Liang Su-Ying, Stults Cheryl D, Jones Veena G, Huang Qiwen, Sutton Jeremy, Tennyson Guy, Chan Albert S
Sutter Health Center for Health Systems Research, Palo Alto, CA, United States.
Clinical Leadership Team, Sutter Health, Sacramento, CA, United States.
JMIR Hum Factors. 2022 Mar 30;9(1):e34090. doi: 10.2196/34090.
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.
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.
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.
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).
Nudges, a behavioral economics-based approach to providing health maintenance reminders, increased 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.
基于行为经济学的技术在医疗保健领域已成为一种越来越常用的方法，通过改变患者沟通中的语言（通过选择架构和措辞框架）来影响行为改变。患者门户网站是促进患者参与自身健康管理的关键工具，通过患者门户网站部署的干预措施已有效提高了预防性健康服务的利用率。
我们研究了基于行为经济学的助推式健康维护提醒对通过患者门户网站进行预约安排以及两项预防性服务（医疗保险健康检查和巴氏涂片检查）预约完成情况的影响。
我们使用来自北加利福尼亚州一个综合医疗保健系统的电子健康记录数据进行了一项回顾性观察研究。2017年11月，针对所有站点实施了基于行为经济学语言的助推式健康维护提醒，用于医疗保险健康检查；2018年2月，针对选定站点实施了用于巴氏涂片检查的提醒。我们分析了2017年1月至2020年2月期间发送的125369条医疗保险健康检查的健康维护提醒以及585358条巴氏涂片检查的健康维护提醒。主要结果是通过患者门户网站安排预约的比率和预约完成率。我们比较了接受新的基于行为经济学的健康维护提醒的人群（助推组）和接受原始标准健康维护提醒的人群（对照组）之间的结果。我们使用分段回归和中断时间序列来评估助推对医疗保险健康检查预约安排的即时和渐进影响，使用逻辑回归来评估助推式健康维护提醒与巴氏涂片检查预约之间的关联，并对接受助推式健康维护提醒的倾向进行调整。
接受助推式健康维护提醒的人群通过患者门户网站安排预约的比率高于接受对照健康维护提醒的人群（医疗保险健康检查 - 助推组：12537/96839，13.0%；对照组：2769/28530，9.7%，P<.001；巴氏涂片检查 - 助推组：8239/287149，2.9%；对照组：1868/120047，1.6%；P<.001）。巴氏涂片检查的助推式健康维护提醒预约完成率更高（助推组：67399/287149，23.5%；对照组：20393/120047，17.0%；P<.001），但医疗保险健康检查的预约完成率相当（助推组：49835/96839，51.5%；对照组：14781/28530，51.8%；P = 0.30）。对于整个医疗保险健康检查样本，助推对通过患者门户网站安排预约的数量有轻微的渐进影响（每月增长率为0.26%，P = 0.09），在已安排的预约中影响显著（每月增长率为0.46%，P = 0.04）。对于巴氏涂片检查，助推式健康维护提醒与通过患者门户网站安排预约的数量呈正相关（总体样本：倾向调整后的优势比[OR]为1.62；95%置信区间1.50 - 1.74；在已安排的预约中：倾向调整后的OR为1.61，95%置信区间1.47 - 1.76），与预约完成情况也呈正相关（倾向调整后的OR为1.07；1.04 - 1.10）。
助推作为一种基于行为经济学的提供健康维护提醒的方法，增加了通过患者门户网站为医疗保险健康检查和巴氏涂片检查安排预约的数量。我们的研究表明，一种简单的方法——在电子信息中构建和修改语言——可以对患者参与度和获得医疗服务产生重大且长期的影响。
