Yakovchenko Vera, Hogan Timothy P, Houston Thomas K, Richardson Lorilei, Lipschitz Jessica, Petrakis Beth Ann, Gillespie Chris, McInnes D Keith
Center for Healthcare Organization and Implementation Research, Bedford Department of Veterans Affairs Medical Center, Department of Veterans Affairs, Bedford, MA, United States.
Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.
J Med Internet Res. 2019 Aug 4;21(8):e14750. doi: 10.2196/14750.
Acceptability of mobile phone text messaging as a means of asynchronous communication between health care systems and patients is growing. The US Department of Veterans Affairs (VA) has adopted an automated texting system (aTS) for national rollout. The aTS allows providers to develop clinical texting protocols to promote patient self-management and allows clinical teams to monitor patient progress between in-person visits. Texting-supported hepatitis C virus (HCV) treatment has not been previously tested.
Guided by the Practical, Robust Implementation and Sustainability Model (PRISM), we developed an aTS HCV protocol and conducted a mixed methods, hybrid type 2 effectiveness implementation study comparing two programs supporting implementation of the aTS HCV protocol for medication adherence in patients with HCV.
Seven VA HCV specialty clinics were randomized to usual aTS implementation versus an augmented implementation facilitation program. Implementation process measures included facilitation metrics, usability, and usefulness. Implementation outcomes included provider and patient use of the aTS HCV protocol, and effectiveness outcomes included medication adherence, health perceptions and behaviors, and sustained virologic response (SVR).
Across the seven randomized clinics, there were 293 facilitation events using a core set of nine implementation strategies (157 events in augmented implementation facilitation, 136 events in usual implementation). Providers found the aTS appropriate with high potential for scale-up but not without difficulties in startup, patient selection and recruitment, and clinic workflow integration. Patients largely found the aTS easy to use and helpful; however, low perceived need for self-management support contributed to high declination. Reach and use was modest with 197 patients approached, 71 (36%) enrolled, 50 (25%) authenticated, and 32 (16%) using the aTS. In augmented implementation facilitation clinics, more patients actively used the aTS HCV protocol compared with usual clinic patients (20% vs 12%). Patients who texted reported lower distress about failing HCV treatment (13/15, 87%, vs 8/15, 53%; P=.05) and better adherence to HCV medication (11/15, 73%, reporting excellent adherence vs 6/15, 40%; P=.06), although SVR did not differ by group.
The aTS is a promising intervention for improving patient self-management; however, augmented approaches to implementation may be needed to support clinician buy-in and patient engagement. Considering the behavioral, social, organizational, and technical scale-up challenges that we documented, successful and sustained implementation of the aTS may require implementation strategies that operate at the clinic, provider, and patient levels.
Retrospectively registered at ClinicalTrials.gov NCT03898349; https://clinicaltrials.gov/ct2/show/NCT03898349.
手机短信作为医疗系统与患者之间异步通信手段的可接受性正在不断提高。美国退伍军人事务部（VA）已采用一种自动短信系统（aTS）进行全国推广。该aTS允许医疗服务提供者制定临床短信协议以促进患者自我管理，并允许临床团队在面对面就诊期间监测患者进展。此前尚未对短信支持的丙型肝炎病毒（HCV）治疗进行过测试。
在实用、稳健实施与可持续性模型（PRISM）的指导下，我们制定了一项aTS HCV协议，并进行了一项混合方法、2型混合有效性实施研究，比较了两个支持实施aTS HCV协议以提高HCV患者用药依从性的项目。
七家VA HCV专科诊所被随机分配到常规aTS实施组与强化实施促进项目组。实施过程指标包括促进指标、可用性和有用性。实施结果包括医疗服务提供者和患者对aTS HCV协议的使用，有效性结果包括用药依从性、健康认知和行为以及持续病毒学应答（SVR）。
在七家随机分组的诊所中，使用一组核心的九种实施策略共进行了293次促进活动（强化实施促进组157次活动，常规实施组136次活动）。医疗服务提供者认为aTS适用，具有很大的扩大规模的潜力，但在启动、患者选择和招募以及诊所工作流程整合方面并非没有困难。患者大多认为aTS易于使用且有帮助；然而，对自我管理支持的低感知需求导致拒绝率较高。覆盖面和使用率适中，共接触了197名患者，71名（36%）登记，50名（25%）认证，32名（16%）使用了aTS。在强化实施促进诊所中，与常规诊所患者相比，更多患者积极使用aTS HCV协议（20%对12%）。发短信的患者报告称，对HCV治疗失败的困扰较低（13/15，87%，对8/15，53%；P = 0.05），对HCV药物的依从性更好（11/15，73%报告依从性极佳，对6/15，40%；P = 0.06），尽管两组的SVR没有差异。
aTS是改善患者自我管理的一种有前景的干预措施；然而，可能需要强化实施方法来支持临床医生的接受和患者的参与。考虑到我们记录的行为、社会、组织和技术扩大规模方面的挑战，aTS的成功和持续实施可能需要在诊所、医疗服务提供者和患者层面实施的策略。
在ClinicalTrials.gov上进行回顾性注册，NCT03898349；https://clinicaltrials.gov/ct2/show/NCT03898349 。
