Trial Outcomes & Findings for Using Behavioral Economics to Enhance Appointment Reminders and Reduce Missed Visits (NCT NCT03850431)

Last Updated: 2024-04-19

Results Overview

The percentage of total appointments that are classified as a no-show, relative to the total number of appointments scheduled. The numerator ("no-shows") consists of appointments marked as a no-show and appointments canceled by the patient or clinic after the appointment time. The denominator ("total appointments") consists of no-shows and completed appointments. For calculation of missed appointments, canceled appointments are not included in the number of units analyzed. The numerator is multiplied by 100 to arrive at a percentage.

Recruitment status

COMPLETED

Study phase

Target enrollment

34516 participants

Primary outcome timeframe

1 year

Results posted on

2024-04-19

Participant Flow

Unit of analysis: Clinics

Participant milestones

Participant milestones
Measure	Primary Care Appointments: Usual Care A Primary Care appointment letter that includes basic appointment information on date, location, and phone number(s) for scheduling changes.	Primary Care Appointments: Caring + Consequences for Self + Behavioral Instructions A Primary Care appointment letter with three types of nudges. One suggests that the institution cares about the patients. One highlights potential negative consequences for the patient if s/he no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Primary Care Appointments: Caring + Consequences for Others + Behavioral Instructions A Primary Care appointment letter with three types of nudges. One suggests that the institution cares about the patient. One highlights a potential negative consequence for others if the patient no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Primary Care Appointments: Social Norms + Behavioral Instructions A Primary Care appointment letter with two types of nudges. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Primary Care Appointments: Combination of All Nudges A Primary Care appointment letter with all types of nudges combined. One suggests that the institution cares about the patients. One highlights a potential negative consequence for others if the patient no-shows. One highlights potential negative consequences for the patient if s/he no-shows. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health Appointments: Usual Care A Mental Health appointment letter that includes basic appointment information on date, location, and phone number(s) for scheduling changes.	Mental Health Appointments: Caring + Consequences for Self + Behavioral Instructions A Mental Health appointment letter with three types of nudges. One suggests that the institution cares about the patients. One highlights potential negative consequences for the patient if s/he no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health Appointments: Caring + Consequences for Others + Behavioral Instructions A Mental Health appointment letter with three types of nudges. One suggests that the institution cares about the patient. One highlights a potential negative consequence for others if the patient no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health Appointments: Social Norms + Behavioral Instructions A Mental Health appointment letter with two types of nudges. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health Appointments: Combination of All Nudges A Mental Health appointment letter with all types of nudges combined. One suggests that the institution cares about the patients. One highlights a potential negative consequence for others if the patient no-shows. One highlights potential negative consequences for the patient if s/he no-shows. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).
Overall Study STARTED	10929 50	13465 51	13525 50	9223 52	12556 51	3737 51	3996 44	4844 48	4760 46	3354 45
Overall Study COMPLETED	5584 47	7287 48	6196 43	5056 44	6543 49	2184 46	2167 39	2863 45	2860 43	2142 42
Overall Study NOT COMPLETED	5345 3	6178 3	7329 7	4167 8	6013 2	1553 5	1829 5	1981 3	1900 3	1212 3

Reasons for withdrawal

Withdrawal data not reported

Baseline Characteristics

The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure	Primary Care Appointments: Usual Care n=4916 Participants A Primary Care appointment letter that includes basic appointment information on date, location, and phone number(s) for scheduling changes.	Primary Care Appointments: Caring + Consequences for Self + Behavioral Instructions n=6592 Participants A Primary Care appointment letter with three types of nudges. One suggests that the institution cares about the patients. One highlights potential negative consequences for the patient if s/he no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Primary Care Appointments: Caring + Consequences for Others + Behavioral Instructions n=5759 Participants A Primary Care appointment letter with three types of nudges. One suggests that the institution cares about the patient. One highlights a potential negative consequence for others if the patient no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Primary Care Appointments: Social Norms + Behavioral Instructions n=4353 Participants A Primary Care appointment letter with two types of nudges. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Primary Care Appointments: Combination of All Nudges n=5920 Participants A Primary Care appointment letter with all types of nudges combined. One suggests that the institution cares about the patients. One highlights a potential negative consequence for others if the patient no-shows. One highlights potential negative consequences for the patient if s/he no-shows. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health Appointments: Usual Care n=1641 Participants A Mental Health appointment letter that includes basic appointment information on date, location, and phone number(s) for scheduling changes.	Mental Health Appointments: Caring + Consequences for Self + Behavioral Instructions n=1666 Participants A Mental Health appointment letter with three types of nudges. One suggests that the institution cares about the patients. One highlights potential negative consequences for the patient if s/he no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health Appointments: Caring + Consequences for Others + Behavioral Instructions n=2305 Participants A Mental Health appointment letter with three types of nudges. One suggests that the institution cares about the patient. One highlights a potential negative consequence for others if the patient no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health Appointments: Social Norms + Behavioral Instructions n=2250 Participants A Mental Health appointment letter with two types of nudges. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health Appointments: Combination of All Nudges n=1558 Participants A Mental Health appointment letter with all types of nudges combined. One suggests that the institution cares about the patients. One highlights a potential negative consequence for others if the patient no-shows. One highlights potential negative consequences for the patient if s/he no-shows. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Total n=36960 Participants Total of all reporting groups
Sex/Gender, Customized Primary Care - Female	349 participants n=4916 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	564 participants n=6592 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	839 participants n=5759 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	444 participants n=4353 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	587 participants n=5920 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	—	—	—	—	—	2738 participants n=27540 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.
Sex/Gender, Customized Primary Care - Male	4567 participants n=4916 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	6028 participants n=6592 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	4920 participants n=5759 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	3909 participants n=4353 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	5333 participants n=5920 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	—	—	—	—	—	24757 participants n=27540 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.
Age, Continuous Primary Care	65.60 years STANDARD_DEVIATION 14.44 • n=4916 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.	64.81 years STANDARD_DEVIATION 14.85 • n=6592 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.	62.77 years STANDARD_DEVIATION 15.92 • n=5759 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.	62.87 years STANDARD_DEVIATION 16.08 • n=4353 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.	62.62 years STANDARD_DEVIATION 16.14 • n=5920 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.	—	—	—	—	—	63.75 years STANDARD_DEVIATION 15.53 • n=27540 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.
Age, Continuous Mental Health	—	—	—	—	—	50.06 years STANDARD_DEVIATION 15.95 • n=1641 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.	49.49 years STANDARD_DEVIATION 16.22 • n=1666 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.	51.39 years STANDARD_DEVIATION 16.16 • n=2305 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.	49.37 years STANDARD_DEVIATION 15.85 • n=2250 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.	49.29 years STANDARD_DEVIATION 15.75 • n=1558 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.	49.99 years STANDARD_DEVIATION 16.01 • n=9420 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for age are based on the 32,946 unique participants.
Sex/Gender, Customized Mental Health - Female	—	—	—	—	—	300 participants n=1641 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	403 participants n=1666 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	477 participants n=2305 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	362 participants n=2250 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	306 participants n=1558 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	1848 participants n=9420 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.
Sex/Gender, Customized Mental Health - Male	—	—	—	—	—	1341 participants n=1641 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	1263 participants n=1666 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	1828 participants n=2305 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	1888 participants n=2250 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	1252 participants n=1558 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.	7572 participants n=9420 Participants • The overall number of participants includes 4014 participants who had appointments in both primary care and mental health in the total twice. Summary statistics for gender are based on the 32,946 unique participants.
Race (NIH/OMB) Primary Care · American Indian or Alaska Native	65 Participants n=4916 Participants • Overall includes both primary care and mental health counts together.	91 Participants n=6592 Participants • Overall includes both primary care and mental health counts together.	71 Participants n=5759 Participants • Overall includes both primary care and mental health counts together.	58 Participants n=4353 Participants • Overall includes both primary care and mental health counts together.	72 Participants n=5920 Participants • Overall includes both primary care and mental health counts together.	—	—	—	—	—	357 Participants n=27540 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Primary Care · Asian	49 Participants n=4916 Participants • Overall includes both primary care and mental health counts together.	60 Participants n=6592 Participants • Overall includes both primary care and mental health counts together.	45 Participants n=5759 Participants • Overall includes both primary care and mental health counts together.	70 Participants n=4353 Participants • Overall includes both primary care and mental health counts together.	57 Participants n=5920 Participants • Overall includes both primary care and mental health counts together.	—	—	—	—	—	281 Participants n=27540 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Primary Care · Native Hawaiian or Other Pacific Islander	37 Participants n=4916 Participants • Overall includes both primary care and mental health counts together.	46 Participants n=6592 Participants • Overall includes both primary care and mental health counts together.	39 Participants n=5759 Participants • Overall includes both primary care and mental health counts together.	45 Participants n=4353 Participants • Overall includes both primary care and mental health counts together.	63 Participants n=5920 Participants • Overall includes both primary care and mental health counts together.	—	—	—	—	—	230 Participants n=27540 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Primary Care · Black or African American	155 Participants n=4916 Participants • Overall includes both primary care and mental health counts together.	218 Participants n=6592 Participants • Overall includes both primary care and mental health counts together.	172 Participants n=5759 Participants • Overall includes both primary care and mental health counts together.	147 Participants n=4353 Participants • Overall includes both primary care and mental health counts together.	199 Participants n=5920 Participants • Overall includes both primary care and mental health counts together.	—	—	—	—	—	891 Participants n=27540 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Primary Care · White	3888 Participants n=4916 Participants • Overall includes both primary care and mental health counts together.	5340 Participants n=6592 Participants • Overall includes both primary care and mental health counts together.	4540 Participants n=5759 Participants • Overall includes both primary care and mental health counts together.	3488 Participants n=4353 Participants • Overall includes both primary care and mental health counts together.	4760 Participants n=5920 Participants • Overall includes both primary care and mental health counts together.	—	—	—	—	—	22016 Participants n=27540 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Primary Care · More than one race	61 Participants n=4916 Participants • Overall includes both primary care and mental health counts together.	70 Participants n=6592 Participants • Overall includes both primary care and mental health counts together.	59 Participants n=5759 Participants • Overall includes both primary care and mental health counts together.	54 Participants n=4353 Participants • Overall includes both primary care and mental health counts together.	63 Participants n=5920 Participants • Overall includes both primary care and mental health counts together.	—	—	—	—	—	307 Participants n=27540 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Primary Care · Unknown or Not Reported	661 Participants n=4916 Participants • Overall includes both primary care and mental health counts together.	767 Participants n=6592 Participants • Overall includes both primary care and mental health counts together.	833 Participants n=5759 Participants • Overall includes both primary care and mental health counts together.	491 Participants n=4353 Participants • Overall includes both primary care and mental health counts together.	706 Participants n=5920 Participants • Overall includes both primary care and mental health counts together.	—	—	—	—	—	3458 Participants n=27540 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Mental Health · American Indian or Alaska Native	—	—	—	—	—	19 Participants n=1641 Participants • Overall includes both primary care and mental health counts together.	25 Participants n=1666 Participants • Overall includes both primary care and mental health counts together.	37 Participants n=2305 Participants • Overall includes both primary care and mental health counts together.	37 Participants n=2250 Participants • Overall includes both primary care and mental health counts together.	29 Participants n=1558 Participants • Overall includes both primary care and mental health counts together.	147 Participants n=9420 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Mental Health · Asian	—	—	—	—	—	27 Participants n=1641 Participants • Overall includes both primary care and mental health counts together.	21 Participants n=1666 Participants • Overall includes both primary care and mental health counts together.	33 Participants n=2305 Participants • Overall includes both primary care and mental health counts together.	34 Participants n=2250 Participants • Overall includes both primary care and mental health counts together.	25 Participants n=1558 Participants • Overall includes both primary care and mental health counts together.	140 Participants n=9420 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Mental Health · Native Hawaiian or Other Pacific Islander	—	—	—	—	—	12 Participants n=1641 Participants • Overall includes both primary care and mental health counts together.	12 Participants n=1666 Participants • Overall includes both primary care and mental health counts together.	29 Participants n=2305 Participants • Overall includes both primary care and mental health counts together.	25 Participants n=2250 Participants • Overall includes both primary care and mental health counts together.	20 Participants n=1558 Participants • Overall includes both primary care and mental health counts together.	98 Participants n=9420 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Mental Health · Black or African American	—	—	—	—	—	83 Participants n=1641 Participants • Overall includes both primary care and mental health counts together.	69 Participants n=1666 Participants • Overall includes both primary care and mental health counts together.	96 Participants n=2305 Participants • Overall includes both primary care and mental health counts together.	101 Participants n=2250 Participants • Overall includes both primary care and mental health counts together.	87 Participants n=1558 Participants • Overall includes both primary care and mental health counts together.	436 Participants n=9420 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Mental Health · White	—	—	—	—	—	1251 Participants n=1641 Participants • Overall includes both primary care and mental health counts together.	1289 Participants n=1666 Participants • Overall includes both primary care and mental health counts together.	1823 Participants n=2305 Participants • Overall includes both primary care and mental health counts together.	1730 Participants n=2250 Participants • Overall includes both primary care and mental health counts together.	1147 Participants n=1558 Participants • Overall includes both primary care and mental health counts together.	7240 Participants n=9420 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Mental Health · More than one race	—	—	—	—	—	33 Participants n=1641 Participants • Overall includes both primary care and mental health counts together.	30 Participants n=1666 Participants • Overall includes both primary care and mental health counts together.	42 Participants n=2305 Participants • Overall includes both primary care and mental health counts together.	47 Participants n=2250 Participants • Overall includes both primary care and mental health counts together.	36 Participants n=1558 Participants • Overall includes both primary care and mental health counts together.	188 Participants n=9420 Participants • Overall includes both primary care and mental health counts together.
Race (NIH/OMB) Mental Health · Unknown or Not Reported	—	—	—	—	—	216 Participants n=1641 Participants • Overall includes both primary care and mental health counts together.	220 Participants n=1666 Participants • Overall includes both primary care and mental health counts together.	245 Participants n=2305 Participants • Overall includes both primary care and mental health counts together.	276 Participants n=2250 Participants • Overall includes both primary care and mental health counts together.	214 Participants n=1558 Participants • Overall includes both primary care and mental health counts together.	1171 Participants n=9420 Participants • Overall includes both primary care and mental health counts together.

PRIMARY outcome

Timeframe: 1 year

Population: The number of participants analyzed is greater than listed in Participant Flow because these results include two additional arms listed for analysis: all 4 Primary Care intervention arms, and all 4 Mental Health intervention arms. These were not individual arms to which participants were randomized but rather a combination of arms for purposes of analysis. The number of appointments analyzed is greater than the number of participants because some participants had multiple appointments.

Outcome measures

Outcome measures
Measure	Primary Care Appointments: Usual Care n=9721 Appointment A Primary Care appointment letter that includes basic appointment information on date, location, and phone number(s) for scheduling changes.	Primary Care Appointments: Caring + Consequences for Self + Behavioral Instructions n=12321 Appointment A Primary Care appointment letter with three types of nudges. One suggests that the institution cares about the patients. One highlights potential negative consequences for the patient if s/he no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Primary Care Appointments: Caring + Consequences for Others + Behavioral Instructions n=7492 Appointment A Primary Care appointment letter with three types of nudges. One suggests that the institution cares about the patient. One highlights a potential negative consequence for others if the patient no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Primary Care Appointments: Social Norms + Behavioral Instructions n=7688 Appointment A Primary Care appointment letter with two types of nudges. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Primary Care Appointments: Combination of All Nudges n=8889 Appointment A Primary Care appointment letter with all types of nudges combined. One suggests that the institution cares about the patients. One highlights a potential negative consequence for others if the patient no-shows. One highlights potential negative consequences for the patient if s/he no-shows. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Primary Care - All 4 Primary Care Intervention Arms Combined n=36390 Appointment Combination of all 4 Primary Care intervention arms. Note: this was not an individual study arm to which participants were randomized, but rather a combination of arms for purposes of data analysis.	Mental Health Appointments: Usual Care n=6144 Appointment A Mental Health appointment letter that includes basic appointment information on date, location, and phone number(s) for scheduling changes.	Mental Health Appointments: Caring + Consequences for Self + Behavioral Instructions n=5750 Appointment A Mental Health appointment letter with three types of nudges. One suggests that the institution cares about the patients. One highlights potential negative consequences for the patient if s/he no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health Appointments: Caring + Consequences for Others + Behavioral Instructions n=8131 Appointment A Mental Health appointment letter with three types of nudges. One suggests that the institution cares about the patient. One highlights a potential negative consequence for others if the patient no-shows. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health Appointments: Social Norms + Behavioral Instructions n=8411 Appointment A Mental Health appointment letter with two types of nudges. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health Appointments: Combination of All Nudges n=6984 Appointment A Mental Health appointment letter with all types of nudges combined. One suggests that the institution cares about the patients. One highlights a potential negative consequence for others if the patient no-shows. One highlights potential negative consequences for the patient if s/he no-shows. One points out the common behavior of attending appointments. And one provides clear, specific instructions for making appointment changes. The appointment reminder also includes usual care (basic appointment information on date, location, and phone number(s) for scheduling changes).	Mental Health - All 4 Mental Health Intervention Arms Combined n=29276 Appointment Combination of all 4 Mental Health intervention arms. Note: this was not an individual study arm to which participants were randomized, but rather a combination of arms for purposes of data analysis.
No-Show Rate	11.9 percentage of appointments no showed	11.1 percentage of appointments no showed	10.5 percentage of appointments no showed	12.1 percentage of appointments no showed	10.6 percentage of appointments no showed	11.1 percentage of appointments no showed	18.0 percentage of appointments no showed	19.2 percentage of appointments no showed	21.9 percentage of appointments no showed	20.0 percentage of appointments no showed	18.9 percentage of appointments no showed	20.1 percentage of appointments no showed

SECONDARY outcome

Timeframe: 1 year

The percentage of scheduled appointments that are marked as canceled.