Using Behavioral Economics to Enhance Appointment Reminders and Reduce Missed Visits

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:

1. Aim 1: Develop and iteratively refine BE-informed messages based on Veterans'
perceptions, and incorporate them into enhanced appointment reminders.

2. Aim 2: Determine the effect of four versions of enhanced appointment reminders on
measures relevant to treatment access, compared with usual reminders.

3. Aim 3: Evaluate differences in treatment effect associated with four versions of
enhanced appointment reminders.

4. 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

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: