According to current estimates, pelvic inflammatory disease (PID) affects as many as 10% of adolescent girls in the United States. The disease can lead to long-term complications, such as infertility and chronic pelvic pain, for up to 40% of sufferers. “Adequate treatment and prevention of repeated episodes is critical, and the CDC recommends follow-up within 72 hours of diagnosis of PID,” says Margaret S. Wolff, MD. Follow-up should involve ensuring clinical improvement, reviewing safe sexual practices, and reinforcing the importance of partner treatment and medication compliance.
Follow-up appointments are particularly important for adolescents who commonly receive the diagnosis of PID in EDs or urgent care centers. EDs are often impacted by time constraints, which can result in limited counseling when a PID diagnosis is made, according to Dr. Wolff. “Research suggests that follow-up rates are low and that the majority of adolescents receiving a diagnosis of PID are not receiving the recommended follow-up care,” she says.
In published studies, several interventions have been used to improve post-ED follow-up for children and adolescents, including telephone reminders, mailed reminders, and having ED providers schedule outpatient appointments. These interventions, however, have had limited success. “Considering that text messaging is used by most adolescents and can be read privately, it is possible that this technology may effectively remind patients with PID about follow-up visits,” Dr. Wolff says. Other research has shown that text messaging can help promote behavior changes, improve medication compliance, and enhance self-management of some chronic diseases.
Taking a Closer Look
For a study published in Annals of Emergency Medicine, Dr. Wolff and colleagues tested the effect of text message reminders on adherence to the recommended post-ED follow-up visit in a group of adolescent patients diagnosed with PID. The investigators also evaluated the feasibility of using text message reminders after ED discharge, identified patient characteristics associated with follow-up, and potential barriers to post-ED follow-up.
Among adolescents with a diagnosis of PID in the ED, study participants either received standard discharge instructions only or standard discharge instructions plus text message reminders. Baseline characteristics were similar between treatment groups. Patients in the text message group received daily, tailored text messages for 4 days as a reminder to schedule and attend primary care provider follow-up. The text messages provided the name and contact information of the physician they should see for follow-up.
The study team did not schedule appointments for patients before discharge. Instead, the text message served as a reminder for patients to schedule an appointment, which required them to both call to schedule an appointment and then to attend it rather than be simply reminded of an appointment. The primary outcome was defined as receiving follow-up within 72 hours of ED discharge.
Text Messages Appear Helpful
Study results show that the rate of follow-up was 15.2% for the standard group and 43.5% for the text message group. Patients receiving text message reminders were more likely to follow up compared with the standard group (Table). The absolute efficacy difference was 28.3%, yielding a number needed to treat of four. Overall, the majority of patients who received follow-up care were treated by their primary care provider.
“Our findings show that frequent, personalized text message reminders after an ED visit for PID appear to improve post-ED follow-up rates for adolescents,” says Dr. Wolff. “The text messages were also well-received by study participants. The near-universal acceptance of text messaging among adolescents—in addition to the privacy and convenience that texts offer—makes this technology an ideal modality to reach these patients.”
The study notes that reasons varied considerably as to why patients did not attend a follow-up appointment, including inadequate primary care provider availability, symptom improvement, and a lack of understanding the importance of follow-up. The authors note that the reasons for not following up are similar to those of other studies that have examined post-ED follow-up care.
Considering the Big Picture
An important note to emphasize, according to Dr. Wolff, is that adolescents diagnosed with PID in the ED are unlikely to have received adequate counseling about safer sexual practices. “This is important because repeated episodes of PID increase the risk of chronic pelvic pain and infertility,” she says. “Teenagers can be a particularly challenging group of patients to reach and motivate.” She adds that text messages to adolescents might be a valuable tool to ensure that they receive proper follow-up care.
Although findings of the text message intervention are encouraging, more research is needed to explore the appropriate frequency and timing of text message reminders after an ED visit. “On average, it took clinicians 1 to 2 minutes to enter the data needed to complete the text messaging intervention,” explains Dr. Wolff. “However, it’s important that EDs are equipped with platforms that are capable of performing this task. Ideally, electronic health records (EHRs) can be used to facilitate the utilization of this data, but few EHRs currently have this capability.”
Wolff M, Balamuth F, Sampayo E, Mollen C. Improving adolescent pelvic inflammatory disease follow-up from the emergency department: randomized controlled trial with text messages. Ann Emerg Med. 2015 Dec 11 [Epub ahead of print]. Available at: http://www.annemergmed.com/article/S0196-0644(15)01421-3/fulltext.
Trent M, Chung SE, Burke M, et al. Results of a randomized controlled trial of a brief behavioral intervention for pelvic inflammatory disease in adolescents. J Pediatr Adolesc Gynecol. 2010;23:96-101.
Arora S, Burner E, Terp S, et al. Improving attendance at post–emergency department follow-up via automated text message appointment reminders: a randomized controlled trial. Acad Emerg Med. 2015;22:31-37.
Suffoletto B, Akers A, McGinnis KA, et al. A sex risk reduction text message program for young adult females discharged from the emergency department. J Adolesc Health. 2013;53:387-393.