Can Text Message Patient Outreach Improve Appointment Adherence?

Patient education ahead of a procedure and appointment adherence are critical to obtaining good outcomes, but the text message patient outreach tools designed to support that may not be a cure-all, according to researchers from the Perelman School of Medicine at the University of Pennsylvania.

The researchers, who looked specifically at colonoscopies for colorectal cancer screenings, noted that making sure patients were prepared for the procedure and actually adhered to screening schedules are important. After all, colorectal cancer is the second leading cause of cancer-related death in the US, they said, and regular colonoscopies can help ensure early detection and therefore better outcomes.

“However, colonoscopy entails a complex process for patients to identify an escort, obtain and purchase the bowel preparation, take a day off from work, adhere to a clear liquid diet, and complete the preparation as recommended,” the researchers explained in JAMA Network Open. “These challenges contribute to high nonattendance and cancellation rates and poor preparation quality, both limiting the patient and population benefit.”

That patient education and appointment adherence imperative has opened up a market for technology-based interventions, including text message patient outreach. Different health IT developers have created text-based tools that push out information regarding a colonoscopy and how the patient can prepare. Those same text message tools remind patients about when they are due for a colonoscopy and when their specific appointment is.

Healthcare organizations adopt these tools with the intention of increasing patient education about colonoscopies and improving patient engagement with the preventive procedure. The technology could potentially better reinforce pre-care instructions and help with practice management, saving nurses and other medical personnel from having to make the calls themselves amid an otherwise busy workflow.

But a randomized control trial comparing the text message and phone call reminders showed negligible difference between usual care and adding text messages.

Of the 386 patients enrolled in the control group—receiving written instructions and one nurse phone call—about half went to their appointment with optimal preparation. A similar proportion in the intervention group—receiving nine patient education and reminder text messages the week before the appointment, plus usual care—also attended their appointments with optimal preparation.

There also wasn’t much difference in secondary outcomes, including appointment non-attendance, last-minute cancellations, appointment rescheduling, or attendance with poor procedure preparation.

In other words, adding the text message patient outreach technology made no difference in improving outcomes.

But there are some nuances the researchers said warrant exploring. For one thing, the text message intervention may have been more accessible for some patients than others. Patients with higher digital health literacy may have been able to get more out of the technology, suggesting a more targeted approach could drive better results.

Additionally, it may be prudent for researchers to compare usual care—written materials and nurse phone calls—with the text message outreach tools alone. In this study, those receiving text messages also received phone calls from nurses, meaning the researchers could not determine if the text messages could be a replacement, not just a supplement, to colonoscopy care.

Future research should consider that, the team said. Such a study could determine if text message patient outreach tools could streamline clinic operations, save clinicians valuable time, and potentially cut costs.

“Nursing telephone calls represent a labor-intensive and time-consuming process,” the researcher team stated. “By contrast, automated scheduled text messages come at minimal cost and do not require any staffing overhead to directly interface with patients.”

This data comes as healthcare organizations work to mitigate significant patient call volume in a cost-effective and efficient way. Automated tools, such as text messages or even chatbots, are presenting some opportunities to streamline workflows. And contrary to this study’s results, anecdotal evidence has shown that automated, technology-based communication can work.

At NYC Health + Hospitals, for example, text message patient outreach helped organization leaders better understand not just patient no-show rates, but the why behind those no-shows. In a January 2020 interview, Kaushal Challa, the senior assistant vice president of Ambulatory Care Services at NYC Health + Hospitals, said the goal was not necessarily to reduce no-show rates. That was another challenge for another time.

Instead, Challa and team used text message patient outreach to ask patients to confirm their appointments, and if they couldn’t make it, tell the organization why. That helped NYC Health + Hospitals detect the social determinants of health and other barriers keeping patients from care.

Challa credited some of the tool’s success—in 2019, NYC Health + Hospitals in Coney Island saw a 21 percent no-show rate—to call center and EHR integration. It was also essential that the tool was accessible to all patients, regardless of the language they spoke.

“The move to embrace a solution that had text messaging capabilities is in part in response to our patient population,” Challa said. “Most people have cell phones, but our patients rely on their cell phones at a higher rate than the average.”

“There has been a historical perception, a misperception, that a poorer overall patient population might not be as tech-savvy, and actually the opposite is true,” he continued. “Our patients rely almost exclusively on mobile phones at a higher rate than the average.”