Ryan J. Shaw

Short message service (SMS) text messaging as an intervention medium for weight loss: A literature review

Nearly 68% of American adults are obese or overweight. Mobile devices such as mobile phones have emerged as a mode of intervention delivery to help people improve their health, particularly in relation to weight loss. This literature review examines the relationship between the use of short message service (SMS) text messaging as an intervention medium and weight loss. Results from this literature review (n = 14) suggest that SMS as an intervention tool for weight loss is still in its infancy. Initial results are promising but continued investigation is needed. We offer several recommendations for future research.

Mobile health messages help sustain recent weight loss.

BACKGROUND Using regulatory focus theory, an intervention of daily weight loss-sustaining messages was developed and tested for acceptability, feasibility, and efficacy on helping people sustain weight loss. METHODS Participants (n = 120) were randomized to a promotion, prevention, or an attention-control text message group after completion of a weight loss program. Participants completed baseline assessments, and reported their weight at 1 and 3 months postbaseline. RESULTS Participants found the message content and intervention acceptable and valuable. A minimum of one message per day delivered at approximately 8:00 am was deemed the optimal delivery time and frequency. The sustained weight loss rate at month 3 for the control, promotion, and prevention groups was 90%, 95%, and 100%, respectively. Medium-to-large effects were observed for the promotion and prevention groups at month 1 and for prevention at month 3 relative to controls. The mean weight loss for promotion and prevention was 15 pounds, compared with 10 in the controls at month 3. CONCLUSION A clinically significant decrease in mean weight, higher rate of sustained weight loss, and medium-to-large effects on sustained weight loss occurred in the promotion and prevention interventions. Tools such as this text message-based intervention that are constructed and guided by evidence-based content and theoretical constructs show promise in helping people sustain healthy behaviors that can lead to improved health outcomes.

Health Information Seeking and Social Media Use on the Internet among People with Diabetes

Patients who are active and involved in their self-management and care are more likely to manage chronic conditions effectively (6, 26). With a 5-fold increase in the incidence of chronic illness over the past 20 years, access to information can provide patients the tools and support to self-manage their chronic illness. New media technologies can serve as tools to engage and involve patients in their health care. Due to the increasing ubiquity of the Internet and the availability of health information, patients are more easily able to seek and find information about their health.. Thus, the Internet can serve as a mechanism of empowerment (4, 5). This is especially important for people with diabetes mellitus where intensive self-management is critical.

Effects of Nurse-Managed Protocols in the Outpatient Management of Adults With Chronic Conditions: A Systematic Review and Meta-analysis

Medical management of chronic illness consumes 75% of every health care dollar spent in the United States (1). Thus, provision of economical and accessibleyet high-qualitycare is a major concern. Diabetes mellitus, hypertension, and hyperlipidemia are prime examples of chronic diseases that cause substantial morbidity and mortality (2, 3) and require long-term medical management. For each of these disorders, most care occurs in outpatient settings where well-established clinical practice guidelines are available (47). Despite the availability of these guidelines, there are important gaps between the care recommended and the care delivered (810). The shortage of primary care clinicians has been identified as 1 barrier to the provision of comprehensive care for chronic disease (11, 12) and is an impetus to develop strategies for expanding the roles and responsibilities of other interdisciplinary team members to help meet this increasing need. The patient-centered medical home concept was developed in an effort to serve more persons and improve chronic disease care. It is a model of primary care transformation that builds on other efforts, such as the chronic care model (13), and includes the following elements: patient-centered orientation toward the whole person, team-based care coordinated across the health care system and community, enhanced access to care, and a systems-based approach to quality and safety. Care teams may include nurses, primary care providers, pharmacists, and behavioral health specialists. An organizing principle for care teams is to utilize personnel at the highest level of their skill set, which is particularly relevant given the expected increase in demand for primary care services resulting from the Patient Protection and Affordable Care Act. With this increased demand, the largest health care workforce, registered nurses (RNs), may be a valuable asset alongside other nonphysician clinicians, including physician assistants, nurse practitioners, and clinical pharmacists, to serve more persons and improve chronic disease care. Robust evidence supports the effectiveness of nurses in providing patient education about chronic disease and secondary prevention strategies (1419). With clearly defined protocols and training, nurses may also be able to order relevant diagnostic tests, adjust routine medications, and appropriately refer patients. Our purpose was to synthesize the current literature describing the effects of nurse-managed protocols, including medication adjustment, for the outpatient management of adults with common chronic conditions, namely diabetes, hypertension, and hyperlipidemia. Methods We followed a standard protocol for all steps of this review. A technical report that fully details our methods and presents results for all original research questions is available at www.hsrd.research.va.gov/publications/esp/reports.cfm. Data Sources and Searches In consultation with a master librarian, we searched MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL from 1 January 1980 through 31 January 2014 for English-language, peer-reviewed publications evaluating interventions that compared nurse-managed protocols with usual care in studies targeting adults with chronic conditions (Supplement 1). Supplement 1. Search Strategy We selected exemplary articles and used a Medical Subject Heading analyzer to identify terms for nurse protocols. We added selected free-text terms and validated search terms for randomized, controlled trials (RCTs) and quasi-experimental studies, and we searched bibliographies of exemplary studies and applicable systematic reviews for missed publications (15, 17, 2029). To assess for publication bias, we searched ClinicalTrials.gov to identify completed but unpublished studies meeting our eligibility criteria. Study Selection, Data Extraction, and Quality Assessment Two reviewers used prespecified eligibility criteria to assess all titles and abstracts (Supplement 2). Eligibility criteria included the involvement of an RN or a licensed practical nurse (LPN) functioning beyond the usual scope of practice, such as adjusting medications and conducting interventions based on a written protocol. Potentially eligible articles were retrieved for further evaluation. Disagreements on inclusion or exclusion were resolved by discussion or a third reviewer. Studies excluded at full-text review are listed in Supplement 3. Abstraction and quality assessment were done by 1 reviewer and confirmed by a second. We piloted the abstraction forms, designed specifically for this review, on a sample of included articles. Key characteristics abstracted included patient descriptors, setting, features of the intervention and comparator, match between the sample and target populations, extent of the nurse interventionists training, outcomes, and quality elements. Supplements 4 and 5 summarize quality criteria and ratings, respectively. Supplement 2. Eligibility Criteria Supplement 3. List of Excluded Studies Supplement 4. Criteria Used in Risk of Bias Assessment Supplement 5. Detailed Study Characteristics Because many studies were done outside the United States, we queried the authors of such studies about the education and scope of practice of the nurse interventionists. Authors were e-mailed a table detailing the credentialing and scope of practice of various U.S. nurses and asked to classify their nurse interventionist. Data Synthesis and Analysis The primary outcomes were the effects of nurse-managed protocols on biophysical markers (for example, glycosylated hemoglobin or hemoglobin A1c [HbA1c]), patient treatment adherence, nurse protocol adherence, adverse effects, and resource use. When quantitative synthesis (that is, meta-analysis) was feasible, dichotomous outcomes were combined using odds ratios and continuous outcomes were combined using mean differences in random-effects models. For studies with unique but conceptually similar outcomes, such as ordering a guideline-indicated laboratory test, we synthesized outcomes across conditions if intervention effects were sufficiently homogeneous. We used the Knapp and Hartung method (30, 31) to adjust the SEs of the estimated coefficients. For categories with several potential outcomes (for example, biophysical markers) that may vary across chronic conditions, we selected outcomes for each chronic condition a priori: HbA1c level for diabetes, blood pressure (BP) for hypertension, and cholesterol level for hyperlipidemia. In 1 example (32), we imputed missing SDs using estimates from similar studies. We computed summary estimates of effect and evaluated statistical heterogeneity using the Cochran Q and I 2 statistics. We did subgroup analyses to examine potential sources of heterogeneity, including where the study was conducted and intervention content. Subgroup analyses involved indirect comparisons and were subject to confounding; thus, results were interpreted cautiously. Publication bias was assessed using a ClinicalTrials.gov search and funnel plots when at least 10 studies were included in the analysis. When quantitative synthesis was not feasible, we analyzed data qualitatively. We gave more weight to evidence from higher-quality studies with more precise estimates of effect. The qualitative syntheses identified and documented patterns in efficacy and safety of the intervention across conditions and outcome categories. We analyzed potential reasons for inconsistency in treatment effects across studies by evaluating variables, such as differences in study population, intervention, comparator, and outcome definitions. We followed the approach recommended by the Agency for Healthcare Research and Quality (33) to evaluate the overall strength of the body of evidence. This approach assesses the following 4 domains: risk of bias, consistency, directness, and precision. These domains were considered qualitatively, and a summary rating of high, moderate, low, or insufficient evidence was assigned. Role of the Funding Source The Veterans Affairs Quality Enhancement Research Initiative funded the research but did not participate in the conduct of the study or the decision to submit the manuscript for publication. Results Our electronic and manual searches identified 2954 unique citations (Figure 1). Of the 23 potentially eligible studies, 4 were excluded because we could not verify whether nurses had the authority to initiate or titrate medications and the author did not respond to our query for clarification (3437). We excluded a trial of older adults in which we could not differentiate the target illnesses (38). Approximately two thirds of the authors we contacted for missing data or clarification responded. Figure 1. Summary of evidence search and selection. * Methods or follow-up articles. We included 18 unique studies (23004 patients) that focused on patients with elevated cardiovascular risk (Table) (32, 3955). Of these, 16 were RCTs and 2 were controlled before-and-after studies on diabetes (49, 53). The comparator was usual care in all but 1 study, in which a reverse-control design was used, and each intervention served as the control for the other. Eleven studies were done in Western Europe and 7 in the United States. Median age of participants was 58.3 years (range, 37.2 to 72.1 years) based on 16 studies. Approximately 47% of the participants were female. Race was not reported in 84% of the studies. Supplement 5 gives detailed study characteristics. No outstanding studies were identified through ClinicalTrials.gov. Supplement 6 provides funnel plots that assess publication bias. Table. Study and Patient Characteristics of Included Diabetes, Hypertension, and Hyperlipidemia Studies Supplement 6. Assessment of Publication Bias: Funnel Plots Overall, these studies displayed moderate risk of bias. Two studies were judged as having a high risk of bias because of inadequate randomization (44, 5

Patient-provider internet portals--patient outcomes and use.

An important emerging information technology tool is the electronic health record with a patient-provider Internet portal. Patient-provider Internet portals offer a venue for providing patient access to personal health data. In this study, we conducted a cross-sectional secondary data analysis to describe the types of diabetes patients who utilize the patient-provider Internet portal and examine any preliminary differences in patient outcomes. Data from this study suggest that a significant portion of patients (29.7%) with diabetes utilize the portal. Clinical outcome results indicated that portal use was not a significant predictor of low-density lipoprotein and total cholesterol levels. However, portal use was a statistically significant predictor of glycosylated hemoglobin (HbA1c) (P < .001). As patient-provider Internet portals are increasingly implemented and utilized across the nation, both clinical and nonclinical impacts must be evaluated. Patient-provider Internet portals have the ability to provide patients with the opportunity tobe increasingly involved in their own care,enhance patient-provider communication, and potentially reduce inequity, improve clinical outcomes, and increase access to care.

Development of a Theoretically Driven mHealth Text Messaging Application for Sustaining Recent Weight Loss

Background Mobile phone short message service (SMS) text messaging, has the potential to serve as an intervention medium to promote sustainability of weight loss that can be easily and affordably used by clinicians and consumers. Objective To develop theoretically driven weight loss sustaining text messages and pilot an mHealth SMS text messaging intervention to promote sustaining recent weight loss in order to understand optimal frequency and timing of message delivery, and for feasibility and usability testing. Results from the pilot study were used to design and construct a patient privacy compliant automated SMS application to deliver weight loss sustaining messages. Methods We first conducted a pilot study in which participants (N=16) received a daily SMS text message for one month following a structured weight loss program. Messages were developed from diet and exercise guidelines. Following the intervention, interviews were conducted and self-reported weight was collected via SMS text messaging. Results All participants (N=16) were capable of sending and receiving SMS text messages. During the phone interview at 1 month post-baseline and at 3 months post-baseline, 13/14 (93%) of participants who completed the study reported their weight via SMS. At 3 months post-baseline, 79% (11/14) participants sustained or continued to lose weight. Participants (13/14, 93%) were favorable toward the messages and the majority (10/14, 71%) felt they were useful in helping them sustain weight loss. All 14 participants who completed the interview thought SMS was a favorable communication medium and was useful to receive short relevant messages promptly and directly. All participants read the messages when they knew they arrived and most (11/14, 79%) read the messages at the time of delivery. All participants felt that at least one daily message is needed to sustain weight loss behaviors and that they should be delivered in the morning. Results were then used to develop the SMS text messaging application. Conclusions Study results demonstrated the feasibility of developing weight loss SMS text messages, and the development of an mHealth SMS text messaging application. SMS text messaging was perceived as an appropriate and accepted tool to deliver health promotion content.

Organizational factors associated with readiness to implement and translate a primary care based telemedicine behavioral program to improve blood pressure control: the HTN-IMPROVE study

BackgroundHypertension is prevalent and often sub-optimally controlled; however, interventions to improve blood pressure control have had limited success.ObjectivesThrough implementation of an evidence-based nurse-delivered self-management phone intervention to facilitate hypertension management within large complex health systems, we sought to answer the following questions: What is the level of organizational readiness to implement the intervention? What are the specific facilitators, barriers, and contextual factors that may affect organizational readiness to change?Study designEach intervention site from three separate Veterans Integrated Service Networks (VISNs), which represent 21 geographic regions across the US, agreed to enroll 500 participants over a year with at least 0.5 full time equivalent employees of nursing time. Our mixed methods approach used a priori semi-structured interviews conducted with stakeholders (n = 27) including nurses, physicians, administrators, and information technology (IT) professionals between 2010 and 2011. Researchers iteratively identified facilitators and barriers of organizational readiness to change (ORC) and implementation. Additionally, an ORC survey was conducted with the stakeholders who were (n = 102) preparing for program implementation.ResultsKey ORC facilitators included stakeholder buy-in and improving hypertension. Positive organizational characteristics likely to impact ORC included: other similar programs that support buy-in, adequate staff, and alignment with the existing site environment; improved patient outcomes; is positive for the professional nurse role, and is evidence-based; understanding of the intervention; IT infrastructure and support, and utilization of existing equipment and space.The primary ORC barrier was unclear long-term commitment of nursing. Negative organizational characteristics likely to impact ORC included: added workload, competition with existing programs, implementation length, and limited available nurse staff time; buy-in is temporary until evidence shows improved outcomes; contacting patients and the logistics of integration into existing workflow is a challenge; and inadequate staffing is problematic. Findings were complementary across quantitative and qualitative analyses.ConclusionsThe model of organizational change identified key facilitators and barriers of organizational readiness to change and successful implementation. This study allows us to understand the needs and challenges of intervention implementation. Furthermore, examination of organizational facilitators and barriers to implementation of evidence-based interventions may inform dissemination in other chronic diseases.

The Role of Home Blood Pressure Telemonitoring in Managing Hypertensive Populations

Hypertension is a common chronic disease affecting nearly one-third of the United States population. Many interventions have been designed to help patients manage their hypertension. With the evolving climate of healthcare, rapidly developing technology, and emphasis on delivering patient-centered care, home-based blood pressure telemonitoring is a promising tool to help patients achieve optimal blood pressure (BP) control. Home-based blood pressure telemonitoring is associated with reductions in blood pressure values and increased patient satisfaction. However, additional research is needed to understand cost-effectiveness and long-term clinical outcomes of home-based BP monitoring. We review key interventional trials involving home based BP monitoring, with special emphasis placed on studies involving additionally behavioral modification and/or medication management. Furthermore, we discuss the role of home-based blood pressure telemonitoring within the context of the patient-centered medical home and the evolving role of technology.

Mobile health devices: will patients actually use them?

Although mobile health (mHealth) devices offer a unique opportunity to capture patient health data remotely, it is unclear whether patients will consistently use multiple devices simultaneously and/or if chronic disease affects adherence. Three healthy and three chronically ill participants were recruited to provide data on 11 health indicators via four devices and a diet app. The healthy participants averaged overall weekly use of 76%, compared to 16% for those with chronic illnesses. Device adherence declined across all participants during the study. Patients with chronic illnesses, with arguably the most to benefit from advanced (or increased) monitoring, may be less likely to adopt and use these devices compared to healthy individuals. Results suggest device fatigue may be a significant problem. Use of mobile technologies may have the potential to transform care delivery across populations and within individuals over time. However, devices may need to be tailored to meet the specific patient needs.

Association Between Perceived Life Chaos and Medication Adherence in a Postmyocardial Infarction Population

Background— The benefits of medication adherence to control cardiovascular disease (CVD) are well defined, yet multiple studies have identified poor adherence. The influence of life chaos on medication adherence is unknown. Because this is a novel application of an instrument, our preliminary objective was to understand patient factors associated with chaos. The main objective was to evaluate the extent to which an instrument designed to measure life chaos is associated with CVD-medication nonadherence. Methods and Results— Using baseline data from an ongoing randomized trial to improve postmyocardial infarction (MI) management, multivariable logistic regression identified the association between life chaos and CVD-medication nonadherence. Patients had hypertension and a myocardial infarction in the past 3 years (n=406). Nearly 43% reported CVD-medication nonadherence in the past month. In simple linear regression, the following were associated with higher life chaos: medication nonadherence (&bgr;=1.86; 95% confidence interval [CI], 0.96–2.76), female sex (&bgr;=1.22; 95% CI [0.22–2.24]), minority race (&bgr;=1.72; 95% CI [0.78–2.66]), having less than high school education (&bgr;=2.05; 95% CI [0.71–3.39]), low health literacy (&bgr;=2.06; 95% CI [0.86–3.26]), and inadequate financial status (&bgr;=1.93; 95% CI [0.87–3.00]). Being married (&bgr;=−2.09, 95% CI [−3.03 to −1.15]) was associated with lower life chaos. As chaos quartile increased, patients exhibited more nonadherence. In logistic regression, adjusting for sex, race, marital status, employment, education, health literacy, and financial status, a 1-unit life chaos increase was associated with a 7% increase (odds ratio, 1.07; 95% CI [1.02–1.12]) in odds of reporting medication nonadherence. Conclusions— Our results suggest that life chaos may be an important determinant of medication adherence. Life chaos screenings could identify those at risk for nonadherence. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT000901277