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Can text messages encourage healthy behavior? Results are mixed

By Jeff Levin-Scherz, MD, MBA | June 22, 2022

This week’s roundup of health care news includes studies on the effectiveness of text messages, breast cancer mortality, medical waste and updates on COVID-19 and monkeypox.
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Two recent studies using text messages to encourage healthy behaviors yielded different results.

In the first, researchers in China sent text messages to children who had survived cancer and their parents encouraging the children to return to regular exercise. The group that was randomly chosen to get these text messages increased exercise by 78%, compared to an increase of 6% in a control group that did not receive the text messages. This small study in children supports other studies that demonstrate the potential of using text messaging to encourage healthy behaviors.

While the Chinese study showed the promise of text messages, another in the U.S. was less promising. In the second study, researchers at the University of Pennsylvania compared the likelihood of COVID-19 vaccination in unvaccinated patients who were randomly assigned to an outbound phone call or various carefully worded text messages that offered an outbound or inbound phone call to schedule a vaccination. The results here were disappointing. No intervention was especially effective. The outbound calls yielded a 3.6% rate of first COVID-19 vaccination within 30 days and the text messages yielded between a 3.1% and a 3.3% rate. However, the news here isn’t all bad. The text messages, which were dramatically less expensive than phone calls, were not statistically less effective than phone calls.

Implications for employers:

  • Text messages can play an important role in engaging members in healthy behaviors and at a lower cost than phone calls.
  • Even well-designed interventions might not work as expected.
  • Building measurement into such interventions can allow changes or discontinuation of ineffective interventions.

Breast cancer mortality declining

JAMA Network Open published data on four million women with breast cancer between 2010 and 2017 and found that deaths from breast cancer are declining. States with less obesity and with higher rates of exercise each have fewer cases and fewer deaths per 100,000 than states with more obesity and lower rates of exercise. Higher rates of mammography are associated with higher rates of diagnosed breast cancer and substantially lower rates of mortality from breast cancer.

Implications for employers:

  • This study offers good observational data that higher mammography rates are associated with decreasing death from breast cancer, providing supportive evidence for employer efforts to encourage mammography every other year for women age 50 to 75.
  • Employers can identify best practice screening rates through the National Committee on Quality Assurance and work with their health plan to meet or exceed those metrics.
  • Employer efforts to encourage employees to exercise regularly and stay in a healthy weight range can decrease breast cancer risk.
  • We should be careful to avoid “blaming the victim” though, because many cases of breast cancer have a strong genetic link, and we do not know the underlying cause of cancer in any individual.
  • Improvements in breast cancer treatment, including chemotherapy, hormonal therapy and immunotherapy continue to increase life expectancy of those with metastatic breast cancer, although new drugs commonly cost more than $10,000 per month.

The toll of medical waste

There is substantial waste in the U.S. health care system, although differences in total costs between the U.S. and other developed countries is largely due to high prices, rather than more waste.

Health Affairs published a review of the literature on health care “clinical waste” last week. The following graphic summarizes the data.

U.S. health spending by type of waste, 2011 and 2019

Source: Health Affairs
Category Billions (2019) % of total medical costs (2019)
Care delivery (care not delivered based on accepted best practices) $102 – $166 2.7% – 4.4%
Care coordination (such as unnecessary readmissions) $27 – $78 0.7% – 2.1%
Overtreatment (care shown to be of no value) $76 – $101 2.0% – 2.7%
Total $205 – $345 5.4% – 15.7%

Administrative waste, which was not covered in detail in this report, was estimated to be even higher than clinical waste ($290 billion to $592 billion).

Implications for employers:

  • Clinical waste represents a sizable portion of total medical costs in the U.S.
  • Programs to prevent readmissions and adoption of evidence-based care utilization management policies can help lower total health care costs.
  • Pricing failures and administrative complexity continue to represent a substantial portion of total waste. Directing members to high-value providers (lower price or higher quality) can help, although employers alone will be hard-pressed to remedy the complexity of health care finance.

COVID-19 update

  • COVID-19 cases across the U.S. continue to inch up, and laboratory-confirmed cases remain above 100,000 daily. Hospitalizations and intensive care (ICU) treatment is also up, and the Omicron strains BA.4 and BA.5, which are more infectious, are now more than a fifth of all U.S. cases.
  • Studies of blood donors conducted in December showed that about 95% of the U.S. population had immune markers either from having had a COVID-19 infection (29%) or from vaccination. Given the high rates of infection of both vaccinated and unvaccinated people, employers should take similar precautions with their vaccinated and unvaccinated employees.
  • The Centers for Disease Control and Prevention (CDC) endorsed vaccines for children ages six months to five years this past weekend. Vaccines from Moderna (2 shots) and Pfizer (3 shots) will be available this week.
  • Babies of mothers who had COVID-19 during pregnancy have two times as high a rate of neurodevelopmental delay in their first year compared to those who were not exposed during pregnancy. The study of 7,772 infants also showed a statistically significant increased risk of premature delivery (14.4% versus 8.7%). Studies show COVID-19 vaccines are safe in pregnancy and cause no decrease in fertility. Unvaccinated women who are pregnant or considering pregnancy should get vaccinated.
  • The U.S. removed the requirement that those traveling by air from abroad have a negative COVID-19 test within 72 hours. This could ease return to international business travel. The CDC continues to recommend against travel if you have:
    • Current COVID-19 symptoms
    • A positive COVID-19 test less than 10 days ago or are awaiting results of COVID-19 test
    • Recently been exposed to someone with COVID-19

Monkeypox update

Over 3,000 cases of monkeypox have now been identified globally, and this is likely an undercount. As of June 17, 2022, there are 113 cases reported in the U.S.

Monkeypox is in the Orthopoxvirus family of viruses that includes variola (which causes smallpox). Monkeypox can initially cause body aches and fatigue and then blisters that later are filled with pus. Those with monkeypox are likely to be contagious until all blisters have crusted over, which can be a number of weeks. Most cases appear to be associated with close (skin-to-skin) contact. The smallpox vaccine can protect people from monkeypox up to four days after exposure and is currently only recommended for lab workers, health care workers and close contacts of those with monkeypox.

Implications for employers:

  • Monkeypox is unlikely to be transmitted in the workplace, so employers currently do not need to implement any special programs to identify or address this virus.

Population Health Leader, Health and Benefits, North America

Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.

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