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

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial aims to find better ways to reduce unnecessary emergency room visits by offering support to frequent emergency department (ED) users. Participants will receive either a phone call from a healthcare worker (live outreach) or interactive messages from a chatbot (automated interactive messages), both providing guidance on alternative care options outside the ED. The study will compare how these two methods affect future ED visits and whether participants act on the advice given. Individuals with Geisinger Health Plan insurance who have visited the ED at least four times in the past six months are well-suited for this trial. As an unphased trial, this study allows participants to contribute to innovative solutions for reducing ED visits and improving healthcare access.

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 prior data suggests that these outreach methods are safe for patients?

Research has shown that automated interactive messages, like chatbots, are generally safe. In previous studies, these tools reminded patients about appointments or answered questions instantly. No major safety issues were reported. Participants usually find these messages helpful and easy to use.

The study under consideration includes two types of communication: traditional phone calls from health workers and text messages from chatbots. Phone calls are a common and well-understood method in terms of safety. Chatbot messages, while newer, have been tested in other situations. They provide information and support without any known risks.

Overall, both methods aim to help patients manage their health and avoid unnecessary ER visits. They focus on offering support rather than any physical treatment, so they are considered very low-risk. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about this trial because it explores new ways to guide patients away from unnecessary emergency room visits. Unlike the standard approach that uses live outreach from community health workers or medical assistants, this trial introduces automated SMS chatbot messages. These messages are interactive and accessible, providing guidance on alternative care options outside of the emergency department. This method could offer a more scalable and immediate way to reduce ER visits by engaging patients directly through their smartphones.

What evidence suggests that this trial's treatments could be effective in reducing unnecessary ED visits?

Studies have shown that automated interactive messages, like chatbots, can effectively help patients manage their health. In this trial, one group of participants will receive SMS chatbot messages. Research indicates these messages can improve follow-up care after emergency room visits by helping patients remember and attend their appointments. In one study, patients using a text message chatbot reported finding these tools helpful and easy to use. Additionally, automated messages have proven to be a cost-effective way to encourage patients to seek appropriate care outside the emergency room, reducing unnecessary visits. Another group in this trial will receive outreach from a community health worker or community medical assistant, which is the current standard practice. ^{1 2 6 7 8}

Who Is on the Research Team?

Amir Goren, PhD

Principal Investigator

Geisinger Clinic

Are You a Good Fit for This Trial?

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 for a Trial Participant

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

What Are the Treatments Tested in This Trial?

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.

How Is the Trial Designed?

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+

Published Research Related to This Trial

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]

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]

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]

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 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]

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]

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]

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]

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]

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]

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]

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]

Citations

1. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC4982545/

Post–Emergency Department Automated Messaging to ... Improving attendance at post-emergency department follow-up via automated text message appointment reminders: a randomized controlled trial.

2. bmchealthservres.biomedcentral.com bmchealthservres.biomedcentral.com/articles/10.1186/s12913-024-11414-0

A trial of a chat service for patients and their family members in ... This study aimed to trial a chat service enabling patients in the ED and their family members to ask questions freely, exploring the service's feasibility and ...

3. jamanetwork.com jamanetwork.com/journals/jama/fullarticle/2827429

Personalized Patient Data and Behavioral Nudges to ... This randomized clinical trial compares different text messaging strategies (generic refill reminders, behavioral nudge refill reminders, ...

4. sciencedirect.com sciencedirect.com/science/article/pii/S2352344124001699

Conversational Engagement Using a Short Message ... We identified 1338 patients (746 knees and 592 hips) who enrolled in a short message service chatbot from 2020-2022 with greater than 3 months of follow-up.

5. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC12571198/

Implementation and Evaluation of a Virtual Transitional ... ED-based transitional care interventions, including automated SMS text messaging, offer scalable, cost-effective means to improve follow-up, ...

6. sciencedirect.com sciencedirect.com/science/article/pii/S2212420924005545

The ERMES chatbot: A conversational communication tool ... A mobile-based conversational communication system developed to facilitate real-time bidirectional communication between control centres, in-field forces, and ...

7. cdn.clinicaltrials.gov cdn.clinicaltrials.gov/large-docs/81/NCT06324981/Prot_000.pdf

Study Protocol “Using artificially intelligent text messaging ... Clinic events (Secondary Outcome): We will also assess for clinical events defined by emergency department (ED) visits or hospitalizations.

8. withpower.com withpower.com/trial/phase-emergencies-1-2025-716fc

Nudging for Emergency Room Visits · Info for Participants Participants receive outreach via phone call from a Community Health Worker or an interactive SMS chatbot message to provide guidance about ED-alternative ...