title: A text messaging intervention to improve heart failure self-management after hospital discharge in a largely African-American population: before-after study.
abstract: BACKGROUND
  There is increasing interest in finding novel approaches to reduce health disparities in readmissions for acute decompensated heart failure (ADHF). Text messaging is a promising platform for improving chronic disease self-management in low-income populations, yet is largely unexplored in ADHF.
  
  
  OBJECTIVE
  The purpose of this pre-post study was to assess the feasibility and acceptability of a text message-based (SMS: short message service) intervention in a largely African American population with ADHF and explore its effects on self-management.
  
  
  METHODS
  Hospitalized patients with ADHF were enrolled in an automated text message-based heart failure program for 30 days following discharge. Messages provided self-care reminders and patient education on diet, symptom recognition, and health care navigation. Demographic and cell phone usage data were collected on enrollment, and an exit survey was administered on completion. The Self-Care of Heart Failure Index (SCHFI) was administered preintervention and postintervention and compared using sample t tests (composite) and Wilcoxon rank sum tests (individual). Clinical data were collected through chart abstraction.
  
  
  RESULTS
  Of 51 patients approached for recruitment, 27 agreed to participate and 15 were enrolled (14 African-American, 1 White). Barriers to enrollment included not owning a personal cell phone (n=12), failing the Mini-Mental exam (n=3), needing a proxy (n=2), hard of hearing (n=1), and refusal (n=3). Another 3 participants left the study for health reasons and 3 others had technology issues. A total of 6 patients (5 African-American, 1 White) completed the postintervention surveys. The mean age was 50 years (range 23-69) and over half had Medicaid or were uninsured (60%, 9/15). The mean ejection fraction for those with systolic dysfunction was 22%, and at least two-thirds had a prior hospitalization in the past year. Participants strongly agreed that the program was easy to use (83%), reduced pills missed (66%), and decreased salt intake (66%). Maintenance (mean composite score 49 to 78, P=.003) and management (57 to 86, P=.002) improved at 4 weeks, whereas confidence did not change (57 to 75, P=.11). Of the 6 SCHFI items that showed a statistically significant improvement, 5 were specifically targeted by the texting intervention.
  
  
  CONCLUSIONS
  Over half of ADHF patients in an urban, largely African American community were eligible and interested in participating in a text messaging program following discharge. Access to mobile phones was a significant barrier that should be addressed in future interventions. Among the participants who completed the study, we observed a high rate of satisfaction and preliminary evidence of improvements in heart failure self-management.
authors.affiliation: Section of General Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL, United States. shantanu.nundy@gmail.com
authors.forename: Shantanu
authors.initials: S
authors.lastname: Nundy
authors.forename: Rabia R
authors.initials: RR
authors.lastname: Razi
authors.forename: Jonathan J
authors.initials: JJ
authors.lastname: Dick
authors.forename: Bryan
authors.initials: B
authors.lastname: Smith
authors.forename: Ainoa
authors.initials: A
authors.lastname: Mayo
authors.forename: Anne
authors.initials: A
authors.lastname: O'Connor
authors.forename: David O
authors.initials: DO
authors.lastname: Meltzer
mesh_terms: D044383:Black People; D005260:Female; D006333:Heart Failure / Q000208:ethnology / Q000628:therapy*; D006760:Hospitalization; D006801:Humans; D008297:Male; D010351:Patient Discharge; D010865:Pilot Projects; D011446:Prospective Studies; D012648:Self Care; D060145:Text Messaging; D001741:Black or African American