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Texted Reminders Flop for Reducing Colonoscopy No-Shows

Automated text message reminders and instructions did not improve outpatient colonoscopy attendance and bowel preparation adherence versus usual care, according to results from a pragmatic randomized trial.

Among 753 randomized patients, achievement of the primary outcome of appointment attendance with good or excellent bowel preparation was similar in the intervention and control groups at 53.1% and 54.4%, respectively (P=0.73).

This finding held after patient stratification by time of enrollment (early or late). Similarly, no significant differences emerged in secondary outcomes, including appointment attendance rate, bowel preparation quality graded as poor or inadequate, fair or adequate, and good or excellent, and cancellation lead time in number of days.

“Future work could optimize the content and delivery of text message interventions or identify patient subgroups that may benefit from this approach,” a research team led by Nadim Mahmud, MD, MS, MPH, MSCE, of Perelman School of Medicine at the University of Pennsylvania in Philadelphia, wrote in JAMA Network Open.

The trial evolved from an earlier quality-improvement pilot study that, in contrast, found high user acceptance and significantly better attendance rates compared with baseline values.

The current study was conducted during routine practice in an endoscopy center at a single urban academic medical center, with the cohort consisting of adult patients scheduled for outpatient colonoscopy in the period January to September 2019.

Median age for participants was 56; just under half were men and 57% were Black. Most colonoscopies were performed for cancer screening or surveillance, with a substantial minority for investigating abnormal bowel habits.

Enrolled by telephone (early phase) or by automated text message (late phase), the 753 patients were randomized 1:1 to usual care — written instructions and a nurse telephone call — or to an intervention arm that combined usual care with an automated series of nine educational or reminder text messages in the week before scheduled colonoscopy.

In other study findings, no differences in primary outcome emerged between the intervention and control groups when stratified by time of enrollment:

Early phase: 57.3% of 67 patients versus 51.1% of 69 patients (P=0.33)

Late phase: 51.2% of 128 patients versus 56.2% of 141 patients (P=0.26)

Similarly, no significant differences were seen between arms in the following:

  • Appointment attendance rate, 65.9% versus 67.9% (P=0.57)
  • Excellent or good bowel preparation quality, 81.6% versus 82.7% (P=0.75)
  • Poor or inadequate bowel prep, 5.4% versus 6.3% (P=0.75)
  • Appointment reschedule rate, 11.4% versus 13.2% (P=0.46)
  • Median cancellation lead time, 4 days (interquartile range 1-7) for both groups (P=0.81).

For all secondary outcomes, when stratified by early- or late-phase enrollment, no significant difference between arms was observed. Similarly, adjustment for differences in sex and baseline opiate use in logistic regression models did not alter the results, and no significant interactions were identified.

In regular care, nurses or trained staff call patients before the procedure, but it is often difficult to reliably reach patients on the phone, and the high cost of personal interventions put them out of reach of many practices, Mahmud and colleagues noted.

One recent study found that predictors of no-shows for GI endoscopy included unpartnered or single patients, African-American race, and non-commercial insurance providers. Patients scheduled for surveillance colonoscopy had better adherence than those scheduled for initial screening.

Other interventions, such as videos or mobile applications, have been limited by poor user experience or limited engagement with patients, Mahmud’s group pointed out.

Yet despite their study’s negative results, they maintained optimism that text-based interventions could be helpful.

In an accompanying commentary, Carolyn M. Clancy, MD, of George Washington University School of Medicine in Washington, D.C., and Jason A. Dominitz, MD, MHS, of the University of Washington in Seattle, said that texting to improve attendance and bowel preparation needs further investigation. And while current study’s findings were negative, they highlight critical issues of content and targeting that may guide future research.

By comparing texting in previous studies in which this intervention was effective, clinicians might better understand the intervention’s key aspects and/or study population and work to improve effectiveness, the commentators, who were not involved in this research, suggested. And with demand for colonoscopies already high and expected to increase with the lowering of the recommended colorectal cancer screening age, interventions to reduce nonattendance are critically needed.

Text messaging is an efficient intervention assuming patients have the necessary devices. “However, to be effective, the message must be received by the patient and contain information that alters behavior to achieve the desired outcome,” the commentators wrote.

In that vein, Clancy and Dominitz questioned whether the study intervention’s particulars were suboptimal. They further noted that text messaging was delivered in addition to the usual care reminders already in place. If the objective was to reduce the need for dedicated staff to make reminder calls, the effects of text messages would need to be compared with outcomes in a group that did not receive these calls.

Mahmud and colleagues acknowledged several limitations to their analysis, including lack of detailed assessment of patients who received previous colonoscopy versus patients undergoing first-time colonoscopy, who might benefit more from a supplemental intervention than colonoscopy-experienced patients. In addition, the manner of enrollment changed halfway through the study, which might have confounded the results.

Disclosures

Mahmud reported funding from the National Institutes of Health and the American College of Gastroenterology. Coauthor Mehta was supported by the National Cancer Institute.

Coauthor Asch reported multiple financial ties to the private sector, including Berkshire Hathaway of VAL Health, Salzburg Global Seminars, GlaxoSmithKline, JFK Health System, Cosmetic Boot Camp, Meeting Designs, Capital Consulting, Healthcare Financial Management Association, and Deloitte, as well as to numerous academic and research funding bodies.

Clancy and Dominitz disclosed no competing interests with regard to their commentary.

Source: MedicalNewsToday.com