Text Messaging in Healthcare Utilization
Condition: Text Messaging
Study type: Interventional

Summary: 
      The overall goal is to assess the feasibility and effectiveness of using text messages as an
      educational tool in order to improve health care utilization among the parents and caregivers
      of newborns; in particular, the investigators seek to understand how educational text
      messages counteract the effects of low health literacy as it relates to non-urgent visits to
      the emergency department.
    

Detailed description: 
      Health care utilization is a issue germane to health care providers, insurers, and patients
      alike. Reducing non-urgent visits to the emergency department (ED) and primary care providers
      can improve both the quality and cost of care. There are barriers, however, to educating
      patients about more appropriate health care utilization. Low health literacy is one such
      barrier, particularly for caregivers of pediatric patients. Research reveals that up to half
      of caregivers seeking treatment at the ED have low levels of health literacy; levels that can
      make it more difficult to not only make sound decisions, but also provide effective follow-up
      care. Moreover, low levels of literacy perpetuate a cycle of seeking care for non-urgent
      conditions. Education initiatives designed to counteract the effects of low health literacy
      on health care utilization have been shown to reduce non-urgent ED visits by as much as 80%.
      These education interventions, while effective, are complex, costly, or time-intensive. For
      example, home visits by a nurse, parenting classes, and video tools are all shown to reduce
      non-urgent ED use, but each poses a unique problem for implementation in high volume, urban,
      pediatric primary care clinic. To date, no study has examined the effectiveness of text
      messaging as a possible avenue for educating caregivers about issues related to health care
      utilization. Text messaging has been shown to support behavioral change, and represents a
      fast and cost-effective alternative to more labor-intensive and expensive alternatives.

      Danis Pediatrics, the pediatric practice of Saint Louis University physicians within SSM
      Cardinal Glennon Children's Medical Center (CGCMC), serves as a medical home to primarily
      urban, low-income patients. In the first half of 2014 alone, there were 5259 visits to the ED
      by caregivers of patients < 13 months of age. Of those, 520 Danis Pediatrics patients
      accounted for 919 of those visits. In short, just under 1 in 5 visits to the CGCMC ED is a
      Danis patient, and Danis patients visit the ED approximately 2 times in the first year.
      Previous studies of patients at Danis Pediatrics suggest that this population has access to
      text messaging and is interested in receiving healthcare-related information from their
      pediatric provider.
    

Intervention name(s): Enhanced Standard of Care (ESoC) + Text; Enhanced Standard of Care (ESoC)
Intervention type(s): Behavioral; Behavioral
Intervention description(s): See above in arm/group description; See above in arm/group description
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Caregivers of newborns (0-10 weeks of age) whose child received primary care at an urban, academic primary care clinic were approached for participation. Inclusion required reliable cellular and text messaging service and the ability to speak English. At intake, caregivers completed a brief demographic survey and were given a researcher-administered health literacy test called the Newest Vital Sign (NVS).
Following the initial visit where consent, demographic information, and the NVS were obtained, participants were randomly assigned, by computer, to one of two groups: (1) caregiver receives only enhanced standard of care documents (ESoC), or (2) caregiver receives text messages in addition to enhanced standard of care documents (ESoC + Text). Both research team members and participants were blind to group assignment at the time of consent and enrollment. Clinic staff and providers were not aware of group assignment unless revealed by the participant.
Masking: Triple (Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Health Services Research
Keywords: Healthcare utilization; Health literacy