Using Behavioral Economics to Enhance Appointment Reminders and Reduce Missed Visits

Study Overview
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Brief Summary
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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
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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: Aim 1: Develop and iteratively refine BE-informed messages based on Veterans' perceptions, and incorporate them into enhanced appointment reminders. Aim 2: Determine the effect of four versions of enhanced appointment reminders on measures relevant to treatment access, compared with usual reminders. Aim 3: Evaluate differences in treatment effect associated with four versions of enhanced appointment reminders. 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

Official Title
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Using Behavioral Economics to Enhance Appointment Reminders and Reduce Missed Visits

Conditions
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Appointment Reminders

Intervention / Treatment
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* 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


Participation Criteria
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Eligibility Criteria
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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

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional 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)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Social Norms + Behavioral Instructions<br>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<br>* 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).<br>|
| Experimental: Caring + Consequences for Others + Behavioral Instructions<br>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<br>* 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).<br>|
| Experimental: Caring + Consequences for Self + Behavioral Instructions<br>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<br>* 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).<br>|
| Experimental: Combination of all Nudges<br>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<br>* 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).<br>|
| No Intervention: Usual Care<br>An appointment reminder that includes basic appointment information on date, location, and phone number(s) for scheduling changes. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| No-Show Rate | 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. | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Cancellation Rate | The proportion of scheduled appointments that are marked as canceled. | 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Behavioral Economics, Mental Health, Veterans, Veterans Health, Primary Care, Appointments and Schedules