BACKGROUND
psychiatric
Missed appointments, frequently referred to as “no-shows,” are a longstanding challenge to providers and administrators in every healthcare system. In the Department of Veterans Affairs (VA), the largest integrated healthcare system in the USA, the national missed appointment rate was 14.9% from October 2020 to September 2021, resulting in 10,109,148 missed appointments.Like many behaviors, the potential reasons behind a missed appointment are myriad, but broadly speaking they can include patient-related characteristics (e.g., history of psychiatric disordersOne of the core ideas of behavioral economics is the idea of supporting behavior change through the use of nudges: small alterations in how options are presented that are designed to influence a person’s decision making without restricting their choices.To date, there have been no large-scale trials of behavioral economics-informed appointment reminders in the USA. Moreover, the effect of other types of nudges, or combining nudges, is not known. The aim of this study was to conduct a large-scale pragmatic trial within the VA to evaluate the effect of a series of nudges on missed and canceled appointments. We hypothesized that the intervention, as compared with usual care, would have a lower missed appointment rate and higher canceled appointment rate. We also hypothesized that effect size of nudges would vary by intervention arm such that some types of nudges would have a larger proportional effect than others.