REFILE-Automated phone calls useful for some aspects of healthcare

(Corrects paras 18 and 20 to indicate that source (Guzman) is not an MD.)

By Marilynn Larkin

NEW YORK (Reuters Health) - Automated telephone communication systems (ATCS) can change patients' health behaviors for the better in areas such as immunization, screening, medication and test adherence and office visits, although the evidence is weak and challenges such as data protection and confidentiality need to be addressed, Cochrane researchers report.

Dr. Josip Car of Nanyang Technological University in Singapore and colleagues assessed the effects of ATCS for disease prevention and managing specific conditions by searching multiple electronic databases and trial registries for relevant randomized and quasi-randomized trials.

They explain in The Cochrane Database of Systematic Reviews, online December 14, that there are four types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR), ATCS with additional functions such as access to an expert (ATCS Plus) and multimodal ATCS, in which calls are delivered as part of a multicomponent intervention.

The review included evidence from 132 trials, with more than four million participants in several clinical areas. Forty-one studies evaluated ATCS for preventive healthcare, 84 for managing chronic conditions, and seven for appointment reminders.

The team downgraded their level of certainty in the evidence because of the risk of bias for many outcomes. Only 16% of studies had a low risk. Key findings include the following:

- Compared with usual care, ATCS Plus, IVR, and unidirectional ATCS appeared to increase immunization uptake in children (risk ratio 1.25) and, to a lesser extent, in adolescents (RR 1.06). The effects in adults were unclear.

- Multimodal ATCS increased the uptake of screening for breast cancer (RR 2.17) and colorectal cancer (RR 2.19) compared with usual care, and may also increase osteoporosis screening.

- Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls. ATCS Plus probably improves medication adherence compared with control but may have little effect on adherence to tests.

- IVR probably slightly improves medication adherence versus control, and test adherence compared with usual care. There was little or no consistent effect of any type of ATCS on clinical outcomes such as blood pressure control.

- Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and type 2 diabetes.

Only four studies (3%) reported adverse events, and it was unclear whether these were related to the interventions.

Summing up, Dr. Car told Reuters Health on behalf of the Cochrane investigators, "ATCS have positive effects in several important areas including immunization, cancer screening, adherence to medications, physical activity (and) weight management, (but) the quality of the evidence was mixed, and of low quality, and was often lowered because of methodological caveats."

"The effects on smoking cessation were uncertain," he said by email, and there was "little or no benefit" for reducing hypertension.

"Several practicalities need to be mentioned, including data protection and confidentiality, participants' age and preferences, language and dialect/ethnical-cultural differences, integration with electronic medical records, storage and back-ups, server use, staffing, etc.," Dr. Car continued. "Nevertheless these systems have a high degree of adaptability to individuals' needs and requirements, and the technology (e.g., voice recognition) is improving rapidly."

Research on cost-effectiveness, acceptability and safety is needed, Dr. Car continued, considering such factors as participants' health status and geographical location, and features of the intervention, such as the frequency, duration, and intensity of delivery of ATCS interventions.

Dr. Anne Spaulding of the Rollins School of Public Health at Emory University in Atlanta, Georgia, told Reuters Health, "This careful review . . . demonstrates an almost uniformly positive association between automated telephone communication systems (ATCS) and health improvement," although "the effect size of most interventions appeared small," given that the authors use "slightly" or "slight" 147 times to describe improvement.

"The most useful contribution of the manuscript," she said by email, "is a delineation of areas where future research in ATCS technology is needed: measurement of cost-effectiveness, studies comparing multiple modes of ATCS, use of theoretical models to guide interventions, and assessing the certainty of evidence."

Vanessa Guzman, director of Quality Improvement at the Montefiore Health System in New York City, said that at her institution, ATCS have "enabled us to effectively use clinical, claims and self-reported data to identify patients missing, overdue for services, and non-engaged with primary care physicians, and to send general reminders about their health or upcoming appointments."

Since launching the system, she told Reuters Health by email, "We've seen an increase in quality of care measures, patient satisfaction and engagement, (and) office visit show rates."

"Some caveats include the need to have accurate data, including phone numbers and clinical gaps, to effectively identify patient needs or target the correct population," Guzman observed. "A dedicated team that proactively analyzes outcomes and data (and can) modify the process or message to patient over time is required. These caveats have been used to optimize our process, instead of being seen as roadblocks."

SOURCE: https://bit.ly/2hExBQB

Cochrane Database Syst Rev 2016

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