Pilot feasibility and staff acceptability of adding question prompt list links to SMS appointment reminders: a mixed methods study

Abstract

Introduction

Question prompt lists (QPLs) show considerable benefits for engaging patients in their healthcare and have previously been implemented with success in lower health literacy populations. QPLs are most valuable just prior to a health care consultation. One method of implementation is to provide QPL links to patients within SMS appointment reminders. The aim was to pilot and assess the feasibility and staff acceptability of implementing QPLs into SMS appointment reminders in a setting where patients attend regularly.

Methods

Appointment reminders for patients attending a public addiction medicine outpatient clinic in Western Sydney, NSW Australia included a weblink to an evaluated QPL, within the Ask Share Know Questions website over a 3-month period. Website access data were collected, implementation costs measured, and clinic staff completed interviews about the impact on service delivery and consultation content.

Results

The website was accessed 22 times via the link during the study period by 13 people (388 SMS sent, additional cost AUD$15.52). Staff were positive about the potential impacts of patients asking questions and receiving more information. Few noticed any impact of the study on service delivery or patient question-asking behaviour. Suggestions for increasing use and incorporation into usual care were made by staff.

Discussion

Whilst cost is feasible, and staff were encouraging about the incorporation of QPLs in routine clinical care, there was low uptake of the weblink by patients. High mobile phone turnover of patients and increasing awareness of scams and government messaging not to click SMS links are likely factors reducing future utility of information delivery to patients via SMS. Using alternate strategies to encourage access to the ASK website such as posters in the clinic may have greater impact. Staff training and education are also required for future successful implementation at scale.

Conclusion

Integrating links to the ASK Questions QPL into SMS appointment reminders sent to patients of an addiction medicine outpatient clinic is feasible and is acceptable to staff. There are several likely barriers at present, which need further investigation prior implementation of QPLs in addiction medicine clinics.

PLAIN LANGUAGE SUMMARY

Patients want easy access to tools to help them make decisions when they see their healthcare professional. This pilot study shows that adding a link to a three question prompt list is a small cost and that staff are happy to support its use. The Australian government is telling people of the risks of opening links in SMSs so other ways of getting prompt lists to people near the time of their appointment will be needed.

Keywords:

• Question prompt list
• health literacy
• implementation science
• shared decision making
• addiction medicine

Background

Shared decision making (SDM) is part of clinical care standards in Australia (Australian Commission on Safety and Quality in Health Care, 2021) and internationally (Bomhof-Roordink et al., 2019). Encouraging patients to ask questions and participate in decisions about their health care is key to achieving these standards. SDM involves collaboration between the healthcare practitioner and the patient to share knowledge about the options and the evidence for the options; the risks and benefits to the patient; the patient’s preferences relevant to the decision; discussion about who will make the decision; and making the decision (Bomhof-Roordink et al., 2019). Questions may be asked by the patient to clarify the options, benefits and harms and likelihood of these can facilitate engagement in making decisions about their health care (Stiggelbout et al., 2015).

Question prompt lists (QPLs) are lists of questions designed to support patients to ask questions in healthcare consultations to aid them in getting the health information they need to make decisions about their health (Sansoni et al., 2015). Research has found QPLs to be effective in facilitating increasing the number of questions patients ask and improving the quality of the information they receive from healthcare professionals, without increasing consultation time (Kinnersley et al., 2007; Sansoni et al., 2015; Shepherd et al., 2011). However routine implementation of SDM and QPLs lags behind evidence of their potential benefits (Sansoni et al., 2015; Scottish Government, 2017; Tracy et al., 2022).

Many QPLs have been developed and studied for specific conditions, most significantly in cancer care settings (Brandes et al., 2015) but also in surgery (Renovanz et al., 2019) and paediatrics (Ahmed et al., 2017) amongst many others. There has been considerable interest and investment in more generic, non-condition specific QPLs over the past two decades (Agency for Healthcare Research & Quality, 2012; Australian Commission on Safety & Quality in Health Care, 2017; National Patient Safety Foundation (NPSF), 2018; Rexwinkel et al., 2021). One example is the US Agency for Healthcare Research and Quality QPL “Question Builder” launched in 2007, which has been adapted by the Australian Commission on Safety and Quality in Health Care and Healthdirect Australia Ltd. for use online in Australia since 2017. Assessment of the use of Question Builder found that the most commonly selected question was “Do I need any tests?,” overall however, users favoured questions which helped clarify their options, “What are my treatment options?” (Tracy et al., 2020)

Our research work has also focused on a brief three question list “Ask Share Know Questions” (ASK Questions, Figure 1) (Tracy et al., 2022), designed specifically to support people to ask questions to clarify their options. ASK Questions has been shown to be effective in increasing question asking and improving the quality of information patients receive (Shepherd et al., 2011). The ASK Questions have also been evaluated as part of an education program with lower health literacy populations (Scottish Government, 2017) and are feasible when made available in waiting rooms of Family Planning NSW clinics (Brandes et al., 2015). Further research using the ASK Questions found that patients wanted to have more ready access to the resource prior to their appointment and that receiving a link was regarded as endorsement by the healthcare provider to use the tool (Tracy et al., 2022). QPLs are most valuable just prior to a health care consultation (Lewer et al., 2020; Tracy et al., 2022). One way of implementing this is to provide links to patients when they receive their appointment reminder via SMS.

Figure 1. Ask share know questions from askshareknow.org.au with permission.

To pilot the feasibility of the addition of an SMS link to a QPL tool we sought a setting where SMS appointment reminders were already in use. In addition, we chose a population known to have a desire to have more control over decisions about their treatment (Muthulingam et al., 2019) and which currently has inequitable health outcomes. In Australia, the life expectancy for those on opioid dependence treatment is approximately 15 years less than the general population with the main cause being non-communicable diseases (Lewer et al., 2020). Other similar populations to our study population have been found to have lower health literacy levels (Degan et al., 2019). In addition, inadequate health literacy about treatment programs is a known barrier to accessing services (Hall et al., 2021). Furthermore, due to stigma and other barriers people in opioid dependence treatment are less likely to a regular general practitioner, further fragmenting their health care and reducing opportunities for screening and preventive healthcare (Ingram et al., 2023). This population could reap potential benefits from resources that support health literacy, health care engagement and question asking (Yarborough et al., 2016).

The aim of this pilot study is to test the feasibility of implementing links via SMS to the ASK Questions into clinical practice. Future studies planned for this program of research with our research partners will involve implementation of patient targeted shared decision-making resources at scale with data linkage to patient reported and clinical data.

Aim

This study aims to assess the feasibility, cost and staff views of the acceptability and appropriateness of implementing tools to support shared decision making via links to an online QPL, the ASK Questions, into short messaging service (SMS) appointment reminders in a drug health outpatient clinical service.

Methods

Setting

We designed an implementation feasibility pilot to provide access to the Ask Share Know Questions in a Western Sydney public addiction medicine outpatient clinic. Patients attend clinical reviews approximately every three months and SMS appointment reminders are currently sent the day prior to the appointment. Clinical reviews are usually conducted in person, with telehealth made available during the COVID-19 pandemic (Degan et al., 2019; Hall et al., 2021; Lewer et al., 2020).

Design

Our implementation and evaluation plan was guided by the Consolidated Framework for Implementing Research framework (Consolidated Framework for Implementation Research, 2023). This framework is based on understanding and responding to the influences of the inner setting (users), the outer setting (system) and the processes involved to shape the intervention to a workable and sustainable addition to clinical practice.

This feasibility pilot study focused on four implementation outcomes (acceptability, appropriateness, feasibility and cost) drawn from the Proctor Implementation Outcomes framework which specifically focuses on understanding implementation processes (Consolidated Framework for Implementation Research, 2023; Shepherd et al., 2019).

There are existing SMS systems to inform patients of their scheduled appointment and reminders being used for patients attending drug health services at Mount Druitt Hospital Centre for Addiction Medicine. Links to ASK utilised this existing service with the usual message remained unchanged other than to include a single sentence to this message “We welcome your questions about your health care. Here is a link to some questions you may like to ask.” This included a hyperlink to the ASK homepage (askshareknow.org.au) which has been optimised for viewing on phone platforms as the messages were to be received by phone.

Links were added from early February to mid-May 2023 to all SMSs. During the first half of the time period (8 Feb–3 April) the additional text was at the end of the SMS; from 4 April to 10 May, the additional text was placed after the greeting near the start of the SMS. The total time frame of just over three months was chosen so that most patients who had ongoing contact with the service would receive the link at least once (appointments are generally every 2–3 months). Staff of the clinic were notified of the change to the SMS at the time the link was added. Staff also attended a brief in-service in the week before adding the links which included information about the pilot study’s aims to test practical aspects of adding the link as well as providing staff with information about the ASK website.

We used mixed methods to address the study aims. Ethics approval for the study was obtained from WSLHD ethics (2022/ETH00647).

Quantitative data analytics

De-identified data of the number of SMSs sent during the study period with links to the ASK website were obtained from WSLHD DHS’ data. To assess feasibility and basic usability of the links we used website data analytics (Google Analytics) embedded in the website to collect data of the number of accesses to the website via links from SMSs.

Additional deidentified website data analytics from the ASK Questions website including time spent on the site and clicks to any other parts of the site were collected. This data provides a proxy measure of engagement with the resource from the SMS. No data collected by use of the website is identifiable back to any individual.

Service staff qualitative interviews

Semi structured interview guides were developed using the Consolidated Framework for Implementing Research framework and in line with guidance of the Standards for Reporting in Implementation studies (Pinnock et al., 2017) in ensuring that reporting of intervention and implementation attributes are clearly identifiable.

Participants

Staff stakeholders of the implementation (n = 23; administrative, nursing, medical, allied health) at the service were invited to take part in a brief semi-structured interview via a service wide staff email invitation which included the Participant Information Statement and Consent (PIS). Staff were sent the email two weeks prior to the time the links were removed from the SMS reminders and interviewed after completion of the SMS intervention. Participating staff were eligible for entry into a draw for a $50 grocery store card following the conclusion of the study data collection and interviews.

Participants’ demographic data was collected at the time of interview including staff professional role (e.g., nursing, administration, medical, allied health), identified gender, years of experience in their field and years of employment at the service.

Interviews and analysis

Interviews were predominantly conducted face-to-face on site at the clinic by a member of the research team, KS, not previously known to clinic staff. Three interviews were conducted via videoconference/phone (as some staff who wanted to participate work part time). The following areas were explored with staff: their experiences and perceptions of the impact of the intervention, any positive or negative issues associated with the intervention or impact of the intervention e.g., patients asking more questions, asking about the link etc., and any flow on impacts to usual service delivery; and any general thoughts/experiences about QPLs in the clinical setting. (See supplementary attachment: “Semi-structured interview guide”)

Interviews were recorded, transcribed and de-identified prior to analysis to minimize bias and identification of individuals during analysis. Data were analysed using thematic analysis as described by Braun and Clarke (Braun & Clarke, 2013). All transcribed deidentified interviews were coded by two (KS and MT) of the three authors, an iterative approach to coding was used and codes and themes were discussed at regular intervals during coding. Further thematic analysis of codes to arrive at the final themes was completed as a team.

Reflexivity statement

We acknowledge that one of the authors (MT) is a staff member of the service. All invitations to participate were sent to staff via central administrative staff. KS was chosen to interview staff as he was not known to staff. All attempts to de-identify transcripts were made to minimize bias in coding and analysis. Interpretation of some comments made by staff was able to be discussed between authors due to detailed understanding of the context by MT.

Results

SMS numbers and costs over the study period

SMS data – 239 messages were sent in the first 8 weeks where the additional text and link were placed at the end of the SMS, and a further 149 were sent over the following 5-week period where the link was moved closer to the start of the SMS (before routine information about COVID-19 procedures).

The cost of the additional text added to the SMSs was $0.04 Australian dollars (AUD) per message with a total over the 3 months of AUD$15.52. Total cost of SMSs AUD$85.36 (AUD$0.22 per message).

Website data

Analysis of the Google Analytics of askshareknow.org.au website showed 22 accesses of the site via the SMS link (via “clicks” on the link) during the study period. Of these accesses to the site, 18 spent more than 1 minute on the site. There were 13 unique people (devices) who received the SMS link and accessed the website via the link. Unit cost per access of the addition of the links was AUD$0.71.

Whilst the link was situated at the end of the SMS (the first half of the three months) 60 (25%) responded to the appointment reminder (by sending a “Y” or “N” back to the clinic) and 6 (10% of respondents) accessed the ASK link. There were 15 “clicks” on the link to the website in this period. During the second half of the study when the link was nearer the start of the SMS 30 (20%) responded to the appointment reminder and 7 (23% of respondents with 7 “clicks”) accessed the website via the link. The background rate of responses to appointment reminders in the seven months prior to the study period was 32% (i.e., a reply to the SMS with Y or N was received by the clinic).

Participant demographics and qualitative data

All staff who responded to the invitation were interviewed. Interviews with 16 participants were conducted over a three-week period starting mid-May 2023. Three interviews were conducted via phone, the remainder were face-to-face at the clinic. Interviews were brief, range 5–15 minutes (mean 8 minutes), excluding time for consent and collection of demographic data.

Our participants’ experience in their role ranged from 1 to 24 years (mean 9.8 years, median 10 years) with a total of 59 years of experience working at the service (range 1–11 years, mean 3.7 years, median 2 years). One quarter of the participants identified as men; the rest were women. Three participants were from the allied health team, nine from the nursing team, one member of the administrative staff (admin) participated and three doctors were interviewed, this was closely proportionate to staff employed at the service.

Themes

The themes from our interview data cover the practicalities of implementing links into SMS appointment reminders for patients but also describe the environment of the implementation in terms of the patient population, the usual question asking behaviour and SDM processes at drug health services and how that might be supported. Staff participants expressed practical barriers and opportunities to support SDM with a patient population with which they have deep knowledge and experience of clinical interactions.

Theme 1. “Our patient cohort is yes, a unique mix”

Staff interviewed described the nature of the interactions between the service and patients who attend. Many patients have had a very long connection to the clinic, “some of them have been on program, like for ten, 20 years.” (P11, nursing) Participants described that clinic patients were “often a disempowered, neglected group who are used to having no voice” (P14, medical) and “very vulnerable.” (P12, admin) They described them with empathy, “some of our clients… can’t read them (the SMSs) or write. And sometimes it might be overwhelming” (P8, nursing) and were cognizant how the service may be viewed by patients:

…most of our patients coming here, their priority is just to really, you know, get the treatment. It’s not really their priority to look at other things that’s going wrong unless it’s life and death or unless it’s really, you know, painful. (P7, nursing)

In addition, staff noted that “people have a lot of other poorly controlled diseases that they don’t really understand.” (P4, nursing) and the service responded to their needs in a bespoke way “that’s the sort of relationship we have that we are encouraging and they basically use us as resources.” (P3, nursing)

Theme 2. SDM and question asking in drug health – usual behaviour and suggestions for supporting SDM and QA

This theme has three subthemes which explore how staff experienced the usual question asking behaviour of patients, the additional challenges and considerations raised when considering how to respond to the ASK questions and how well the service was placed to address patient questions and engage in SDM.

Subtheme 2.1. Usual question asking behaviour

Participants described the ways they had observed patients accessing information, for instance, “a lot of these patients talk to each other.”(P3, nursing) They had also had experiences of patients asking them about treatment choices, “You do have patients asking you, you know, ‘can I can I switch to another treatment?’ or, ‘I heard that this has better outcomes’ and ‘I don’t want to do this because, you know, it might be more suitable for my lifestyle’.” (P3, nursing) Overall, there was a sense that “I think now they’re pretty open to (asking questions) they ask us things when they need to” (P11, nursing) but that there was always room for improvement, “Well, patients often arrive with a whole set of questions and I guess – and this is something that I think we don’t do well enough in medicine in general and that includes drug and alcohol. I’d like to think we do it a bit better in drug and alcohol.” (P14, medical)

Subtheme 2.2. Fit and support of drug health services for question asking and SDM

Whilst almost no staff noticed a change in question asking behaviour during the study, they were positive about supporting question asking and SDM:

Well, I’d be happy that they’re asking these questions, yeah… I would be more than happy to answer them. I wish patients would ask more of these questions… (P15, medical)

They also recognised that the ASK Questions could support patients’ right to questions asking,

Yeah, I think it’ll help the patient think about these things because sometimes they don’t really have that and they need like prompting to be able to ask certain questions that they probably wouldn’t think to ask themselves. (P11, nursing)

I think it would give them very much confidence to be able to feel they’ve got a right to ask questions. (P8, nursing)

and improve the information shared with people attending the clinic:

It gives clients a lot more sort of control and insight into their treatment. It opens up a conversation around giving them an understanding of what their options are, I suppose. (P1, allied health)

…it’s a prompt for us too, to sort of like tell them more health information. (P3, nursing)

Participants also saw sharing the questions with patients might be a prompt for patients to prepare for their appointment, “So when they are given these options, all these questions to think about, they give it thought before they come to an appointment.”(P11, nursing) One stated that this “might even save a bit of time, you know.” (P2, nursing)

Subtheme 2.3. Challenges/considerations when responding to ASK questions

Logistics about answering questions with the right information, from the most appropriate person, at the right time and in the right part of the service was a consideration for some, “if they were to ask a dispensary, you know, it might cause a bit of waiting time.” (P6, nursing) One reflected on need to shift the focus of interactions with patients to be more patient centred to achieve the best outcomes:

…patients’ issues, ideas, concerns, expectations; I don’t think we ask about or we don’t always elicit those things from patients.(P14, medical)

Another felt it was important that staff were adequately trained and ready to do this work, “So I’m not equipped, I don’t have to be. But like, you know how much our staff is prepared.” (P12, admin)

Participants described using the ASK Questions as a natural fit with usual care:

It just helps them, you know, prepare for their assessments. (P2, nursing);

We discuss their global care plan with them, so we ask about their issues and what their treatment goals are. So, this actually helps to improve on it, just like having more knowledge about their issues and goals as well. (P4, nursing)

Theme 3. Implementing QPLs into outpatient clinical care

This theme focuses on participants’ experiences of the intervention and their suggestions for future implementation of the ASK Questions. One of the 16 participants commented of the direct impacts on the clinic with the addition of the link to appointment reminders, “I’ve noticed they’ve been asking what the options are. I have. Okay. Yeah.” (P11, nursing)

Participants suggested that any QPL intervention needed to better meet the needs of the patients such as:

• ensuring an appropriate literacy level, “…it’s only three questions. Yeah, it’s not too detailed, so that’s good.” (P5, allied health); “Because again, our patients won’t like long questions and things like that.”(P2, nursing)

• making it available in other languages, “if another language is your primary language, click on this button and a translated version will come up on your phone screen…” (P14, medical)

• making it available in other formats,” We could always have like a printout of the questions up in our waiting room. Some people don’t even have phones and people don’t get text messages.” (P6, nursing) “You could potentially even have posters around the place in the waiting room or something as well. Yeah, we’ve got the TV out there that flashes different information about the service.” (P1, allied health)

There was a suggestion to add something that assesses the person’s understanding, similar to the principle of teachback, “And maybe ask them to, you know, click a yes or no whether or not they understand at the end of it somewhere.” (P10, nursing) Integration into software and processes were other suggestions to improve the potential impact of implementing the questions, “Something like a pop up on the (electronic medical record), you can do a quick review.” (P3, nursing)

Discussion

Over a three-month period, a link to a previously evaluated QPL tool for low health literacy populations, the ASK Questions website, was sent 388 times as part of the appointment reminder system in a drug health clinic. Overall, the implementation was feasible, affordable to the service and acceptable to staff participants in the study. The additional cost was four cents per message (22% increase cost). The focus of this pilot study tested the logistics and pathways to implement links to a resource via appointment reminders. There was no component in this pilot to additionally promote access to patients and accordingly there was a low rate of access of the link to the QPL. In addition, we observed that over time patients are responding less often to clinic appointment reminders.

Thematic analysis of interviews with staff following the addition of the links reflected participants’ knowledge, experience and their interactions with what they described as a unique patient cohort who attend the service. Participants described their willingness to respond to questions form patients and even that they encouraged greater engagement through question asking but that there were times they recognised that patients were not ready to engage. Staff participants were supportive shared decision making whilst acknowledging challenges such as staff preparation to engage in SDM and time barriers. Interviews also provided insight into how the service might apply alternate access points to SDM tools such as waiting room posters in future implementation of the ASK Questions. They felt that integration of SDM tools into usual care pathways could be enhanced to better meet the needs of the service and the specific needs of this patient cohort. Few staff noted any positive or negative impacts of the addition of the SMS links on the day-to-day running of the clinic or question asking behaviour despite most staff being aware of the change.

Implementing patient-focused changes in healthcare settings have been shown to encounter both barriers and facilitators at system, staff and intervention levels (Geerligs et al., 2018). Despite in-person and online information about the implementation, staff participants at the service were unaffected by the addition of the SMS reminders in their daily work. Staff at this service showed commitment, acceptance and positive attitudes to change and the intervention.

Research has found that people using QPL tools want easy access to them prior to an appointment with their health professional (Tracy et al., 2022; Ramlakhan et al., 2023). Utilising existing systems for appointment reminders appeared an inexpensive way to provide access which was timely, targeted and accessible to many patients. The absolute cost to the service of the addition of the small amount to the length of the SMS initially appeared reasonable. However, we noted a relative decline over time in both responses to the clinic regarding appointments and in website access hits to ASK Questions from the appointment reminders which also coincided with new Australian government education and recommendations that people avoid clicking SMS links. This includes a specific example that perpetrators of information misuse using embedded weblinks may masquerade as a trusted source such as your doctor (Australian Signals Directorate Australian Government, 2023). Given there is likely to be an ongoing reduction in engagement with even legitimate messages from services the cost will become unjustifiable over time.

In terms of the appropriateness of using SMS links to access QPL tools for shared decision making in this population exploration of other tools and strategies to support both staff and patients will be required. Alternate delivery of tools such as QPLs are clearly needed, staff recommendations for this population included access to links in the waiting room and from staff directly in a paper format. An additional logistical factor in the utility of using SMS to communicate with people who attend drug health services is the high turnover rate of phones/digital devices (Tofighi et al., 2019) which was highlighted by several staff participants.

Strengths and limitations

Whilst we report the percentage access of a website to support shared decision making from an SMS appointment reminder the focus of this study was not aiming to maximise this and the patient population were not aware of the study. The access data likely represent baseline response levels to such an intervention and should not be used to predict the success of similar additions. The population is known to have a high turnover of devices and an internal survey at the clinic has shown there is a preference to provide feedback to the clinic using non-digital means. Future work should include an exploration of preferences for participation in SDM, attitudes to tools to assist SDM such as QPLs, and preferences for accessing these.

Conclusion

Integrating links to the ASK Questions QPL into appointment reminders sent via SMS to patients of a public addiction medicine outpatient clinic is feasible and acceptable to clinic staff. Multiple factors including an evolving cyber security environment may increasingly limit the utility of SMS to support patients’ access to shared decision making resources. Exploring whether personalization of messages, other modes of providing access to validated QPLs in a timely manner to support SDM and readiness to participate in SDM are still required for this population. Future work is needed to evaluate whether tools such as ASK Questions will meet the needs of this population to better assist them participating in SDM.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.