| Background:Coronary heart disease(CHDD)is the leading cause of deaths and disabilities in China.During the past two decades,the mortality of CHD has doubled to 1 million deaths per year and is still increasing.Diabetes mellitus(DM)is a CHD risk equivalent,and the mortality of patients with diabetes is 2-4 times that of patients only with CHD.China is facing increasing disease burden on health services.The benefits of secondary prevention strategies for CHD targeting lifestyle modification and risk factor management are well-established worldwide,however adoption of these strategies is suboptimal and medication adherence is poor.Long-term education and support for disease management,which focus on risk factors control and lifestyle modification,is a cornerstone of secondary prevention in patients with DM and CHD.Traditional education strategies have included health seminars,telephone consultations,however,it is often difficult to generalize and implement such interventions nationally because of the high costs of organization and demanding labor investment.Mobile phones and text messages are pervasive and widely used to schedule alerts and reminders,highlighting the potential for mobile health to circumvent the practical barriers of traditional healthcare visits.During the past decade,previous studies on text-messaging interventions have showed some preliminary results.However,most of them were conducted in developed countries,have targeted at one condition;few were based on behavior change theory,and were also limited to small sample size and short observation period.Meanwhile,despite the rapid growing in mobile health investment,(e.g.the market size of mobile health has raised to 23.14 billion in China in 2017),few trials have been conducted in China.More data are needed to address these gaps and scientifically evaluate text message-based disease management interventions among diverse populations.Objective:To evaluate the effects of a simple,low-cost,automated text message-based intervention in improving risk factor control and adoption of healthy lifestyle behaviors,including glycemic control,blood pressure,lipids level,physical activity and body mass index(BMI),among patients with known CHD and DM,and to generate evidence for future decision making in long-term disease management in China.Methods:The Cardiovascular Health And Texting-Diabetes Mellitus(CHAT-DM)study was a multicenter,parallel-group,randomized clinical trial that included 502 patients with both CHD and DM from 34 hospitals in China.The follow-up time is 6 months.Participants were randomized to either the intervention or control group in a 1:1 ratio.The intervention group received six text messages per week for 6 months.The control group received usual care and two thank you messages per month.The text messages were developed based on clinical guidelines and behavioral change techniques,and messages were culturally tailored to provide educational and motivational information on glucose monitoring,blood pressure control,medication adherence,physical activity and lifestyle.The primary outcome was change in glycemic hemoglobin(HbAic)from baseline to 6 months.Secondary outcomes were change in proportion of patients achieving HbAic<7%,fasting blood glucose(FBG),systolic blood pressure(SBP),low-density lipoprotein cholesterol(LDL-C),BMI,and physical activity from baseline to 6 months.Exploratory outcomes included health status at 6 months measured by the Seattle Angina Questionnaire(SAQ)and EuroQol five-dimensional questionnaire(EQ-5D).Analyses were conducted according to the intention-to-treat principle.The endpoints were assessed using analyses of covariance(ANCOVA)adj usting for baseline values.Results:3,392 patients were screened for eligibility and 502 patients were consented.The follow-up rate was 99.6%.Baseline characteristics were similar between the intervention(n=251)and control groups(n=251).Participants had a mean age of 59.5�9.3 years,17.5%were female,52.4%had junior or senior high school educational attainment.When compared with the control group at 6 months,HbAic level was 6.7%in the intervention group and 7.2%in the control group,with a mean absolute difference in HbAic level of 0.3%(95%CI-0.5%to-0.1%,P=0.003).Change in FBG was larger in the intervention group with a between group difference of-0.6 mmol/L(-0.5 vs.0.1mmol/L,95%CI-1.1 to-0.1;P=0.001).The intervention group had a greater proportion of participants who achieved HbAic<7%(69.3%vs.52.6%;RR 1.2,95%CI 1.1-1.3;P=0.004).Other secondary and exploratory outcomes,including SBP,LDL-C,BMI,physical activity,and SAQ and EQ-5D scores,did not differ between groups.There was no significant interaction between the intervention and the pre-specified subgroups levels including age,sex,education level,urban or rural,and smoking status.Among the intervention participants who attended the 6-month visit,nearly all participants reported that the messages were easy to understand(97.1%)and useful(94.1%).Over 80%of participants reported reading>75%of the messages,and 93.7%were willing to receive future messages.Conclusions:A text message intervention providing educational and motivational information resulted in better glycemic control in patients with DM and CHD and were readily accepted by participants.While the mechanism of this benefit remains to be determined,the results suggest that a simple,low-cost and scalable text messaging program may provide an effective way to improve disease self-management as supplements to current clinical practice,and they offer potential to generate public health benefits for millions across diverse populations especially for low and middle-income countries including China. |
PDF Full Text Request