The use of text messaging to improve asthma control: a pilot study using the mobile phone short messaging service (SMS)

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1 RESEARCH Original article... Q The use of text messaging to improve asthma control: a pilot study using the mobile phone short messaging service (SMS) Lathy Prabhakaran*, Wai Yan Chee*, Kia Chong Chua, John Abisheganaden and Wai Mun Wong *Nursing Service, Tan Tock Seng Hospital; Clinical Research Unit, Tan Tock Seng Hospital; Respiratory Medicine, Tan Tock Seng Hospital; National Health Care Group, Tan Tock Seng Hospital, Singapore Summary We have evaluated the feasibility of using the mobile phone short message service (SMS) for symptom monitoring in patients with asthma. All consecutive patients admitted to hospital for asthma during an 11-month period were considered for enrolment (n ¼ 497). Those meeting the inclusion criteria were randomized into a control (n ¼ 60) and intervention group (n ¼ 60). Patients in the intervention group received SMS messages according to a structured workflow, while patients in the control group had no SMS support. In the intervention group, the mean response rate to the messages was 82%. There was an improvement in the Asthma Control Test (ACT) scores in 36 subjects in the intervention group compared to 28 subjects in the control group. There were reductions in the number of nebulizations in 54 subjects in the control group compared to 50 subjects in the intervention group, and reductions in emergency department visits in 57 subjects in the control group compared to 51 subjects in the intervention group. However, none of these differences were significant. There was no reduction in admission rates in either group (P ¼ 0.5). The service was accepted by most patients, but its long-term effectiveness on the management of asthma remains to be determined. Introduction Asthma is a chronic disease that affects 140,000 people in Singapore. The prevalence is 20% among school children, 1 and 5% among the adult population. 2 We have developed an Internet-based service called ecare for communication with the patients. It receives information from the patient via three modalities: (1) SMS using a mobile phone; (2) Internet through a website; (3) Interactive voice response (IVR) through a fixed telephone line. We have evaluated the effectiveness of the first channel of communication via SMS using mobile phones. SMS service The service was designed to generate alerts if it detected increased use of reliever from patients baseline. The workflow is shown in Figure 1. Accepted 5 February 2010 Correspondence: Lathy Prabhakaran, Department of Nursing, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore (Fax: þ ; Journal of Telemedicine and Telecare 2010; 16: Before using the service, patients were instructed on the work flow. The explanation emphasized the standard messages that would be sent, the frequency of messages, the timing of messages, how to input the reply in a single word, and when the asthma nurse would call to verify the alerts. We compared the clinical status of asthma patients who used the service for 12 weeks with those who received conventional inpatient asthma management over the same period. The primary objectives were to evaluate the feasibility of using the short message service (SMS) for symptom monitoring through mobile phones from the user s perspective, and to evaluate patient compliance with SMS monitoring as measured by response rates over time. The secondary objectives were to compare clinical asthma outcomes before and after recruitment into the study. Patient satisfaction with the SMS service was also evaluated. Methods All patients admitted consecutively to our hospital with a primary diagnosis of asthma from 1 August 2007 to 30 June 2008 were screened by two asthma nurses for enrolment into the study. To be included, the subjects had to (1) be aged 21 years or above; (2) be admitted for an acute DOI: /jtt

2 Figure 1 System workflow exacerbation of asthma; (3) own a mobile phone; (4) know how to use an SMS system; (5) be English speaking since the SMS messages were in English; and (5) be willing to participate in the study and give written consent. Patients who were excluded were those who (1) had significant co-morbidity e.g. bronchiectasis, heart failure, diabetes mellitus with complications, stroke, renal impairment, chronic obstructive pulmonary disease; (2) did not know how to use an SMS system; (3) were non-english speaking; or (4) had mild intermittent asthma. Study design This was a randomized controlled study. The study was approved by the appropriate ethics committee. We wanted to recruit 120 subjects: 60 in the control and 60 in the intervention group. Allocation was from an envelope with slips of paper. Subjects had to draw from the envelope to discover their allocated group. Subjects who fitted the inclusion criteria provided written consent prior to participation in the study. Asthma education All the 120 patients recruited were seen by a trained asthma nurse educator who assessed their asthma control, compliance to treatment and inhaler technique prior to administration of individualized asthma education. The asthma education was tailored to the subject s educational needs. The 60 patients in the control group were left to selfmanage their asthma for three months. The 60 patients in the intervention group had SMS monitoring to assist with the management of their asthma control for the next three months. At the end of the third month, all study subjects received a follow-up telephone call from the asthma nurse. Subjects were assessed on asthma control using the Asthma Control Test (ACT), use of nebulization, emergency department (ED) visits and hospital admissions for asthma since the last admission 12 weeks previously. Patients in the intervention group had three additional questions about the SMS service. The first question was Are you satisfied with the SMS service? The subject s responses to this question was elicited using a five-point Likert scale (1 ¼ strongly disagree Journal of Telemedicine and Telecare Volume 16 Number

3 to 5 ¼ strongly agree). The second question asked what they liked about this service and the third asked what they did not like about the service. Statistical analysis To examine whether those who enrolled in the programme differed from those who declined in terms of their demographic characteristics (age, gender, ethnicity), we performed a logistic regression. To examine whether the two groups ( vs Control) were similar, we performed chi-square analyses for categorical variables (e.g. gender), and paired t-tests for continuous variables (e.g. age). To examine whether the intervention had improved patient outcomes, we performed chi-square tests to see whether improvement in ACT (20), reduction in nebulization, number of ED visits and admissions were greater in the intervention group. Results A total of 497 patients were screened: 377 (76%) subjects were excluded from the study and 120 (24%) subjects were recruited into the study. Feasibility The demography of the subjects screened but excluded is shown in Table 1 and the reasons for exclusion are shown in Table 2. The logistic regression suggested that males did not have a significantly greater chance of being recruited than females (OR ¼ 1.01, P. 0.05). Those who were older on the other hand were slightly less likely to be recruited (OR ¼ 0.95, P, 0.001). Both Malays (OR ¼ 2.80, P, 0.01) and Table 1 Details of patients who were excluded from the study Excluded (n 5 377) Sex Female Male Race Chinese Malay Indian Others 5 1 Mean age, years 55 (SD 19) Table 2 Reasons for exclusion Percentage Number Age below 21 years 31 Significant co-morbidity 78 Does not own a mobile phone 128 Does not know how to use SMS 121 Non-English speaking 111 Unwilling to participate in the study 49 Intermittent asthma 13 Indians (OR ¼ 2.90, P, 0.001) were more likely than Chinese to be recruited for the study. This did not appear to be the case for the ethnic group Others (OR ¼ 1.86, P. 0.05). The demographic profiles of the subjects included in the study are shown in Table 3. There were no significant differences between the control and intervention group. The groups did not differ in gender, race, age, duration of asthma, mean co-morbid condition, number of smokers included and baseline asthma control at time of recruitment. A total of 57 (95%) subjects from the control group and 58 (97%) subjects from the intervention group completed the study. One patient in the intervention group died immediately after the study period. Compliance with SMS monitoring The response rate per patient was calculated by adding the number of responses to the SMS messages divided by the number of SMS messages sent. The system was programmed to send 24 messages per patient over a period of 12 weeks. The mean response rate per patient was 82% (range 0 100%). Two patients requested to be withdrawn from the SMS service. One was leaving the country and the other was dissatisfied with the service. The subject did not like using the SMS and found it troublesome and irritating, and did not wish to incur a cost for the SMS reply. Clinical outcomes Since all patients received the inpatient phase of asthma education, the intention-to-treat 3 approach was used to analyse the secondary objective on clinical outcomes. We were not able to contact three subjects from the control Table 3 Details of the patients studied. The values shown are the number (%) Control group (n 5 60) group (n 5 60) Sex NS Female 32 (53) 39 (65) Male 28 (47) 21 (35) Race Chinese 12 (20) 11 (18) NS Malay 25 (42) 27 (45) Indian 22 (37) 22 (37) Others 1 (1) 0 (0) Mean age, years 40 (SD 13) 37 (SD 12) NS Mean duration of asthma, 19.4 (SD 12.2) 19.8 (SD 13.3) NS years Mean number of 0.44 (SD 0.5) 0.45 (SD 0.5) NS co-morbidities Smoker NS Yes 17 (28) 18 (30) No 43 (72) 42 (70) Asthma control at recruitment Uncontrolled ACT score (95) 56 (93) NS Chi-square test used for all categorical variables (sex, race, smoker); paired t-test used for age, duration of asthma and ACT scores NS, P Journal of Telemedicine and Telecare Volume 16 Number

4 group and two subjects from the intervention group to assess their asthma control and number of nebulizations. Nevertheless, information about the number of emergency visits and hospital admissions for asthma were retrieved for all patients from the hospital computer system. There was an improvement in ACT (to greater than 20 points) in 36 subjects (62%) in the intervention group compared to 28 subjects (49%) in the control group, but this was not significant (P ¼ 0.113) (see Table 4). There were reductions in number of nebulizations in 54 subjects (94%) in the control group compared to 50 subjects (86%) in the intervention group (P ¼ 0.053) and reductions in ED visits in 57 subjects (95%) in the control group compared to 51 subjects (85%) in the intervention group (P ¼ 0.063). There was no reduction in admission rates in either group (P ¼ 0.5). Technical errors The system generated alerts for 32 subjects, although only 9 subjects had ED visits and 4 subjects were admitted (see Table 5). Six subjects had no alert but did have ED visits, and two subjects were admitted. We further analysed the data by looking at system errors in alert set up. A total of 35 subjects had no errors in the system but 8 subjects had ED visits and 3 were admitted. The system under-alerted for 20 subjects and 7 subjects had ED visits and 3 were admitted. The system missed alerting of 5 subjects, but none of them had ED visits or hospitalization. Patient satisfaction A total of 55 subjects (92%) in the intervention group were satisfied with the SMS service. The subjects also provided comments on what they liked and did not like about the SMS service. Table 4 Improvement in clinical outcome at three months 1. Improvement of ACT score to 20 improved ACT scores 2. Reduction in number of nebulizations a reduction in nebulizations 3. Reduction in emergency department visits fewer emergency department visits 4. Reduction in admissions fewer admissions Chi-square tests Control group (n 5 57) group (n 5 58) 28 (49%) 36 (62%) (96%) 50 (86%) Control group (n 5 60) group (n 5 60) 57 (95%) 51 (85%) (93%) 55 (92%) 0.50 Table 5 Technical errors No. of emergency department visits No alert Yes alert Total No. of hospital admissions No alert Yes alert Total No. of emergency department visits No error in system alerts System under alerted System missed an alert Total No. of hospital admissions No error in system alerts System under alerted System missed an alert Total Discussion The primary objective of the study was to investigate the feasibility of using the mobile phone SMS for symptom monitoring of patients admitted for acute exacerbation of asthma. We experienced difficulties in recruiting and it took 11 months to recruit 120 subjects from 497 consecutive patients admitted for acute exacerbation of asthma. There were some significant age and race differences in the subjects, which may be relevant to the successful implementation of an SMS service. The mean age of those excluded was 55 years, compared to the control group (40 years) and the intervention group (37 years). That is, many older patients did not have mobile phones or if they had one, most of them did not know how to use the SMS or were non-english speaking. This supports the need to take into consideration language preferences during the installation of a telemonitoring system. 4,5 A total of 31 subjects below the age of 21 years were excluded because of the inconvenience of getting consent from their parents. It is mandatory to obtain consent from parents or guardians for any research study in Singapore. We know that the majority of these younger subjects are users of SMS and that this service would probably be acceptable to them. 6 A total of 78 subjects were excluded due to significant co-morbidity. We excluded these patients because we assumed it would be difficult for them to understand the nature of many illnesses and differentiate their signs and symptoms from asthma, i.e. their replies might not be Journal of Telemedicine and Telecare Volume 16 Number

5 correct. A total of 49 subjects were unwilling to participate in the study. It has been stated that telemonitoring is usually beneficial for well-motivated patients. 4 The subjects in our study used their own mobile phones during the study and they did not receive any reimbursement for the cost of sending SMS messages. Some patients voiced concerns about the cost of SMS replies, despite the fact that sending a text message in Singapore is relatively cheap. This may explain why the mean response rate for SMS was only 82%. However our response rate was higher than that of another study. 4 Two subjects in the intervention group did not reply to any SMS messages and we were not able to contact them. In our study there was improvement in the ACT score in more subjects in the intervention group than the control group, even though it was not significant (P ¼ 0.113). These findings are similar to those of Kim et al. 7 A limitation of our service was that the nurse had to telephone the patient when there was an alert to verify the accuracy of the SMS message before giving advice, unlike other studies where clinical recommendations were generated automatically through a knowledge algorithm. 7 We had several reasons to verify the alert; there were occasions when patients misunderstood the question about relievers. Also, we wanted to exclude the possibility that these patients were not using the reliever inhaler regularly instead of on demand. Some patients feel secure in using a reliever regularly to avoid symptom occurrence, despite being educated to use it only on demand. The service did send out automated messages weekly after analysing the patients replies (see flow chart) but it was not personalized. In addition to the automated messages, the asthma nurse could also send customized messages to reinforce the clinical recommendations. Patients gave positive and negative feedback about the service. Even though 55 subjects (92%) claimed to be satisfied with the service there were many negative comments. This finding was similar to Anhoj and Møldrup s study 4 where subjects wanted the system to be more interactive and responsive. Some patients found the daily SMS message to be irritating and preferred weekly monitoring. Each time the server received new data from a patient, it retrieved the previous results and analyzed the frequency of reliever use. If it was higher than the preset threshold, an alert was sent to the asthma nurse. The server would also send the alert if the patient did not reply to three consecutive SMS messages. All alerts were verified by the asthma nurse through telephone contact with the patients. Conclusion In our study, the SMS intervention using a mobile phone improved asthma control scores but did not reduce the number of ED visits or hospital admissions during a short-term study lasting 12 weeks. The long-term effectiveness of the system on the management of asthma remains to be determined. The service was accepted by most patients. We believe that SMS monitoring may be more effective than conventional nurse telephone-call management. Acknowledgements: We thank Ms Syahidah Salleh for her assistance with data entry. Mr Tho Chin Yue (Netlyn Communications) developed and monitored the system responses. References 1 Goh DY, Chew FT, Quek SC, Lee BW. Prevalence and severity of asthma, rhinitis, and eczema in Singapore schoolchildren. Arch Dis Child 1996;74: Ng TP, Hui KP, Tan WC. Prevalence of asthma and risk factors among Chinese, Malay, and Indian adults in Singapore. Thorax 1994;49: Kirkwood BR. Essential Medical Statistics. Massachussets: Blackwell Sciences, Anhøj J, Møldrup C. Feasibility of collecting diary data from asthma patients through mobile phones and SMS (short message service): response rate analysis and focus group evaluation from a pilot study. J Med Internet Res 2004;6:e42 5 Finkelstein J, Cabrera MR, Hripcsak G. Internet-based home asthma telemonitoring: can patients handle the technology? Chest 2000;117: Farmer A, Gibson O, Hayton P, et al. A real-time, mobile phone-based telemedicine system to support young adults with type 1 diabetes. Inform Prim Care 2005;13: Kim C, Kim H, Nam J, et al. Internet diabetic patient management using a short messaging service automatically produced by a knowledge matrix system. Diabetes Care 2007;30: Journal of Telemedicine and Telecare Volume 16 Number

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