Effects of Behavioral Economics–Based Messaging on Appointment Scheduling Through Patient Portals and Appointment Completion: Observational Study

Abstract

Background Behavioral economics–based techniques have been an increasingly utilized method in health care to influence behavior change by modifying language in patient communication (through choice architecture and the framing of words). Patient portals are a key tool for facilitating patient engagement in their health, and interventions deployed via patient portals have been effective in improving utilization of preventive health services. Objective We examined the impacts of behavioral economics–based nudge health maintenance reminders on appointment scheduling through a patient portal and appointment completion for 2 preventive services: Medicare wellness visits and Pap smear. Methods We conducted a retrospective observational study using electronic health record data from an integrated health care system in Northern California. Nudge health maintenance reminders with behavioral economics–based language were implemented for all sites in November 2017 for Medicare wellness visits and for selected sites in February 2018 for Pap smears. We analyzed 125,369 health maintenance reminders for Medicare wellness visits, and 585,358 health maintenance reminders for Pap smear sent between January 2017 and February 2020. The primary outcomes were rate of appointments scheduled through the patient portal and appointment completion rate. We compared the outcomes between those who received the new, behavioral economics–based health maintenance reminders (the nudge group) and those who received the original, standard health maintenance reminders (the control group). We used segmented regression with interrupted time series to assess the immediate and gradual effect of the nudge for Medicare wellness visits, and we used logistic regression to assess the association of nudge health maintenance reminders, adjusting for the propensity to receive a nudge health maintenance reminder, for Pap smear. Results The rates of appointments scheduled through the patient portal were higher for nudge health maintenance reminder recipients than those for control health maintenance reminder recipients (Medicare wellness visits—nudge: 12,537/96,839, 13.0%; control: 2,769/28,530, 9.7%, P<.001; Pap smear—nudge: 8,239/287,149, 2.9%; control: 1,868/120,047, 1.6%; P<.001). Rates of appointment completion were higher for nudge health maintenance reminders for Pap smear (nudge: 67,399/287,149, 23.5% control: 20,393/120,047, 17.0%; P<.001) but were comparable for Medicare wellness visits (nudge: 49,835/96,839, 51.5% control: 14,781/28,530, 51.8%; P=.30). There was a marginally gradual effect of nudge on number of appointments scheduled through the patient portal for the overall Medicare wellness visits sample (at a monthly rate of 0.26%, P=.09), and a significant gradual effect among scheduled appointments (at a monthly rate of 0.46%, P=.04). For Pap smear, nudge health maintenance reminders were positively associated with number of appointments scheduled through the patient portal (overall sample: propensity adjusted odds ratio [OR] 1.62; 95% CI 1.50-1.74; among scheduled appointments: propensity adjusted OR 1.61, 95% CI 1.47-1.76) and with appointment completion (propensity adjusted OR 1.07; 1.04-1.10). Conclusions Nudges, a behavioral economics–based approach to providing health maintenance reminders, imcreased the number of appointments scheduled through the patient portal for Medicare wellness visits and Pap smear. Our study demonstrates that a simple approach—framing and modifying language in an electronic message—can have a significant and long-term impact on patient engagement and access to care.

Are behavioral economics interventions effective in increasing colorectal cancer screening uptake: A systematic review of evidence and meta-analysis?

“…For example, underserved women answered more positively to tailored letter than to a general letter encouraging breast cancer screening. The results of a study by Liang et al [ 82 ] disclosed that nudging (an approach based on behavioral economics) improved the number of appointments scheduled for Medicare health visits and Pap smear test. The authors further conclude that framing and modifying the language of e-messaging can have a significant and long-term impact on patient engagement and access to care [ 82 ].…”

Effect of Electronic Outreach Using Patient Portal Messages on Well Child Care Visit Completion

“…Nudge health maintenance reminders sent via the patient portal were associated with increased appointment scheduling rates among adults aged 65 years and older; however, no significant differences were observed between the control and nudge groups on wellness visit completion rates. 24 Success rates for studies using text messaging or telephone call interventions to promote completion of well child appointments range from 14% to 72%. 13 , 14 , 32 , 33 , 34 Differences in rates of WCC completion compared with these studies may be due to (1) longer duration of follow-up in earlier studies, ranging from 6 to 18 months; (2) more than half the sample in previous studies had a WCC in the 12 months before intervention vs none in ours; or (3) earlier studies used higher intensity interventions.…”

“…To our knowledge, no previous studies have determined the effect of patient portal messaging to promote WCC scheduling and completion among pediatric patients overdue for care. Nudge health maintenance reminders sent via the patient portal were associated with increased appointment scheduling rates among adults aged 65 years and older; however, no significant differences were observed between the control and nudge groups on wellness visit completion rates . Success rates for studies using text messaging or telephone call interventions to promote completion of well child appointments range from 14% to 72% .…”

“…Portal messages have successfully increased the scheduling, but not completion, of wellness visits among adults. 24 Yet little is known about the effect of patient portal messages on the scheduling and completion of overdue pediatric WCC visits and research has highlighted racial, ethnic, and insurer disparities in portal activation and use among pediatric patients. 25 , 26 To our knowledge, no pediatric studies have tested EHR portal messaging to increase WCC visits despite its potential to increase access by enabling direct scheduling of appointments, eliminating the constraint of calling during business hours.…”

“…Portal reminders to schedule influenza vaccines among pediatric and adult patients have been minimally effective. Portal messages have successfully increased the scheduling, but not completion, of wellness visits among adults . Yet little is known about the effect of patient portal messages on the scheduling and completion of overdue pediatric WCC visits and research has highlighted racial, ethnic, and insurer disparities in portal activation and use among pediatric patients .…”