Text Messaging: A New Tool for Improving Preventive Services

PREVENTION OF INFLUENZA DISEASE THROUGH VACCInation is a public health challenge. Influenza disease causes substantial morbidity and mortality in children, adolescents, and adults; vaccination is the best method to prevent this disease. In light of the increasing understanding of the burden of influenza among children and adolescents and its spread from children to adults, the Advisory Committee on Immunization Practices expanded its influenza vaccination recommendations in 2008 to include all children and adolescents between 6 months and 18 years of age. More than 65 million children and adolescents should be vaccinated annually, usually within a short timeframe of several months when the vaccine is available. While influenza vaccination coverage nationwide has increased, it remains low—only about half of all children and adolescents are vaccinated. In the United States, primary care practices bear the major burden of vaccinating children and adolescents, and because most do not have health care visits during the influenza vaccination season, experts have recommended patient reminder/ recall to remind families to bring their child or adolescent in for vaccination. Patient reminder/recall has traditionally consisted of mailed letters or postcards or telephone calls made by office staff or by autodialer machines that can call hundreds of families per hour. Yet practice-based reminder/ recall is easier to suggest than implement. Many primary care practices do not use reminder/recall because of the logistical challenges in setting up and maintaining these systems. Furthermore, although initial studies suggested a positive effect of reminder/recall on influenza vaccination rates, recent studies of patient reminder/recall targeting low-income populations have found minimal or no effect, in large part because of changing or inaccurate patient telephone numbers and addresses. Thus new strategies are needed for patient reminder/ recall, particularly for low-income populations. In this issue of JAMA, Stockwell and colleagues leverage a rapidly expanding application—text messaging, within a ubiquitous technology—the cellular telephone. They present findings from a randomized controlled trial of text message reminders to low-income families about influenza vaccination. The study was a pragmatic trial located in 4 primary care clinics in New York, New York. These practices are part of a network with a common electronic health record (EHR) that has an institutional immunization information system that links with the EHR and the New York Citywide Immunization Registry, and that was customized to send text messages. The investigators randomized 9213 children and adolescents to receive either a set of text message reminders about influenza vaccination (intervention group) or a single telephone reminder call (usual care group). The first 3 text messages informed parents about influenza and vaccine safety and effectiveness; subsequent text messages provided specific information about Saturday vaccination clinics. The clinical trial noted a modest increase in vaccination rates. Among the 7574 children and adolescents, 43.6% of the intervention group and 39.9% of the usual care group were vaccinated. Ultimately, vaccination rates remained low, but the cost of the intervention also was minimal. The strengths of this clinical trial include its study design, incorporation of a new patient-physician communication technology (text messaging), a focus on a vulnerable urban population, and its application to time-critical vaccination because the vaccine must be administered prior to influenza season. The text message intervention served to both educate and remind parents and was rather aggressive with an average of 5 reminders sent to families. Furthermore, the study was conducted in a setting with integrated information systems that are not yet replicable in many primary care practices. Nevertheless, several methodological features probably diminished the potential effect of the intervention. The control group received 1 automated telephone reminder. While the reminders mentioned Saturday vaccination clinics, they did not mention regular weekday hours, which is when most children and adolescents received their immunizations. Thus, refinements might increase the effect of the intervention. This study highlights the potential for patient reminder/ recall but also its challenges. The potential is substantial, and in the right setting with automated, integrated information systems, text message reminders can target large numbers of patients at relatively low cost. They can be sent from centralized clinical information systems (as in this study), or from state-based immunization registries so that individual practices may not need to create their own patient reminder systems. In fact, immunization experts are currently debating the relative merit of individual practice-based vs system-based pa-