The American Journal of Managed Care March 2011
Improving Endoscopy Completion: Effectiveness of an Interactive Voice Response System
Objective: To test whether an interactive voice response (IVR) system phone call was equally effective as a nurse-delivered phone call at educating and preparing patients for flexible sigmoidoscopy (FS) and colonoscopy examinations.
Study Design: Three-arm randomized controlled trial.
Methods: The trial included patients with upcoming FS or colonoscopy appointments to test the equivalence of an IVR system to nurse-delivered phone calls in reducing appointment nonattendance and inadequate preparation for an examination. Message timing and satisfaction with the intervention were assessed. The 3 study conditions included the following: nurse phone call 7 days before the procedure, IVR system call 7 days before the procedure, and IVR system call 3 days before the procedure. All calls included an appointment reminder, information about preparation for the examination, and encouragement to prepare for and attend the examination.
Results: A total of 3610 patients were eligible for the study; of these, 1229 (34%) were scheduled for FS and 2381 (66%) for colonoscopy. There were no statistically significant differences across the 3 study arms in appointment attendance or adherence to preparation instructions. Significantly more patients in IVR conditions reported neutral perceptions about the phone calls, and more patients receiving nurse calls reported very positive perceptions about the phone calls.
Conclusion: An IVR system call is as effective as a nurse phone call for ensuring that patients attend appointments and are adequately prepared for endoscopy examinations.
(Am J Manag Care. 2011;17(3):199-208)
An interactive voice response (IVR) system, an automated phone–based technology that allows for 2-way communication between clinics and patients, was used to remind patients of upcoming flexible sigmoidoscopy and colonoscopy appointments and to provide them with information about how to prepare for the examination. Our findings include the following:
- The IVR system was effective at reminding patients of their appointments.
- An IVR system can effectively deliver complex information, such as preparation information.
- An IVR system is equally effective as phone calls from clinic nurses at delivering information.
- Patients receiving IVR messages reported more “neutral” perceptions about the phone calls; patients receiving nurse calls reported more “very positive” perceptions about the phone calls.
National CRC screening rates remain low compared with frequencies of other cancer screening tests.3 Likewise, completion rates of follow-up diagnostic tests after a positive screening test result are low. In a study4 conducted through the Veterans Health Administration, where screening rates are typically higher than in other settings, only 44% of those with a positive fecal occult blood test result completed a diagnostic colonoscopy within 12 months. Even when appointments are scheduled, screening completion rates are low, with a study5 finding that only 44% of those scheduled for a colonoscopy and 59% of those scheduled for an FS completed their examination. Clinicians, researchers, and patients agree that preparation for endoscopy examinations is complex and can be difficult but needs to be performed properly to complete the examination.6 In addition to finding transportation home after the procedure, other barriers to endoscopy that reduce attendance and completion rates include the following: fear of positive findings7; poor understanding of the procedure8; discomfort, embarrassment, and anxiety about the procedure9; forgetting the appointment10,11; lack of patient self-efficacy12; and worries and concerns about the procedure and an absence of symptoms.13 Studies have found that patient education14 and appointment reminder phone calls11 significantly reduce appointment cancellations. Other researchers have found that education can lead to higher endoscopy completion rates, especially when information is delivered multiple times and in understandable formats.15
Using innovative cost-effective approaches for improving FS and colonoscopy completion rates might benefit patients by assuring essential and timely care that could reduce morbidity and mortality. A novel approach used in other healthcare settings is an interactive voice response (IVR) system, an automated phone–based technology that allowsfor 2-way communication between clinics and patients. Interactive voice response is a mode of message delivery that has been shown to be effective in medical contexts.16,17 It allows for calls to be delivered at any appointed time and for information to be repeated, both of which increase the likelihood that the call will be delivered and received. For example, phone appointment reminders delivered via IVR have been shown to increase appointment adherence and preappointment procedure completion18 and to decrease appointment nonattendance.16,17,19-27 Fewer studies28-31 have used IVR to deliver educational messages.
Guided by models of behavior change32 and social marketing principles,33,34 we developed an IVR system that provided patients with cues to action for appointment attendance and procedure preparation, including targeted educational information about susceptibility and severity of CRC and motivational messages that addressed risks, benefits, barriers, and self-efficacy associated with preparation and procedures. Our objectives were to assess the following: (1) the equivalence of theory-based phone messages and education provided by an IVR system and by nurse-delivered calls (NDCs) in promoting appointment attendance and adherence to preparation instructions for FS and colonoscopy, (2) the effect of the timing of IVR messages delivered 3 days versus 7 days before the scheduled appointment, and (3) any differences in patient satisfaction between IVR messages and NDCs.
We conducted a 3-arm randomized controlled trial among patients with upcoming FS or colonoscopy appointments scheduled in 2 gastrointestinal (GI) endoscopic procedure clinics at the Minneapolis Veterans Affairs Medical Center. Patients included those being screened and those having follow-up appointments after receipt of abnormal test results. While these clinics provide both upper and lower GI examinations, we included only the 2 lower GI examinations (FS and colonoscopy) because they comprise 67% of the endoscopic workload and because 69% of all cancellations in these clinics are for these 2 procedures.
During the study period, an automated program was applied each night to the hospital computerized record system to identify new appointments made in the clinics. Patients scheduled for an appointment were evaluated for study eligibility criteria (described herein). Those eligible were randomized to 1 of 3 study arms, with the randomization stratified by procedure type. Clinic procedure nurses and physicians were blinded to the randomized conditions. Study arms included the following: (1) NDC (phone call from a nurse 7 days before the procedure), (2) IVR7 (phone call from the IVR system 7 days before the procedure), and (3) IVR3 (phone call from the IVR system 3 days before the procedure). The NDC was the clinic’s usual care procedure. For the intervention to be unobtrusive to clinic staff and to retain blinding to the intervention condition, an NDC at 3 days before the procedure was not included. Intervention calls were initiated from a Minneapolis Veterans Affairs Medical Center computer server running a software program (AudioCARE; AudioCARE Systems, Berwyn, PA), and NDCs were initiated by nurses in the recovery room of the GI clinic.
Appointment and GI procedure data, including patient appointment records and procedure notes for the initial scheduled appointment, were extracted from medical records to assess study outcomes for all condition arms. Additional patient health information was extracted, including diagnoses of chronic physical and mental health conditions in the year before the index appointment.
One week following the initial appointment, patients were sent a questionnaire about their experiences with the reminder system and the scheduled procedure. The questionnaire asked patients if they recalled a preappointment phone call, the type of call (whether an IVR message or an NDC was received), and (if they received the call) their opinion about the thoroughness of preparation instructions. If they prepared for and attended their appointment, they were also queried about their experiences with the preparation and procedure and any perceived barriers and facilitators to appointment attendance and procedure preparation. Questionnaires were mailed directly to participants’ homes by study staff.
All patients scheduling an FS or a colonoscopy appointment between August 20, 2007, and October 31, 2008, in either clinic were assessed for study inclusion. Patients were ineligible for the study if, based on a medical record review before randomization, they lived in a nursing or group home or a homeless shelter, had no listed phone number, scheduled the appointment less than 8 days in advance, had multiple GI procedures scheduled for the same day (such as patients with both upper and lower GI procedures), or had a diagnosis of type 1 diabetes mellitus, dementia, or Alzheimer’s disease. These patients had unreliable means of receiving the intervention (eg, no phone), or the IVR system would have provided inappropriate or inaccurate information (eg, based on their health conditions).
Intervention. More than 95% of the FS and colonoscopy appointments were scheduled within 40 days before the appointment; 85% were scheduled 20 to 40 days before the appointment. The clinic protocol was to mail all patients their appointment information, preparation instructions, and preparation materials within 1 week after their appointment was made. For patients in the NDC arm, a recovery room nurse attempted to call to remind patients of the appointment and review preparation instructions 7 days before the appointment. Nurses used computerized templates to guide them through the call. The templates, one for FS and another for colonoscopy, included logistical information about the appointment (such as time, place, what to bring, and whether the patient needed someone to drive him or her home) and preparation instructions (such as what medications to stop and how and when to take the prescribed colon cleansing laxatives). Nurses also answered any questions during the call. An NDC was considered complete if a nurse spoke directly with the patient. Per clinic protocol, nurses did not leave any message if a patient was not reached, but made 1 more attempt the following afternoon. If that call was unsuccessful, no message was delivered.
Patients in the IVR study arms (IVR7 and IVR3) were mailed appointment information and preparation instructions and materials identical to those mailed in the NDC arm. Instead of NDCs, they received appointment reminder information and preparation instructions via an IVR system.
There is no evidence base concerning effective time frames for prompting patients. We selected a 7-day window based on current NDC practices and protocol and a 3-day window because this was the day before patients were to start the colon cleansing preparation, and we hypothesized that the immediacy of the message might be a cue to action. While the IVR system allows for calls to be delivered at any time, patient preferences for the time of day to be called for the NDC were unknown. Phone calls were programmed to start in the morning. If an answering machine picked up on the initial call, the IVR system left a general message about the purpose of the call. The system was programmed to call again in the afternoon and then again in the evening until the patient answered. Messages were left only on the first attempt. If the IVR call was not completed that day, the process was repeated the following day. Patients who answered the call had the option to have the system call back at a later time. An IVR call was considered complete if the patient answered and confirmed his or her appointment.
The IVR system allowed patients to verify and confirm their appointment, respond to instructions about logistics, request additional preparation materials, answer queries about their current health, listen to preparation instructions, have any information repeated, ask for a summary of instructions, or leave a message for a nurse who would call back within 24 hours. Embedded in these messages was the educational information about susceptibility and severity of CRC, as well as motivational messages that addressed risks, benefits, barriers, and self-efficacy associated with preparation and procedures. At any time during the call, the patient could request to be transferred to the clinic to leave a message for a nurse.