Reducing VA No-Shows: Evaluation of Predictive Overbooking Applied to Colonoscopy

Study Overview
=================
Brief Summary
-----------------
In this research study, investigators use colonoscopy as a case example to evaluate a predictive overbooking model derived using patient-level predictors of absenteeism. The no-show overbooking intervention employs a logistic regression model that uses patient data to predict the odds of no-showing with 80% accuracy. These projected no-show appointments will be overbooked by clerks for patients who agree to join a fast track short-call line. By rapidly processing endoscopy patients and moving them out of traditional slots, investigators predict more scheduling slots would become available for patients awaiting colonoscopy.

Detailed Description
-----------------
Patient no-shows are especially common in VA gastrointestinal (GI) endoscopy units, where both open-access endoscopy scheduling and patient dislike of procedures contribute to high absenteeism. In this proposal, investigators use endoscopy as a case example to evaluate a predictive overbooking model derived using patient-level predictors of absenteeism. The no-show overbooking intervention employs a logistic regression model that uses patient data to predict the odds of no-showing with 80% accuracy. These projected no-show appointments will be overbooked by clerks for patients who agree to join a fast track short-call line. However, patients scheduled for upper endoscopies in the fast track assume a small risk of service denial on the day of their overbooking in case of inaccurate predictions. If this occurs, the patient is guaranteed service in the next available position and is assured of having a shorter wait time. Patients scheduled for colonoscopies will never be turned down but may experience delays in the waiting room the day of their fast track appointment. By rapidly processing endoscopy patients and moving them out of traditional slots, investigators predict more scheduling slots would become available for patients awaiting colonoscopy. Investigators propose to conduct a prospective, 24-month, interrupted time series (ITS) trial in the WLAVA (West Los Angeles Veterans Administration) GI clinic endoscopy unit. During intervention periods, investigators will activate the no-show predictive overbooking strategy described above. Investigators will compare outcomes between scheduling strategies, including differences in percent utilization of capacity (primary outcome), number of Veterans served, mean patient lag time between scheduling and procedure, number of unexpected service denials (bumps) from no-show predictive overbooking, and direct costs of care. Investigators will analyze differences using both traditional univariate and multivariate approaches, and using autoregressive integrated moving average (ARIMA) analyses to adjust for auto-correlations in ITS data.

Official Title
-----------------
Reducing VA No-Shows: Evaluation of Predictive Overbooking Applied to Colonoscopy

Conditions
-----------------
Colon Cancer

Intervention / Treatment
-----------------
* Other: Predictive no-show overbooking


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Patients who are scheduled for upper endoscopy and agree to the terms of fast track offer. Exclusion Criteria: If a patient expresses concern about service denial, confusion about the bargain, or refuses to participate, the investigators will schedule these patients routinely.

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Fast-tracked<br>'Predictive no-show overbooking' intervention. Patients who volunteer to enroll in fast-track line, which gives them an opportunity to overbook their appointment for endoscopy earlier in a predictive no-show slots. | Other: Predictive no-show overbooking<br>* During intervention period, every Veteran scheduled for an endoscopy will be offered fast-track offer, which gives them a chance to get their endoscopy procedure done earlier than usual scheduling by overbooking their appointment in a predictive no-show slot.<br>|
| No Intervention: Control<br>Patients who are scheduled routinely | |

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percentage of GI Clinic Capacity Filled | Investigators' primary objective will be to evaluate the impact of no-show predictive overbooking on percentage of the GI endoscopy clinic that are filled on a given day. Days where at least one Fast-tracked patient attended an appointment were compared to days where only Control patients attended appointments. Percentage of GI Clinic Capacity is calculated as the number of appointments completed divided by number of appointment spots available on a given day. This percentage was compared between Fast-tracked days and Control days, using data from 1672 patients. | After 12 months of running study in clinic | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Scheduling-to-procedure Lag Time | The investigators will calculate the mean daily lag time for all colonoscopy and upper endoscopies performed per day | After 12 months of running study in clinic | 
| Daily Service Denials (Bumps) | The investigators will compare the number of patients bumped per day between scheduling approaches | After 12 months of running study in clinic | 
| Advanced Adenoma Detection/Cecal Intubation Rates | The investigators will compare daily advanced adenomatous polyp detection and daily cecal intubation rates between groups. | After 20 months of running study in clinic | 
| Length of Workday | Length of Workday in hours (comparing days with Fast-Tracked Appointments to Control days without) | After 12 months of running study in clinic | 
| Cost Comparisons | For cost comparisons, the investigators will aggregate total provider overtime costs for colonoscopies performed. Cost is reported per day. | After 12 months of running study in clinic | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
quality improvement, Organization and Administration, Costs and cost analysis, Patient satisfaction, Health plan implementation