?No-shows,? or missed visits are a persistent problem in all health care systems. They compromise patient access, lengthen wait times, increase health care inefficiencies, and worsen clinical care. The VA?s no-show rate has shown no improvement in years, resulting in a staggering nine million ambulatory no-shows in 2015 and perhaps over $1 billion in additional annual costs. Appointment reminders are an essential element to addressing no-shows but major research gaps exist. Behavioral economics (BE) suggests that ?nudges? can be designed to make it easier for people to do the ?right? thing while retaining individual autonomy. We draw from BE, psychology and related fields to identify concepts that can be applied to innovating the field of appointment reminders. One concept is social norms, which suggests that Veterans are likely to attend appointments if they sense that it is the norm for Veterans to do so. Another concept is based on the idea that providing clear instructions and an implementation plan increases the target behavior. A third approach is to highlight potential harms or losses to the Veteran from missing an appointment, while a fourth approach instead highlights potential negative consequences of no- showing to other Veterans. Each of these concepts can be transformed into messages that can be incorporated into appointment reminders. We will design and evaluate four intervention groups varying in type of nudge included in appointment reminder letters. We will address the following Specific Aims: 1) Develop and iteratively refine BE-informed messages based on Veterans? perceptions, and incorporate them into enhanced appointment reminders; 2) Determine the effect of four versions of enhanced appointment reminders on measures relevant to treatment access, compared with usual reminders; 3) Evaluate differences in treatment effect associated with four versions of enhanced appointment reminders; 4) Characterize potential barriers and facilitators to widespread implementation of enhanced appointment reminder messages. Applying insights from BE to enhance appointment attendance in VA is highly significant and innovative. VA leaders describe reducing no-shows as critical to efforts to improve access, the top priority in VA. Appointment reminders are especially important in mental health (where no-show rates are high) and primary care (where appointments are scheduled far in advance). With the exception of a few studies in the U.K.?s National Health Service, BE has not been incorporated and evaluated in the design and content of appointment reminders. After iterative refinement of nudges to include in enhanced appointment reminders, we will conduct a cluster randomized controlled trial to test four interventions. Intervention arms will vary by what type of nudge and messages are added to appointment reminders. Appointments will be randomly allocated at the provider-level to one of the four interventions or a control group of usual appointment reminders. The study will be conducted at VA Portland Health Care System in primary care and mental health clinics. We will evaluate effect on a variety of access-related metrics, including appointment no-show, attendance, and cancelation rates. We will also explore impact on wait times. Finally, we will also conduct a qualitative assessment consisting of semi- structured interviews with key informants (Veterans and VA leaders) to inform future implementation of the intervention. Together, we believe this will result in a reduction in no-show rates, increased attendance and access by Veterans, decreased wait times for scheduled appointments, and information to prepare to extend the results to other VA facilities. Study results will have direct implications for VA at local and national levels. Individual VA facilities interested in reducing their no-show rates could benefit from implementation of the most effective study intervention, and VA leaders nationally, including our operational partners working on access and no- show issues, could utilize our results for future changes to appointment reminder systems.
Access to healthcare, in particular mental health and primary care, is a vital issue to Veterans. Unfortunately, while some Veterans have long waits to get an appointment, many other Veterans miss appointments, which leads to many unutilized VA appointments. Appointment reminders are an important element to preventing no- shows. However, Veterans are often dissatisfied with existing reminders, and reminders have not been optimized to fully encourage Veterans to attend their appointment or cancel it if no longer necessary. In this research project, we will evaluate the effectiveness of adding innovative ?nudges? to appointment reminders and determine their effect on Veterans? attendance of, and access to, VA appointments in mental health and primary care. This proposal can benefit VA by identifying simple and scalable enhancements to appointment reminders.
