Aim and Key Question
Numerous barriers to outpatient colonoscopy completion exist, causing undue procedure cancellations and poor bowel preparation.
Current approaches to engaging patients include pre-procedure phone calls or patient navigators. Both interventions are challenging and costly, making them less scalable. Other interventions such as instructional videos or mobile applications have been hampered by poor user experience or limited patient engagement. They hypothesized that a bidirectional messaging approach informed by principles of behavioral science might foster improved engagement and improve outpatient colonoscopy show rates.
Intervention and Design
They conducted a prospective study at an urban academic endoscopy center. Based on power calculations to enable detection of a ~30% difference in the primary outcome, we offered a text messaging program using the Way to Health platform to 22 patients scheduled for outpatient colonoscopy (for any indication) in the first 2 weeks of April 2018 and compared them with 50 comparison patients in the last 2 weeks of April 2018. They included patients aged 18 to 75 years who were scheduled for outpatient colonoscopy within 2 months of initial contact and excluded patients on any diabetic medications due to differences in the bowel preparation process.
Interventions - Intervention patients were enrolled via telephone using a script approved by our institutional review board. Comparison patients were not contacted for this study. All patients were selected using a random number generator. Patients in the comparison arm received usual care, consisting of paper instructions and a phone call in the week prior to colonoscopy. Intervention patients also received these measures. For each patient, basic demographic and clinical comorbidity data, appointment adherence (show, no-show, cancellation), bowel preparation quality (excellent, good, fair, poor), and colonoscopy completion (cecum reached) were obtained through electronic medical record review.
Main Outcomes and Measures - The primary outcome was appointment adherence. The secondary outcomes were bowel preparation quality and colonoscopy completion between groups.
Way to Health Use
- Study Enrollment: Enroll and randomize participants across the study arms
- Automated Messaging: Send participants automated text messages
- Randomization: Randomize participants into one of two groups
Findings and Conclusions
Of 22 patients successfully contacted, 21 agreed to participate in the text message intervention (one declined because of reported familiarity with the colonoscopy process), and 50 patients were randomly selected as the comparison arm. There were no significant differences in demographics or comorbidities between groups (Table 2). Intervention patients were significantly more likely to show for colonoscopy (90% vs. 62% show rate; p = .049). This difference persisted on secondary analysis when the patient who declined the intervention was included (91% vs. 62% show rate, p = .040). There were 2 cancellations and 0 no-shows in the intervention group as compared with 14 cancellations and 5 no-shows in the comparison group. Among those who showed, there were no significant differences in preparation quality or completeness between arms (p = .12 and p = .43, respectively).
A total 16 of 21 (76.2%) intervention patients responded to automated texts. The most common questions pertained to the timing of bowel preparation components and food restrictions on the day before the procedure. Poststudy survey results indicated excellent patient satisfaction (100% high/very high), reported ease of use (92% high/very high), and perceived usefulness of the text messaging program (95% high/very high).
In this prospective study, we found that patients enrolled in a bidirectional, automated text message navigation program had significantly higher colonoscopy show rates as compared with patients receiving usual care. Among those who completed the procedure, the preparation quality was comparable. The texting program was well-received and survey responses indicated high patient satisfaction and good user experience.