Text Message Delivery of a Digital Tool for Reproductive Health Discussions in Primary Care: A Cluster Randomized Clinical Trial.

Importance: Discussions about individuals' reproductive desires and needs for services (eg, prepregnancy care, contraception) are critical but often lacking in primary care. Objective: To investigate the effectiveness of a 1-way text message invitation to use MyPath, a patient-facing digital reproductive decision support tool, prior to primary care visits in increasing reproductive health discussions at the visit. Design, Setting, and Participants: This hybrid type 1 study using a cluster randomized clinical trial design was conducted from March 2021 to March 2025 at 12 Veterans Administration health care systems. Participants included primary care practitioners (PCPs), randomized 1:1 to intervention or control, and female veterans aged 18 to 44 years who had an upcoming appointment with a randomized PCP. Intervention: Veterans in the intervention group were sent a text message invitation to use the decision support tool 1 to 2 days prior to their appointment; veterans in the control group received usual care (no text message). Main Outcomes and Measures: The primary outcome was self-reported occurrence of a discussion of reproductive health with optimal shared decision-making (SDM) at the visit. Any reproductive health discussion (with or without optimal SDM) was a secondary outcome. The primary analyses followed intent-to-treat (ITT) principles. A prespecified secondary analysis estimated the complier average causal effect to account for nonuse of the decision support tool. Results: Data from 66 PCPs (mean [SD] age, 47.7 [10.6] years; 61 [92.4%] female) and 349 veterans (mean [SD] age, 35.3 [5.9] years) were analyzed, with 34 PCPs and 190 veterans in the intervention group and 32 PCPs and 159 veterans in the control group. Although all but 1 of the intervention participants were sent a text invitation, only half (83 of 167 [49.7%]) used the decision support tool. Differences between the intervention and control groups in the occurrence of reproductive health discussion with optimal SDM (29 of 168 [17.3%] vs 20 of 139 [14.4%]) or the occurrence of any reproductive health discussion (119 of 168 [70.8%] vs 93 of 142 [65.5%]) were not significant in ITT analyses (adjusted odds ratio, 1.46 [95% CI, 0.70-3.06] and 1.37 [95% CI, 0.79-2.38], respectively). In secondary analyses estimating the intervention effect among compliers, use of the decision support tool was associated with greater odds of any reproductive health discussion (adjusted odds ratio, 3.46 [95% CI, 1.23-9.76]). Conclusions and Relevance: In this cluster randomized clinical trial of a text invitation to use a decision support tool prior to PCP visits, there were no significant differences in reproductive health discussions between the intervention and usual care groups in ITT analyses. Given higher than expected nonuse of the decision support tool, intervention modifications and implementation strategies to promote greater use while maintaining scalability and sustainment in primary care settings should be explored. Trial Registration: ClinicalTrials.gov Identifier: NCT04584294.