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Using Behavioral Economics to Enhance Appointment Reminders and Reduce Missed Visits (No Show)

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ClinicalTrials.gov Identifier: NCT03850431
Recruitment Status : Recruiting
First Posted : February 21, 2019
Last Update Posted : November 19, 2020
Sponsor:
Collaborators:
Iowa City VA Health Care System
VA Salt Lake City Health Care System
Information provided by (Responsible Party):
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.


Condition or disease Intervention/treatment Phase
Appointment Reminders Behavioral: Social Norms + Behavioral Instructions Behavioral: Caring + Consequences for Others + Behavioral Instructions Behavioral: Caring + Consequences for Self + Behavioral Instructions Behavioral: Caring + Consequences for Others + Consequences for Self + Social Norms + Behavioral Instructions Not Applicable

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

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 64000 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Intervention Model Description: The primary objective is to systematically develop and test the effectiveness of a series of changes to appointment letters in a cluster RCT with the goal of reducing no-shows and increasing access. First, the investigators will iteratively obtain feedback and refine messages in draft interventions (Aim 1). Then evaluate the effects of four enhanced appointment reminder interventions informed by BE and the Theory of Planned Behavior, and compare them to usual care and each other (Aims 2 and 3). Appointments will be randomly allocated to one of the four interventions or usual care at the provider-level, with providers blinded to allocation. The trial will be conducted at eight locations across VAPORHCS in both mental health and primary care. The investigators will also conduct a qualitative assessment with key informants (Aim 4) to provide data that will be useful for future implementation (if intervention is effective) or suggest modifications to the intervention (if ineffective).
Masking: None (Open Label)
Primary Purpose: Health Services Research
Official Title: Using Behavioral Economics to Enhance Appointment Reminders and Reduce Missed Visits
Actual Study Start Date : December 17, 2019
Estimated Primary Completion Date : September 30, 2021
Estimated Study Completion Date : October 31, 2021

Arm Intervention/treatment
Experimental: Social Norms + Behavioral Instructions
A letter with two types of nudges. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).
Behavioral: Social Norms + Behavioral Instructions
A letter with two types of nudges. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).

Experimental: Caring + Consequences for Others + Behavioral Instructions
A letter with three types of nudges. One suggests that the institution cares about the patient. One highlights a potential negative consequence for others if the patient no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).
Behavioral: Caring + Consequences for Others + Behavioral Instructions
A letter with three types of nudges. One suggests that the institution cares about the patient. One highlights a potential negative consequence for others if the patient no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).

Experimental: Caring + Consequences for Self + Behavioral Instructions
A letter with three types of nudges. One suggests that the institution cares about the patients. One highlights potential negative consequences for the patient if s/he no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).
Behavioral: Caring + Consequences for Self + Behavioral Instructions
A letter with three types of nudges. One suggests that the institution cares about the patients. One highlights potential negative consequences for the patient if s/he no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).

Experimental: Combination of all Nudges
A letter with all four types of nudges combined. One suggests that the institution cares about the patients. One highlights a potential negative consequence for others if the patient no-shows. One highlights potential negative consequences for the patient if s/he no-shows. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).
Behavioral: Caring + Consequences for Others + Consequences for Self + Social Norms + Behavioral Instructions
A letter with all four types of nudges combined. One suggests that the institution cares about the patients. One highlights a potential negative consequence for others if the patient no-shows. One highlights potential negative consequences for the patient if s/he no-shows. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).

No Intervention: Usual Care
An appointment reminder that includes basic appointment information on date, location, and phone number(s) for scheduling changes.



Primary Outcome Measures :
  1. No-Show Rate [ Time Frame: 1 year ]
    The proportion 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.


Secondary Outcome Measures :
  1. Cancellation Rate [ Time Frame: 1 year ]
    The proportion of scheduled appointments that are marked as canceled.



Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   Yes
Criteria

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

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03850431


Contacts
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Contact: Emily E Metcalf, MA (503) 220-8262 ext 54898 Emily.Metcalf@va.gov
Contact: Alan R Teo, MD MS (503) 220-8262 ext 52461 Alan.Teo@va.gov

Locations
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United States, Oregon
VA Portland Health Care System, Portland, OR Recruiting
Portland, Oregon, United States, 97239
Contact: Danielle N Beaudry, MA    503-220-8262 ext 57524    danielle.beaudry@va.gov   
Principal Investigator: Alan R. Teo, MD MS         
Sub-Investigator: Anais Tuepker, PhD MPH         
Sub-Investigator: Steven K. Dobscha, MD         
Sponsors and Collaborators
VA Office of Research and Development
Iowa City VA Health Care System
VA Salt Lake City Health Care System
Investigators
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Principal Investigator: Alan R. Teo, MD MS VA Portland Health Care System, Portland, OR
Publications of Results:
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Responsible Party: VA Office of Research and Development
ClinicalTrials.gov Identifier: NCT03850431    
Other Study ID Numbers: IIR 17-134
HX002449 ( Other Grant/Funding Number: VA Health Services Research and Development )
First Posted: February 21, 2019    Key Record Dates
Last Update Posted: November 19, 2020
Last Verified: November 2020
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: No
Keywords provided by VA Office of Research and Development:
Behavioral Economics
Mental Health
Veterans
Veterans Health
Primary Care
Appointments and Schedules