UCLA Health Patient Health Maintenance Text Reminder

Study Overview
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Brief Summary
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This is a prospective randomized clinical trial evaluating how behaviorally-informed outreach text message reminders impact patient engagement with primary care. This prospective randomized control trial is being implemented in conjunction with UCLA Health's larger quality improvement initiative (the My Action Plan Quality Improvement Initiative) in order to improve primary care preventive measure completion rates.

Detailed Description
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UCLA Health will launch an initiative called My Action Plan which is an outreach effort targeting the primary care patients at UCLA who have an outstanding, clinically indicated primary care preventative care gap (e.g., overdue colorectal cancer screening, outstanding diabetes tests) and aims at encouraging patients to complete their overdue health maintenance measures. At the beginning of each month, identified UCLA Health primary care patients will be enrolled in a trial the investigators have pre-registered under the title UCLA Health Patient Health Maintenance Outreach Text Message and randomized to receive one of four text messages informing them that they have overdue health maintenance measures and urging them to take action to complete these measures. These text messages will contain a link to their MyChart patient portal account, specifically linking them to a My Action Plan electronic letter that will contain a personalized list of outstanding preventive care items and actionable steps to complete the items. In March and April 2023, if participants do not open their My Action Plan electronic letter within 7 days after the initial outreach, they will be enrolled in the trial described in the current pre-registration. This trial will evaluate the effect of sending a text reminder about health gaps as well as compare the effectiveness of different outreach text reminders. Patients will be randomly assigned in a 1:1:1:1 ratio to either the holdout control condition (without a reminder) or one of the three reminder arms (receiving one of three text reminders 2 weeks after the initial outreach message). Additionally, within each text-reminder arm, patients will be randomized to one of three time slots for getting the reminder. The investigators will examine patients' interaction with these reminders and how that ultimately translates to them completing their indicated health maintenance measures. The UCLA Department of Medicine (DOM) intends to roll out this QI initiative at the beginning of the 2023 calendar year and continue it for a span of at least 12 months. Each month, the initiative targets patients whose birthday falls into that month. This proposed trial will run for two months (March and April 2023). Analysis Plan: The investigators will utilize patient-level ordinary least squares (OLS) estimation, with statistical inferences based on model-robust standard errors. The primary model term will be indicator variables for arm assignment. The analysis will adjust for sex, age, race/ethnicity, indicators for screenings/tests that patients are due for, and whether patients have upcoming primary care appointments. Missing covariate values will be handled by including 'unknown' indicators, along with mean imputation for quantitative covariates. The investigators will use this dataset to address two separate research questions. Research question 1: The investigators will compare the average of Arms 2-4 with Arm 1 to test the average effect of sending a text reminder. If the average effect is significant, the investigators will explore if Arms 2, 3, and 4 separately differ from Arm 1. Research question 2: The investigators will compare Arm 3, Arm 4, with Arm 2 to test whether, compared to a simple (control) reminder, it is more effective to boost patients' intentions to close the health gap via an anecdote or to prompt patients to take actions quickly. Exploratory analyses will investigate heterogeneous treatment effects by patients' baseline motivation (i.e., the extent to which patients seem to have some intentions to get the screenings/tests) in two ways. First, the investigators will use each patient's history of screenings/tests to construct a proxy for their baseline motivation to obtain the due screenings/tests. Specifically, the investigator will calculate, among all the screenings/tests that are included in the My Action Plan Initiative and that a patient was due for in the past few years (exact time window TBD based on data availability), what percentage was completed by the patient (as far as UCLA Health could tell). A higher percentage indicates a higher baseline motivation to get the screenings/tests patients are due for during the study period. Second, the investigators will obtain demographics and medical information that UCLA Health is willing to provide (e.g., gender, age, race/ethnicity, history of cancer and other pre-existing conditions, family cancer history, past adherence to screenings/tests that are included in the My Action Plan Initiative, past receipt of influenza vaccination, frequency of doctor visits; time window of these variables is TBD depending on data availability). With such information, the investigators will train an algorithm to predict patients' baseline motivation level using patients in the holdout condition (Arm 1) as the ground truth. Specifically, the investigators will take the aforementioned information about patients in Arm 1 as input, and use whether they complete any of the screenings/visits recommended in the My Action Plan letter within 6 months as the outcome measure. Then the investigators will apply the algorithm to all patients to predict their baseline motivation level. For both approaches, the proxy for baseline motivation (Approach 1) and the predicted baseline motivation level (Approach 2) will be used to analyze the heterogeneous treatment effects of (1) Arms 3 and 4 (vs. Arm 2) and (2) the combination of Arms 2 and 4 vs. Arm 1. Additionally the investigators will investigate proxies for whether patients face structural barriers to get screenings/tests as moderators, including socioeconomic factors at the zipcode level, insurance type, proxies for accessibility to healthcare resources such as distance from UCLA Health clinics. The investigators will also explore how the effect of text reminders varies across the three times of the day when the reminders will be sent.

Official Title
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UCLA Health Patient Health Maintenance Text Reminder

Conditions
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Health Maintenance, Diabetes, Cancer

Intervention / Treatment
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* Behavioral: Reminder of preventive care measures
* Behavioral: Persuasion via anecdote
* Behavioral: Behavioral: Action prompt


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Empaneled to UCLA Health DOM Primary Care Has at least one overdue health maintenance measure that the My Action Plan initiative focuses on Has an active MyChart status Can accept SMS messages from UCLA Health Has not opened the My Action Plan electronic letter within 7 days of initial outreach Has a March or April Birthday Exclusion Criteria: Under the age of 18 Deceased patients Hospice patients Has opted out electronic communication (bulk messages, email, and/or text) For the final analysis, the investigators will further exclude patients who have scheduled appointments for all screenings/tests or completed all screenings/tests prior to the date when they are supposed to receive the reminder from this trial

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Parallel-arm randomized control trial
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Holdout Condition: No reminder<br>Eligible, randomized participants will receive no text message reminder. | |
| Experimental: Control Reminder<br>Eligible, randomized participants will receive a generic text message reminding them to close their outstanding health gap. | Behavioral: Reminder of preventive care measures<br>* The investigators will send randomized participants an SMS reminder encouraging them to click the provided link and close their outstanding, overdue preventive care measures. The provided link will take them to their MyChart login page; after logging in, they would see their personalized My Action Plan Letter detailing their personalized, overdue preventive care measures.<br>|
| Experimental: Anecdote-based Reminder<br>Eligible, randomized participants will receive a text message reminding them to close their outstanding health gap. This message will contain an anecdote of a patient whose cancer was caught early through similar, recommended preventive screenings. | Behavioral: Reminder of preventive care measures<br>* The investigators will send randomized participants an SMS reminder encouraging them to click the provided link and close their outstanding, overdue preventive care measures. The provided link will take them to their MyChart login page; after logging in, they would see their personalized My Action Plan Letter detailing their personalized, overdue preventive care measures.<br>Behavioral: Persuasion via anecdote<br>* The message will contain an anecdote of a patient whose cancer was caught early through similar, recommended preventive screenings.<br>|
| Experimental: Call-to-action Reminder<br>Eligible, randomized participants will receive a text message reminding them to close their outstanding health gap. This message will prompt people to take care of the health gap right away before it slips their mind. | Behavioral: Reminder of preventive care measures<br>* The investigators will send randomized participants an SMS reminder encouraging them to click the provided link and close their outstanding, overdue preventive care measures. The provided link will take them to their MyChart login page; after logging in, they would see their personalized My Action Plan Letter detailing their personalized, overdue preventive care measures.<br>Behavioral: Behavioral: Action prompt<br>* The message will prompt people to take care of the health gap right away before it slips their mind.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| MyChart letter opened | Percentage of participants across the different arms who open their personalized My Action Plan letter on MyChart | 1 week after getting the reminder | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Opening link within SMS Text message | Percentage of participants across the different reminder arms who click on the link in the reminder message | 1 week after getting the reminder | 
| Direct scheduling appointment rate | Rate of which eligible participants directly schedule an appointment for diabetic retinal exams, diabetes education, or breast cancer screening in order to complete these overdue screening/test(s). These screenings/tests have dedicated appointment resources that people can directly schedule for. | Time Frame: 2 weeks after getting the reminder | 
| Rate of taking action for one overdue screening/test | Rate of which participants schedule an appointment to complete their overdue screening/test or start the online tool for colorectal screening | Time Frame: 2 weeks after getting the reminder | 
| Completion rate of one screening/test | Rate of completion of at least one screening/test within the observation window. | Time Frame: 6 months after getting the initial outreach text message | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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primary care, digital outreach