Using Social Media to Decrease Healthcare Utilization for Pediatric Asthma: a Pilot Randomized Control Trial
Phase: NA
Conditions: Asthma in Children
Sponsor: The University of Texas Health Science Center, Houston

IRB NUMBER: HSC-MS-21-0426 
IRB APPROVAL DATE: 07/28/2021 
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Using Social Media to Decrease Healthcare Utilization for Pediatric Asthma: a Pilot 
Randomized Control Trial 
 
NCT05013788 
 
Version Date: 07/28/2021 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

IRB NUMBER: HSC-MS-21-0426 
IRB APPROVAL DATE: 07/28/2021 
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Protocol Title: 
Using Social Media to Decrease Healthcare Utilization for Pediatric Asthma: a 
Pilot Randomized Control Trial 
Principal Investigator: 
Raymond Parlar-Chun, MD 
 
Co-Investigators: 
Ricardo Mosquera, MD, MS; Elenir Avritscher, MD, PhD, MBA/MHA; Cynthia 
Bell, PhD, MS; Keely Smith, MD; Angela Stotts, PhD 
Population: 
200 Children 3-17 years old hospitalized at Children’s Memorial Hermann for 
asthma 
Number of Sites: 
Single site Children’s Memorial Hermann 
 
Study Duration: 
Two years 
 
Subject Duration: 
One year 
 
 
Title: 
 Using Social Media to Decrease Unplanned Health Care Utilization for Pediatric Asthma: A Pilot 
Randomized Control Trial 
 
Abstract: 
 
Background: Pediatric asthma is a leading reason for healthcare utilization. Successful strategies for 
decreasing utilization have focused on increasing asthma education. However, traditional teaching 
methods are often fragmented and time-limited sessions on the day of discharge or office visits. Social 
media may provide a forum for more consistent and sustained education. Design: We propose a pilot 
randomized control trial of social media enhanced education (SME) versus usual asthma education to 
decrease treatment days within one year of enrollment. We will randomize 200 patients to 1) usual 
asthma education supplemented with SME: education provided throughout the year with at least once- 
a-week posts on Facebook, Twitter, Instagram, and Snapchat. 2) Usual asthma education: education 
provided in the clinic, emergency room, and hospital without modification. Hypothesis: We hypothesize 
that SME will reduce treatment days in a medical setting, missed school days, and health system costs. 
We believe that treatment effect will be stronger in patients with higher social media engagement, and 
also in those that both patient and caregivers join the intervention compared to either only the patient 
or the caregiver. Analysis: Bayesian analyses will be used to assess the probability of benefit and cost 
reduction with the intervention. We aim to show that social media can be used as a resource 
inexpensive modality to provide frequent and consistent asthma education to patients and their 
families, ultimately leading to decreased healthcare utilization. 
 
Background: 
 
Asthma is the most common chronic condition among children, a leading reason for pediatric 
hospitalization in the United States, and a leading cause of potentially preventable pediatric 
admissions.1 Hospital readmissions and emergency room utilization is common among children with 
asthma, and is responsible for a large economic burden on the healthcare system with $1.5 billion in 
hospital charges annually in the US2 and approximately $6 billion in estimated direct healthcare costs.3 

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Many strategies for decreasing asthma-related emergency department (ED) visits and hospital 
admissions have been investigated.4 The most successful interventions have involved increasing asthma 
education and teaching of self-management techniques to patients and their families.5 Traditional 
teaching is often limited by fragmented or rushed sessions on the day of discharge from the hospital or 
ED, or during time-limited follow up visits at the clinic. Other strategies such as comprehensive home 
visits, specialized asthma clinics, or community-based initiatives, although effective, are costly and 
resource intensive.6-8 
 
Given the limited time for patient-provider interaction, there’s a need to develop more efficient 
ways for healthcare providers to interact with patients and parents outside medical settings. Social 
media is a forum that could provide more frequent contact with patients and families, and allow for 
continuing education. It is estimated that more than 70% of the U.S population uses some form of social 
media.9 For teenagers, this usage jumps to over 90%. About 95% of teenagers have access to a smart 
phone and 45% of teenagers report being online on a near constant basis.10 Reaching this age group may 
be of particular importance, as it has been shown that adolescents have decreased compliance, 
increased improper usage with asthma treatments, and comprise of a large proportion of hospital 
readmissions and emergency room utilization.11-13 
 
Social media is a promising tool to provide education. Previous studies have used social media in 
a wide range of topics to provide education to both patients and clinicians. Positive effects have been 
seen in adults in promotion of breastfeeding, diabetes management, dementia management, and 
reproductive health education in adolescents14-17. Studies have also supported the use of social media as 
improving learning, engagement, and motivation in learners.18 
 
We propose to conduct a Bayesian pilot randomized trial to assess the overall probability and 
magnitude of benefit of supplementing usual asthma education with a social media intervention as a 
resource inexpensive modality to provide consistent asthma education to patients and their families in 
reducing the total days of care in a medical setting (primary outcome), other adverse outcomes, and 
health system costs. 
 
We plan on utilizing four of the most common social media platforms to deliver asthma 
education. 
 
1. Facebook 
 
Facebook is the world’s largest social media platform and has over 196 million daily active users in 
the United States and Canada as of the third quarter of 2020.19 In terms of age distribution, 51% of 
those 13-17 years, and 70-80% of adults use the platform.20 Users can post text, polls, photos, and 
videos that can be shared directly to “friends” or within a group. Facebook has been used in 
previous studies as a media for education, and has been used successfully in trials as a tool in 
providing continuous dementia education, promotion of exclusive breastfeeding, and diabetes self- 
management. 14-16 
2. Twitter 
 
Twitter is a social media platform that has over 68.7 million users in the United States.21 In terms of 
age distribution, 32% of teenagers, and 22% of adults use the platform.9,20 Users can “tweet” a 

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message of 280 characters, link photos/videos, and conduct polls. Studies have supported the use of 
Twitter in improving learning, engagement, and motivation.18 
3. Instagram 
 
Instagram is primarily a photo based social media platform and has over 140 million users in the 
United States.22 In terms of age distribution, 72% of teenagers, and 37% of adults use the platform. 
Users post photos or videos that are shared to their followers who can then “like” or comment on 
the posts. 
4. Snapchat 
Snapchat is a mobile app for Android and iOS devices that is primarily a photo based social media 
platform. It has over 80 million users in the United States. In terms of age distribution, 69% of 
teenagers, and 24% of adults use the platform. Among teenagers, it is the social media platform that 
they use most often.9,10 While most “snaps” are made available to the receiver for only a short time 
before it becomes inaccessible, Snapchat has a “snapcode” feature that functions similarly to QR 
reader. This can be used to open an internet link through the Snapchat application. A previous study 
has used this feature to promote reproductive health education in hospitalized adolescents.17 
 
Social media is now a part of daily life for the majority of Americans and particularly for 
adolescents. Given that social media is already a forum utilized by our patients and families, using it 
seems like a promising resource inexpensive modality to provide consistent asthma education. 
 
Specific Aims: 
 
1. To randomize 200 eligible children with asthma to social media enhanced education or to usual care 
to evaluate whether SME will: 
a. Reduce total number of treatment days defined as summation of days of subsequent hospital 
admission, emergency room visits, and clinic visits 
b. Reduce missed school days 
c. Reduce total costs from a health system perspective 
d. Have increased effect with increased social media engagement 
e. Have increased effect in participants with both caregiver and patient (combined) with social 
media accounts, compared to participants where only the patient or only the caregiver uses 
social media (single) 
f. 
Have increased patient satisfaction in the asthma education received 
2. To obtain the experience and data needed to refine SME to be able to expand this platform for 
other chronic medical conditions with high healthcare utilization including pediatric diabetes, 
epilepsy, and sickle cell disease 
 
Hypotheses: Social media enhanced education will result in 
 
1. Reduction in treatment days in a medical setting from enrollment to one year from enrollment 
(primary hypothesis) 
2. Reduction in missed school days 
3. Reduction in total health system costs 
4. Increased treatment effect in those patients with high social media engagement compared to 
low social media engagement 
5. Increased treatment effect in those with combined (patient + caregiver) social media accounts 
compared to single participants 
6. Increase in patient satisfaction of amount and frequency of asthma education. 

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Study Design and Methods: 
 
 
 
Population: We will recruit children age 3-17 years old hospitalized to Children’s Memorial Hermann admitted 
for asthma exacerbation. To be eligible, the patient and/or primary caregiver must have internet access 
on cellular phones or at home and use a social media account (Facebook, Twitter, Instagram, and/or 
Snapchat). Exclusion criteria include children with other chronic conditions besides asthma that may 
necessitate frequent health care utilization. i.e. children with complex chronic conditions, sickle cell, 
seizures, diabetes. Children less than 3 years are excluded as a formal diagnosis of asthma prior to this 
age is difficult, and we aim to homogenize the population and exclude similar diagnoses such as 
bronchiolitis or wheezing of infancy. 
 
Randomization, Consent, Allocation, Blinding: The PI (RPC) will be primarily responsible for enrollment and 
randomization. We will submit our study to the UTHealth Institutional Review Board as a quality 
improvement (QI) trial to verify the benefits of an intervention to increase access to asthma education 
beyond what would otherwise be provided in usual care. As allowed under federal regulations for QI 
studies judged unlikely to increase patient risk,23-25 we will request waiver of consent from the IRB, but 
we plan to still seek verbal permission to be able to contact patients monthly to assess their healthcare 
utilization. 
 
Block randomization with variable block sizes and stratification by age will occur. Stratification 
for age will occur, (3-11 years or 12-17 years) to allow for equal allocation of teenagers to each arm. 
Allocation ratio of 1:1 will be used. Patients will be randomized during their hospitalization. While 
patients and caregivers cannot be blinded, the statistician and healthcare economist will be. 
 
Interventions: 

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Usual Asthma Education: (which will not be modified by the study protocol) For patients who are admitted to 
Children’s Memorial Hermann for asthma exacerbation, asthma education is provided to patients and 
families on the day of discharge by the nurse and respiratory therapist. Respiratory therapists spend 
approximately 20-30 minutes educating on the following topics: Triggers, Signs & Symptoms, Medication 
Use, Medication Delivery, Peak Flow, Zones and how to respond to each, and Cleaning equipment. 
Nursing staff are responsible for printing out education sheets to give to patients and showing an 
education video that is ~20 minutes long. An asthma action plan (paperwork with a plan of action ie. 
how many puffs of albuterol to take, when to come to the emergency room, etc.) are given to families 
on discharge. Patients that are discharged from the emergency room are given the same educational 
materials by the nurses and/or respiratory therapists except for the asthma video. Patients receive a 
variable amount of asthma education when going to usual clinic visits. The education provided is 
dependent on the provider, and usually limited in length to the time of the visit (~10-20 minutes). 
 
Social Media Enhanced Education: Along with usual asthma education received in the hospital, ED, or office 
visits, patients and families randomized to the SME arm will receive asthma education via various social 
media platforms – Facebook, Twitter, Instagram, and/or Snapchat. Topics of education will include those 
typically covered in usual asthma education. These include background on asthma and pathophysiology, 
asthma severity classification, asthma triggers, different medications and indications for when to take 
them, how to use an inhaler technique, and symptom monitoring. Online resources from the American 
Lung Association and the National Asthma Education and Prevention Program will also be posted. Social 
media educational posts will be based off the framework of the Health Belief Model. This model for 
behavior change consists of six components: 1) Perceived susceptibility, 2) Perceived severity, 3) 
Perceived benefits, 4) Perceived barriers, 5) Cue to action, and 6) Self-efficacy. The research team 
consists of two pulmonary specialists (RM, KS) and pediatric hospitalists (RPC, KS). This medical team will 
craft pre-planned educational posts and the PI (RPC) will disseminate the posts at a minimum frequency 
of one post/platform per week. Other unplanned posts (retweets of asthma organizations, interactive 
polls, reminders of medication compliance etc.) will be posted at the discretion of the PI. 
 
Facebook 
 
For the participants who use Facebook, the research team will utilize multiple features of the platform 
to engage users. 
 
1. The team will “friend” them. This will allow participants to be provided information on their “news 
feed” as well as have access to “stories” – a photo or text post displayed separate to their “news 
feed.” 
2. Participants will be able to directly message or post questions or comments on the group page. This 
will provide an informal avenue of communication with the team as well as other members of the 
group. Previous studies have shown that this “peer group” aspect of social media to be an effective 
form of support. 
 
Twitter 
 
The research team will engage participants of Twitter in several ways. 

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1. The research team will post “tweets” of asthma education, uploads of photos and videos, and 
conduct of polls. 
2. Relevant twitter posts that provide education or important information from various asthma 
organizations will be retweeted ie. @CDCasthma, @AllergyAsthmaHQ, @NAECB_Official, 
@accpchest. 
3. Participants will have an informal avenue of communication to the team by tweeting questions or 
comments to the team. 
 
Instagram 
 
The research team will post photos and short videos to be shared with participants. Participants can 
comment on the posts to discuss or ask questions to the team. 
 
Snapchat 
 
The research team will post pictures and videos similar to the Instagram platform. The team will also 
create snapcodes that link participants to our cloud based asthma education website run via google 
drive. This will allow for text based education along with the typical photo based content of this 
platform. 
 
Outcomes: 
 
Primary Outcome: Total number of treatment days in a medical setting (hospital, ED, clinic) within one 
year of enrollment. Treatment days are defined as the summation of days in the hospital, ED, or in the 
clinic. We chose one year because of the chronicity of asthma, as well as its seasonal variation. 
 
Secondary Outcomes: Total number of hospitalizations, total number of readmissions, total number of 
emergency room visits, and the total number of clinic visits, patient satisfaction and understanding of 
asthma education, number of missed days of school, and total estimated health system costs, hospital 
costs, and clinic costs. 
 
Healthcare utilization will be primarily assessed by parental report. The PI will contact families 
every month and ask if their child had been admitted, visited the emergency room, had a clinic 
appointment for asthma, or missed any days of school within that month. We will also verify utilization 
of any of the 14 Memorial Hermann hospitals (MHHS) and the UT Health clinics from their respective 
electronic medical records and claims data. While we are aware of the risk of recall bias, we believe a 
contact every month is frequent enough to minimize the bias. We will also obtain multiple ways of 
contact (phone call, text, email, social media) in order to reduce loss to follow up. 
 
Level of engagement will be tabulated by the following: Facebook engagement will be tracked 
through “likes,” comments, unfriending, completion of learning units, completion of polls. Twitter 
engagement will be tracked through “retweets,” comments, completion of polls, and unfollowings. 
Instagram engagement will be tracked by “likes,” comments, and unfollowings. Snapchat engagement 
will be tracked by number of snapcode links viewed, and any unfollowings. 

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Hospital and clinic costs will be assessed from the health system perspective. For each ED visit 
and hospitalization in the MHHS, total hospital-specific costs will be obtained from the cost-accounting 
system for these hospitals. Costs for physician services provided at CMHH will be estimated using 
UTHealth claims data and Relative Value Units (RVUs) from the Medicare Fee Schedule. The costs at 
other hospitals outside MHHS will be estimated based on the mean costs of these encounters at MHHS. 
Costs for clinic visits at UT Health will be estimated using UTHealth claims data and using the standard 
RVU-based method. The costs for office visits occurring outside our center will be estimated based on 
the mean costs observed at UTHealth. For the social media intervention group, we will also add the 
costs of the personnel time spent curating and managing the educational material to be used in the 
social media platforms. The total time spent with the social media intervention will be prospectively 
collected by the PI (who will be primarily responsible for managing the social media intervention and will 
also include time from the pulmonologist [RM] and hospitalist [KS] whenever their input is required) and 
will then be multiplied by the unit time costs based on the personnel salary, fringes, and overhead costs. 
All costs will be inflated to the year of analysis based on the Consumer Price Index for medical services. 
 
 
Data Analysis Plan: 
 
Effect size, recruitment, power & statistical analysis 
 
Based on retrospective data of patients hospitalized at CMHH as well as estimated national 
data,27,28 we estimate a 25% hospital readmission rate and 35% emergency visit rate within one year of 
discharge for those receiving usual asthma education. We also assume a 35% unplanned clinic visit rate 
within one year of discharge. Each admission accounts for 2.4 treatment days, and each clinic and ER 
visit accounts for 1 treatment day. In a population of 100 patients, we then expect the total number of 
treatment days to be 114 days or 1.14 days per child-year. With an expected 25% effect size (based on 
the 20%-30% effect size reported in the Cochrane reviews on the impact of asthma education on 
healthcare utilization among pediatric patients,4 recruitment of 200 patients will give 0.80 power to 
show reduction in total number of unplanned treatment days with probability of benefit >60%. 
 
Power analysis assumed data arise from negative binomial distribution with standard deviation 
1.5 times mean total treatment days. In 1000 simulations, relative risks were estimated from negative 
binomial model with prior relative risks centered at 0 with credible interval 0.3-3.0 and posterior 
probabilities were derived from normal approximation of model coefficients. 
 
We believe this to be a conservative estimate since we assume that each patient with 
readmission, clinic visit, and ER visit would only have done so once within the year. Previous studies 
suggest that there is a population of frequent healthcare utilizers, and that one visit often is the 
precursor for multiple subsequent visits in this population.29-31 We also believe the 25% effect size is 
reasonable, as systematic reviews and previous studies have shown that asthma education can increase 
compliance with medications by at least 20%32, decrease hospital admissions by 20%, decrease ER 
utilization by 25%, and decrease clinic visits by more than 30%.4 We also believe the sample size is 
feasible. CMHH alone admits ~250 – 300 patients for asthma each year. 

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We propose the use of Bayesian analysis to provide direct estimates of the probability of benefit 
(reduction in treatment days and health system cost reduction) as well as the magnitude of benefit or 
harm. In this pilot study, some treatment effects that would be considered important for patients, 
families, and clinicians may not be statistically significant by traditional frequentist analysis. While we 
have planned feasible patient recruitment in this pilot study to demonstrate a high probability of benefit 
with moderate effect size, we have avoided arbitrary probability thresholds (p<0.05) used in frequentist 
analysis to define trial success. Moreover, given the low-risk, low-cost nature of this intervention, 
substantial cost reduction could be achieved with small decreases in health care utilization. As the first 
pilot study testing efficacy of SME in the pediatric asthma population, our planned Bayesian analysis will 
allow study conclusions to depend on the probability of benefit based on actual observed effect size 
balanced with potential harms/costs from the intervention and will inform future implementation and 
expansion of the intervention to additional patient populations. 
 
All statistical and economic analyses will be conducted under the intent-to-treat analyses 
principle using generalized linear models with appropriate link function based on data distribution (ie, 
negative binomial or Poisson with log link). All Bayesian models will use neutral, vaguely informative 
prior such as those with relative risk centered at 1 with credible interval range from 0.3-3.0 
encompassing the largest likely effect size for major outcomes in RCTs. Cost differences between the 
two arms will be assessed using generalized linear models with log-link and gamma distribution. To 
account for patients who may not be hospitalized or incur hospital-related costs during the study period, 
zero-inflated models will be considered. All models will be adjusted for stratifying variables (asthma 
control, recruitment site, and age) and account for patient clustering as necessary. Optimal model fit for 
each outcome will be determined from model diagnostics and comparison of likelihood-based statistics. 
All analyses will be conducted in R. 
 
Data Storage and Handling: We will use Research Electronic Data Capture (REDCap) to randomize patients and 
collect predefined study data needed to address each of our hypotheses. REDCap is a secure, web- 
based application designed to support data capture for research studies, providing: 1) an intuitive 
interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 
3) automated export procedures for seamless data downloads to common statistical packages; and 4) 
procedures for importing data from external sources 
 
Study Procedures: Participants will be approached for enrolment during their index hospitalization. Consent 
will be obtained. Study duration will last one year from enrolment. Participants will be contacted once a 
month (12 contacts total) to assess healthcare utilization within that past month. The PI on enrollment 
will ask for several different methods of contact and ask which the participants prefer ie. calling - what 
times of day/day of week, emailing, texting, directly messaging on social media etc. The PI will contact 
each participant by their mode of preference once a month. During the follow up contacts, participants 
will also be asked a short questionnaire (approximately 10 minutes). 
 
Information to be gathered will be missed school days, total number of hospitalizations, emergency 
room visits, and clinic visits. We will also gather costs of these visits. Engagement data will be obtained 
from the various social media platforms. 

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Interpretation and Potential Importance of Findings: 
 
If we are able to demonstrate successful effects of social media enhanced asthma education in 
decreasing unplanned healthcare utilization, we believe the impact to be substantial. First, there is a 
large disease burden. Asthma is the most common chronic disease in childhood that affects 5.5 million 
children in the United States. Second, the intervention is easily implementable since social media use is 
so ubiquitous. Third, the outcome of a cost dominant intervention has implications for tremendous 
savings on costs to the healthcare system. Compounding this, we think the results of the study would be 
easily generalizable – 1. To the adult population, encompassing another 19.2 million patients with 
asthma in the US (339 million worldwide), and 2. To other chronic pediatric medical conditions that have 
frequent unplanned healthcare utilization such as pediatric diabetes, sickle cell, and epilepsy. 
 
Plans for Dissemination of Results: 
 
Once the project is completed, we plan on dissemination of results through submissions to national 
conferences (Pediatric Academic Societies, American Academy Pediatrics, and Pediatric Hospital 
Medicine) as well as manuscript publication in a peer-reviewed journal (JAMA Pediatrics, Pediatrics, 
Hospital Pediatrics). 
 
 
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IRB NUMBER: HSC-MS-21-0426 
IRB APPROVAL DATE: 07/28/2021 
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ATTACHMENTS 
 
1. Script of follow up visits