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Missed Care Opportunities For Urodynamics Before And After Transition From Human Phone Reminders To Automated Text Message Reminders: A Lesson In The Importance Of The Quality Improvement Process
Kaitlin Scarpaci, MSN, FNP-BC, CPN, Christina Chen, MSN, FNP-C, Mary Micker, MSN, CPNP, Hunter Gibbs, MS, PA-C, Perry Harlan, MSN, CPNP, Celicia Little, DNP, APRN, CPNP-PC, CNEn, Nicole Allentuck, BSN, RN, Bruce M. Sprague, BS, Hans Pohl, MD, Christina Ho, MD, Briony Varda, MD, MPH.
Children's National Hospital, Washington, DC, USA.


Background: To remind families of their upcoming urodynamics (UDS) visits while decreasing human workload, we transitioned from human phone call reminders to automated text reminders. The objective of this quality improvement project was to sustain a missed care opportunity (MCO) rate <15% after transitioning to automated reminders.
Methods: A single-institution prospective database was established in 2022 to track UDS appointment data. In the pre-intervention period, APPs called all patients scheduled for UDS two weeks prior to the appointment. An automated reminder system was initiated in 2/2023 and reminder calls were stopped. Scheduled UDS care opportunities and MCOs (missed and canceled visits) were tracked. Unadjusted associations were calculated. We created a pareto chart to identify the largest contributor to MCOs and a focused P-chart to track the monthly proportion of MCOs. The median MCO was calculated. IHI criteria were used to identify special cause variation.
Results: There were 877 UDS care opportunities scheduled between 4/2022 - 2/2024: 68% non-video UDS (nvUDS) and 32% video UDS (vUDS). SB patients accounted for 67% (587/877) of scheduled care opportunities, and 76% (454/595) of nvUDS care opportunities. The overall MCO rate was 29% (nvUDS 31% v. vUDS 28%; p = 0.18). The overall MCO rate for patients with SB was 30% (179/587) versus 26% among all other patients (74/290), p = 0.15. Patients with SB, however, accounted for 79% of MCOs (Pareto chart).
The median MCO rate for patients with SB scheduled for nvUDS was 0.31 (P-chart). There was a significant, steady decline in MCO during the 8 months patients received human phone calls (median 0.24, nadir 9%). Following the transition to automated messages, the MCO rate rose immediately above 15%. A 3- month PDSA cycle found text messages had not been deployed by the IT provider, which was correct by 6/2023. During the next 3-month PDSA cycle, it was revealed that only generic institutional text reminders were being sent (rather than bespoke UDS-specific reminders). This was corrected in 2/2024. The median MCO was 0.37 during the post-intervention period.
Conclusions: During this QI project, two-thirds of UDS care opportunities were nvUDS with three-quarters scheduled for patients with SB. Unfortunately, patients with SB accounted for 80% of MCO for nvUDS. The MCO rate for SB patients scheduled for nvUDS was mitigated during a period of human phone reminders. The
transition to an automated text system led to MCO rates consistently >15%. Though ideally technology would be applied to reduce human workload, human phone calls for a focused sub-set of patients may be a more reliable approach to decrease MCOs in UDS.


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