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Patient acceptance of educational voice messages: a review of controlled clinical studies |
Krishna S, Balas E A, Boren S A, Maglaveras N |
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Authors' objectives The authors assessed the effect of automated computer-based telephone messaging technology in delivering health care information to the patients.
Searching Best Evidence, MEDLINE, PREMEDLINE, HealthSTAR, BIOSIS Previews and CINAHL were searched up to July 2000 for reports published in the English language. The reference lists in identified studies were checked.
Study selection Study designs of evaluations included in the reviewRandomised controlled trials (RCTs) and non-randomised controlled clinical trials (CCTs) were eligible for inclusion.
Specific interventions included in the reviewStudies of the use of automated computer-based telephone technology for delivering health care information, advice or reminders to patients were eligible for inclusion. Studies in which a person delivered the message were excluded. The messages delivered in the included studies were on preventive care education and the management of chronic conditions. The former (education) covered immunisations in childhood, compliance with drug treatment, influenza vaccination, screening and testing for tuberculosis, and routine preventive health maintenance. The latter (management) related to hypercholesterolaemia, diabetes, hypertension and congestive heart failure. The systems used in the studies were Diet Adherence Intervention for Dyslipidaemia, Automated Disease Management System (ADMS), Telephone-Linked Computer (TLC) system, Telephone-Linked Communication-Activity Counselling and Tracking system (TLC-ACT), Home Talk, computer-generated phone message, TeleMinder, voice mail, and Healthy Talk-Health screening system.
Participants included in the reviewThe inclusion criteria were not explicitly defined in terms of the participants. The participants in the included studies were adults, adolescents, children and caregivers from a variety of language, ethnic and cultural backgrounds.
Outcomes assessed in the reviewStudies that assessed health outcomes or utilisation of health care resources were eligible for inclusion. The included studies assessed cholesterol level, satisfaction with system, completion of self-assessments, depression, self-efficacy, compliance with medication, blood-pressure control, knowledge of disease, completed immunisations, kept appointments, change in exercise, recall of message, and visits by nurses for home care.
How were decisions on the relevance of primary studies made?The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.
Assessment of study quality Validity was assessed and scored on the basis of study location, characteristics of the participants, randomisation, and the methods used to collect and analyse the data. The maximum possible score was 100 points. The review authors developed the scale. The validity criteria were extracted onto a standardised form. The authors did not state how many reviewers performed the validity assessment.
Data extraction The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.
Data were extracted on the institution conducting the study, the characteristics of the patient group targeted, and the intervention. The intervention details included the timing and frequency of messages, the methods used to construct messages, the methods of delivering messages, and factors considered when developing the automated systems. Data on the outcomes measured, significance and direction of effect, and difference in effect size between the intervention and control groups were also extracted.
Methods of synthesis How were the studies combined?The studies were synthesised in the narrative, under the headings of technical features of the automated systems and factors that influenced construction of the systems (i.e, message content, message length, frequency of calls, level of interactivity, number of repetitions of message, level of personalisation of message, and acceptance by patients and caregivers).
How were differences between studies investigated?Differences between the studies were not discussed.
Results of the review Sixteen RCTs (at least 17,500 patients or carers) and 3 non-randomised CCTs (471 patients or carers) were included. The sample size ranged from 16 to 3,158.
The quality scores ranged from 40 to 81 points among RCTs and from 24 to 54 points among non-randomised CCTs.
Most studies (more than 80%) found that the use of automated computer-based telephone technology significantly improved health outcomes.
One CCT (6 patients) found that computer-generated messages reduced missed scheduled medications and reduced mistakes in the quantity of drugs.
Two RCTs (5,166 patients) found that the TeleMinder system significantly reduced missed appointments at a tuberculosis clinic by 12.9% (P<0.001) and 9% (P<0.01), respectively.
One RCT (248 patients) found that an ADMS significantly improved health-related quality of life and ability to self-care, and decreased depression, among low-income diabetic patients.
One RCT (267 patients) found that automated weekly phone calls to elderly people significantly increased compliance with medication and improved blood-pressure control.
One RCT (68 patients) found that an interactive voice mail system (TLC-ACT) increased the duration of walking by 46 minutes per week in women (P<0.05).
One RCT (252 patients) found that the use of an ADMS resulted in diabetic patients completing 77% of self-assessments. It also helped to identify people with high blood sugar.
One RCT (189 patients) found that repetition of the message increased the accuracy of answers to questions about the message. The patients and caregivers acceptance of and satisfaction with the systems were high: 69% of users rated the system as very satisfactory (1 RCT, 267 patients); 84.9% of users would like the system to remind them of future appointments (1 RCT, 37 patients); all users of the Home Talk system were satisfied or very satisfied and 95% would use the system again (1 RCT, 37 patients); this RCT also found that nurses were very satisfied with the ability of the system to alert them about changes in the patients' condition.
Cost information Studies that assessed cost-savings of the intervention were eligible for inclusion. One study found that automated immunisation reminder systems were more cost-effective than mailed postcard reminders: the average cost per reminder was $1.47 versus $2.28, while the incremental cost per extra immunisation was $4.06 versus $12.82 (the costs did not include the system cost). One study found that a TLC system that improved medication adherence and blood-pressure control was cost-effective: the cost-effectiveness ratio for change from before use of the system was $5.42 per 1% increase in adherence.
Authors' conclusions Automated telephone communication systems can improve quality of health care and are acceptable to patients.
CRD commentary The review question was clear in terms of the study design, intervention and outcomes. Several relevant sources were searched, but the search terms were not stated. Limiting the included studies to those in English may have omitted some relevant studies. No attempt was made to locate unpublished studies, thus raising the possibility of publication bias. The methods used to select the studies, assess validity and extract the data were not described. Hence efforts made to reduce errors and bias cannot be judged. Validity was assessed and scored using defined criteria, but the relative weight given to each criterion in the scoring system was not reported and the authors used a scale developed by themselves rather than a validated scale.
Some relevant information on the included studies was tabulated or described in the text. Given the variety of automated systems used and the behaviours targeted, a narrative synthesis was appropriate. However, the text did not mention results from all of the RCTs; only positive results appear to have been presented. Although the validity scores for all of the included studies were presented in tabular format, there was no mention of flaws in the individual studies that would allow the quality of the evidence presented to be assessed. In addition, higher quality evidence was not highlighted and there was no assessment or mention of differences in results among the studies. The evidence presented appears to support the authors' conclusion, but a more rigorous synthesis would have strengthened the reliability of the evidence.
Implications of the review for practice and research Practice: The authors stated that automated phone messages can increase compliance with medication and improve health outcomes.
Research: The authors did not state any implications for further research.
Funding National Heart, Lung and Blood Institute, grant number 1 F31 HL 10205-01; National Library of Medicine, grant number LM05545; Information Society General Directorate of the European Commission, grant number CHS IST-1999-13352.
Bibliographic details Krishna S, Balas E A, Boren S A, Maglaveras N. Patient acceptance of educational voice messages: a review of controlled clinical studies. Methods of Information in Medicine 2002; 41(5): 360-369 Indexing Status Subject indexing assigned by NLM MeSH Automation; Controlled Clinical Trials as Topic; Humans; Patient Acceptance of Health Care; Patient Education as Topic /methods; Randomized Controlled Trials as Topic; Reminder Systems; Telecommunications; User-Computer Interface; Voice AccessionNumber 12003000173 Date bibliographic record published 30/06/2004 Date abstract record published 30/06/2004 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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