Effectiveness of a Novel Text-Messaging Bot in Patients Undergoing Total Joint Arthroplasty: A Prospective Randomized Controlled Trial
Phase: NA
Conditions: Osteoarthritis, Knee, Osteoarthritis, Hip
Sponsor: Rush University Medical Center

Cover Letter 
 
 
Title: Effectiveness of a Patient Centered Mobile Engagement Tool after Total 
Joint Arthroplasty 
 
Date Effective: January 19, 2017 

 
 
 
 
 
 
Investigators: Philip Louie MD, Kevin Campbell MD, Daniel Bohl MD, Brett Levine 
MD, Scott Sporer MD, Tad Gerlinger MD 
 
Contact Information: 1611 W. Harrison St., Suite 300, Chicago, IL 60612 (312)-432-
2883  
 
Title of Study: Effectiveness of a Patient Centered Mobile Engagement Tool after Total 
Joint Arthroplasty 
 
Sponsor: Department of Orthopedics 
 
Introduction 
Orthopedic surgeons work with a highly motivated group of patients that are particularly 
active in their recovery after surgery. As our ability to complete surgeries in an 
arthroscopic manner has increased, post-operative rehabilitation has become increasingly 
important. Unfortunately, rehabilitation can be extraordinary complex and difficult for 
patients to understand. In addition, as patient volume has increased, office visits are less 
frequent and are often separated by several weeks. During those times, patients have 
reported that they have poor access to their physician and are often confused about the 
best way to rehab even if they have close follow-up with a physical therapist. 
 
This problem is exacerbated when patient retain only a small amount of information at 
their office visits. We have seen patients present to their follow-up appointments without 
attempting any of their recommended home exercises. At the present time, orthopedic 
surgeons deliver important post-operative instructions at an inopportune time when 
patients are recovering from anesthesia. The caregiver accompanying the patient may or 
may not understand the patient’s diagnosis. This is especially true following same-day 
outpatient orthopedic surgery. When patients are discharged and need additional 
information about their postoperative care, they search online for information. This may 
cause them to follow instructions for the wrong condition (misunderstanding their 
diagnosis) or follow recommendations that are not verified by their individual provider. 
 
At the present time, our offices are using outdated communication methods in an age of 
new technology that include text messaging, smart-phone apps, and social media. 
Multiple surveys have reported that patients would actually prefer digital communication 
from their provider. Moreover, physicians have expressed that “professional burnout” is 
related to excessive paperwork and generalized office inefficiencies. The best available 
electronic communication is email, but this becomes overbearing for office staff and 
patients usually have the same predictable questions. Typically, we can predict what 
types of questions patients will have at their respective time point after surgery. 

 
There has been a recent surge in the development of electronic patient engagement 
platforms. These new technologies aim to provide patients with a new form of digital 
communication and optimize our delivery of healthcare information. These digital 
communication tools are designed to increase patient activation and promote positive 
patient behavior. There have been a small number of scientific studies that support their 
efficacy. The reported data suggests that health text messaging is a convenient way for 
patients to receive information, allows timely distribution of information, increases 
patient compliance, improves patient outcomes (medication adherence, decrease surgical 
infections with antiseptic showers), and can reach a large patient population, including 
those who are socioeconomically isolated. 
 
This has led us to develop our proposed study, which implements an automated 
unidirectional electronic patient engagement tool that sends patients diagnosis and 
treatment specific information at the appropriate time to maximize patient outcomes. The 
program relies on specific SMS text messages that are less than 160 characters; packaged 
with instructional videos that are less than 30 seconds which demonstrate key points and 
proper technique for home exercises. The utility of the program is that it anticipates the 
most common reasons for non-compliance or readmissions in the early (<12 weeks) 
postoperative period and sends SMS messages to guide patients through this difficult 
time and prevent additional communication to the office staff and physician. We expect 
that the results of this study help us understand the utility of text messaging patient 
instructions in the postoperative period. 
 
Study Rationale 
The effect of a digital patient engagement platform will be assessed as it pertains to the 
improvement in postoperative knee range of motion, office staff efficiency, and patient 
satisfaction following total joint arthroplasty (TJA) in the form of a total knee 
arthroplasty (TKA) or total hip arthroplasty (THA). 
 
Hypothesis 
The hypothesis is that following the implementation of an electronic digital patient 
engagement platform will improve the amount of time spent on rehabilitation activities 
daily, deep vein thrombosis (DVT) compliance, narcotic use, overall mood, save office 
staff time and resources, and improve patient satisfaction scores in a cohort of patients 
indicated for TKA or THA. 
 
Study Plan 
This study will be a large, prospective trial of patients undergoing TKA or THA.  All 
patients who sign the consent will be enrolled in the study.  Enrollment will continue for 
150 patients, 75 in each group, where a power analysis will be performed to determine 
the total number to show a clinically important difference. 
 
 
 

Enrollment Process 
Patients over 18 who are determined clinically and by knee/hip radiographs to have 
symptomatic total joint disease, and elect to have surgery will be invited to participate in 
this study. Informed consent will be obtained preoperatively in the office setting. Only 
patients recommended to undergo TKA or THA by the treating surgeon will be offered 
enrollment in the study. 
 
Eligibility 
 
Inclusion Criteria 
1. Patient scheduled to undergo a TKA or THA. 
2. Written informed consent is obtained 
Exclusion Criteria 
1. Patients without smartphone capabilities 
2. Revision surgery 
3. Any patient lacking decisional capability 
Study Procedures 
• 
Eligibility - Once a patient has met the pre-operative criteria, s/he will be offered 
the opportunity to participate in this study. 
• 
Patient Consent - The patient must be made fully aware of the protocol 
requirements and s/he must acknowledge his/her understanding and agreement by 
signing the informed consent and privacy statement. 
• 
Text Messaging – 1-84messages will be sent to the patient in the initial 6-week 
postoperative period between the hours of 9AM and 7PM. Some messages will be 
associated with Internet links to instructional videos (authorized by the treating 
physician) for home exercises. 
 
Timeline of Events 
 
1. All patients will have a preoperative knee/hip radiographs. 
2. Once informed consent is obtained, the patient will be provided a one-page 
“diary” with areas to record the amount of time spent on rehabilitation activities 
daily, overall mood, narcotic use, and DVT prophylaxis compliance. 
3. Patients will be randomized to either the control or experimental group. The 
control group will receive their post-operative instructions in the usual manner. 
The experimental group will receive their postoperative instruction in the usual 
manner but will also receive the digital text messages for the initial 6-week 
postoperative period. 
4. If the patient is randomized to the experimental group, we will obtain their 
preferred cell phone number and this number will be added into the postoperative 
texting program algorithm. 
5. The patient will then undergo surgical reconstruction in the usual manner. The 
text-messaging program will begin on postoperative day #0. 
6. Any phone call or email from patients in the control and experimental treatment 
groups will be recorded by the surgeon’s office staff for data processing at the 
completion of the study. 

7. The patients will present for the postoperative visits in the standard manner. At 
the 6-week post-operative visit, the patient will be prompted to return the 
completed one-page diary. 
8. All patients will complete their prescribed physical therapy as determined by the 
surgeon. The physical therapy protocols will be identical for the control and 
experiment study cohorts. 
9. At their 6-week postoperative visit, the experimental study cohort will be also be 
asked to fill out a 7 question survey to gather their feedback and satisfaction with 
the electronic postoperative text messaging program. There will also be a 
commentary section in the survey to allow them to provide any further 
recommendations or insight. 
 
Benefits of Participation 
There is no direct benefit to the patient for their participation in this study. The results 
will contribute to the improvement in postoperative care after total joint arthroplasty. The 
use of this type of electronic patient engagement protocol may improve their recovery 
and change the way we interact and deliver healthcare information to patients in the 
future. The study will help determine the extent to which patient enjoy receiving digital 
information in the postoperative period. 
 
Alternatives to Participation 
The alternative to participation in this study is not to participate. Patients who decline to 
participate will proceed with the recommended total joint arthroplasty, which is the 
current standard of care and will receive the customary or standard of care postoperative 
information as currently completed. They will return to the office for postoperative 
follow-up per the rehab protocol for the specific procedure performed. 
 
 
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