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The American Journal of Managed Care March 2011
Fracture Risk Tool Validation in an Integrated Healthcare Delivery System
Joan C. Lo, MD; Alice R. Pressman, MS, PhD; Malini Chandra, MS; and Bruce Ettinger, MD
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Improving Endoscopy Completion: Effectiveness of an Interactive Voice Response System
Joan M. Griffin, PhD; Erin M. Hulbert, MS; Sally W. Vernon, PhD; David Nelson, PhD; Emily M. Hagel, MS; Sean Nugent, BA; Alisha Baines Simon, MS; Ann Bangerter, BS; and Michelle van Ryn, PhD
Healthcare Spending and Preventive Care in High-Deductible and Consumer-Directed Health Plans
Melinda Beeuwkes Buntin, PhD; Amelia M. Haviland, PhD; Roland McDevitt, PhD; and Neeraj Sood, PhD
Regulating the Medical Loss Ratio: Implications for the Individual Market
Jean M. Abraham, PhD; and Pinar Karaca-Mandic, PhD
On Telephone-Based Disease Management: Wrong Diagnosis, Right Prescription
Christobel Selecky; Reply by Brenda Motheral, BPharm, MBA, PhD
Connecting Statewide Health Information Technology Strategy to Payment Reform
John S. Toussaint, MD; Christopher Queram, MA; and Josephine W. Musser
Health Information Technology and Physicians' Perceptions of Healthcare Quality
Hai Fang, PhD, MPH; Karen L. Peifer, PhD, MPH, RN; Jie Chen, PhD; and John A. Rizzo, PhD
COPD-Related Healthcare Utilization and Costs After Discharge From a Hospitalization or Emergency Department Visit on a Regimen of Fluticasone Propionate-Salmeterol Combination Versus Other Maintenanc
Anand A. Dalal, PhD, MBA; Manan Shah, PhD; Anna O. D'Souza, PhD; and Douglas W. Mapel, MD
Telemonitoring With Case Management for Seniors With Heart Failure
Marcia J. Wade, MD, FCCP, MMM; Akshay S. Desai, MD, MPH; Claire M. Spettell, PhD; Aaron D. Snyder, BA; Virginia McGowan-Stackewicz, RN, CCM; Paula J. Kummer, RN, BA; Maureen C. Maccoy, RN, MBA; and Ra

Improving Endoscopy Completion: Effectiveness of an Interactive Voice Response System

Joan M. Griffin, PhD; Erin M. Hulbert, MS; Sally W. Vernon, PhD; David Nelson, PhD; Emily M. Hagel, MS; Sean Nugent, BA; Alisha Baines Simon, MS; Ann Bangerter, BS; and Michelle van Ryn, PhD
An interactive voice response system is as effective as nurse phone calls for ensuring that patients attend appointments and are adequately prepared for endoscopy examinations.
Process Measures. To assess whether the intervention was delivered in a uniform way, we collected details about the appointments and then calculated the proportion of attempted and completed calls for each study condition. Attempted and completed IVR calls were collected via the IVR system, while attempted and completed NDCs were recorded on the computerized nurse template. For the IVR system, the proportion of requests to be transferred to the clinic was also assessed and compared across IVR arms. The mean number of attempts made before reaching the patient was also calculated, and the total time spent on the IVR call was recorded. For NDCs, these data were unavailable; however, for the number of attempted calls, the nurse protocol was to make a maximum of 2 attempts to reach each patient.

Survey. All randomized patients were mailed a questionnaire regardless of appointment attendance. The questionnaire was based on health belief model32 constructs and assessed attitudes and beliefs about preparing for and completing an endoscopy examination. Sent with an introduction letter, postage-paid return envelope, and $5 unconditional cash incentive, the 12-page survey included questions about perceived disease susceptibility and severity and about benefits, barriers, and self-efficacy relative to completing an endoscopy examination. We also included questions about satisfaction with the reminder phone calls and about general patient demographics, including age, employment status, race/ethnicity, education, income, and marital status. Using a modification of the method by Dillman et al,35 we mailed a reminder postcard 14 days after the survey was sent. A second survey packet without the incentive was sent to nonresponders 21 days after the initial mailing. Study staff phoned patients 28 days after the initial mailing to remind them about the survey but did not attempt to administer the questionnaire over the phone.


We hypothesized that equal proportions of patients in the NDC and IVR conditions (1) would not attend their scheduled FS or colonoscopy appointment and (2) would not have thorough bowel preparation for the scheduled FS or colonoscopy. Likewise, we hypothesized that equivalent proportions of patients would be nonadherent to appointment attendance and preparation instructions when the intervention message was delivered 3 days versus 7 days before the index appointment date. Finally, we hypothesized that patients in the NDC arm would have a more positive perception of the calls than those in the IVR arms.

Sample Size

The standard equivalence test (at a .015 significance level) examines whether a 97% 2-sided confidence interval for a difference in outcome rates falls within a prespecified equivalence boundary. Because no literature specifies the clinically significant difference in completion rates, we relied on clinician experts to specify the equivalence boundary. Four practicing gastroenterologists were queried about their perceptions of equivalence. The unanimous opinion was that at least a 10% difference in completion rates would be clinically significant and that anything less than 10% would be considered equivalent.

Clinic data from a 6-month period before the study (December 2006 through May 2007) showed appointment completion rates of 67% and 62% for FS and colonoscopy, respectively. Using an equivalence boundary of 0.10, a sample size of 743 subjects per group provided 90% power for the study with a level of .05 divided by 3 and an underlying 65% baseline completion rate. We initially planned to obtain 743 patients in each study arm for each procedure, but changes in clinic practices after the study planning prohibited recruitment of sufficient numbers of FS cases.

Outcome Measures

The study evaluated the following 2 main outcomes: appointment nonattendance and preparation nonadherence. Nonattendance was defined as canceling the appointment or not attending the appointment. We did not consider appointments canceled by the clinic as nonattendance. Preparation nonadherence assessed whether patients had adequately prepared to complete the procedure. We used procedure notes to determine if the patient was adequately prepared or if the physician was unable to evaluate the quality of the preparation. Four participants arrived for their appointment but were then deemed inappropriate for the procedure because of serious complicating health conditions. These 4 patients were excluded from analyses.

Perceptions of preappointment phone calls were measured using a survey question about how satisfied respondents were with the reminder phone calls. Response options were “very positive,” “positive,” “neutral,” “negative,” or “very negative.”


All hypotheses were tested separately for FS and colonoscopy using intent-to-treat analysis. To test whether outcomes for NDCs and IVR messages were equivalent and whether the 2 IVR interventions were equivalent, we constructed 2-sided 97% confidence intervals for the difference in completion rates, with the confidence level chosen as a Bonferroni multiple comparisons adjustment for the main comparisons. If the confidence interval fell within −10% and 10%, the conditions were considered equivalent.

To address potential survey response bias, we estimated response propensities using administrative measures available for all subjects, stratified the sample into strata with estimated propensities within .05 of one another, and verified the balance of the covariate measures between respondents and nonrespondents within strata. We estimated treatment differences using weighted means of within-stratum differences, weighting by the sample proportions of the strata. Likelihood ratio tests comparing a generalized linear model using only stratum as a predictor and a model using stratum, treatment, and their interaction were used to test for differences.

To assess whether the intervention was implemented uniformly across patients in the intervention arms, appointment details (including distance traveled to the appointment, appointment day and time, and proportion of attempted and completed calls) were compared across intervention arms.


Figure 1 and Figure 2 show the flow of participants for the intervention and survey using Consolidated Standards of Reporting Trials guidelines.36,37 A total of 3610 patients were eligible for the study. Of these, 1229 (34%) were scheduled for FS and 2381 (66%) for colonoscopy. Approximately 36% of all procedures were for screening, while the others were for diagnosis or surveillance.

Because of study modifications, questionnaires were approved by the institutional review board 6 weeks after initiation of the intervention trial. The protocol was to survey within 1 week of the initial appointment to assure that patients were assessing the initial appointment and not subse quent appointments. Therefore, the number of questionnaires did not equal the number of patients eligible for the trial. We mailed questionnaires to 2947 of 3610 patients (82%) eligible for the trial. Of those, almost 75% returned a questionnaire, 7% refused, almost 3% had either died or did not have a valid address, and 15% did not return a questionnaire. Response rates for FS and colonoscopy patients were almost equal, aswere the rates across study conditions and outcomes.

There were no significant differences in age, sex, marital status, race/ethnicity, employment status, education, or yearly income across the 3 study arms (Table 1). In separate analyses for FS and colonoscopy (data not shown), there were no significant differences in patient demographics across intervention arms.

For FS and colonoscopy, appointment nonattendance and preparation nonadherence were equivalent across all 3 study arms (Figure 3). For colonoscopy, 38%, 42%, and 41% did  not attend in the IVR7, IVR3, and NDC arms, respectively; likewise, 40%, 44%, and 44% did not have adequate preparation in the IVR7, IVR3, and NDC arms, respectively. For FS, 38%, 41%, and 40% did not attend in the IVR7, IVR3, and NDC arms, respectively, while 40%, 42%, and 41% did not have adequate preparation in the IVR7, IVR3, and NDC arms,  respectively. Timing of the IVR message did not influence appointment attendance or preparation adherence. Comparing colonoscopy patients in the IVR7 versus IVR3 arms, participants were equally likely to not attend their apn pointment (39% vs 42%) or to not prepare adequately (40% vs 44%); findings were similar for FS, with 38% versus 41% not attending appointments and 40% versus 42% not adequately preparing.

As summarized in Table 2, most colonoscopy and FS patients had very positive or positive reactions to both IVR messages and NDCs; less than 6% in any study condition had negative or very negative perceptions about the call. There were no significant differences in perceptions of experiences across conditions for the FS group. However, for the colonoscopy group, significantly more patients who received the NDC versus the IVR3 versus the IVR7 (35% vs 21% vs 26%) had very positive perceptions about the call. Almost equal proportions had positive perceptions. However, more colonoscopy patients had neutral perceptions about the call in the IVR3 versus the IVR7 (27% vs 20%) and in the IVR3   versus the NDC (27% vs 18%) (P <.01 for both). Across both IVR and NDC arms, more patients with very positive perceptions about the call attended their appointments and prepared appropriately, while fewer patients with neutral perceptions attended their appointments and prepared appropriately (data not shown).

Process Outcomes

On average, appointments were made 28 to 29 days in advance and did not vary by study arm. Appointment day or time also did not vary by study arm. Differences in proportion of received calls between IVR groups were not significantly different for colonoscopy (56% for NDC, 51% for IVR7, and 52% for IVR3) or for FS (46% for NDC, 48% for IVR7, and 50% for IVR3). Of patients in the IVR arms, 4% of those who confirmed their appointment requested to be transferred to the clinic to talk to a nurse; these requests did not vary across the IVR7 and IVR3 arms.


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