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The American Journal of Managed Care August 2018
Impact of a Medical Home Model on Costs and Utilization Among Comorbid HIV-Positive Medicaid Patients
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.

A total of 65,038 appointments were scheduled for 55,829 patients at 25 primary care clinics over the 2-month study period. After exclusions shown in the Figure, we analyzed 54,066 visits for 54,066 patients. Text messages were sent to 41,339 individuals (76.4%), IVR calls were made to 8038 (14.9%), and 4689 (8.7%) could not be reached by either modality. Of these 54,066 patients, 18,135 were randomized to receive a 3-day reminder call, 18,029 to receive a 1-day reminder call, and 17,902 to receive both 3-day and 1-day reminders. Patient characteristics were balanced across intervention arms (Table 1 [part A and part B]).

Overall, 5.2% of appointments were missed, 15.2% were cancelled, and 79.7% were completed. As shown in Table 2, the group receiving both 3-day and 1-day reminders had the lowest rate of missed visits (P <.0001). The number needed to treat (NNT) was 76; in other words, 1 fewer appointment was missed for every 76 patients who received both reminders compared with those who received a single reminder. In separate comparisons between missed and completed appointments and between cancelled and completed appointments, the intervention reduced missed appointments (<.0001) but had no effect on cancellations (P = .53). The 3 groups did not differ in satisfaction with the number or timing of reminders or in overall visit satisfaction (Table 2). Individuals who received 2 IVR-T reminders did report receiving more reminder messages (a mean of 1.8 reminders vs 1.5 reminders in the other 2 groups; P <.0001).

Text messages and telephone calls were equally effective in reducing the rate of missed appointments. Among those who received text messages, rates of missed appointments were 5.6%, 4.9%, and 4.2% for the 3-day, 1-day, and both-days intervention groups, respectively, whereas among those who received calls, rates of missed appointments were 4.8%, 4.4%, and 3.8% (P <.001).

The statistical model for missed appointments included 45,873 patients after excluding 8193 individuals who cancelled appointments. Predictors of missing an appointment are shown in Table 3 (part A and part B). The strongest individual predictor was the number of missed outpatient appointments within the prior 6 months. The multivariable model showed excellent discrimination (C statistic = 0.93). A model limited to linear and quadratic terms for the number of prior missed visits also showed excellent discrimination (C statistic = 0.92).

The missed appointment rate in the highest-risk quartile was 23.3%, compared with 0.4% in the 3 lower-risk quartiles. In the highest-risk quartile, 2 reminders reduced the rate of missed appointments by 4.5% compared with the 3-day reminder and by 3.7% compared with the 1-day reminder (Table 4). The 2-reminder intervention had an NNT of 25 compared with a single reminder. In the 3 lower-risk quartiles, 2 reminders remained significantly more effective than a single reminder, but the NNT was 1328. The interaction among subgroups was statistically significant (P = .047).20


In this 3-armed randomized trial, we found that 2 reminders, delivered by text message or telephone 3 days and 1 day prior to a primary care visit, were more effective than a single reminder delivered either 3 days or 1 day prior to a visit. The intervention was effective despite a low baseline rate of missed appointments.1,5 Member satisfaction with the reminder process and the primary care visit was similar in the 3 study arms. The effectiveness of the intervention was substantially greater in patients at highest risk of missing their appointments, as defined by a multivariable prediction model.

The effectiveness of a single visit reminder in medical settings is well established.1-5 Less is known about the effect of varying the timing or number of reminders. One randomized trial in an endoscopy clinic found that IVR reminders 3 days versus 7 days prior to the appointment were equally effective.21 Systematic reviews have found that the effectiveness of a single reminder was comparable when delivered between 1 and 7 days prior to a visit, although they did not report any trials that directly compared the timing or number of reminders.4,5 Thus, our finding that 2 automated reminders were more effective than a single reminder in reducing missed appointments suggests a simple approach to increase reminder effectiveness.

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