Reducing VA No-Shows: Evaluation of Predictive Overbooking Applied to Colonoscopy (No-show)

In this research study, investigators use colonoscopy as a case example to evaluate a predictive overbooking model derived using patient-level predictors of absenteeism. The no-show overbooking intervention employs a logistic regression model that uses patient data to predict the odds of no-showing with 80% accuracy. These projected no-show appointments will be overbooked by clerks for patients who agree to join a "fast track" short-call line. By rapidly processing endoscopy patients and moving them out of traditional slots, investigators predict more scheduling slots would become available for patients awaiting colonoscopy.

Patient "no-shows" are especially common in VA gastrointestinal (GI) endoscopy units, where both open-access endoscopy scheduling and patient dislike of procedures contribute to high absenteeism. In this proposal, investigators use endoscopy as a case example to evaluate a predictive overbooking model derived using patient-level predictors of absenteeism. The no-show overbooking intervention employs a logistic regression model that uses patient data to predict the odds of no-showing with 80% accuracy. These projected no-show appointments will be overbooked by clerks for patients who agree to join a "fast track" short-call line. However, patients scheduled for upper endoscopies in the "fast track" assume a small risk of service denial on the day of their overbooking in case of inaccurate predictions. If this occurs, the patient is guaranteed service in the next available position and is assured of having a shorter wait time. Patients scheduled for colonoscopies will never be turned down but may experience delays in the waiting room the day of their "fast track" appointment. By rapidly processing endoscopy patients and moving them out of traditional slots, investigators predict more scheduling slots would become available for patients awaiting colonoscopy. Investigators propose to conduct a prospective, 24-month, interrupted time series (ITS) trial in the WLAVA (West Los Angeles Veterans Administration) GI clinic endoscopy unit. During intervention periods, investigators will activate the no-show predictive overbooking strategy described above. Investigators will compare outcomes between scheduling strategies, including differences in percent utilization of capacity (primary outcome), number of Veterans served, mean patient lag time between scheduling and procedure, number of unexpected service denials ("bumps") from no-show predictive overbooking, and direct costs of care. Investigators will analyze differences using both traditional univariate and multivariate approaches, and using autoregressive integrated moving average (ARIMA) analyses to adjust for auto-correlations in ITS data.

quality improvement, Organization and Administration, Costs and cost analysis, Patient satisfaction, Health plan implementation

'Predictive no-show overbooking' intervention. Patients who volunteer to enroll in "fast-track" line, which gives them an opportunity to overbook their appointment for endoscopy earlier in a predictive no-show slots.

During intervention period, every Veteran scheduled for an endoscopy will be offered "fast-track" offer, which gives them a chance to get their endoscopy procedure done earlier than usual scheduling by overbooking their appointment in a predictive no-show slot.

Investigators' primary objective will be to evaluate the impact of no-show predictive overbooking on percentage of the GI endoscopy clinic that are filled on a given day. Days where at least one Fast-tracked patient attended an appointment were compared to days where only Control patients attended appointments. Percentage of GI Clinic Capacity is calculated as the number of appointments completed divided by number of appointment spots available on a given day. This percentage was compared between Fast-tracked days and Control days, using data from 1672 patients.

The investigators will calculate the mean daily lag time for all colonoscopy and upper endoscopies performed per day

The investigators will compare daily advanced adenomatous polyp detection and daily cecal intubation rates between groups.

For cost comparisons, the investigators will aggregate total provider overtime costs for colonoscopies performed. Cost is reported per day.

Inclusion Criteria: Patients who are scheduled for upper endoscopy and agree to the terms of "fast track" offer. Exclusion Criteria: If a patient expresses concern about service denial, confusion about the bargain, or refuses to participate, the investigators will schedule these patients routinely.

Reid MW, Cohen S, Wang H, Kaung A, Patel A, Tashjian V, Williams DL Jr, Martinez B, Spiegel BM. Preventing patient absenteeism: validation of a predictive overbooking model. Am J Manag Care. 2015 Dec;21(12):902-10.

Reid MW, May FP, Martinez B, Cohen S, Wang H, Williams DL Jr, Spiegel BM. Preventing Endoscopy Clinic No-Shows: Prospective Validation of a Predictive Overbooking Model. Am J Gastroenterol. 2016 Sep;111(9):1267-73. doi: 10.1038/ajg.2016.269. Epub 2016 Jul 5.

May FP, Reid MW, Cohen S, Dailey F, Spiegel BM. Predictive overbooking and active recruitment increases uptake of endoscopy appointments among African American patients. Gastrointest Endosc. 2017 Apr;85(4):700-705. doi: 10.1016/j.gie.2016.09.001. Epub 2016 Sep 10.