Using Behavioral Economics to Enhance Appointment Reminders and Reduce Missed Visits
No Show
2 other identifiers
interventional
34,516
1 country
1
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.
Trial Health
Trial Health Score
Automated assessment based on enrollment pace, timeline, and geographic reach
participants targeted
Target at P75+ for not_applicable
Started Dec 2019
Typical duration for not_applicable
1 active site
Health score is calculated from publicly available data and should be used for screening purposes only.
Trial Relationships
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Study Timeline
Key milestones and dates
First Submitted
Initial submission to the registry
February 19, 2019
CompletedFirst Posted
Study publicly available on registry
February 21, 2019
CompletedStudy Start
First participant enrolled
December 17, 2019
CompletedPrimary Completion
Last participant's last visit for primary outcome
October 14, 2021
CompletedStudy Completion
Last participant's last visit for all outcomes
October 14, 2021
CompletedResults Posted
Study results publicly available
April 19, 2024
CompletedApril 19, 2024
October 1, 2023
1.8 years
February 19, 2019
September 19, 2022
October 13, 2023
Conditions
Keywords
Outcome Measures
Primary Outcomes (1)
No-Show Rate
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.
1 year
Secondary Outcomes (1)
Cancellation Rate
1 year
Study Arms (5)
Social Norms + Behavioral Instructions
EXPERIMENTALClinics assigned a letter with two types of nudges (Social Norms + Behavioral Instructions)
Caring + Consequences for Others + Behavioral Instructions
EXPERIMENTALClinics assigned a letter with three types of nudges (Caring + Consequences for Others + Behavioral Instructions)
Caring + Consequences for Self + Behavioral Instructions
EXPERIMENTALClinics assigned a letter with three types of nudges (Caring + Consequences for Self + Behavioral Instructions)
Combination of all Nudges
EXPERIMENTALClinics assigned a letter with a combination of all types of nudges (Behavioral: Caring + Consequences for Others + Consequences for Self + Social Norms + Behavioral Instructions)
Usual Care
NO INTERVENTIONClinics assigned to usual care. Usual care consisted of a letter with basic appointment information on date, location, and phone number(s) for scheduling changes
Interventions
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).
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).
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).
A letter with all 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).
Eligibility Criteria
You may qualify if:
- 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.
You may not qualify if:
- None
Contact the study team to confirm eligibility.
Sponsors & Collaborators
- VA Office of Research and Developmentlead
- Iowa City VA Health Care Systemcollaborator
- VA Salt Lake City Health Care Systemcollaborator
Study Sites (1)
VA Portland Health Care System, Portland, OR
Portland, Oregon, 97239, United States
Related Publications (4)
Teo AR, Metcalf EE, Strange W, Call AA, Tuepker A, Dobscha SK, Kaboli PJ. Enhancing Usability of Appointment Reminders: Qualitative Interviews of Patients Receiving Care in the Veterans Health Administration. J Gen Intern Med. 2021 Jan;36(1):121-128. doi: 10.1007/s11606-020-06183-5. Epub 2020 Sep 9.
PMID: 32909229RESULTZikmund-Fisher BJ, Tuepker A, Metcalf EE, Strange W, Teo AR. Applying user-centered design in the development of nudges for a pragmatic trial to reduce no-shows among veterans. Patient Educ Couns. 2022 Jun;105(6):1620-1627. doi: 10.1016/j.pec.2021.10.024. Epub 2021 Oct 23.
PMID: 34756639RESULTLafferty M, Strange W, Kaboli P, Tuepker A, Teo AR. Patient Sense of Belonging in the Veterans Health Administration: A Qualitative Study of Appointment Attendance and Patient Engagement. Med Care. 2022 Sep 1;60(9):726-732. doi: 10.1097/MLR.0000000000001749. Epub 2022 Jul 26.
PMID: 35880766RESULTTeo AR, Niederhausen M, Handley R, Metcalf EE, Call AA, Jacob RL, Zikmund-Fisher BJ, Dobscha SK, Kaboli PJ. Using Nudges to Reduce Missed Appointments in Primary Care and Mental Health: a Pragmatic Trial. J Gen Intern Med. 2023 Jul;38(Suppl 3):894-904. doi: 10.1007/s11606-023-08131-5. Epub 2023 Jun 20.
PMID: 37340264RESULT
MeSH Terms
Conditions
Condition Hierarchy (Ancestors)
Results Point of Contact
- Title
- Dr. Alan Teo
- Organization
- Center to Improve Veteran Involvement in Care (CIVIC), HSR&D Center of Innovation, VA Portland Health Care System
Study Officials
- PRINCIPAL INVESTIGATOR
Alan R. Teo, MD MS
VA Portland Health Care System, Portland, OR
Publication Agreements
- PI is Sponsor Employee
- Yes
Study Design
- Study Type
- interventional
- Phase
- not applicable
- Allocation
- RANDOMIZED
- Masking
- NONE
- Masking Details
- The intervention arms were assigned letters and the statistician was blinded for analysis.
- Purpose
- HEALTH SERVICES RESEARCH
- Intervention Model
- PARALLEL
- Sponsor Type
- FED
- Responsible Party
- SPONSOR
Study Record Dates
First Submitted
February 19, 2019
First Posted
February 21, 2019
Study Start
December 17, 2019
Primary Completion
October 14, 2021
Study Completion
October 14, 2021
Last Updated
April 19, 2024
Results First Posted
April 19, 2024
Record last verified: 2023-10
Data Sharing
- IPD Sharing
- Will not share