Nadim Mahmud, MD, MS, MPH, MSCE
Sahil Doshi, MD
Mary Coniglio, MBA
Michelle Clermont, MD
Donna Bernard, MSN
Vandana Khungar, MD, MSc
National Center for Advancing Translational Science
Institute for Translational Medicine and Therapeutics
Colorectal cancer (CRC) is the second leading cause of cancer-related deaths among men and women in the United States. It is recommended that individuals begin regular screenings for CRC at the age of 45. Screening can prevent cancer by discovering precancerous polyps that can be removed before they turn into cancer. It can also find CRC early when treatment often leads to a cure. However, various barriers lead to substantial no-shows and cancellations for screenings done through colonoscopy.
Current approaches to increase screening rates are challenging and costly (as in the case of phone calls and patient navigators) or have low patient engagement (as with instructional videos or mobile apps). Poor bowel preparation before colonoscopies is also common.
We leveraged Way to Health to pilot a bi-directional texting program to connect with colonoscopy patients and help them prepare for upcoming CRC colonoscopy screenings. Patients in the program received automated reminders and instructions via text message one week before their colonoscopy. The texts were written in conversational language to engage patients and foster commitment. Patients could also send questions to the service and receive answers from staff within one day.
We then conducted a clinical trial to test the texting program in a larger population. In this trial, the texting program was modified to be unidirectional (patients could not text back) to make it feasible at scale. In addition, some participants were enrolled through phone calls and others through opt-out text messaging so that we could test different recruitment strategies.
Although the initial pilot suggested the intervention could increase colonoscopy show rates, the subsequent clinical trial found that attendance rates did not differ significantly between participants receiving usual care, comprising written instructions and a nurse phone call, and those receiving the automated texts as well as usual care. Nor was bowel preparation quality substantially different between the groups.
Even though the automated program did not improve show rates or bowel preparation quality, it did save the clinical team considerable time by unburdening nurses from placing and fielding multiple calls. Based on this, the texting program has been implemented as the standard of care at Penn Medicine Radnor, and work is underway to scale to additional locations in 2023.
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Fake back end
Fake back end
For the first phase of the automated texting pilot in colonoscopy preparation, we asked open-ended questions that were answered by a GI fellow. This enabled us to learn more about the needs of patients quickly and at a low cost. It also helped us identify portions of the support process that could be automated.
Fake back end
It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service.
A fake back end is a temporary, usually unsustainable, structure that presents as a real service to users but is not fully developed on the back end.
Fake back ends can help you answer the questions, "What happens if people use this?" and "Does this move the needle?"
As opposed to fake front ends, fake back ends can produce a real outcome for target users on a small scale. For example, suppose you pretend to be the automated back end of a two-way texting service during a pilot. In that case, the user will receive answers from the service, just ones generated by you instead of automation.