An investigation into whether using text and email to remind patients about their blood test appointments reduces delays and improves monitoring
Ludlow, H. et al (2009) Using email and text messaging to remind patients to have blood monitoring tests. Nursing Times; 105: 28, early online publication.
Background: Patients with inflammatory bowel disease may need immunosuppressant therapy to help control their disease. This involves frequent blood tests to ensure results are within safe limits.
Aim: To investigate whether the use of email and text messaging to remind patients to have blood tests might result in better compliance than using more conventional methods of communication.
Method: Patients were divided into three groups through self-selection: one who wanted email reminders; one who wanted texts; and a control group who received telephone calls and occasionally letters. Data on the number of days of delays and significant delays in monitoring was collected and analysed.
Results: In all groups receiving email, text messages or traditional phone call reminders, delays were reduced. Patients in the email/text messaging groups overwhelmingly found these contact methods helpful and wished it to continue.
Discussion and conclusion: The use of email and text messaging helped to reduce delays in monitoring and patients who selected these methods found it helpful. We aim to continue this service.
Keywords: Long-term conditions, Email, Text messaging, Communication
- This article has been double-blind peer reviewed
Helen Ludlow, MSc, BSc, RGN,is inflammatory bowel disease specialist nurse; Joanna Hurley, MBBCh, MRCP, is specialist registrar, gastroenterology; Sunil Dolwani, MD, MRCP, is consultant physician and gastroenterologist; all at University Hospital Llandough, Cardiff and Vale NHS Trust.
- Patient reminders via text messaging or email can reduce delays in the monitoring process and patients find these contact methods helpful.
- Email and text are popular and useful means of communication. They may be useful in managing other long-term conditions.
- Those considering a similar initiative should ensure their trust’s data protection department is involved in setting up the service.
Patients with inflammatory bowel disease (IBD) are often treated with immunosuppressant agents to help control their disease. These include azathioprine, mercaptopurine, methotrexate and biological therapies, all of which have seen a marked increase in their use during the last decade (Viget et al, 2008).
Due to the nature of immunosuppressant therapy, side-effects such as leukopenia and raised liver function test results are relatively common.
Adverse events with the thiopurines (azathioprine and mercaptopurine), including blood dyscrasias and intolerance such as nausea and arthralgia, may lead to discontinuing treatment in 9–28% of patients (Hindorf et al, 2006).
Generally, patients will be aware of symptomatic side-effects such as rashes and flu-like illnesses and so be able to inform their healthcare professional. However, potentially more severe problems such as myelosuppression (in which bone marrow activity is reduced, resulting in fewer blood cells) may not become apparent until either shown with blood tests or when patients become seriously unwell.
The British National Formulary (2009) states that monitoring of blood tests for those patients on a stable dose of azathioprine should be done at least every three months, although there is great variation in practice (Gisbert and Gomollon, 2008).
Our departmental guidelines suggest monitoring a full blood count and liver function tests every two weeks following initiation and during dose escalation, then on a two-monthly basis once the patient is on a stable dose.
Our immunosuppressant monitoring service
Before the IBD nurse role was introduced, monitoring of patients on immunosuppressants was done rather inconsistently, either by GPs or opportunistically at clinic appointments.
This did not provide regular monitoring as per departmental guidelines and it was occasionally unclear about where overall responsibility for safety monitoring lay.
This situation became apparent early on in the first few months of the IBD nurse’s role, where areas for improvement were identified, as well as the need for a high-quality monitoring service to benefit patients, GPs and the hospital-based IBD team.
Guidelines were agreed with the consultants and a system of reminding patients by either telephone or letter started. Patients were asked to inform the nurse when blood tests had been taken and the results were checked and noted on a filing card system. This provided a way of highlighting abnormal results and of liaising with patients and GPs about any treatment concerns.
Although this worked reasonably well, it became quite time-consuming. Many patients receiving these medications were of working age so were not available during the day to answer telephone calls. Messages left on answering machines were often rather vague to protect patient confidentiality and this reduced their effectiveness as reminders to patients. Letters were sent where telephone contact was not possible but this was time-consuming and used further resources in the trust.
It became clear that a better method of reminding patients was needed. Given the perception that methods of communication such as text messaging and email are now widely accepted by society, the idea of using these methods was considered.
We wanted to investigate if using text or email helped to improve the service we could offer patients and to reduce the time delays of blood tests.
The use of email and mobile phones is increasing constantly in the UK. In 2005–2006, 59% of all UK homes had a computer, rising to 67% in 2006–2007 (Wyatt, 2008). These numbers are expected to continue climbing. An average of 6.5 billion text messages are sent each month in the UK (Mobile Data Association, 2008).
Many people now use these communication methods as a regular part of their daily lives. They provide a convenient way of sending and leaving messages to be read at the receiver’s convenience.
There are also many published reports of healthcare teams contacting patients through these methods to help in healthcare management.
Rodgers et al (2005) carried out a trial in New Zealand involving 1,705 smokers in a smoking cessation programme. Those allocated to the group who received supportive text messages had higher quit rates than others.
A similar project looked at improving diabetes management in young people via a text messaging support system (Franklin et al, 2006). Encouraging young people by text messaging to use their inhaled steroids for asthma management has also produced encouraging results (Neville et al, 2002).
Studies using text messaging to remind patients about hospital appointments have shown successful results in trials. Leong et al (2006) and Downer et al (2005) both compared clinic attendance rates between those receiving text reminders and those who did not; non-attendance figures were significantly lower when text messages were used.
Once we had agreed to trial these communication methods, we made a funding application and the trust awarded a research and development grant. This meant we could buy a relatively cheap mobile phone with texting capability and ‘pay as you go’ running costs for one year.
The South East Wales research ethics committee and the trust’s research and development department gave ethical approval. The trust’s Caldicott guardian also approved the project, as data protection was a potential issue.
Patients established on a stable dose of azathioprine or mercaptopurine, and so needed blood tests at two-monthly intervals, were approached either during clinic visits or by letter.
A patient information leaflet clearly explained the trial’s purpose. It also highlighted important data protection principles (for example, a family member may read messages or the mobile phone could be lost).
Patients were also advised that these methods were only to be used as a reminder service and not for any other reason such as advice on their condition. The regular telephone advice line number for all other contact purposes was clearly printed on this leaflet.
The total number of patients invited to participate in the study between September 2007 and August 2008 was 126. Each was on a stable dose of either azathioprine or mercaptopurine. Newly started patients having their medication regimen titrated were not included in the study as it was felt that traditional telephone contact was important in the initial stages in case of side-effects or other problems.
Of the 126 patients, 61 had ulcerative colitis, 62 had Crohn’s disease and three had indeterminate disease. Of the total group, 46 indicated they would like to receive the reminder via email, 43 wanted text messaging and 37 did not wish to take part (n=27) or did not reply (n=10). The non-participating group acted as a control group. This group received telephone calls (and occasionally letters if they could not be contacted on the phone and the delay was too long).
The median age of the email group was 41 years (22 women, 24 men); in the text group it was 40 (27 women, 16 men); and in the non-participant group was 61 (22 women, 15 men). All were aged over 18.
Further analysis of the ‘did not want to take part’ group showed that 22 of the 27 people who declined to take part did so because they did not have a computer or mobile phone. The median age of those in this category was 64.5 years. One person felt these communication methods were too intrusive and four people did not give a reason.
Before this study, the monitoring process (telephone calls and so on) was spread throughout the week and took around 5–6 hours per week. A card filing system, used before, during and after the study, allowed clear identification of which patients were due to have tests.
During the study, a Monday morning session was set aside to contact patients via their chosen method the week before the blood test was due, to give them time to make arrangements to have the tests taken, which were usually done at their GP practice or local hospital.
Patients were then reminded again the week the test was due and also the following week if no results were available, which indicated they had not had their test.
If they had still not had the tests taken at the end of the second week then a telephone call was made to make contact. On two occasions, the message had not been received, because of the loss of a mobile phone and a change of number.
Pre-study delays in monitoring
We aimed to compare the length of delays in blood tests before the IBD nurse was in post and before the text/email study started. This would give an indication of any change in service once the nurse was in post and would provide a further benchmark with which to compare study results.
Patients who went on to receive email reminders had a maximum delay of 144 days in having their blood tests taken before the IBD nurse was in post.
After the introduction of this role, this group’s maximum range actually increased, although this was probably skewed because there were significant compliance issues with one patient. Excluding that patient, the maximum delay was 48 days (with seven episodes of a delay of at least 28 days).
Patients in the text messaging group had a pre-nurse maximum delay of 186 days which fell to a maximum of 73 days (nine episodes of at least 28 days’ delay). Those in the control group had a pre-nurse delay of a maximum of 307 days which fell to 64 days (14 episodes of at least 28 days’ delay).
These figures show that, following the introduction of the IBD nurse, there was a significant reduction in blood test delays. We hoped the study would show further improvement.
During the study, data was collected on the number of contacts needed for each monitoring episode and the number of days of delays from two months since the last blood test.
A comparison was made between the numbers of delays >28 days both before and during the study. The results are shown in Table 1.
Table 1. Delays of >28 days before and during the study
|Bold figures – median delays|
Light figures – range
|Days late before|
IBD nurse post
|Days late before|
|Days late during study|| 2|
|Delays >28 days before|
|Delays >28 days during|
Email group: the number of reminders needed before and during the study stayed the same, as did the median number of delays recorded. The maximum delay fell from 240 days (144 pre-IBD nurse in post) to 37 days, and the episodes of delay >28 days fell from seven to three.
Text group: the number of reminders needed fell slightly during the study from a median of two to one. The delay before the study was a median of four days, which fell to two during the study. The episodes of delay >28 days also fell from nine to five.
Control group: The number of reminders before and during the study remained the same at a median of one. The delay before the study was a median of 5.5 days which fell to one during the study. The episodes of delay >28 days also fell from 14 to four.
The results showed an improvement in all three groups in the number of days’ delay and the number of significant overall delays (over 28 days), although the text message and email groups had fewer delays than the control group. The general improvement may have been due to reminders being more organised than previously.
Across all groups, a questionnaire was sent out towards the end of the study to all patients originally included who were still undergoing monitoring (n=68). Fifty-four questionnaires were returned, and all said they found the new contact methods helpful and wanted them to continue.
It became obvious that a system needed to be in place when tests were still not carried out despite reminders. We found on two occasions that the text message had not been received and this only came to light following a telephone call.
The reasons given by those patients who did not want to take part in the study also provided evidence that the option of telephone reminders needed to be available.
The average age of those who did not own a computer or mobile phone was 64.5 years, compared to an average age of 41 for the email and 40 for the text group.
However, it must not be assumed that all older people do not have access to these modern facilities – the eldest person who chose email was 79 and the eldest who chose text messaging was 74.
As patients self-selected their preferred means of contact, the groups were not randomised so the control group was not a true control. This meant that a group may have had older participants or have had the disease and treatment for longer so may have been more used to regular monitoring.
As the whole monitoring service became more organised, the group receiving telephone reminders were probably contacted more often than previously, thus improving the delays in this group as well as those having additional input.
The use of email and text messaging helped to reduce delays in blood test monitoring and those patients who selected these methods found it helpful.
Such methods improve contact with many patients who are at work during the day. This also means fewer messages are left on answering machines, reducing the possibility of lost messages and breaches of confidentiality.
The study also identified that reminding patients with these alternative methods was efficient and cost-effective. A basic model of mobile phone is relatively cheap (ours cost £29.99 and currently retails at £19.99), and text messages are cheaper to send (around 5p) than calls to mobile phones (around 10p).
Time management was significantly improved as it is quicker to send text messages than to make telephone calls – which can often turn into lengthy conversations.
Our study has proved extremely beneficial to both patients and the nurse running the monitoring service. This has potential implications for developing a patient-tailored and streamlined monitoring service. It also underlines the significant positive impact that the IBD specialist nurse can have on managing this long-term condition.
We anticipate that a similar service would be helpful in other areas of chronic disease management.
This study was funded by a research grant from the research and development department at Cardiff and Vale NHS Trust. We would like to thank: John T. Green and Jill Swift, consultant physicians and gastroenterologists, University Hospital Llandough; and all those patients who took part in the study.
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