Findings in Relation to the Literature
multiple chronic diseases, T2D, CHD, diabetes
RECRUITMENT, CHRONIC DISEASES, MULTIPLE CHRONIC DISEASES, HYPERTENSION, DIABETES
Previous studies using SMS text messaging suggest that this may be effective in supporting patient management and improving clinical risk factors. The earlier TEXT ME study delivered a similar SMS text messaging program to participants with CHD (messages nearly identical to those for participants with CHD in SupportMe) and demonstrated improvements in multiple clinical risk factor measures, including LDL-C level, BP, BMI, physical activity, and smoking cessation [The lack of improvement in clinical metrics in SupportMe may be due to baseline metrics that were within or close to the guideline targets among many participants. The mean baseline SBP was 128.9 (SD 17.2) mm Hg, and the mean LDL-C level was 2.0 (SD 0.9) mmol/L. In Australian guidelines, for most people with hypertension, a BP target of <140/90 mm Hg is recommended [The involvement of specialist and hospital teams as part of the WSICP may have contributed to the favorable baseline metrics in SupportMe. GPs who referred community patients had greater engagement in the management of T2D and CHD and were supported by care facilitators who helped with guideline management of patients with these chronic diseases [The age of the SupportMe participants, particularly with respect to the participants with diabetes (mean 60.2, SD 11.4 years), might be another factor that influenced the results. The mean age of participants in SMS4BG, Rapid Education/Encouragement and Communications for Health, and CHAT-DM was 47, 56, and 60 years, respectively, so our participants were among the oldest in these studies. The SupportMe CHD participants (mean age 64.0, SD 10.8 years) were also older than the TEXT ME participants (mean age 57 years). Perhaps older patients are less responsive to this mode of engagement as they are less familiar with the regular use of this technology, although our evaluation did indicate that most of the messages were read. It would be interesting to test a similar SMS text messaging program for a younger population with multiple chronic diseases.Some programs have incorporated return messages from participants, which may improve interaction and engagement [We found better self-reported medication adherence with the SMS text messaging intervention. This is consistent with other studies, with a meta-analysis of 16 RCTs showing that SMS text messaging is effective in increasing medication adherence independently of whether 2-way communication is used [Although we did not find an improvement in short-term clinical metrics, the high levels of engagement and acceptability may have other positive implications. Patient engagement and activation have been linked to better health outcomes and patient experience and reduced health care costs [A limitation of this study was the failure to reach the planned sample size for the primary outcome. However, it is unlikely that recruitment of an extra 98 participants would have changed the results to be significantly in favor of the intervention. It was also disappointing that primary outcome data could not be obtained for 10.5% (95/902) of the participants. Although many participants were very engaged, there was also a group in which engagement and follow-up were challenging. Arguably, these are the patients who most require support, and SMS text messaging may not be the optimal means of achieving this. Finally, we accepted blood test results ordered from a range of clinicians performed in different laboratories. In some cases, clinical metrics for participants who were unable to return for review were obtained from their primary physicians. Thus, laboratory testing and some physical measurements were not standardized.The question of whether the SMS text messages could have been better formulated is a vital one. The messages were developed through a proven and rigorous process [