Nudging for Emergency Room Visits

Overseen By Amir Goren, PhD

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: Geisinger Clinic

Disqualifiers: Institutionalized, Admitted, Deceased, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: Unknown

2279 Participants Needed

Trial Summary

What is the purpose of this trial?

The goal of this campaign is to reduce unnecessary ED visits by providing patients who are high ED utilizers (with a visit of any acuity) with alternative resources to manage their health outside of the ED. In this campaign, patients will be randomized to receive one of two types of outreach following discharge aligned with the goal. Outreach may occur via (1) a phone call from a Geisinger Community Health Worker (CHW) or Community Medical Assistant (CMA); current standard practice or (2) an interactive chatbot message providing similar information and questions to those provided by the CHW/CMA. The study team will measure whether ED use differs across patients in different outreach conditions. The study team will also examine whether patients followed through on the message-specific calls to action in the messages differently across conditions.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications.

What data supports the effectiveness of the treatment Automated interactive messages, Live outreach for reducing emergency room visits?

Research shows that carefully crafted digital messages can significantly reduce hospital no-show rates, suggesting that similar messaging strategies could effectively encourage patients to avoid unnecessary emergency room visits. ^{1 2 3 4 5}

Is the use of nudging techniques in clinical settings safe for participants?

The research on nudging techniques, such as behavioral nudges in clinical settings, does not report any safety concerns or evidence of harm to participants. In a study involving surrogate decision-makers in intensive care units, there was no evidence of undue or unjust inducement, suggesting that these techniques are generally safe. ^{1 3 6 7 8}

How does the 'Nudging for Emergency Room Visits' treatment differ from other treatments for this condition?

This treatment is unique because it uses 'nudges' to subtly influence behavior without limiting choices or changing financial incentives. Unlike traditional medical treatments, it focuses on altering the decision-making environment to encourage desired actions, such as reducing unnecessary emergency room visits. ^{5 9 10 11 12}

Research Team

Amir Goren, PhD

Principal Investigator

Geisinger Clinic

Eligibility Criteria

This trial is for patients who frequently visit the emergency department (ED) for any level of urgency. It aims to guide them towards alternative healthcare options outside of the ED after they're discharged.

Inclusion Criteria

Any PCP or no PCP

Visit of any acuity

I've been to the emergency department 4 or more times in the last 6 months.

Exclusion Criteria

Institutionalized

Deceased prior to messaging

Cannot be contacted via the communication modality being used in the study (i.e., SMS), due to insufficient/missing contact information in the electronic health record or because the patient opted out

Timeline

Screening

Participants are screened for eligibility to participate in the trial

1-2 weeks

Outreach

Participants receive outreach via phone call from a Community Health Worker or an interactive SMS chatbot message to provide guidance about ED-alternative resources.

30 days

Outreach via phone or SMS

Follow-up

Participants are monitored for ED use and response to outreach messages.

120 days

Treatment Details

Interventions

• Automated interactive messages
• Live outreach

Trial Overview The study compares two methods to reduce unnecessary ED visits: standard phone calls from health workers or automated chatbot messages with similar information and prompts. The effectiveness will be measured by changes in ED usage and follow-up actions.

Participant Groups

Group I: SMS Chatbot Messages Experimental Treatment 1 Intervention

Patients will be sent interactive SMS chatbot messages, including guidance about ED-alternative resources to encourage care outside of the ED when appropriate; patients will not receive outreach from a community health worker or community medical assistant.

Group II: Community Health Worker/Community Medical Assistant Outreach Active Control 1 Intervention

Patients will receive outreach from a community health worker or a community medical assistant, as is current standard practice, including guidance about ED-alternative resources to encourage care outside of the ED when appropriate.

Who Is Running the Clinical Trial?

Geisinger Clinic

Lead Sponsor

Trials

159

Recruited

1,976,000+

Findings from Research

A scoping review of 51 studies found that nudging techniques can effectively influence healthcare professionals' behaviors, with 40 studies reporting statistically significant results, particularly in areas like prescriptions, hand hygiene, and vaccinations.

The most common nudging strategies included defaults (like automatic generic prescriptions) and reminders, which often required no active decision-making from healthcare professionals, raising questions about the ethical implications of such passive interventions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Using nudges to promote clinical decision making of healthcare professionals: A scoping review. Wolf, A., Sant'Anna, A., Vilhelmsson, A.[2022]

A study involving 161,587 patients from Clalit Health Services found that pre-appointment SMS reminders designed to evoke emotional guilt significantly reduced no-show rates from 21.1% to 14.2%.

The research demonstrated that carefully crafted reminder messages can effectively decrease missed appointments, potentially preventing up to one-third of the 352,000 annual no-shows in Israel.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

It's how you say it: Systematic A/B testing of digital messaging cut hospital no-show rates. Berliner Senderey, A., Kornitzer, T., Lawrence, G., et al.[2020]

In a pilot study involving 101 emergency department patients with high blood pressure, most participants preferred receiving both reminder and informational text messages, indicating a strong interest in using text messaging to improve medication adherence.

Participants who were Black, had lower income, or lower medication adherence found the text messaging program more helpful and expressed a desire for additional features, highlighting the potential of targeted interventions to support vulnerable populations and reduce health disparities.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

User preferences for and engagement with text messages to support antihypertensive medication adherence: Findings from a pilot study evaluating an emergency department-based behavioral intervention. Nelson, LA., Spieker, AJ., Kripalani, S., et al.[2023]

A survey of 664 emergency department patients revealed that 90% preferred technology-based behavioral health interventions, indicating a strong interest in using technology for health support.

Younger patients (aged 13-24) showed a greater preference for technology-based interventions related to unintentional injuries and peer violence, while concerns about confidentiality were significant, especially regarding Internet and social networking platforms.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Emergency department patients' preferences for technology-based behavioral interventions. Ranney, ML., Choo, EK., Wang, Y., et al.[2012]

In a study involving 131 adolescents with food allergies, text message nudges alone did not significantly increase the carrying of epinephrine auto-injectors (EAIs), with only a 28% carrying rate compared to 38% in the control group.

However, when text message nudges were combined with modest financial incentives, the carrying rate of EAIs increased to 45%, significantly higher than the 23% rate in the control group, indicating that financial incentives can effectively promote EAI-carrying behavior.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Food Allergy Management for Adolescents Using Behavioral Incentives: A Randomized Trial. Dupuis, R., Feuerstein-Simon, R., Brown-Whitehorn, TF., et al.[2023]

In a study of over 2.9 million emergency department visits, only 0.2% had electronic behavioral alerts, but these alerts were associated with significant safety concerns, particularly for younger, Black non-Hispanic, publicly insured, and male patients.

Patients flagged with safety-related electronic behavioral alerts experienced higher rates of discontinuance of care, indicating that these alerts may negatively impact treatment and contribute to systemic inequities in healthcare.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Disparities Associated With Electronic Behavioral Alerts for Safety and Violence Concerns in the Emergency Department. Haimovich, AD., Taylor, RA., Chang-Sing, E., et al.[2023]

In a study of 246 emergency department patients with acute chest pain, the method of presenting risk information significantly influenced their preferences for admission versus discharge, highlighting the importance of communication in clinical decision-making.

The results showed that many patients had varying risk thresholds based on how risks were presented, with 59% choosing the lowest or highest risk values, indicating that traditional expected utility models may not effectively capture patients' true risk preferences.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Measuring patient tolerance for future adverse events in low-risk emergency department chest pain patients. Chen, JC., Cooper, RJ., Lopez-O'Sullivan, A., et al.[2014]

A behavioral nudge survey aimed at improving enrollment in a critical care randomized controlled trial did not significantly increase enrollment rates compared to standard informed consent procedures, with 29% enrollment in the nudge group versus 34% in the standard group among 182 surrogate decision-makers.

The study found that white surrogate decision-makers were more likely to enroll patients than non-white decision-makers, and those who perceived a higher risk of participation were less likely to enroll, indicating potential demographic and perception-related factors influencing enrollment in critical care trials.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A Randomized Controlled Trial of Behavioral Nudges to Improve Enrollment in Critical Care Trials. Krutsinger, DC., O'Leary, KL., Ellenberg, SS., et al.[2021]

Nudges can effectively change behavior by modifying the decision-making environment without limiting options or altering financial incentives, as shown in a review of 174 articles across various disciplines.

Nudges that automate decision-making processes have a greater average effect size (Cohen's d of 0.193) compared to other types of nudges, highlighting the importance of understanding which nudges are most effective for future research.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Nudging: Progress to date and future directions. Beshears, J., Kosowsky, H.[2021]

In a study involving 2827 patients in two urban academic emergency departments, having providers sit during patient encounters significantly improved patient satisfaction scores across multiple measures, such as feeling cared for and listened to.

The introduction of folding seats in the intervention ED increased the likelihood of providers sitting by 30%, while educational efforts alone did not change provider behavior, highlighting the importance of environmental factors in enhancing patient care.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Grab a Seat! Nudging Providers to Sit Improves the Patient Experience in the Emergency Department. Orloski, CJ., Tabakin, ER., Shofer, FS., et al.[2022]

The concept of 'nudgeability' suggests that people's responsiveness to nudges is influenced more by their personal preferences than by the transparency of the nudge or their thinking mode.

The study indicates that individuals cannot be nudged into choices they fundamentally do not want, which implies that concerns about the legitimacy of nudging as a policy tool may be overstated.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Nudgeability: Mapping Conditions of Susceptibility to Nudge Influence. de Ridder, D., Kroese, F., van Gestel, L.[2022]

The Swedish Region of Uppsala increased COVID-19 vaccine uptake among 16- to 17-year-olds by sending letters with pre-booked appointments, demonstrating an effective nudge strategy.

This approach led to higher vaccination rates compared to control regions, suggesting that simplifying the booking process can encourage vaccination in populations that may perceive a lower risk.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Vaccination nudges: A study of pre-booked COVID-19 vaccinations in Sweden. Bonander, C., Ekman, M., Jakobsson, N.[2022]

References

1. United States pubmed.ncbi.nlm.nih.gov

Using nudges to promote clinical decision making of healthcare professionals: A scoping review. [2022]

2. United States pubmed.ncbi.nlm.nih.gov

It's how you say it: Systematic A/B testing of digital messaging cut hospital no-show rates. [2020]

3. Ireland pubmed.ncbi.nlm.nih.gov

User preferences for and engagement with text messages to support antihypertensive medication adherence: Findings from a pilot study evaluating an emergency department-based behavioral intervention. [2023]

4. United States pubmed.ncbi.nlm.nih.gov

Emergency department patients' preferences for technology-based behavioral interventions. [2012]

5. United States pubmed.ncbi.nlm.nih.gov

Food Allergy Management for Adolescents Using Behavioral Incentives: A Randomized Trial. [2023]

6. United States pubmed.ncbi.nlm.nih.gov

Disparities Associated With Electronic Behavioral Alerts for Safety and Violence Concerns in the Emergency Department. [2023]

7. United States pubmed.ncbi.nlm.nih.gov

Measuring patient tolerance for future adverse events in low-risk emergency department chest pain patients. [2014]

8. United States pubmed.ncbi.nlm.nih.gov

A Randomized Controlled Trial of Behavioral Nudges to Improve Enrollment in Critical Care Trials. [2021]

9. United States pubmed.ncbi.nlm.nih.gov

Nudging: Progress to date and future directions. [2021]

10. United States pubmed.ncbi.nlm.nih.gov

Grab a Seat! Nudging Providers to Sit Improves the Patient Experience in the Emergency Department. [2022]

11. United States pubmed.ncbi.nlm.nih.gov

Nudgeability: Mapping Conditions of Susceptibility to Nudge Influence. [2022]

12. England pubmed.ncbi.nlm.nih.gov

Vaccination nudges: A study of pre-booked COVID-19 vaccinations in Sweden. [2022]