTS Among the 562 patients included, the mean age was 62.1 (SD 11.1); 56.8% were male, 51.1% had Medicare, and 40.6% were Black. At 6 months, 27.6% (95% CI: 19.5-35.7) completed ultrasound in the Usual care arm, 54.5% (95% CI: 47.9-61.0) in the Letter + Order arm, and 54.1% (95% CI: 47.5-60.6) in the Letter + Order + Incentive arm. There was a significant increase in the Letter + Order arm compared to Usual care (absolute difference of 26.9%; 95% CI: 16.5-37.3; p<0.001), but no significant increase in the Letter + Order + Incentive arm compared to Letter + Order (absolute difference of -0.4; 95% CI: -9.7 to 8.8; p=0.93). CONCLUSIONS There was an increase in HCC surveillance from mailed outreach with opt-out framing and a signed order slip, but no increase in response to the financial incentive.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Caitlin McDonald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Shivani Kastuar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Evelyn Okorie
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Kiernan McNelis
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Hamzah Shaikh
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Tessa S. Cook
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - David S. Goldberg
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Kenneth Rothstein
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Waddell KJ, Mehta SJ. Designing Effective and Appropriate Opt-Out Approaches for Patient Outreach. JAMA Intern Med 2023; 183:1194-1195. [PMID: 37695578 PMCID: PMC10810178 DOI: 10.1001/jamainternmed.2023.4628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Affiliation(s)
- Kimberly J Waddell
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Shivan J Mehta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
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Rivera Rivera J, Fuzzell LN, Garcia J, Rathwell J, Robinson EJ, Chavez M, Fulton H, Whitmer A, Mathew E, Giuliano AR, Vadaparampil ST. Development of a Patient Activation Toolkit for Hepatitis C Virus Testing. J Cancer Educ 2023; 38:931-939. [PMID: 35971055 PMCID: PMC10187067 DOI: 10.1007/s13187-022-02209-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 05/18/2023]
Abstract
We evaluated the acceptability of a patient activation toolkit for hepatitis C virus (HCV) testing amidst universal adult guidelines. We developed a patient-facing toolkit that included a letter to the patient from their healthcare provider, HCV factsheet, and question prompt list, which contained questions for their provider about HCV infection and testing. We conducted qualitative interviews with patients ages 18-78 (n = 17), using a semi-structured interview guide based on learner verification. We assessed attraction, comprehension, cultural-linguistic acceptability, self-efficacy, and persuasiveness of toolkit materials using direct content analysis. Participants reported materials were attractive, offering suggestions to improve readability. They reported some understanding of materials but requested use of less medical jargon, particularly for the factsheet. Participants discussed cultural acceptability and suggested ways to improve language inclusiveness and comfort with content, given stigma surrounding HCV risk factors. Participants reported that including a letter, factsheet, and QPL improved the persuasiveness of materials, and they conveyed their motivation to be tested for HCV. Results indicate preliminary acceptability for use of the patient activation toolkit, which will be refined based on participants' recommendations. Overall, this patient activation toolkit holds promise for increasing HCV testing rates.
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Affiliation(s)
- Jessica Rivera Rivera
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, USA.
| | - Lindsay N Fuzzell
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Jennifer Garcia
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Julie Rathwell
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center, Tampa, USA
- Center for Immunization and Infection Research in Cancer, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Edmondo J Robinson
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, USA
- Center for Digital Health, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Melody Chavez
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Hayden Fulton
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Ashley Whitmer
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Ebin Mathew
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Anna R Giuliano
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center, Tampa, USA
- Center for Immunization and Infection Research in Cancer, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Susan T Vadaparampil
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, USA.
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LaVine N, Emmert K, Itty J, Martins-Welch D, Carney M, Block A, Burgess L, Volandes AE, Zupanc SN, Jacome S, Gromova V, Davis AD, Schwartz P, Alvarez-Suarez A, Burns E. Reaching Ambulatory Older Adults with Educational Tools: Comparative Efficacy and Cost of Varied Outreach Modalities in Primary Care. J Gen Intern Med 2023; 38:125-130. [PMID: 36217070 PMCID: PMC9550308 DOI: 10.1007/s11606-022-07808-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 09/13/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Providing patients with access to health information that can be obtained outside of an office visit is an important part of education, yet little is known about the effectiveness of outreach modalities to connect older adults to online educational tools. The objective was to identify the effectiveness and cost of outreach modalities providing online information about advance care planning (ACP) for older adults. METHODS Six different outreach modalities were utilized to connect patients to online educational tools (ACP video decision aids). Participants were 13,582 patients aged 65 and older of 185 primary care providers with appointments over a 30-month period within a large health system in the greater New York City area. Main outcome measures were number of online video views and costs per outreach for each modality. KEY RESULTS There were 1150 video views for 21,407 remote outreach events. Text messages, sent to the largest volume of patients (8869), had the highest outcome rate (9.6%) and were the most economical ($0.09). Characterization of phone calls demonstrated 21.7% engagement in the topic of ACP but resulted in minimal video views (<1%) and incurred the highest cost per outreach ($2.88). In-office handouts had negligible results (<1%). CONCLUSIONS Text was the most cost-effective modality to connect older adults to an online educational tool in this pragmatic trial, though overall efficacy of all modalities was low.
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Affiliation(s)
- N LaVine
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA
| | - K Emmert
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - J Itty
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - D Martins-Welch
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA
| | - M Carney
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA.,Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - A Block
- New York Medical College School of Health Sciences and Practice, Westchester, NY, USA
| | - L Burgess
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - A E Volandes
- Harvard Medical School, Boston, MA, USA.,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,ACP Decisions, Boston, MA, USA
| | - S N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - S Jacome
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - V Gromova
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | | | | | - A Alvarez-Suarez
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Edith Burns
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA. .,Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA.
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Halket D, Dang J, Phadke A, Jayasekera C, Kim WR, Kwo P, Downing L, Goel A. Targeted Electronic Patient Portal Messaging Increases Hepatitis C Virus Screening in Primary Care: a Randomized Study. J Gen Intern Med 2022; 37:3318-3324. [PMID: 35230622 PMCID: PMC9551157 DOI: 10.1007/s11606-022-07460-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 02/04/2022] [Indexed: 12/09/2022]
Abstract
IMPORTANCE Electronic health record (EHR) tools such as direct-to-patient messaging and automated lab orders are effective at improving uptake of preventive health measures. It is unknown if patient engagement in primary care impacts efficacy of such messaging. OBJECTIVE To determine whether more engaged patients, defined as those who have an upcoming visit scheduled, are more likely to respond to a direct-to-patient message with an automated lab order for hepatitis C virus (HCV) screening. DESIGN Randomized trial PARTICIPANTS: One thousand six hundred randomly selected Stanford Primary Care patients, 800 with an upcoming visit within 6 months and 800 without, born between 1945 and 1965 who were due for HCV screening. Each group was randomly divided into cohorts of 400 subjects each. Subjects were followed for 1 year. INTERVENTION One 400 subject cohort in each group received a direct-to-patient message through the EHR portal with HCV antibody lab order. MAIN OUTCOME AND MEASURE The EHR was queried on a monthly basis for 6 months after the intervention to monitor which subjects completed HCV screening. For any subjects screened positive for HCV, follow-up through the cascade of HCV care was monitored, and if needed, scheduled by the study team. KEY RESULTS Of 1600 subjects, 538 (34%) completed HCV screening. In the stratum without an upcoming appointment, 18% in the control group completed screening compared to 26% in intervention group (p<0.01). Similarly, in the stratum with an upcoming appointment, 34% in the control group completed screening compared to 58% in the intervention group (p<0.01). CONCLUSION Direct-to-patient messaging coupled with automated lab orders improved HCV screening rates compared to standard of care, particularly in more engaged patients. Including this intervention in primary care can maximize screening with each visit, which is particularly valuable in times when physical throughput in the healthcare system may be low.
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Affiliation(s)
- Douglas Halket
- Division of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA.
| | - Jimmy Dang
- Population Health, Stanford Hospital and Clinics, Palo Alto, CA, USA
| | - Anuradha Phadke
- Division of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA
| | | | - W Ray Kim
- Division of Gastroenterology & Hepatology, Stanford University, Palo Alto, CA, USA
| | - Paul Kwo
- Division of Gastroenterology & Hepatology, Stanford University, Palo Alto, CA, USA
| | - Lance Downing
- Department of Medicine, Center for Biomedical Informatics Research, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Aparna Goel
- Division of Gastroenterology & Hepatology, Stanford University, Palo Alto, CA, USA
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Mehta SJ, Mallozzi C, Shaw PA, Reitz C, McDonald C, Vandertuyn M, Balachandran M, Kopinsky M, Sevinc C, Johnson A, Ward R, Park SH, Snider CK, Rosin R, Asch DA. Effect of Text Messaging and Behavioral Interventions on COVID-19 Vaccination Uptake: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2216649. [PMID: 35696165 PMCID: PMC9194662 DOI: 10.1001/jamanetworkopen.2022.16649] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE COVID-19 vaccine uptake among urban populations remains low. OBJECTIVE To evaluate whether text messaging with outbound or inbound scheduling and behaviorally informed content might increase COVID-19 vaccine uptake. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial with a factorial design was conducted from April 29 to July 6, 2021, in an urban academic health system. The trial comprised 16 045 patients at least 18 years of age in Philadelphia, Pennsylvania, with at least 1 primary care visit in the past 5 years, or a future scheduled primary care visit within the next 3 months, who were unresponsive to prior outreach. The study was prespecified in the trial protocol, and data were obtained from the intent-to-treat population. INTERVENTIONS Eligible patients were randomly assigned in a 1:20:20 ratio to (1) outbound telephone call only by call center, (2) text message and outbound telephone call by call center to those who respond, or (3) text message, with patients instructed to make an inbound telephone call to a hotline. Patients in groups 2 and 3 were concurrently randomly assigned in a 1:1:1:1 ratio to receive different content: standard messaging, clinician endorsement (eg, "Dr. XXX recommends"), scarcity ("limited supply available"), or endowment framing ("We have reserved a COVID-19 vaccine appointment for you"). MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients who completed the first dose of the COVID-19 vaccine within 1 month, according to the electronic health record. Secondary outcomes were the completion of the first dose within 2 months and completion of the vaccination series within 2 months of initial outreach. Additional outcomes included the percentage of patients with invalid cell phone numbers (wrong number or nontextable), no response to text messaging, the percentage of patients scheduled for the vaccine, text message responses, and the number of telephone calls made by the access center. Analysis was on an intention-to-treat basis. RESULTS Among the 16 045 patients included, the mean (SD) age was 36.9 (11.1) years; 9418 (58.7%) were women; 12 869 (80.2%) had commercial insurance, and 2283 (14.2%) were insured by Medicaid; 8345 (52.0%) were White, 4706 (29.3%) were Black, and 967 (6.0%) were Hispanic or Latino. At 1 month, 14 of 390 patients (3.6% [95% CI, 1.7%-5.4%]) in the outbound telephone call-only group completed 1 vaccine dose, as did 243 of 7890 patients (3.1% [95% CI, 2.7%-3.5%]) in the text plus outbound call group (absolute difference, -0.5% [95% CI, -2.4% to 1.4%]; P = .57) and 253 of 7765 patients (3.3% [95% CI, 2.9%-3.7%]) in the text plus inbound call group (absolute difference, -0.3% [95% CI, -2.2% to 1.6%]; P = .72). Among the 15 655 patients receiving text messaging, 118 of 3889 patients (3.0% [95% CI, 2.5%-3.6%]) in the standard messaging group completed 1 vaccine dose, as did 135 of 3920 patients (3.4% [95% CI, 2.9%-4.0%]) in the clinician endorsement group (absolute difference, 0.4% [95% CI, -0.4% to 1.2%]; P = .31), 100 of 3911 patients (2.6% [95% CI, 2.1%-3.1%]) in the scarcity group (absolute difference, -0.5% [95% CI, -1.2% to 0.3%]; P = .20), and 143 of 3935 patients (3.6% [95% CI, 3.0%-4.2%]) in the endowment group (absolute difference, 0.6% [95% CI, -0.2% to 1.4%]; P = .14). CONCLUSIONS AND RELEVANCE There was no detectable increase in vaccination uptake among patients receiving text messaging compared with telephone calls only or behaviorally informed message content. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04834726.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | | | - Pamela A. Shaw
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Caitlin McDonald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Matthew Vandertuyn
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Mohan Balachandran
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Michael Kopinsky
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Christianne Sevinc
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Aaron Johnson
- Penn Medicine, University of Pennsylvania, Philadelphia
| | - Robin Ward
- Penn Medicine, University of Pennsylvania, Philadelphia
| | - Sae-Hwan Park
- Penn Medicine, University of Pennsylvania, Philadelphia
| | | | - Roy Rosin
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
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Mehta SJ, Torgersen J, Small DS, Mallozzi CP, McGreevey JD, Rareshide CA, Evans CN, Epps M, Stabile D, Snider CK, Patel MS. Effect of a Default Order vs an Alert in the Electronic Health Record on Hepatitis C Virus Screening Among Hospitalized Patients: A Stepped-Wedge Randomized Clinical Trial. JAMA Netw Open 2022; 5:e222427. [PMID: 35297973 PMCID: PMC8931559 DOI: 10.1001/jamanetworkopen.2022.2427] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
IMPORTANCE Hepatitis C virus (HCV) screening has been recommended for patients born between 1945 and 1965, but rates remain low. OBJECTIVE To evaluate whether a default order within the admission order set increases HCV screening compared with a preexisting alert within the electronic health record. DESIGN, SETTING, AND PARTICIPANTS This stepped-wedge randomized clinical trial was conducted from June 23, 2020, to April 10, 2021, at 2 hospitals within an academic medical center. Hospitalized patients born between 1945 and 1965 with no history of screening were included in the analysis. INTERVENTIONS During wedge 1 (a preintervention period), both hospital sites had an electronic alert prompting clinicians to consider HCV screening. During wedge 2, the first intervention wedge, the hospital site randomized to intervention (hospital B) had a default order for HCV screening implemented within the admission order set. During wedge 3, the second intervention wedge, the hospital site randomized to control (hospital A) had the default order set implemented. MAIN OUTCOMES AND MEASURES Percentage of eligible patients who received HCV screening during the hospital stay. RESULTS The study included 7634 patients (4405 in the control group and 3229 in the intervention group). The mean (SD) age was 65.4 (5.8) years; 4246 patients (55.6%) were men; 2142 (28.1%) were Black and 4625 (60.6%) were White; and 2885 (37.8%) had commercial insurance and 3950 (51.7%) had Medicare. The baseline rate of HCV screening in wedge 1 was 585 of 1560 patients (37.5% [95% CI, 35.1%-40.0%]) in hospital A and 309 of 1003 patients (30.8% [95% CI, 27.9%-33.7%]) in hospital B. The main adjusted model showed an increase of 31.8 (95% CI, 29.7-33.8) percentage points in test completion in the intervention group compared with the control group (P <. 001). CONCLUSIONS AND RELEVANCE This stepped-wedge randomized clinical trial found that embedding HCV screening as a default order in the electronic health record substantially increased ordering and completion of testing in the hospital compared with a conventional interruptive alert. TRIAL REGISTRATION Clinicaltrials.gov: NCT04525690.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Jessie Torgersen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Dylan S. Small
- The Wharton School, University of Pennsylvania, Philadelphia
| | - Colleen P. Mallozzi
- University of Pennsylvania Health System, University of Pennsylvania, Philadelphia
- Center for Applied Health Informatics, University of Pennsylvania Health System, Philadelphia
| | - John D. McGreevey
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- University of Pennsylvania Health System, University of Pennsylvania, Philadelphia
- Center for Applied Health Informatics, University of Pennsylvania Health System, Philadelphia
| | - Charles A.L. Rareshide
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
| | - Chalanda N. Evans
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
| | - Mika Epps
- University of Pennsylvania Health System, University of Pennsylvania, Philadelphia
| | - David Stabile
- University of Pennsylvania Health System, University of Pennsylvania, Philadelphia
| | - Christopher K. Snider
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
| | - Mitesh S. Patel
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- The Wharton School, University of Pennsylvania, Philadelphia
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Ascension Health, St Louis, Missouri
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