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. Author manuscript; available in PMC: 2017 Jun 1.
Published in final edited form as: Patient Educ Couns. 2015 Dec 21;99(6):953–959. doi: 10.1016/j.pec.2015.12.010

Appendix B.

Reminders

Citation Martini da Costa, (2010)[24] Wright, (2008) [13] Munoz, (2009) [23] Boman, (2010)[12]
Clinical Domain Primary care Health Prevention Health Prevention Cgnitive Impairment
Reminder Purpose/Technology Intervention Appointment reminder/Text message Health screening/Tethered Personal Health Records Healthy behavior/Web-based application, email Self-care management/Computer home reminder system
Study Objective Assessed efficacy of a text message appointment reminder. Assessed if sending a health screening reminder via EHR would increase screening. Assessed efficacy of internet based smoking cessation program. Assessed if acquired brain injury (ABI) patients could learn to use a set of electronic memory aids integrated in a training apartment, and to identify activities commonly forgotten by patients.
Study n >29000 4534 1000 14
Study Design Retrospective review RCT RCT Case study
Setting Brazil/Large clinic USA/11 primary care centers Worldwide (68 countries)/Internet users enrolled at two websites. Sweden/TBI clinic
Measurement Appointment non-attendance rates Number of health screenings sought by patients Self-reported smoking cessation rates Number of reminders for activities
Results Non-attendance rates decreased in 3 of 4 clinics: 0.82% (p = .590), 3.55% (p = .009), 5.75% (p = .022), and 14.49% (p = <.001). Patients significantly increased pap smear screening 1.68 95% CI (1.04–2.70, p < 0.05) - no significant difference for other screenings (p > 0.05). No significant difference was seen among conditions tested; 7-day abstinence rates over 12 months were 20.2% for Spanish speakers and 21.0% for English speakers. Participants made significant improvements learning how to use memory aids provided (p < 0.05); no significant correlation was found among the number of kitchen alarms and reminder messages.
Citation Hanauer, (2009)[28] Dowshen, (2012)[27] Dokkum, (2012)[26] DeFrank, (2009)[25]
Clinical Domain Diabetes HIV STI Oncology
Reminder Purpose/Technology Intervention Self-care management/Text message; email Medication adherence/Text message Health Screening/Text message; email Health Screening/Automated telephone call
Study Objective Compared glucose monitoring using email versus text message reminders. Assessed the effect and feasibility of daily text messages to increase adherence to antiretroviral therapy. Assessed response rates of chlamydia home testing using mail, email and text message. Compared efficacy of screening reminders including an automated phone call, mailed letter, and enhanced mailed letter.
Study n 40 25 93,094 3547
Study Design Randomized sample Prospective Case study RCT
Setting USA/Diabetes center USA/LGBT focused health center Netherlands/Public community USA/North Carolina teacher and state employee database
Measurement Patients entering blood glucose levels on website Self-reported adherence using the visual analog scale (VAS). Rate of package return (home chlamydia testing kit) Appointment attendance rates
Results The text message group requested significantly more reminders (text message group = 180.4, email group = 106.6) and submitted more glucose values (30.0 vs. 6.9 per user, p = 0.04). Visual analog scale scores increased significantly from a baseline of 74.7 to 93.3 at 12 weeks, p < .001; and 93.1 at 24 weeks, p < .001. Participation rates increased from 10% to 14% after the email/SMS reminders in round 1, and 7% to 10% in round 2. Participants receiving automated telephone reminders significantly increased overall repeat mammography adherence following the intervention (17.8% (p<0.0001).
Citation Altuwaijri, (2012)[32] Holbrook, (2009)[31] Guy, (2012)[30] Bourne, (2011)[29]
Clinical Domain Immunization Diabetes STI HIV
Reminder Purpose/Technology Intervention Appointment reminder/Text message Appointment reminder/Web-based application Health Screening/Text message Health Screening/Text message
Study Objective Evaluated the effect of text messaging reminders with electronic medical record on nonattendance rates. Assessed the impact of electronic shared decision support between the patient and PCP on the quality of diabetes management primary care. Evaluated text message reminders on chlamydia re-testing rates. Examined the impact of a text message reminder on HIV/sexually transmitted infection retesting rates among men who have sex with men.
Study n 271,894 511 338 714
Study Design Retrospective review RCT Before and After Nonrandom cohort comparison
Setting Saudi Arabia/Outpatient clinic of Saudi National Guard Canada/Community based care providers Australia/Health center Australia/Sexual health clinic
Measurement Pre/post intervention attendance rates A composite score measuring process improvement for mean change in individual patients at baseline and 6 months after randomization. Chlamydia retesting rates STI retesting rates
Results Post-intervention non-attendance rates decreased (pre-intervention = 23.9%, post-intervention = 19.7%) 4.13% (p < 0.001, T=4.81). The intervention group reported process composite scores were significantly higher than the control (1.27, 95% CI 0.79–1.75, p < 0.001); 19.1% improvement was seen in the intervention group (p <0.001); reported satisfaction was higher in the intervention group. Re-testing was significantly higher in participants after receiving text messages than before (30% vs. 21%, p=0.04); adjusted OR = 1.57 (95% CI 1.01 to 2.46). HIV/STI re-testing rates were significantly higher in the text message intervention group than the control (64% 30%; P<0.001); HIV/STI re-testing in the intervention group was 4.4 times greater than the control (95% CI 3.5 to 5.5; p < 0.002).
Citation Bender, (2010)[35] Balato,. (2012)[34] Arora, (2012)[33] Armstrong, (2009)[19]
Clinical Domain Asthma Dermatology Diabetes Dermatology
Reminder Purpose/Technology Intervention Medication adherence/Automated telephone call Treatment adherence/Text message Healthy behavior/Text message Healthy behavior/Text message
Study Objective Evaluated the impact of an automated, interactive phone call on adherence to asthma medication. Determined the impact of text messages on treatment adherence and patient outcomes in psoriasis patients. Assessed the impact of daily healthy reminders on inner city low income diabetes patients. Assessed the impact of a text message weather report and reminder to use sunscreen.
Study n 50 40 23 70
Study Design RCT RCT Prospective RCT
Setting USA/Participants recruited from allergy clinics and through the newspaper Italy/Dermatology clinics USA/ED University County Hospital USA/General population
Measurement Medication adherence Pre/post intervention self assessment on Psoriasis Area Severity Index, Self-Administered Psoriasis Area Severity Index, body surface area, Physician Global Assessment, Dermatology Life Quality Index, evaluation of patient-physician relationship, adherence to therapy. Self-reported lifestyle changes, AIC, & self-efficacy Frequency of sunscreen use
Results Patients in the intervention group had higher adherence by 32% compared to the control group (p = 0.003). Intervention group also had a more favorable shift in perception of inhaled corticosteroids as shown by the BMQ scores (p = 0.003), which also correlated with degree of adherence change (r = 0.342; p = 0.0152). Intervention group had significant improvement (p < 0.05) in disease severity, quality of life and treatment adherence (p < 0.001). Control group remained stable. Overall lifestyle improvement was seen following text message reminders (consumption of fruits and vegetables: 56.5% before versus 83% after; exercising: 43.5% before versus 74% after; foot checks: 74% before versus 85% after; self-efficacy increased from 3.9 to 4.2 on the Morisky Medication Adherence Scale). Daily adherence in the intervention group was significantly higher than the control (56.1% [95% CI, 48.1%–64.1%] versus 30.0% [95% CI, 23.1%–36.9%], p<0.001.)
Citation Chen, (2008)[39] Britto, (2011)[38] Bos, (2005)[37] Boker, (2012)[36]
Clinical Domain Health Screening Asthma Orthodontics Dermatology
Reminder Purpose/Technology Intervention Appointment reminder/Text message; Automated phone call Customized medical remiders/Text message Appointment reminder/Text message; Automated phone call Medication adherence/Text message
Study Objective Compared the effectiveness of text message and phone reminders on appointment attendance rates. Evaluated feasibility, acceptability, and utility of a text messaging system allowing teenagers to customize medical reminders sent to mobile phones. Examined multiple types of reminders on orthodontic appointment attendance. Assessed if daily text reminders increased acne medicine adherence.
Study n 1848 19 301 40
Study Design RCT Nonrandomized pilot RCT RCT
Setting China/Hospital USA/Children’s medical center Netherlands/University dental clinic USA/Community - university dermatology clinics, medical campus advertisements, and Craigslist.com.
Measurement Appointment attendance rates Score on asthma control test; a Likert-type scale rating for usefulness and acceptability Appointment attendance rates Amount of medication used and severity of acne
Results Attendance rates were highest in the telephone intervention group (88.3%), followed by text message (87.5%) and control (80.5%), showing a significant increase with the text message and telephone groups together (OR 1.698, 95% CI 1.224–2.316, P=0.001; OR1.829, 95% CI 1.333–2.509, P<0.001, respectively) but no significant difference between the two groups (P=0.670). Participants reported high ratings of usefulness, acceptability, and ease of use. Comparison and intervention group self reported asthma control was similar across the study. Attendance rates by type of reminder were: mail 90.6%, telephone 90.4%, text 82.4%, and control 83.7%. There was no significant difference in attendance rates (p > 0.05). There was no significant difference in the adherence rates (p = 0.75) between the intervention group (mean = 33.9%) and the control group (mean = 36.5%); both groups showed improvement in the severity of their acne.
Citation Dick, (2011)[43] Martini da Costa, (2012)[42] Corkrey, (2005)[41] Cocosila, (2008)[40]
Clinical Domain Diabetes HIV Oncology Health prevention
Reminder Purpose/Technology Intervention Self-care management/Text message Medication adherence/text message Health screening/Automated interactive telephone call Adherence to preventative activities/Text message
Study Objective Pilot tested a text messaging system for a diabetes management care adherence system. Examined the effect and perception of a text messaging reminder system on adherence to antiretroviral medication regimens for HIV-infected women. Assessed the effect of automated interactive telephone calls delivering screening status and an advisory message on cervical screening rates Determined the effectiveness of text messaging on healthy behavior adherence.
Study n 18 21 17,008 102
Study Design Pilot study: surveys and interviews RCT RCT Randomized, unblinded, controlled trial
Setting USA/University primary care group clinics Brazil/University clinic Australia/Community Canada/University-community
Measurement Interview & survey responses Self-reported adherence, pill counting, microelectronic monitors (MEMS) and a satisfaction interview with respect to incoming messages. Cervical cancer screening rate Self-reported healthy behavior adherence and the number of participant text messages
Results Weekly missed medication doses decreased from 1.6 to 0.6 (p = 0.003); confidence significantly increased during and 1 month post-pilot (p = 0.002, p = 0.008); 94 % strongly agreed that text messaging was easy to perform and helped with diabetes self-care; participant response = 80%. Overall results improved for the intervention group. Self-reported adherence intervention = 100%, control = 84.62%; counting pills compliance intervention = 50%, control = 38.46%; microelectronic monitoring adherence intervention = 75%, control = 46.15%. 81.81% of participants perceived that text messaging assisted with treatment adherence; 90.9% requested to continue to receive text messages after the study. Intervention group screening rates were 0.43% higher than control. The intervention group resulted in a larger increase in healthy behavior (246%) than the control group (131%). No significant difference was found in the number of pills missed, a significant correlation was found (coefficient = −0.352, sig. = 0.01) in the intervention group between the average number of text messages sent and number of pills reported missed.
Citation Fischer, (2012)[18] Feldstein, (2006)[46] Fairhurst, (2008)[45] Downer, (2005)[44]
Clinical Domain Diabetes Primary Care Primary Care Outpatient multi-specialty clinics
Reminder Purpose/Technology Intervention Self-care management; Appointment reminder/Text message Medication adherence/Automated telephone voice message Appointment reminder/Text message Appointment reminder/Text message
Study Objective Pilot tested a text messaging system to support self-management behavior for adults with diabetes. Evaluated automated voice messaging system and lab outreach intervention patient to improve completion of lab monitoring for patients at onset of new study medication. Evaluated text message appointment reminders for patients who failed to attend two or more appointments in the previous year. Evaluated the use of automated text messages for outpatient clinic appointment reminders.
Study n 47 961 173 2864
Study Design Quasi-experimental pilot Cluster randomized trial RCT Cohort study with historical control
Setting USA/Family health clinic USA/Primary care clinic Scotland/Inner city general practice Australia/Children’s hospital
Measurement Patient responses to text and focus group Quantitative: completion of baseline laboratory testing upon initiation of new study medication. Qualitative: Content analysis. Appointment non-attendance rates Appointment attendance rates
Results 1585 text messages were sent with a 68.14% response rate. 98.7% of the responses were correctly formatted. Upon receipt of medical measurement text message requests, 66.4% provided blood sugar values that were correctly formatted. The study was underpowered and no significant changes in study attendance were detected. 8 participants participated in a focus group and reported satisfaction with the program and found the technology easy to use. Quantitative: Each intervention increased laboratory monitoring: EMR reminder (provider) = 2.5 (95% CI 1.8–3.5), automated voice message reminder (patient) = 4.1 (95% CI 3.0–5.6) lab tech outreach (patient) = 6.7 (95% CI, 4.9–9.0), p < 0.001. Qualitative: Interventions were acceptable to primary care providers and patients. Non-attendance was lower in the intervention group (=12%) than the control (=17%), however did not reach statistical significance (p = 0.11). Non-attendance rates were significantly lower in the intervention group than the control (14.2% v 23.4%; p < 0.001).
Citation Gerber, (2009)[50] Geraghty, (2008)[49] Franklin, (2008)[48] Foreman, (2012)[47]
Clinical Domain Weight management ENT Diabetes Medications
Reminder Purpose/Technology Intervention Self-care management/Text message Appointment reminder/Text message Self-care management/Two-way text message Medication adherence/Text message
Study Objective Investigated feasibility of mobile phone text messaging to enable ongoing communication with African-American women participating in a weight management program. Retrospectively evaluated nonattendance rates after a text reminder system was implemented. Evaluated utility of the “Sweet Talk” system for type 1 diabetes patients. Evaluated text message medication reminders on patient’s medication adherence.
Study n 95 3981 64 290
Study Design Feasibility study Retrospective review Descriptive/Qualitative Retrospective observational cohort analysis
Setting USA/Participants in ORBIT (other) study UK/Outpatient clinic UK/Community USA/Community
Measurement Satisfaction questionnaire and telephone interviews Appointment non-attendance rates Frequency of messages sent by patients in response to automated system messages. Chronic oral medication adherence measured as the proportion of days covered (PDC).
Results Feasibility was demonstrated: 96% of participants reported they read the text messages; 79% reported that the text messages assisted with their weight loss goals. The text reminder group mean non-attendance rate was 22% (range, 21.9–22.2%) compared to the historical control group of 33.6% (range, 32.1–34.8%) (p < 0.001). Participants used the Sweet Talk system as a successful communication method with providers. Messages sent in response to the Sweet Talk were almost half of total messages (472/1180). The number of messages participants sent to Sweet Talk was significantly correlated to the number of response messages received by participants (r = .521, P= .01). Adherence measured by PDC via prescription claims, for the intervention group was significantly higher than the control group (intervention = 85%; control = 77%; p < 0.001).
Citation Hardy, (2011)[20] Harbig, (2012)[15] Green, (2013)[52] Glanz, (2012)[51]
Clinical Domain HIV Medications Gastroenterology Ophthalmology
Reminder Purpose/Technology Intervention Medication adherence/Text message; One way beeper Medication adherence/Portable electronic reminder service Health screening/Automated telephone call; EHR linked mailings Medication adherence; Appointment reminder/Automated interactive telephone call
Study Objective Compared the effects and feasibility of a customized phone-based reminder system versus a one-way pager to motivate and track antiretroviral medication adherence. Evaluated an electronic reminder system for medication non-adherence with elderly patients with complex health regimens. Assessed the impact of interventions utilizing electronic health records, automated mailings, and stepped increases in support on colorectal screening adherence. Evaluated the efficacy of an automated, interactive, telephone based health communication intervention on improvement of glaucoma treatment adherence.
Study n 31 168 4675 312
Study Design Parallel RCT RCT RCT
Setting USA/Large teaching hospital Denmark/Patients recruited from National Health Insurance Population Register USA/21 primary care medical centers USA/Hospital based ophthalmology clinics
Measurement Medication adherence using multiple measures Medication adherence monitoring Proportion of patients current for screening Medication adherence and appointment attendance rates
Results Phase I resulted in intervention content development. Phase II mean percent adherence rates by pill count, self-report, and medication event monitoring system remained significantly higher in the mobile phone group at weeks 3 and week 6. A significant difference in overall adherence was found between the automated electronic reminder service (Telesvar) 79% and (control) pill count 92% (p < 0.000), with the most reliable method of medication adherence monitoring was pill count. The intervention group demonstrated overall significantly more current screenings, including increases by intensity (usual care: 26.3% [95% CI, 23.4–29.2%]; automated: 50.8% [CI, 47.3–54.4%]; assisted: 57.5% [CI, 54.5–60.6%]; navigated: 64.7% [CI, 62.5–67.0%]; p < 0.001). All 6 adherence measures significantly improved from baseline in both the intervention and control group (p<0.01); participants in the intervention group did provide feedback reporting that the automated message system was easy to use, relevant, and recommended continuation.
Citation LeBaron, (2004)[56] Koshy, (2008)[55] Homko, (2012)[54] Henry, (2012)[53]
Clinical Domain Immunization Ophthalmology Diabetes HIV
Reminder Purpose/Technology Intervention Immunization/Automated telephone call Appointment reminder/Text message Medical monitoring parameters documentation/Automated interactive telephone call Appointment reminder/Automated telephone call
Study Objective Evaluated the impact of registry-based, reminder-recall interventions on immunization rates. Assessed the efficacy of text message appointment reminders to increase attendance at a hospital based ophthalmology clinic. Evaluated enhanced telemedicine systems targeting glucose control and pregnancy outcomes for women with gestational diabetes. Evaluated an automated telephone reminder that was added to the standard set of three HIV clinic appointment reminders to reduce no-shows for HIV primary care appointments.
Study n 3050 9959 80 584
Study Design RCT Observational RCT Quasi-experimental
Setting USA/County clinics UK/Hospital-based ophthalmology clinic USA/Prenatal clinics USA/VA HIV primary care clinic
Measurement Completion of 24 month vaccination series Appointment non-attendance rates Blood glucose level, infant birth weight, communication between provider and patient Appointment non-attendance rates
Results Overall, all intervention groups resulted in somewhat higher vaccination rates, however only the auto dialer group results were significant for the entire vaccination series (p = 0.02). The intervention group resulted in a 38% decrease in appointment non-attendance (relative risk of non-attendance = 0.62; 95% CI 0.48 – 0.80, p = 0.0002). No significant differences were seen between telemedicine and control groups for maternal blood glucose levels (p = 0.53) and infant birth weight (p = 0.3). Data transfer between provider and patient increased significantly however among the telemedicine group (p<0.01) The intervention did not reduce missed appointments among many of the patient subgroups, and the greatest effect was seen among the least vulnerable populations. Patients who weren’t homeless (OR= 0.77, CI = 0.61–0.98), non depressed patients (OR = 0.65, CI = 0.49–0.86), patients with 5> appointments in 6 months (OR = 0.66, CI = 0.47–0.92) had significantly fewer no-shows post intervention (p < .05).
Citation Perry, (2011)[59] Parker, (2012)[14] Parikh, (2010)[58] Lin, (2012)[57]
Clinical Domain Dental Medications Outpatient multi-specialty clinics Ophthalmology
Reminder Purpose/Technology Intervention Appointment reminder/Text message Medication adherence/Electronic personal response unit Appointment reminder/Automated telephone call Appointment reminder/Text message
Study Objective Examined the use of automated text reminders to improve attendance rates for two dental practices To determine the usability, acceptability, and effectiveness of an electronic medication reminder system on medication adherence. Comparison of an automated appointment reminder system, a clinic staff reminder, and no reminder on clinic nonattendance rates. Evaluated the impact of a text message service targeting improvement on follow-up adherence and procedures completion for parents of children with cataracts.
Study n 150 31 9835 135
Study Design Retrospective review Prospective Prospective, randomized, parallel clinical trial RCT
Setting Scotland/Dental clinic New Zealand/GP practices USA/Academic outpatient clinic China/Ophthalmic center
Measurement Appointment non-attendance rates Patient compliance, perception of the service, and health-related quality of life measures. Appointment non-attendance rates Appointment attendance rates
Results The non-attendance rate significantly decreased overall (p = 0.001) from 31% (46/150) to 14% (21/150). Both practices individually had significantly reduced non-attendance rates (practitioner A, p = 0.04; practitioner B, p = 0.01). Rate of self-assessed medication compliance significantly improved from pre (52%) and post (81%) implementation (p = 0.012). There was a significant improvement in perceived self-care at home ability (p = 0.001). The percentage of participants who rated their self-care at home ability as excellent increased from 42% to 68%. The most effective intervention was a clinic staff reminder followed by an automated reminder; no reminder was least effective (non-attendance rates = 13.6%, 17.3%, and 23.1%, respectively; p=0.004). Attendance rates for the intervention group were significantly higher than those for the control group (91.3% vs 62.0%, p = 0.005).
Citation Suffoletto, (2012)[63] Solomon, (2007)[62] Sims, (2012)[61] Pop-Eleches, (2011)[60]
Clinical Domain Medications Osteoporosis Mental health HIV
Reminder Purpose/Technology Intervention Medication adherence/Text message Health screening/Automated telephone call Appointment reminder/Text message Medication adherence/Text message
Study Objective Assessed the impact of an automated text messaging system on adherence to post-discharge antibiotic prescriptions. Tested mailed letters and automated telephone calls designed to improve osteoporosis management among primary care physicians. Examined the effect of text message reminders on the attendance of appointments at four community mental health clinics. Examined the impact of text message reminders on anti-retroviral therapy adherence.
Study n 144 2407 2817 431
Study Design RCT RCT Nonrandomized pilot RCT
Setting USA/Emergency department USA/Primary care practices UK/Outpatient mental health clinic Kenya/Rural clinic
Measurement Patient self-report adherence questionnaire Undergoing a bone mineral density (BMD) testing or filling a prescription for a boneactive medication during the 10 months of follow-up. Appointment attendance rates Medication adherence
Results Adherence rates were not significant between intervention and control groups (57% vs. 45%; p = 0.1). A statistically significant 4% absolute increase and a 45% relative increase (95% confidence interval 9–93%, p = 0.01) in osteoporosis management was found between groups. The text message reminder intervention significantly increased appointment attendance (p < .001). 53% of the weekly SMS reminders group achieved adherence of at least 90%, compared with 40% of participants in the control group (p = 0.03). The weekly reminders group were significantly less likely to experience treatment interruptions exceeding 48h than participants in the control group (81 vs. 90%, p = 0.03).
Citation Suh, (2012)[64] Suffoletto, (2012)[63] Solomon, (2007)[62] Sims, (2012)[61] Pop-Eleches, (2011)[60]
Clinical Domain Immunization Medications Osteoporosis Mental health HIV
Reminder Purpose/Technology Intervention Immunization/Automated telephone call Medication adherence/Text message Health screening/Automated telephone call Appointment reminder/Text message Medication adherence/Text message
Study Objective Assessed the impact of an immunization reminder/recall notification via letter or auto-dialer on increasing immunization rates for TdaP, MCV4, and first dsoe HPV. Assessed the impact of an automated text messaging system on adherence to post-discharge antibiotic prescriptions. Tested mailed letters and automated telephone calls designed to improve osteoporosis management among primary care physicians. Examined the effect of text message reminders on the attendance of appointments at four community mental health clinics. Examined the impact of text message reminders on anti-retroviral therapy adherence.
Study n 1596 144 2407 2817 431
Study Design RCT RCT RCT Nonrandomized pilot RCT
Setting USA/Private pediatric practices USA/Emergency department USA/Primary care practices UK/Outpatient mental health clinic Kenya/Rural clinic
Measurement Receipt of > 1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention. Patient self-report adherence questionnaire Undergoing a bone mineral density (BMD) testing or filling a prescription for a boneactive medication during the 10 months of follow-up. Appointment attendance rates Medication adherence
Results The intervention group received significantly higher vaccine rates that the control for a minimum of one vaccine (47.1% versus 34.6%, p < 0.0001) and receipt of all vaccines (36.2% versus 25.2%, p < 0.0001). Adherence rates were not significant between intervention and control groups (57% vs. 45%; p = 0.1). A statistically significant 4% absolute increase and a 45% relative increase (95% confidence interval 9–93%, p = 0.01) in osteoporosis management was found between groups. The text message reminder intervention significantly increased appointment attendance (p < .001). 53% of the weekly SMS reminders group achieved adherence of at least 90%, compared with 40% of participants in the control group (p = 0.03). The weekly reminders group were significantly less likely to experience treatment interruptions exceeding 48h than participants in the control group (81 vs. 90%, p = 0.03).