Tuesday, May 18, 2010

The Evidence for Texting As "mHealth": Another Tool For Population-Based Care, Medical Homes and Disease Management

Did you know that in some countries, the number of cell phones in circulation exceeds the number of persons? That in the U.S., 58% of persons have sent text messages, 89% of teens use text messaging regularly and that 30% of teens do so daily? That the widespread of texting has already prompted a number of highly innovative researchers to investigate the role of texting in improving health? That there is a really really cool term that you can use to bedazzle your colleagues, impress your boss, stymie your competitors and bore your spouse called "mHealth?"

The Disease Management Care Blog didn't know any of this either until it stumbled across this highly informative article by Heather Cole-Lewis and Trace Kershaw in the medical science journal Epidemiologic Reviews titled "Text Messaging as a Tool for Behavior Change in Disease Prevention and Management."

The DMCB managed to get its hands on the full manuscript and found a well-written and up-to-date scientific review of the literature on "mHealth" (short for "Mobile Health"). To be included, studies had to be randomized or quasi-experimental and focus on text messaging as an independent variable. After winnowing some publications over quality issues and others that were duplicative, the authors settled on a total of 5 studies on disease prevention (vitamin pill adherence, physical activity, smoking cessation and two on weight loss) and seven on disease management (six on diabetes mellitus and one on asthma). The oldest was from 2005, only two were from the U.S., most were prospective and all assessed a variety of behavioral and clinical outcomes in age groups ranging from 15 to 45 years.

Frequency of text messaging varied from once a week to five times a day. One study used automated texting, while the reminder were written by health professionals. Much of the texting was also two-way and highly tailored, using nicknames, commonly including personal goals, culture, gender, age and health status along with informal language. Three studies allowed the participants to dictate the frequency of their messaging. Supplementary email, internet links and other self-management tools were not unusual. Three gave the patients cell phones.

Results you ask? Three studies (on vitamin pill adherence, physical activity and peak flow in asthma) showed no statistically significant effects but were also "underpowered" to detect small but significant differences. Of the remaining nine studies, eight showed a beneficial effect compared to controls, including short term tobacco cessation, weight loss and, among persons with diabetes, increased blood glucose monitoring/reporting as well as lower A1c levels; one of the diabetes studies failed to show a difference in the A1c. While it was difficult to pool the results, the outcomes benefited adolescents and adults, minorities and non-minorities and all nationalities.

The authors correctly point out, given the widespread use of cell phones across the globe, how surprising it is that few studies have been performed in developing countries. In addition, other than a single inconclusive vitamin study, there don't appear to be any good studies on medication adherence. Last but not least, there are a variety of adult learning theory constructs that were largely unmentioned and probably neglected in these studies which, if used, could have probably improved the impact of texting.

According to the authors, texting has the advantage of being inexpensive, personalized, efficient, widely accessible, consumerist and 'asynchronous.' The bad news is that it can medically marginalize persons without access to cell phones or who are unable to read. They point out that more studies are needed and have some important suggestions on how this can be done, including adapting texting to behavior change theory, considering the ethics mHealth and including cost-benefit analyses.

What does the DMCB think?

It suspects some innovative U.S. care management companies are already using texting and, given the paucity of research findings, they have an opportunity if not responsibility to deploy transparent, efficient and cost-effective research methodologies to study their impact. They owe it to themselves, their customers and the medical community to advance the science of mHealth.

For those U.S. care management companies that aren't using texting in their outreach and engagement strategies, it would appear that there are a sufficient number studies to justify its use. How well it compares to other traditional communication interventions remains to be seen, but the more channels the better. The DMCB suspects this will get complicated, especially as we discover that different individuals have different communication preferences.

By the way, the same is true for Patient Centered Medical Homes.

In the meantime, our government's unwieldy approach to meaningful use, comparative effectiveness research, disseminating advances in care as well as relying on vanilla forms of consumer support and persistently failing to accomodate older forms of telemedicine suggests texting could emerge in commercial care settings long before the ink is dry on health reform. Despite the best of intentions, D.C.'s inertia could lead to a digital texting divide.

Last but not least, updates on unique news like this is a good reason to regularly check in with the DMCB. Stay tuned, because it has a manuscript on social media and population-based care management that will be published shortly.


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