JMIR--A Text Messaging Intervention to Improve Heart Failure Self ...

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Original Paper

A Text Messaging Intervention to Improve Heart Failure Self-Management After Hospital Discharge in a Largely African-American Population: Before-After Study

Shantanu Nundy¹, MD; Rabia R Razi², MD, MPH; Jonathan J Dick³, MD; Bryan Smith⁴, MD; Ainoa Mayo⁵, MA; Anne O'Connor⁶, MD; David O Meltzer⁵, MD, Ph.D

¹Section of General Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL, United States
²Cedars-Sinai Heart Institute, Los Angeles, CA, United States
³Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, United States
⁴Department of Medicine, University of Chicago Medical Center, Chicago, IL, United States
⁵Section of Hospital Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL, United States
⁶Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, United States

Corresponding Author:
Shantanu Nundy, MD

Section of General Internal Medicine
Department of Medicine
University of Chicago Medical Center
5841 S Maryland Ave
MC2007
Chicago, IL, 60637
United States
Phone: 1 7737020620
Fax: 1 7738342238
Email:

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ABSTRACT

Background: There is increasing interest in finding novel approaches to reduce health disparities in readmissions for acute decompensated heart failure (ADHF). Text messaging is a promising platform for improving chronic disease self-management in low-income populations, yet is largely unexplored in ADHF.
Objective: The purpose of this pre-post study was to assess the feasibility and acceptability of a text message?based (SMS: short message service) intervention in a largely African American population with ADHF and explore its effects on self-management.
Methods: Hospitalized patients with ADHF were enrolled in an automated text message?based heart failure program for 30 days following discharge. Messages provided self-care reminders and patient education on diet, symptom recognition, and health care navigation. Demographic and cell phone usage data were collected on enrollment, and an exit survey was administered on completion. The Self-Care of Heart Failure Index (SCHFI) was administered preintervention and postintervention and compared using sample t tests (composite) and Wilcoxon rank sum tests (individual). Clinical data were collected through chart abstraction.
Results: Of 51 patients approached for recruitment, 27 agreed to participate and 15 were enrolled (14 African-American, 1 White). Barriers to enrollment included not owning a personal cell phone (n=12), failing the Mini-Mental exam (n=3), needing a proxy (n=2), hard of hearing (n=1), and refusal (n=3). Another 3 participants left the study for health reasons and 3 others had technology issues. A total of 6 patients (5 African-American, 1 White) completed the postintervention surveys. The mean age was 50 years (range 23-69) and over half had Medicaid or were uninsured (60%, 9/15). The mean ejection fraction for those with systolic dysfunction was 22%, and at least two-thirds had a prior hospitalization in the past year. Participants strongly agreed that the program was easy to use (83%), reduced pills missed (66%), and decreased salt intake (66%). Maintenance (mean composite score 49 to 78, P=.003) and management (57 to 86, P=.002) improved at 4 weeks, whereas confidence did not change (57 to 75, P=.11). Of the 6 SCHFI items that showed a statistically significant improvement, 5 were specifically targeted by the texting intervention.
Conclusions: Over half of ADHF patients in an urban, largely African American community were eligible and interested in participating in a text messaging program following discharge. Access to mobile phones was a significant barrier that should be addressed in future interventions. Among the participants who completed the study, we observed a high rate of satisfaction and preliminary evidence of improvements in heart failure self-management.

(J Med Internet Res 2013;15(3):e53)
doi:10.2196/jmir.2317

KEYWORDS

heart failure; self-care; patient education; cellular phone; text messaging; African Americans

Despite major scientific advances, heart failure continues to be a common and costly condition, and each year over 1 million people are admitted to an inpatient setting for acute decompensated heart failure (ADHF) [1,2]. National attention has turned toward reducing 30-day readmissions for ADHF, partially because financial penalties from the Centers for Medicare and Medicaid Services (CMS) for higher than expected rates of readmissions began in October 2012 [3,4]. This problem is particularly salient to hospitals serving larger proportions of African Americans because these patients have higher rates of readmissions than white patients [5-7]. Thus, there is an urgent need for low-cost solutions to reduce heart failure readmissions in African Americans.

Approximately 40% of ADHF hospitalizations are preventable because of varied factors, such as dietary indiscretion, medication nonadherence, and lack of timely medical consultation [8]. Patient nonadherence to heart failure drugs ranges from 30% to 60% and nonadherence to lifestyle recommendations ranges from 50% to 80%, with higher rates occurring in socioeconomically disadvantaged groups [9].

Mobile technology, in particular text messaging (also known as SMS: short message service), is emerging as a promising platform for chronic disease management in low-income populations [10,11], in part because it has high rates of utilization across socioeconomic groups [12,13]. Recent studies of mobile phone-based telemonitoring interventions in heart failure have demonstrated mixed success in reducing heart failure readmissions [14,15]. However, these interventions were not designed or evaluated in African American patients and may not be as effective in these populations. For one, these interventions typically required Internet- or Bluetooth-enabled phones, which may not always be available in these communities. Second, these interventions largely focused on telemonitoring rather than self-management support. The results of a recent large multicenter clinical trial found that self-management education was effective only in low-income patients (<$30,000 family income) [16], suggesting that a one-size-fits-all approach to improving heart failure outcomes does not work, and that self-management education is particularly effective in vulnerable health populations.

In this study, we pilot-tested a text message?based self-management intervention in an urban, largely African American population for 30 days following hospitalization for ADHF. Our study aims were to assess the feasibility and acceptability of the intervention and to test the hypothesis that the intervention was associated with improvements in self-management.

Patient Recruitment

After study approval was obtained from the Institutional Review Board, patients were recruited from the University of Chicago Medical Center (UCMC) inpatient cardiology service. Patients were recruited until target enrollment was achieved from November 2011 to January 2012 for a 4-week study. Informed consent was obtained prior to recruitment. Eligible patients included adult patients over the age of 18 years who were diagnosed with ADHF either with decreased or preserved systolic function as determined by the admitting physicians. Because the intent of the study was to provide self-management support, individuals who were not their own primary caregiver, were being discharged to a rehab facility, or who had poor mental status (Mini-Mental score<17) were excluded [17]. In addition, patients who did not have access to a personal mobile phone were not eligible for enrollment.

Consent was obtained from the attending physicians for contacting their patients for enrollment. Discharge planners were encouraged to notify the study team of any new admissions for ADHF. Study participants received $30 for study participation and to offset the costs of text messages. They were also provided with a scale to measure their weight.

Study Design

The pilot was designed as a single-arm prospective study. The primary endpoint was change in the Self-Care of Heart Failure Index (SCHFI), a well-described measure of self-management in heart failure [18], which was administered at enrollment and at the end of the 30-day intervention. In addition, a mobile phone usage survey was administered on enrollment [19], and demographic and clinical data were obtained through chart review. At the completion of the intervention, a telephone-based patient experience survey, including Likert-scale and open-ended questions, was administered [19].

Study Intervention

A text message communication platform developed for health researchers, SMS-Care (mHealth Solutions LLC, New York, NY, USA), was used for this study. Participants were enrolled in SMS-Care prior to discharge from the hospital and began receiving text messages on their personal cell phones the day after discharge. Text messages were composed to reflect literature published for patient education by the American Heart Association [20]. In addition, language similar to that used by the UCMC inpatient heart failure education team was incorporated into the texts. For a 30-day period, each participant received automated messages in the following domains:

1. Medication adherence: a daily reminder message (eg, ?Time to take your heart failure medications?) and a biweekly adherence question (eg, ?Did you take all your heart failure medications today??)

2. Dietary compliance: educational messages (eg, ?Remember to avoid salt. Items high in salt include canned soups, deli meats, and fried foods.?)

3. Appointment adherence: a reminder 48 hours before and the day of their cardiology or primary care follow-up appointments (eg, ?Please remember to go to your appointment with Dr. Smith today. Take all your medicines with you.?)

4. Heart failure signs and symptom recognition: warning signs of heart failure (eg, ?Know the signs of fluid buildup: your weight going up, swelling of your legs, and having trouble breathing.?)

5. Management if experiencing symptoms (?Have you noticed that your legs are swollen or are you having trouble fitting into your shoes? If yes, call your physician.?)

6. Health care navigation: knowing how to get in touch with cardiologist, obtaining medications after discharge (?If you have not done so already, make sure you have all the medicines that you were discharged on.?), and dealing with complications of paying for medications (?If you?re having trouble paying for your medicines, please make sure your doctor knows about this.?)

Each participant?s text message programming was personalized to reflect his/her medication regimen and follow-up appointments. Participants were provided a tutorial on receiving, reading, and sending text messages on enrollment. At the time of enrollment, each patient was sent a test message and replied to it, ensuring basic competency with the use of text messages. Participants were regularly reminded that the system was automated and was not an emergency response system.

Data Analysis

Per the most recent scoring procedure [18], raw scores from the SCHFI were tabulated into standardized 100-point scales: maintenance, management, and confidence. Preintervention and postintervention scores for each scale were compared using paired t tests. Individual items were compared using Wilcoxon rank sum tests. Stata version 11 was used for the analysis (StataCorp LP, College Station, TX, USA).

Study Recruitment and Sample Characteristics

Of 61 patients initially identified for ADHF, 51 were successfully approached for enrollment prior to discharge and 27 agreed to participate. Twelve of the patients approached did not own a personal cell phone. An additional 6 patients did not meet inclusion criteria because they failed their Mini-Mental exam (n=3), needed a health care proxy (n=2), or were hard of hearing (n=1). Only 3 patients approached for the study who met all inclusion criteria refused to participate. Of the 27 patients who met inclusion criteria, 15 were successfully enrolled. The remainder were unable to be enrolled due to logistical barriers (eg, off the floor, discharged early). Eight of 15 enrollees completed the text messaging portion of the study. Of the remaining 7 participants, 2 died, 1 was admitted to a subacute facility, and 4 had technology issues, including their cell phone being disconnected. A total of 6 participants completed the entire study including preintervention and postintervention surveys.

All but 1 participant in the study was African American (Table 1). The average age of participants was 50 years (range 23-69) and 40% (6/15) were female. The majority had Medicaid as primary or secondary insurance with Medicare or were uninsured. Approximately half of participants (47%, 7/15) had systolic heart failure. The mean ejection fraction for those with systolic dysfunction was 22%, and two-thirds (67%, 10/15) of all participants had at least 1 prior hospitalization in the past year. Most participants were on evidence-based heart failure therapies on admission including angiotensin-converting enzyme (ACE) inhibitors (53%, 8/15) and beta-blockers (86%, 13/15).

Cellular Phone Use

Most participants (93%, 14/15) carried their cell phone with them always or almost always (Table 2). All participants reported being somewhat or very comfortable with text messaging, although actual usage varied widely from 0 to 60 text messages per day. All but 1 participant had an unlimited text messaging plan, and only one-third (33%, 5/15) of participants in our sample had a smartphone capable of accessing the Internet and running applications (apps).

Source: http://www.jmir.org/2013/3/e53/

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