Speakers

Michael Ho, MD, PhD
Kaiser Permanente Colorado

Sheana Bull, PhD
University of Colorado School of Public Health

Slides

Keywords

Text Messaging; Artificial Intelligence; Chatbots; Health Behaviors

Key Points

• Ample evidence now exists demonstrating the benefit of using text messaging in support of health behavior and access to care. It’s ubiquitous, increasing reach; theory in message design is impactful; and it can improve adherence to medical appointments and health behaviors.

• Two NIH Collaboratory Trials, Nudge and Chat 4 Heart Health (C4HH), test the effectiveness of text messaging interventions to support behavior change. Nudge randomized patients to receive usual care, generic texts, behavioral texts, or behavioral texts plus chatbot messages. Their primary outcome was medication adherence.

• C4HH, the subsequent trial, is randomizing patients to receive a generic text message curriculum; an AI chatbot messaging curriculum; or AI chatbot messages plus proactive pharmacist support. Their primary outcome is cardiovascular risk factors, as measured by the American Heart Association’s “Life’s Essential 8” adherence.

• Nudge used an opt-out consent approach where CC4H used an opt-in consent approach. In the former, the research team noted, patients who identified as Black, Hispanic, and primary Spanish speakers were more likely to remain in the study. An opt-out approach in the appropriate context may be a way to diversify clinical trial populations and improve external validity of results.

• The use of AI chatbots allows users to generate questions in their own words and the system to retrieve a response from a closed, curated library.

• Message engagement is key to text messaging interventions. Participants in the Nudge study who were randomized to optimized texts had more questions. Questions were related to medications, refill logistics, and costs. The study team hypothesizes that the optimized texts may have led to greater patient engagement, and therefore more questions about their medications.

• Over 12 months, the Nudge study found no significant difference in the rates of prescription refills, between the 3 intervention arms and usual care. CC4H is ongoing, and will send a higher volume of messages in an effort to engage patients and change patient behavior.

• So far, the top 5 topics in messages initiated by C4HH participants have been healthy eating, physical activity, managing cholesterol, quitting smoking, and medication management.

Discussion Themes

The study team had to be very careful to ensure that patient health data, including cell phone numbers and the messages sent, were encrypted. Vendors and phone carriers were not able to access this data and it was not stored on their servers.

One of the challenges they encountered was that their systems weren’t integrated into the health care organizations’ pharmacies or electronic health records. The integration piece will be key to any future sustainability.

As technology evolves significantly over the course of, say, a 5-year study, developing the skillset to utilize interactive interventions or a SMART design could be helpful for investigators interested in conducting research in this area.