JMIR Publications

ABSTRACT

Background:

Behavioral economics has been an increasingly utilized method in healthcare to “nudge” behavior change through the use of techniques such as choice architecture and framing of words. Patient portals are a key tool for facilitating patient engagement in their health, and deployment of interventions via patient portals have been effective in improving utilization of preventive health services. Our integrated healthcare system was one of the first to employ behavioral economics in health maintenance reminder (HMR) messages sent through the online patient portal to improve patient engagement and preventive service use.

Objective:

We examined the impacts of behavioral economics-based nudge HMRs on online scheduling uptake and appointment completion for two preventive services, Medicare wellness visits (MWV) and pap smears.

Methods:

This was a retrospective observational study using electronic health record data from an integrated healthcare system in Northern California. Nudge HMRs with behavioral economics-based language were implemented in November 2017 to all sites for MWV and selected sites in February 2018 for pap smears. We analyzed 125,369 HMRs for MWV, and 585,358 HMRs for pap smears sent between January 2017 and February 2020. The primary outcomes were online scheduling and appointment completion. The predictor was the receipt of a nudge HMR. We used segmented regression with interrupted time series design to assess the immediate and gradual effect of the nudge for MWV. For Pap smear, we used logistic regression models to assess the association of the nudge HMR on study outcomes, adjusting for the propensity to receive a nudge HMR.

Results:

Rates of online scheduling were higher for nudge HMRs recipients than control HMRs (13.0% nudge vs. 9.7% control for MWV; 1.4% nudge vs. 0.6% control for pap smears; p<0.001 for all comparisons). Rates of appointment completion were higher in nudge HMRs for pap smears (21.4% nudge vs. 15.3% control, p<0.001) but comparable for MWV between the two groups (51.5% nudge vs. 51.8% control, p=0.30). Regression results suggest a marginally gradual effect of nudge on online scheduling for the overall MWV sample (at a monthly rate of 0.26%, p=0.09), and a significant gradual effect among scheduled appointments (at a monthly rate of 0.46%, p=0.04). For pap smears, nudge HMRs were positively associated with online scheduling (propensity adjusted odds ratio [OR] 1.68; 95% confidence interval [CI] 1.50–1.88 overall sample; propensity adjusted OR 1.65 [1.45–1.87] among scheduled appointments) and appointment completion (propensity adjusted OR 1.07 [1.04–1.10]).

Conclusions:

Nudge for health, a behavioral economics-based approach to providing HMRs, improves patient online scheduling for Medicare wellness visits and pap smears. Our study demonstrates that a simple approach of framing and modifying language in an electronic message can have a significant and long-term impact on patient engagement and access to care. Clinical Trial: No