Strengthening evidence for text-based telehealth in post-operative care: A pragmatic study of the reach and effectiveness of two-way, text-based follow-up after voluntary medical male circumcision in South Africa.

Caryl Feldacker, Isabella Fabens, Tracy Dong, Khumbulani Moyo, Calsile Makhele, Motshana Phohole, Nelson Igaba, Sizwe Hlongwane, Jacqueline Pienaar, Maria Sardini, Felex Ndebele, Hannock Tweya, Marrianne Holec, Evelyn Waweru, Geoffrey Setswe
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Abstract

Building upon evidence of safety and efficiency gains from a randomized control trial (RCT) in South Africa, we further scaled implementation of two-way, short message service (SMS), text-based (2wT) follow-up after voluntary medical male circumcision (VMMC). We aimed to determine if gains in adverse event (AE) identification and reduced follow-up visits could be maintained when 2wT was implemented in routine VMMC settings. A pragmatic, stepped wedge design (SWD) study was implemented across three districts in South Africa. Men ages 15 and older could opt into the 2wT telehealth follow-up approach when their facility was in the intervention period. Men in routine periods were offered the standard of care (SoC): in-person post-operative visits on days 2 and 7 as per national VMMC guidelines. 2wT participants were not required to attend any postoperative visits but could return for care if desired or referred. Two quality of care markers, safety (AE ascertainment rate) and efficiency (# in-person follow-up visits), were compared between groups. We aimed for at least 200 men per step to have 80% power to detect a change in AE rate from before to after 2wT was implemented. Secondary analysis explored response rates; client and site uptake; and AE details. Among 6842 clients in the intervention period, 2856 opted into 2wT (37.8%) across three intervention waves and two platforms (SMS or WhatsApp). Among those with post-operative follow-up, the AE ascertainment rate was higher among 2wT (0.60%) than SoC (0.13%) clients (p = 0.0018), demonstrating safety gains. On average, 2wT participants had 2.1 fewer visits compared to SoC clients (p<0.001), demonstrating gains in follow-up efficiency. Among 2wT men, 2069/2586 (80%) responded via 2wT over 14 days, demonstrating engagement in post-operative care. Of all intervention clients, 93 2wT (3.6%) and 342 (8.0%) SoC were considered lost to follow-up. In this expansion trial, we provided additional evidence that the 2wT approach maintains the quality of post-operative care for adult VMMC clients. 2wT should be scaled to augment in-person, post-operative visits after VMMC for eligible, interested males ages 15 and older. To achieve potential impact, effort is needed to improve access and uptake to 2wT among providers and sites, expanding the 2wT approach for other acute follow-up care especially among men.

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加强术后护理中基于文本的远程保健的证据:对南非男性包皮自愿医疗切割术后基于文本的双向随访的覆盖范围和有效性的实用研究。
南非的一项随机对照试验(RCT)证明了安全性和效率的提高,在此基础上,我们进一步扩大了自愿男性包皮环切术(VMMC)后双向短信服务(SMS)、基于文本的随访(2wT)的实施规模。我们的目标是确定在常规包皮环切术环境中实施 2wT 后,能否保持不良事件(AE)识别和随访次数减少的成果。我们在南非的三个地区开展了一项务实的阶梯式楔形设计(SWD)研究。15 岁及以上的男性可在其所在机构处于干预期时选择 2wT 远程保健随访方法。常规时期的男性可接受标准护理(SoC):根据国家自愿医疗管理(VMMC)指南,在术后第 2 天和第 7 天进行上门随访。2wT 参与者无需参加任何术后访视,但可根据需要或转诊返回接受护理。我们比较了不同组别之间的两个护理质量指标,即安全性(AE 确定率)和效率(亲自随访次数)。我们的目标是每个步骤至少有 200 名男性参与,以便有 80% 的力量检测到 2wT 实施前和实施后 AE 发生率的变化。二次分析探讨了响应率、客户和站点接受率以及 AE 详情。在干预期间的 6842 名客户中,有 2856 人(37.8%)在三个干预阶段和两个平台(短信或 WhatsApp)上选择了 2wT。在进行术后随访的客户中,2wT 客户的 AE 确定率(0.60%)高于 SoC 客户(0.13%)(p = 0.0018),表明安全性有所提高。与 SoC 客户相比,2wT 参与者的就诊次数平均减少了 2.1 次(p = 0.0018)。
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