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The American Journal of Managed Care March 2011
Fracture Risk Tool Validation in an Integrated Healthcare Delivery System
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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
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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
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.
Automation of routine clinic processes using technology is often considered a method for reducing costs, especially if the processes include expensive personnel time. If IVR systems are more efficient and costs are significantly lower relative to NDCs, even small differences in patient outcomes may be meaningful for clinics. A recent randomized trial tested whether providing an educational and motivational message to patients via IVR was as effective as no intervention in promoting the initiation of CRC screening and found no statistically significant difference between the control and intervention groups.31 Our study is the first to date to evaluate the use of IVR to deliver both appointment reminder and educational information after an appointment for CRC testing is made. It is also the first to compare its effectiveness with person-to-person calls having identical message content. While the IVR system may lead to equally effective outcomes, we found that more patients who received the NDC had very positive perceptions about the call, while more patients who received the IVR message had neutral perceptions about the call. Because satisfaction reports are often positively skewed, differences between neutral, positive, and very positive perceptions might represent a meaningful degree of negative reaction. Therefore, while the IVR system may be equally effective as NDCs, we conclude that additional work to improve patient acceptability of messaging systems is needed to reduce high no-show and cancellation rates for endoscopy examinations.

This study had notable strengths. First, in addition to assessing endoscopy appointment outcomes, we were able to assess satisfaction with the intervention from the patient survey. Even with the advantages that IVR affords, such as flexible calling times, repetition of information, and supplemental messages, we found that patients had more neutral perceptions of IVR messages than of NDCs. Understanding whether patients will accept information in a specific format and whether the benefit of an automated system outweighs the effort and expense of delivering messages personally repnresents critical information for clinicians and managers when considering technological innovations to improve services. Second, throughout the course of the study, several practice changes were made to improve patient care, including slight changes in preparation materials (the addition of another laxative for colonoscopy preparation) and preparation instructions (prescription of the last dose of laxative the morning of the examination), and broader use of colonoscopy for screening purposes. Despite these changes, which were made across clinics and were equally distributed across intervention arms, the IVR system was as effective as NDCs, suggesting that the IVR system is flexible enough for a dynamic clinical environment.

The study also had several limitations. First, with options for multiple call attempts, the IVR group had more opportunities to receive messages, but it is unclear without data on the length of the NDCs whether patients engaged with nurses for longer periods than patients spent receiving IVR messages. Second, it was not feasible to include another intervention condition with no phone call, which would have provided data to determine if any form of preappointment prompting is effective, although previous meta-analysis and systematic review show that reminder calls are effective and should be the standard of care.38,39 Third, the procedure in this setting for scheduling appointments is based on clinic availability and not on patient availability. Therefore, it is possible that other solutions not tested herein, such as flexibility and convenience in scheduling or options for opting in or opting out of the call after the appointment reminder, would help improve overall completion rates.

We conclude that an IVR system is as effective as NDCs for ensuring that patients attend appointments and are adequately prepared for endoscopy examinations. However, strategies to increase patient satisfaction, including additional options integrated into IVR systems, may help improve these outcomes.

With appointment attendance and preparation adherence rates only near 60% across all study conditions, a combination of different approaches may be necessary to improve endoscopy completion. A potential application of an IVR system may be to shift staff effort from preprocedure education phone calls for all individuals with scheduled procedures to more intensive outreach only to those individuals identified before referral or through medical record review with increased likelihood of appointment nonattendance. The less intensive IVR technology could then be used for all other patients.

Author Affiliations: From the Center for Chronic Disease Outcomes Research (JMG, EMH, DN, EMH, SN, ABS, AB), Minneapolis Veterans Affairs Medical Center, Minneapolis, MN; Department of General Internal Medicine (JMG, DN), University of Minnesota School of Medicine, Minneapolis, MN; Division of Health Promotion and Behavioral Sciences (SWV), University of Texas–Houston School of Public Health, Houston, TX; and Department of Family Medicine and Community Health (MVR), University of Minnesota School of Medicine, Minneapolis, MN.

Funding Source: This study is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, IIR 03-295. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.


Author Disclosures: The authors (JMG, EMH, SWV, DN, EMH, SN, ABS, AB, MVR) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.


Authorship Information: Concept and design (JMG, SWV, DN, SN, MVR); acquisition of data (JMG, SN, ABS, AB, MVR); analysis and interpretation of data (JMG, Ms Hulbert, SWV, DN, Ms Hagel, SN, ABS, AB, MVR); drafting of the manuscript (JMG, Ms Hulbert, SWV, DN, Ms Hagel, SN); critical revision of the manuscript for important intellectual content (JMG, SWV, DN, Ms Hagel, ABS, MVR); statistical analysis (JMG, DN, Ms Hagel); provision of study materials or patients (JMG); obtaining funding (JMG, DN,MVR); administrative, technical, or logistic support (JMG, Ms Hulbert, SN, ABS, AB); and supervision (JMG).


Address correspondence to: Joan M. Griffin, PhD, Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center (152/3E-109), One Veterans Dr, Minneapolis, MN 55417. E-mail:

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