Improving follow-up adherence in a primary eye care setting: a prospective, randomized controlled trial
Callinan, Catherine Elizabeth
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INTRODUCTION Lack of follow-up to recommended appointments can decrease vision outcomes. Research is needed to determine the best approach to scheduling follow-up appointments in the primary eye care setting to help overcome barriers and decrease disparities in vision health. The specific aim of this work is to evaluate the effectiveness of automated and personal telephone interventions to improve follow-up adherence in the primary eye care setting. METHODS In a prospective, single-blind, randomized, controlled trial, 1,095 patients seen in the Cataract and Primary Care service (CPEC) at Wills Eye Hospital who were due for follow-up appointments were randomly assigned to usual care, automated telephone intervention or personal telephone intervention group. Patients in the usual care group (n=364) received a form letter reminding them to make an appointment and an automated reminder phone call one day prior to their scheduled visit. Automated intervention participants (n=365) received the usual care form letter and an automated call 1-month prior to their recommended follow-up date, a mailed appointment reminder if an appointment was scheduled, and an automated telephone reminder the day before the scheduled appointment. If a patient in the automated intervention group did not attend the scheduled appointment, a reminder postcard was sent. Personal intervention participants (n=365) received the traditional form letter and a personal telephone call 1-month prior to the recommended follow-up date, a mailed appointment reminder if an appointment was scheduled, and a personal telephone reminder prior to the scheduled appointment. If a patient in the personal intervention group did not attend the scheduled appointment, they received a personal call. Scheduling and attendance data were extracted from the electronic medical record system. RESULTS Patients in the personal intervention group had greater adherence to follow-up recommendations than patients in the usual care group (37.70% vs. 27.47%; RR: 1.37; CI 1.24-1.52; p<0.001) and automated intervention group (29.59%; RR: 1.27; CI 1.15-1.41; p=0.02). Patients in the usual care group were not significantly different than patients in the automated intervention group in regards to adherence to follow-up recommendations (27.47% vs. 29.59%; RR: 1.08; CI 0.98-1.18; p=0.53). Personal intervention improved adherence for patients who have been previously recognized as at risk including men (37.04% vs. 22.39%; RR: 1.65; CI: 1.41-1.94; p=0.01), African Americans (39.58% vs. 29.52%; RR: 1.34; CI 1.16-1.55; p=0.03), patients under 65 (28.93%-18.67%; RR: 1.55; CI 1.40-1.71; p=0.01), and patients who live greater than 20 miles from Wills Eye Hospital (44.74% vs. 12.50%; RR: 3.58; CI 2.59-4.95; p=0.01). Additionally, personal intervention improved adherence in patients with Medicare (58.42% vs. 43.56%; RR: 1.34; CI 1.01-1.79; p=0.03) and urban patients who live within 2 miles of Wills Eye Hospital (41.18% vs. 17.54%; RR: 2.35; CI 1.81-3.04; p=0.01). As a secondary endpoint, personal intervention significantly improved appointment scheduling over usual care (51.09% vs. 32.14%; RR 1.59; 95% CI 1.33-1.90; p<0.001) and automated intervention (51% vs. 36%; RR: 1.40; CI 1.18-1.66; p<0.001). Automated intervention did not significantly improve appointment scheduling over usual care (36% vs. 32%; RR: 1.13; CI 0.93-1.39; p=0.22). CONCLUSION Personal intervention improved adherence to recommended follow-up for primary eye care appointments overall and in at-risk populations. Automated intervention had no significant improvement over usual care. The cost effectiveness of personal intervention to improve outcomes in a primary ophthalmology setting should be evaluated to determine whether the intervention should be implemented as a process change at Wills Eye Hospital and at other primary ophthalmology care centers.