Using Behavioral Economics to Enhance Appointment Reminders and Reduce Missed Visits

Not Applicable

Completed

Conditions: Appointment Reminders

Interventions: Behavioral: Caring + Consequences for Others + Consequences for Self + Social Norms + Behavioral Instructions
Behavioral: Caring + Consequences for Others + Behavioral Instructions
Behavioral: Social Norms + Behavioral Instructions
Behavioral: Caring + Consequences for Self + Behavioral Instructions

Registration Number: NCT03850431

Lead Sponsor: VA Office of Research and Development

Brief Summary: "No-shows," or missed visits are a persistent problem in all health care systems. They contribute to worsened patient access, longer wait times, and inefficient use limited health care resources. The VA's no-show rate has shown no improvement in years, resulting in a staggering 9 million ambulatory no-shows in Fiscal Year (FY) 2015. Appointment reminders are an essential and proven element to addressing no-shows but major research gaps exist. Behavioral economics (BE) and allied fields offer key insights that are relevant to developing innovation in the field of appointment reminders. Adding "nudges" informed by concepts such as social norms, behavioral intentions, clear instructions, and potential negative consequences to the Veteran and others is a novel but evidence-based way to create enhanced appointment reminders. Seemingly small changes to appointment letters can create measurable shifts in appointment attendance and no-shows. Even more, these behavioral nudges can produce large benefits when taken to scale and compounded across a population.

This project will address several aims, including: developing BE-informed messages to incorporate into enhanced appointment reminders; evaluating the effect of several versions of enhanced appointment reminders; and identifying potential barriers and facilitators to widespread implementation of enhanced appointment reminder messages.

Detailed Description: Objectives: The overarching objective of this proposal is to test the effectiveness of simple and scalable enhancements to appointment reminders in reducing no-shows, and prepare for larger-scale implementation.

Plan: "No-shows," or missed visits are a persistent problem in all health care systems. They contribute to worsened patient access, longer wait times, and inefficient use limited health care resources. The VA's no-show rate has shown no improvement in years, resulting in a staggering 9 million ambulatory no-shows in FY2015. Appointment reminders are an essential and proven element to addressing no-shows but major research gaps exist. Behavioral economics (BE) and allied fields offer key insights that are relevant to developing innovation in the field of appointment reminders. Adding "nudges" informed by concepts such as social norms, behavioral intentions, clear instructions, and potential negative consequences to the Veteran and others is a novel but evidence-based way to create enhanced appointment reminders. Seemingly small changes to appointment letters can create measurable shifts in appointment attendance and no-shows. Even more, these behavioral nudges can produce large benefits when taken to scale and compounded across a population.

The investigators will address the following aims:

1. Aim 1: Develop and iteratively refine BE-informed messages based on Veterans' perceptions, and incorporate them into enhanced appointment reminders.

2. Aim 2: Determine the effect of four versions of enhanced appointment reminders on measures relevant to treatment access, compared with usual reminders.

3. Aim 3: Evaluate differences in treatment effect associated with four versions of enhanced appointment reminders.

4. Aim 4: Characterize potential barriers and facilitators to widespread implementation of enhanced appointment reminder messages.

Methods: The investigators will first determine the validity of a series of draft messages, which are informed by concepts and principles from BE, psychology, and related fields and will be included in the intervention; the investigators will also explore potential mechanisms of action, and measure any harms by assessing Veterans' perceptions of the messages (Aim 1). After intervention refinement, the investigators will conduct a cluster randomized controlled trial to test 4 interventions, consisting of variations in nudges included in appointment letters, and compare them to usual appointment letters (Aims 2 and 3). The trial will be conducted at VA Portland Health Care System (VAPORHCS) in primary care and mental health clinics. The investigators will evaluate changes in no-show rates, attendance and cancellation rates and appointment wait times. Finally, the investigators will conduct a qualitative assessment with key informants to inform potential barriers and facilitators to implementation of revised appointment reminders (Aim 4).

Relevance to VA's Mission: This proposal directly addresses two of the six Health Services Research and Development Service (HSR\&D) priority areas: access and mental and behavioral health. First, reducing no-shows is likely to improve efficiency of access to care and reduce wait time. Second, this proposal includes a focus on interventions in mental health settings, which have especially high no-show rates and may have more potential for improvement.

Medical Subject Heading Terms: Economics, Behavioral; Mental Health; Healthcare Quality, Access, and Evaluation

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 34516

Inclusion Criteria

All subjects will be a minimum of 18 years old.
All subjects will be patients with scheduled outpatient appointments (either primary care or mental health) in the VA Portland Health Care System.
Race and ethnicity will not be used in determining inclusion or exclusion of subjects.

Exclusion Criteria

None

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Combination of all Nudges	Caring + Consequences for Others + Consequences for Self + Social Norms + Behavioral Instructions	Clinics assigned a letter with a combination of all types of nudges (Behavioral: Caring + Consequences for Others + Consequences for Self + Social Norms + Behavioral Instructions)
Caring + Consequences for Others + Behavioral Instructions	Caring + Consequences for Others + Behavioral Instructions	Clinics assigned a letter with three types of nudges (Caring + Consequences for Others + Behavioral Instructions)
Social Norms + Behavioral Instructions	Social Norms + Behavioral Instructions	Clinics assigned a letter with two types of nudges (Social Norms + Behavioral Instructions)
Caring + Consequences for Self + Behavioral Instructions	Caring + Consequences for Self + Behavioral Instructions	Clinics assigned a letter with three types of nudges (Caring + Consequences for Self + Behavioral Instructions)

Primary Outcome Measures

Name	Time	Method
No-Show Rate	1 year	The percentage of total appointments that are classified as a no-show, relative to the total number of appointments scheduled. The numerator ("no-shows") consists of appointments marked as a no-show and appointments canceled by the patient or clinic after the appointment time. The denominator ("total appointments") consists of no-shows and completed appointments. For calculation of missed appointments, canceled appointments are not included in the number of units analyzed. The numerator is multiplied by 100 to arrive at a percentage.

Secondary Outcome Measures