2023 HSR&D/QUERI National Conference

1114 — Using Nudges to Enhance Appointment Reminders and Reduce No-Shows

Lead/Presenter: Alan Teo,  COIN - Portland
All Authors: Teo AR (Center to Improve Veteran Involvement in Care, VA Portland Health Care System), Handley R (Center to Improve Veteran Involvement in Care, VA Portland Health Care System) Zikmund-Fisher BJ (Department of Health Behavior of Health Education, School of Public Health, University of Michigan) Niederhausen M (School of Public Health, Oregon Health & Science University and Portland State University) Metcalf E (Center to Improve Veteran Involvement in Care, VA Portland Health Care System) Call AA (Center to Improve Veteran Involvement in Care, VA Portland Health Care System) Dobscha SK (Center to Improve Veteran Involvement in Care, VA Portland Health Care System) Kaboli PJ (Comprehensive Access and Delivery Research and Evaluation Center, Iowa City Veterans Affairs Healthcare System)

No-shows are a persistent and costly problem in all healthcare systems. In the Veterans Health Administration (VHA), there are over 8 million no-shows annually, representing approximately 12% of all outpatient clinic appointments. Appointment reminders are widely used but rarely include messages designed to nudge patients to attend their appointment. The objective of the present study was to determine the effect of incorporating nudges in appointment reminder letters on measures of outpatient appointment attendance.

Design and participants: This pragmatic cluster randomized controlled trial included 231 primary care clinics and 215 mental health clinics in one VHA medical center and its satellite clinics. Patients with appointments scheduled between October 15, 2020 and October 14, 2021 were eligible for analysis. Interventions: Clinics were randomized to one of five study arms using equal allocation, four nudge arms and one control arm. The four nudge arms included varying combinations of brief messages developed with veteran input and based on concepts in behavioral science, including social norms around attending appointments (e.g., “Most veterans make a point to attend their VA appointments. If they can’t make their appointments, most Veterans also make an effort to let us know.”), specific behavioral instructions for canceling appointments (e.g., “If you need to reschedule your appointment, call now so we can help another Veteran in need. Take these 2 simple steps today….”), and consequences to the Veteran and others for missing an appointment (e.g., “If you miss your appointment, you may have to wait a while to be seen.”). Data Sources/Main Measures: The primary outcome was no-show rate, and the secondary outcome was cancellation rate. Statistical analysis: Results are based on logistic regression models adjusting for demographic and clinical characteristics, and clustering for clinics and patients.

There were 27,540 patients with 49,598 primary care appointments, and 9,420 patients with 38,945 mental health appointments. The no-show rates for the treatment group (all four nudge arms combined) and control group, respectively, were 11.1% and 11.9% in primary care, and 20.1% and 18.0% in mental health. There was no effect of nudges on no-show rate in primary care (OR = 1.14, 95%CI = 0.96-1.36, p = 0.15) or mental health (OR = 1.20, 95%CI = 0.90-1.60, p = 0.21) clinics, when comparing the treatment groups to the control group. When comparing individual study arms, no differences in no-show rates were observed, nor were there significant differences in cancellation rates.

Appointment reminder letters incorporating brief behavioral nudge messages were not effective in reducing no-shows in primary care or mental health clinics in VHA.

It may be that more complex or intensive interventions are necessary to reduce no-shows, and there is likely a floor rate for no-shows at which further interventions may have diminishing returns.