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The American Journal of Managed Care August 2018
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Paul Crits-Christoph, PhD; Robert Gallop, PhD; Elizabeth Noll, PhD; Aileen Rothbard, ScD; Caroline K. Diehl, BS; Mary Beth Connolly Gibbons, PhD; Robert Gross, MD, MSCE; and Karin V. Rhodes, MD, MS
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Optimizing Number and Timing of Appointment Reminders: A Randomized Trial
John F. Steiner, MD, MPH; Michael R. Shainline, MS, MBA; Jennifer Z. Dahlgren, MS; Alan Kroll, MSPT, MBA; and Stan Xu, PhD
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Optimizing Number and Timing of Appointment Reminders: A Randomized Trial

John F. Steiner, MD, MPH; Michael R. Shainline, MS, MBA; Jennifer Z. Dahlgren, MS; Alan Kroll, MSPT, MBA; and Stan Xu, PhD
Two text message or phone reminders were more effective in reducing missed primary care appointments than a single reminder, particularly in patients at high risk of missing appointments.
ABSTRACT

Objectives: To compare missed appointment rates for patients receiving a single reminder either 3 days prior to a primary care visit, 1 day prior to the visit, or both 3 days and 1 day prior to the visit.

Study Design: Three-armed randomized controlled trial.

Methods: Text messages or interactive voice response calls were sent to patients with appointments at 25 primary care clinics in an integrated delivery system. A multivariable prediction model was developed to identify patients at high risk of missing appointments, based on prior appointment-keeping history and other variables from electronic health records.

Results: Among 54,066 randomized patients, those who received reminders both 3 days and 1 day prior to the visit were less likely to miss their appointment than those who received only a 3-day or 1-day reminder (4.4% vs 5.8% vs 5.3%, respectively; P <.001). In patients at high risk, 20.5% of those who received 2 reminders missed their visit, compared with 25.0% and 24.2% of those with only 3-day or 1-day reminders, respectively (P <.001). Visit satisfaction was unaffected by providing an additional reminder.

Conclusions: Two automated reminders were more effective than 1 in reducing missed appointments and did not reduce visit satisfaction. A predictive model based on clinical characteristics and prior appointment history can accurately identify patients who are at highest risk of missing appointments. These individuals may benefit more from multiple reminders, but additional strategies are necessary to further reduce their rates of missed appointments.

Am J Manag Care. 2018;24(8):377-384
Takeaway Points

Text message or phone reminders 3 days and 1 day before a primary care appointment were more effective in reducing missed appointments than a single reminder, particularly in patients whom a clinical prediction rule identified as at high risk of missing appointments.
  • Decision makers posed the question to fine-tune existing reminder protocols through collaboration with researchers in a learning health system.
  • Because prior randomized trials had not directly compared either the timing or number of reminder calls, the findings may apply to other organizations.
Healthcare delivery systems use many strategies to remind patients of upcoming clinic appointments. A 1992 meta-analysis found that mailed reminders or telephone calls from clinic staff consistently reduced missed appointments.1 Newer tools, such as interactive voice response (IVR) telephone calls and text messages, have also been effective while improving the efficiency and reducing the cost of appointment reminders.2-5

Although the effectiveness of visit reminders is well established, little is known about the optimal number or timing of reminders. A reminder several days in advance provides patients an opportunity to cancel their appointment with sufficient lead time for a clinic to schedule other patients into vacated slots. On the other hand, a reminder the day prior to an appointment may allow the patient to better assess whether the visit remains necessary or conflicts with other obligations.5 Although multiple reminders may be more effective than a single reminder, patients may perceive them as unnecessary or intrusive.

Learning health systems combine clinical data, quality improvement methods, and research skills to address operational questions rapidly and at low cost.6,7 When operational interventions are randomized, the resulting information is both directly actionable and potentially generalizable to other delivery systems. We previously reported the results of a collaborative trial between operational leaders and researchers in an integrated healthcare system, which found that a single reminder delivered by text or IVR message 1 day prior to a primary care appointment reduced the rate of missed appointments compared with no reminder.8 To refine the approach to delivering appointment reminders, we conducted a second randomized controlled trial to evaluate 3 strategies for providing primary care visit reminders: (1) a single reminder 3 days prior to the visit, (2) a single reminder 1 day prior to the visit (the standard approach based on the initial trial), or (3) reminders both 3 days and 1 day prior to the visit. We also assessed the effect of these 3 approaches on visit satisfaction and the impact of the intervention in the subgroup of patients at highest risk of missing their appointments.

METHODS

Study Setting

This project took place at Kaiser Permanente Colorado (KPCO), an integrated healthcare delivery system with more than 650,000 members in the Rocky Mountain West. Patients received care at 27 primary care clinics that were staffed by family physicians, internists, pediatricians, nurse practitioners, and physician assistants. Patients could make appointments for primary care visits in person, by telephone, or through a web portal. Since 2005, KPCO's research department has operated a visit reminder system that initiates telephone calls to landlines or cellular phones and text messages to cellular phones. Text messages are the primary communication modality unless the recipient has requested voice messages. We designate this system as IVR-T (interactive voice response or text). This system has been used in numerous interventions, several of which have been deployed operationally after completion of the research.8-11

At the time of this study, the delivery system sent a single IVR-T reminder to each primary care patient 1 day before their scheduled visit, based on the results of our prior randomized trial.8 To fine-tune the approach to visit reminders, operational leaders then asked whether a 3-day reminder might be preferable to a 1-day reminder, because it provided greater opportunity to fill slots vacated through cancellations. Although leaders were also interested in determining whether 2 reminders would further reduce missed appointments, they raised concerns that multiple calls might be burdensome to patients and encouraged us to use existing visit satisfaction data to explore this issue.

Intervention Design

In response to these questions, we designed a pragmatic intervention trial. Stratifying by clinic site, we randomly assigned all patients with primary care appointments between October 15, 2016, and December 15, 2016, to 1 of 3 groups: a single IVR-T reminder 3 calendar days prior to the appointment; a single IVR-T reminder 1 calendar day prior to the appointment; or 2 IVR-T reminders, with one made 3 days and the other 1 day prior to the appointment. Calls were made on weekends, as well as business days. All patients were eligible if they had a primary care appointment and had made their appointment 3 or more days in advance of the scheduled visit. Patients who previously requested not to be contacted by phone or text message were excluded. One clinic was excluded because its staff made personal calls rather than using IVR-T reminders, whereas a second site was excluded because it opted to continue using the 1-day reminder protocol. We excluded scheduled telephone visits, visits for office procedures, and visits to non–primary care departments, such as radiology and ophthalmology. Patients who made appointments online through the KPCO patient portal and received email reminders were included in the intervention. Although information about email reminders was unavailable, the randomized design is likely to have distributed individuals who received these reminders equally among the 3 groups.

All text messages or calls were delivered in English. Those receiving a text message were asked to respond with their medical record number if they wished to cancel the appointment. Patients who answered the IVR call confirmed their identity by providing their medical record number, then received a short message confirming the date and time of the appointment and were offered the opportunity to cancel their appointment through the appointment line. If an answering machine responded, a recorded message provided the same information.

We used a randomization algorithm in the program that managed the IVR database to assign each visit to 1 of the 3 groups. Because randomization took place at the visit level, patients with multiple visits during the study period could receive the IVR-T intervention for some visits but not others. We limited the analysis to the first appointment randomized.


 
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