Evaluation of an Automated Text Message–Based Program to Reduce Use of Acute Health Care Resources After Hospital Discharge

Abstract

ImportancePosthospital contact with a primary care team is an established pillar of safe transitions. The prevailing model of telephone outreach is usually limited in scope and operationally burdensome.ObjectiveTo determine whether a 30-day automated texting program to support primary care patients after hospital discharge is associated with reductions in the use of acute care resources.Design, Setting, and ParticipantsThis cohort study used a difference-in-differences approach at 2 academic primary care practices in Philadelphia from January 27 through August 27, 2021. Established patients of the study practices who were 18 years or older, were discharged from an acute care hospitalization, and received the usual transitional care management telephone call were eligible for the study. At the intervention practice, 604 discharges were eligible and 430 (374 patients, of whom 46 had >1 discharge) were enrolled in the intervention. At the control practice, 953 patients met eligibility criteria. The study period, including before and after the intervention, ran from August 27, 2020, through August 27, 2021.ExposurePatients received automated check-in text messages from their primary care practice on a tapering schedule during the 30 days after discharge. Any needs identified by the automated messaging platform were escalated to practice staff for follow-up via an electronic medical record inbox.Main Outcomes and MeasuresThe primary study outcome was any emergency department (ED) visit or readmission within 30 days of discharge. Secondary outcomes included any ED visit or any readmission within 30 days, analyzed separately, and 30- and 60-day mortality. Analyses were based on intention to treat.ResultsA total of 1885 patients (mean [SD] age, 63.2 [17.3] years; 1101 women [58.4%]) representing 2617 discharges (447 before and 604 after the intervention at the intervention practice; 613 before and 953 after the intervention at the control practice) were included in the analysis. The adjusted odds ratio (aOR) for any use of acute care resources after implementation of the intervention was 0.59 (95% CI, 0.38-0.92). The aOR for an ED visit was 0.77 (95% CI, 0.45-1.30) and for a readmission was 0.45 (95% CI, 0.23-0.86). The aORs for death within 30 and 60 days of discharge at the intervention practice were 0.92 (95% CI, 0.23-3.61) and 0.63 (95% CI, 0.21-1.85), respectively.Conclusions and RelevanceThe findings of this cohort study suggest that an automated texting program to support primary care patients after hospital discharge was associated with significant reductions in use of acute care resources. This patient-centered approach may serve as a model for improving postdischarge care.

Health Care Delivery Innovations—Implementation Matters in Understanding What Works

“…Nonetheless, the increase in readmissions among controls had no explanation. 4 The positive result of the 2020 to 2021 study by Bressman et al 4 could have been due to chance, since sample sizes were small, readmission is affected by many factors, and acute care utilization declined more (relative to controls) than in prior studies of transitional care interventions. 6 However, another explanation for the divergent findings in the 2 studies by Bressman et al 3,4 is implementation.…”

“…Furthermore, unadjusted readmission rates increased more at the control practice (6.9% to 11.3%) than they declined at the intervention practice (9.7% to 7.4%). 4 The difference-in-differences method assumes that changes in the control group reflect factors with equal influences in the intervention group; therefore, the increase in readmissions at the control practice site accounted for much of the intervention's apparent effectiveness. To address this concern, Bressman et al 4 added 5 more control practices, and findings were unchanged.…”

“…8 Neither study by Bressman et al 3,4 described the implementation process at study sites or how well practice nurses engaged the texting program, such as the frequency, timing, mode, and quality of responses to patient texts. Moreover, the implementation process and nurse engagement may have differed between the 2020 to 2021 analysis 4 and the 2022 to 2023 trial. 3 Innovations are often first tested in settings with leadership buy-in or a strong local champion.…”

“…Yet there was no difference between the intervention and control groups in 30-day returns to acute care (emergency department visits plus readmissions, 23.9% vs 23.4%; adjusted relative risk, 1.02; 95% CI, 0.92-1.13), or other measures of health care utilization, including primary care visits. 3 Interestingly, Bressman et al 4 evaluated the same texting program in 2020 to 2021 using a rigorous quasi-experimental difference-in-differences study design. At 1 primary care practice, nurses enrolled patients in the texting program during routine transitional care calls.…”

“…The difference-in-differences approach involved calculating, for each practice site, the change from a baseline period to the intervention period in returns to acute care and then comparing these changes between practice sites. 4 The analysis included 1885 discharges, with 430 enrolled out of 604 eligible for the intervention. Methods resembled the trial in most other ways, including context, baseline conditions, intervention design, eligibility criteria, measures, data sources, and funders.…”