Text message incentives increased patient-reported outcomes survey response in emergency care: SWAT findings

To determine if text message-based behavioral interventions could increase response rates to a patient-reported outcomes survey in the emergency department (ED).

We conducted a study within a trial (SWAT), within the NUDG-ED trial. The NUDG-ED trial aimed to reduce low-value care for patients with back pain presenting to eight EDs in Sydney, Australia. This SWAT was a 3-arm randomized controlled trial (RCT) nested within the NUDG-ED trial. After discharge from the ED, patients were randomized to receive one of the three text message invitations to complete a follow-up patient-reported outcome survey: a standard control message, or one of two behaviorally informed messages including either a prize draw incentive or prosocial framing. Our primary outcome measure was the response rate in each study group. We performed a linear mixed-effects model controlling for hospital heterogeneity and patient characteristics to estimate the mean difference (MD) in proportions with 95% CI, to determine the effectiveness of the behavioral interventions.

A total of 1494 patients were randomized between May 15, 2024 and January 29, 2025. Of these, 52% were women, the median age was 46 years (IQR 35, 62), 43% were from disadvantaged areas and 51% were triaged with a clinically urgent condition. Baseline characteristics were balanced across all groups. Our primary analysis found that compared to the control, the prize draw incentive increased response rates (n = 997 patients, MD = 6.9%, 95% CI: 1.8% to 11.9%, P = .007). Our adjusted mixed-effects model also found a significant increase in response rates (n = 979 patients, MD = 6.4%, 95% CI 1.3% to 11.4%, P = .013). Compared to the control, the prosocial framing message may have slightly increased response rates, but the results were not statistically significant (n = 996 patients, 17.2% vs 21.1%, MD = 3.9%, 95% CI: -1.1% to 8.9%).

In this randomized trial, a prize draw incentive modestly improved response rates to a patient-reported outcomes survey in routine emergency care settings. Prosocial framing may have slightly increased response rates, but the effect was uncertain. Both behavioral approaches warrant further testing in routine care settings.

Patient-reported outcomes, such as surveys about how people feel and recover after care, are important for understanding what matters most to patients. However, response rates to these surveys are often very low, especially in real clinical settings. This makes it difficult to draw strong conclusions about whether treatments are helping patients. So, researchers and health services need to find ways to improve response rates. This study looked at whether simple text message strategies could encourage more patients to complete follow-up surveys after visiting the ED for low back pain. We conducted a RCT involving 1494 patients in Sydney. After being discharged from the ED, patients were randomly assigned to receive one of the three text message invitations to complete a survey: a standard message, a message offering entry into a prize draw, or a message using prosocial wording (emphasizing how their response could help others). We found that patients who received the prize draw message were more likely to complete the survey. About 24% responded to this message, compared to 17% who received the standard message, an increase of around 7%. We are uncertain whether the prosocial message was effective. These findings suggest that adding a prize draw incentive to a text message-based study invitation can modestly increase survey participation in routine health-care settings. Improving response rates helps ensure that patient perspectives are more accurately represented in research and health-care improvement efforts. Further studies are needed to confirm these results and explore other effective ways to increase participation.