RESEARCH/Original article
Improving attendance in psychiatric outpatient clinics by using reminders
Journal of Telemedicine and Telecare 2014, Vol. 20(8) 464–467 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X14555642 jtt.sagepub.com
Girish Kunigiri, Niman Gajebasia and David Sallah
Summary We compared non-attendance rates at follow-up appointments in an adult psychiatry outpatient clinic using three different reminder methods: letters, telephone prompts and text message reminders. Two of the three strategies resulted in a significant increase in the rate of attendance. Reminder letters increased attendance from 62% to 85% (P < 0.001) and text messaging increased attendance from 72% to 80% (P < 0.002). The attendance rate was not significantly different between the two groups when telephone reminders were used (P ¼ 0.068). However, telephone prompts resulted in an 8% higher cancellation rate compared to controls. When all factors were taken into consideration, no method demonstrated clear superiority. Efforts should be made to reduce patient non-attendance, as this is a predictor of patients being unwell and at higher risk of relapse. Text messages are an inexpensive method of reminding patients, although appropriate safeguards for patient confidentiality are required. Accepted: 21 July 2014
Introduction In the UK, there are high non-attendance rates – over 10% – for hospital outpatient appointments. Psychiatry is particularly poor in comparison with other medical specialities.1,2 Non attendance represents poor utilization of resources but also produces poorer outcomes.3–5 More than one-quarter of non-attenders in psychiatric clinics3,4 and other medical specialities6–8 cited forgetting the appointment as the cause. This has led to interest in methods of reminding patients about their appointments. Various reminder methods have been tried, with varying degrees of success, in psychiatric settings. These include reminder letters,9 telephone calls10,11 and more recently, text messages for mobile phones.12,13 Few studies have compared the effectiveness of different reminder methods,14,15 and these have been conducted in non-psychiatry settings. A Cochrane review16 of reminders for mental health patients identified only four studies. One study compared a standard letter with an ‘orientation statement’ letter that was sent 1–3 days prior to appointment (this provided details of doctor and fees, as well as appointment details), and another study compared an ‘orientation statement’ at the time the appointment was made with telephone prompts. However these studies were limited to initial appointments. None of these were compared with text messaging, which is an efficient reminder system.17 The purpose of the present study was to compare nonattendance rates at follow-up appointments in a psychiatry outpatient clinic using three different reminder
methods: letters, telephone prompts and text message reminders.
Methods The study was conducted in general adult psychiatry outpatient clinics in a locality delivering mental health services to patients aged 18–65 years. This service is part of a wider mental health, learning disability and community health service in the UK.18 On average this locality serviced 6–8 new patients and provided 50–60 follow up appointments per week. The study was conducted in three phases, see Table 1. In Phase 1, patients receiving standard appointments (control group) were compared with those receiving reminder letters, which were sent two weeks prior to the outpatient (OP) appointment. Only those patients who had an appointment at an interval of 3 months or longer were included in the study. In Phase 2, patients received telephone reminders from the medical secretary one week prior to their appointment and were compared with those who did not (control group). In Phase 3, text messages were sent to consenting patients 2 weeks and 2
General Adult Psychiatry Department, Leicestershire Partnership NHS Trust, Leicester, UK Corresponding author: Girish Kunigiri, Bradgate Mental Health Unit, Leicester LE3 9EJ, UK. Email: [email protected]
Downloaded from jtt.sagepub.com at Univ of Illinois at Chicago Library on May 3, 2015
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Table 1. Reminder methods.
Phase 1 (Letter)
Phase 2 (Telephone)
Phase 3 (Text)
Intervention group*
Control group
Reminder letter sent 2 weeks prior to OP appointment scheduled 3 months or later (8 December 2004 to 8 February 2005) Medical secretary telephoned one week prior to appointment. If unsuccessful after 2 attempts, a reminder letter was sent (1 July 2006 to 31 August 2006) All consenting patients received an automated text message sent 14 days and 2 days prior to appointment. The text read ‘‘This is a reminder that you have a hospital appointment on . . . (date) at . . . (time) with Dr . . . at . . . (venue). If unable to attend please contact . . . ’’ (1 September 2010 to 28 February 2011)
Standard appointment card issued after OP clinic followed by confirmation letter from medical secretary (7 September 2004 to 7 December 2004) Same as above (1 May 2006 to 30 June 2006)
Same as above (1 September 2010 to 28 February 2011)
*The reminder was in addition to standard procedure.
days prior to the appointment, and compared with those who did not receive such text reminders (control group). In each phase, appointments were recorded as attended, did not attend (DNA) or cancelled by the patient. This information was tabulated on a spreadsheet. The control group were compared with the intervention group in each phase and also with each other using a chisquared test.
Results
Table 2. Attendance rates in the two groups. Intervention group Control group Number (%) Number (%) P-value Letter Attended 44 (85) Did not attend 1 (2) Cancelled by patient 7 (14) Telephone Attended 71 (72) Did not attend 9 (9) Cancelled by patient 19 (19) Text Attended 155 (80) Did not attend 13 (7) Cancelled by patient 25 (13) Pooled Attended 270 (79) Did not attend 23 (7) Cancelled by patient 51 (15)
63 (62) 27 (27) 12 (12)
0.001
97 (73) 22 (16) 14 (11)
0.068
893 (72) 137 (11) 210 (17)
0.002
1053 (71) 186 (13) 236 (16)
0.005
In Phase 1, 62% of patients in the control group (n ¼ 102) attended their appointment. In the intervention group who received reminder letters (n ¼ 52), 85% attended, see Table 1. The attendance rate was significantly higher in the intervention group (P < 0.001). In Phase 2, 73% of patients in the control group (n ¼ 133) attended their appointment. In the intervention group, who received reminder telephone calls (n ¼ 99), 72% attended. The attendance rate was not significantly different between the two groups (P ¼ 0.068). In Phase 3, 72% of patients in the control group (n ¼ 1240) attended their appointment. A total of 248 patients opted for the text messaging reminder service, but there was failure to send a text message to 55 patients (22%). Thus in the intervention group, who received text reminders (n ¼ 193), 80% attended. The attendance rate was significantly higher in the intervention group (P < 0.002). When the three reminder systems were compared with each other using a chi-squared test, there was no difference between them (P ¼ 0.26). The pooled chi-squared test suggested that the pooled intervention group differed significantly from the pooled control group (P < 0.005), see Table 2.
using telephone prompts. When the three methods were compared with each other, no method was significantly different from any other in reducing non-attendance rates. Telephone prompts resulted in an 8% higher cancellation rate compared to controls. Although this difference was not significant, it helped to free up clinic space and so assisted in reducing the waiting lists. Sending the reminder letter and the first text message two weeks prior to the appointment allowed enough time for the treating team to schedule an appointment for another patient if a patient chose to cancel the appointment.
Discussion
Previous work
In the present study, non-attendance rates were reduced significantly by using letters and text messages, but not by
The results from our study are similar to those from other studies that used letter,9 telephone prompts10,11 and text
Downloaded from jtt.sagepub.com at Univ of Illinois at Chicago Library on May 3, 2015
466
Journal of Telemedicine and Telecare 20(8)
messages13 to remind patients about their appointments. In a recent study patients who received reminder letters demonstrated improved clinic attendance (72% vs 56%),9 although this was lower than the attendance rate in our sample. This study too lacked randomization. Letter reminders may be safe in terms of ensuring confidentiality compared to telephone or text messages, but this comes at an additional cost (administrative and postal charges). With regard to telephone reminders, some studies reported an improvement in the initial appointment10 while others did not when contacted by staff compared to therapists.11 The Cochrane review16 on the subject found that telephone prompting, although beneficial, had only a weak positive effect on attendance at the first appointment, in comparison to a letter (orientation statement). This is similar to the findings of the present study. Cancellation by patients was higher in our study when using telephone reminders. This may have been because patients had the option of rescheduling their next appointment directly when they were contacted by the administrative staff to confirm their attendance. One of the problems with telephone messages is with confidentiality, specifically when leaving messages on an answerphone. Consequently, many hospitals refuse to leave messages on such devices unless the patient has previously consented to this. A systematic review of text messaging found that it had positive results on attendance rates.19,20 Using an automated text messaging system avoids the administrative costs associated with sending reminder letters.21 An additional advantage of text message reminders is that it is compatible with electronic patient records and is very time efficient. A key limitation of this technique is that only about half of mobile phone owners agreed to be contacted in this way.12 A recent pilot study13 conducted over a 3-year period examining the effectiveness of text messages sent a couple of days prior to the appointments, found a reduction in non-attendance of 25–28% compared to those who had no reminders. The attendance rate over three successive years was 47%, 54% and 49%, i.e. the improvement in attendance rate was only 2% in year 3 compared to year 1, raising questions about the real benefits of text messages. However the high cancellation rate (21%) of appointments by clinic or clinicians in the final year of study could have contributed to this.
National context Non-attendance in clinics comes at a cost to both the patients and the NHS, particularly in mental health, where the non-attendance rate is twice that of medical clinics.2 The cost of each missed appointment in England was 61 in 1996–9722 amounting to about 760 million per year in total.20 Sims et al.13 estimated that a reduction in non-attendance by a quarter, using text messages, could save the NHS 150 million per year. The Department of Health in the UK encourages general
practices and hospitals to reduce non-attendance by various initiatives.23 Each mental health trust in UK has its own non-attendance policy. Non-attendance is associated with poor outcome in patient care. Investigation of both new and follow-up psychiatric patients’ reasons for non-attendance suggest that active symptoms of the illness are a major contributor to non-attendance.1,2 Lack of insight, apathy and reduced organisational skills also appeared to be linked to missed appointments.1 Patients who miss follow-up appointments after discharge are more unwell, have greater social impairment, have higher admission rates and are a risk to themselves and others.3,4,24 There are more indirect benefits of increasing attendance having a positive effect on patient care, such as reduced morbidity by providing continuity of care.1,2,4 Hence some authors have stressed the additional benefits beyond the pure economic evaluation of reminder systems.15
Clinical implications Reducing non-attendance rates in psychiatric outpatient clinics by using reminder systems should be advocated. No one particular reminder system appears to be superior, although Reda et al.16 found the (orientation) letter to be more effective than telephone prompts. Text messages are an inexpensive method of reminding patients, although appropriate safeguards for patient confidentiality are required.25 Clinicians should make efforts to reduce patient nonattendance as this is a predictor of patients being unwell and at higher risk of relapse.1,2 Clinicians need to establish a good therapeutic alliance, involve patients in care planning, psycho-education and pre-discharge contact between inpatient services and the community team.2,26 Other simple measures include offering appointments promptly and at a convenient time at the moment of cancellation by the patient.2 Reducing non-attendance will reduce waiting time for new and follow-up patients, allowing judicious use of resources.
Limitations The present study was confined to a single psychiatric outpatient clinic in a small geographical region of the UK. Therefore the results of this study may not be generalizable. Each reminder system was used over a different time period; there was significant delay in setting up the SMS reminders because of technical and governance problems. The study period was from 2004 until 2011, and during this time new teams (crisis resolution, assertive outreach and early intervention team for psychosis) were set up by the Trust; these may have altered the profile of the patients seen in the outpatient follow-up clinic. It is possible that some patients might have received more than one reminder. There was a relatively small sample size for the letter and telephone interventions, compared to the text message intervention. Also the results may have
Downloaded from jtt.sagepub.com at Univ of Illinois at Chicago Library on May 3, 2015
Kunigiri et al.
467
been different if SMS had been used in 2004, when the percentage of SMS users in the population was lower. Mobile phones were then owned mainly by people from higher socioeconomic groups, whose attendance is generally better. A three-month criterion was chosen for sending reminder letters, although the interval between appointments is not known to affect non-attendance.4 There could be sampling bias in the text messaging reminders, as only those patients who gave consent received a text reminder. This might have indicated better engagement with the clinic and therefore greater likelihood of attendance, whether or not they received a reminder. A substantial proportion of patients (22%) did not receive text message reminders, which could have been due to reasons such as change of mobile number, poor signal coverage and keeping their mobile phone switched off. The study was not randomised and hence further work is required. The study did not examine if the non-attendance rate differed between psychiatric conditions, particularly schizophrenia, using different reminder system which is a potential topic for future research. Acknowledgements We thank Leicestershire Health Informatics System for setting up the automated text message system, Christine Green, Dr S Battacharya (Institute of Psychiatry, London) and Dr J Devapriam.
References 1. Killaspy H. Psychiatric out-patient services: origins and future. Adv Psychiatr Treat 2006;12:309–19. 2. Mitchell AJ, Selmes T. Why don’t patients attend their appointments? Maintaining engagement with psychiatric services. Adv Psychiatr Treat 2007;13:423–34. 3. Koch A, Gillis LS. Non-attendance of psychiatric outpatients. S Afr Med J 1991;80:289–91. 4. Killaspy H, Banerjee S, King M, Lloyd M. Prospective controlled study of psychiatric out-patient nonattendance. Characteristics and outcome. Br J Psychiatry 2000;176:160–5. 5. Nelson EA, Maruish ME, Axler JL. Effects of discharge planning and compliance with outpatient appointments on readmission rates. Psychiatr Serv 2000;51:885–9. 6. Murdock A, Rodgers C, Lindsay H, Tham TC. Why do patients not keep their appointments? Prospective study in a gastroenterology outpatient clinic. J R Soc Med 2002;95:284–6. 7. Neal RD, Hussain-Gambles M, Allgar VL, Lawlor DA, Dempsey O. Reasons for and consequences of missed appointments in general practice in the UK: questionnaire survey and prospective review of medical records. BMC Fam Pract 2005;6:47. 8. Zailinawati AH, Ng CJ, Nik-Sherina H. Why do patients with chronic illnesses fail to keep their appointments? A telephone interview. Asia Pac J Public Health 2006;18:10–5. 9. Krishna M, Amarjothi S. Reminder letters to improve rate of attendance at Community Mental Health Centre. British Journal of Medical Practitioners 2012;5:a502.
10. MacDonald J, Brown N, Ellis P. Using telephone prompts to improve initial attendance at a community mental health center. Psychiatr Serv 2000;51:812–4. 11. Shoffner J, Staudt M, Marcus S, Kapp S. Using telephone reminders to increase attendance at psychiatric appointments: findings of a pilot study in rural Appalachia. Psychiatr Serv 2007;58:872–5. 12. Donaldson A, Tayar Z. Mobile telephone text messaging of clinic appointments in psychiatry. Psychiatric Bulletin 2009;33:39. 13. Sims H, Sanghara H, Hayes D, et al. Text message reminders of appointments: a pilot intervention at four community mental health clinics in London. Psychiatr Serv 2012;63:161–8. 14. Irigoyen MM, Findley S, Earle B, Stambaugh K, Vaughan R. Impact of appointment reminders on vaccination coverage at an urban clinic. Pediatrics 2000;106:919–23. 15. Hasvold PE, Wootton R. Use of telephone and SMS reminders to improve attendance at hospital appointments: a systematic review. J Telemed Telecare 2011;17:358–64. 16. Reda S, Rowett M, Makhoul S. Prompts to encourage appointment attendance for people with severe mental illness (Review). Cochrane Database Syst Rev 2001;(2):CD002085. 17. Agyapong VIO, Farren CK, McLoughlin DM. Mobile phone text message interventions in psychiatry – what are the possibilities? Curr Psychiatry Rev 2011;7:50–56. 18. Mitchell AJ, Selmes T. A comparative survey of missed initial and follow-up appointments to psychiatric specialties in the United Kingdom. Psychiatr Serv 2007;58:868–71. 19. Guy R, Hocking J, Wand H, Stott S, Ali H, Kaldor J. How effective are short message service reminders at increasing clinic attendance? A meta-analysis and systematic review. Health Serv Res 2012;47:614–32. 20. Atun AR, Sittampalam SR, Mohan A. Uses and benefits of SMS in health care delivery. See http://www.sermos.nl/filesystem/downloads/imperial_college%20schotland.pdf (last checked 17 July 2014). 21. Chen ZW, Fang LZ, Chen LY, Dai HL. Comparison of SMS text messaging and phone reminder to improve attendance at a health promotion center: a randomized controlled trial. See http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2170466/pdf/JZUSB09-0034.pdf (last checked 25 June 2014). 22. Stone CA, Palmer JH, Saxby PJ, Devaraj VS. Reducing non-attendance at outpatient clinics. J R Soc Med 1999;92:114–8. 23. Department of Health. Hospitals and patients urged to take action on missed appointments. See https://www.gov.uk/ government/news/hospitals-and-patients-urged-to-takeaction-on-missed-appointments (last checked 25 June 2014). 24. Centre for Suicide Prevention. National confidential inquiry into suicide and homicide by people with mental illness: annual report 2013. See http://www.rcpsych.ac.uk/pdf/ 19%20Appleby%20KN9%20IC2013.pdf (last chedked 21 July 2014). 25. Department of Health Informatics Directorate. Guidance: Short Messaging System (SMS) and Texting. See http:// www.connectingforhealth.nhs.uk/systemsandservices/infogov/links/sms2010.pdf (last checked 21 July 2014). 26. Nose´ M, Barbui C, Gray R, Tansella M. Clinical interventions for treatment non-adherence in psychosis: meta-analysis. Br J Psychiatry 2003;183:197–206.
Downloaded from jtt.sagepub.com at Univ of Illinois at Chicago Library on May 3, 2015
Improving attendance in psychiatric outpatient clinics by using reminders
Journal of Telemedicine and Telecare 2014, Vol. 20(8) 464–467 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X14555642 jtt.sagepub.com
Girish Kunigiri, Niman Gajebasia and David Sallah
Summary We compared non-attendance rates at follow-up appointments in an adult psychiatry outpatient clinic using three different reminder methods: letters, telephone prompts and text message reminders. Two of the three strategies resulted in a significant increase in the rate of attendance. Reminder letters increased attendance from 62% to 85% (P < 0.001) and text messaging increased attendance from 72% to 80% (P < 0.002). The attendance rate was not significantly different between the two groups when telephone reminders were used (P ¼ 0.068). However, telephone prompts resulted in an 8% higher cancellation rate compared to controls. When all factors were taken into consideration, no method demonstrated clear superiority. Efforts should be made to reduce patient non-attendance, as this is a predictor of patients being unwell and at higher risk of relapse. Text messages are an inexpensive method of reminding patients, although appropriate safeguards for patient confidentiality are required. Accepted: 21 July 2014
Introduction In the UK, there are high non-attendance rates – over 10% – for hospital outpatient appointments. Psychiatry is particularly poor in comparison with other medical specialities.1,2 Non attendance represents poor utilization of resources but also produces poorer outcomes.3–5 More than one-quarter of non-attenders in psychiatric clinics3,4 and other medical specialities6–8 cited forgetting the appointment as the cause. This has led to interest in methods of reminding patients about their appointments. Various reminder methods have been tried, with varying degrees of success, in psychiatric settings. These include reminder letters,9 telephone calls10,11 and more recently, text messages for mobile phones.12,13 Few studies have compared the effectiveness of different reminder methods,14,15 and these have been conducted in non-psychiatry settings. A Cochrane review16 of reminders for mental health patients identified only four studies. One study compared a standard letter with an ‘orientation statement’ letter that was sent 1–3 days prior to appointment (this provided details of doctor and fees, as well as appointment details), and another study compared an ‘orientation statement’ at the time the appointment was made with telephone prompts. However these studies were limited to initial appointments. None of these were compared with text messaging, which is an efficient reminder system.17 The purpose of the present study was to compare nonattendance rates at follow-up appointments in a psychiatry outpatient clinic using three different reminder
methods: letters, telephone prompts and text message reminders.
Methods The study was conducted in general adult psychiatry outpatient clinics in a locality delivering mental health services to patients aged 18–65 years. This service is part of a wider mental health, learning disability and community health service in the UK.18 On average this locality serviced 6–8 new patients and provided 50–60 follow up appointments per week. The study was conducted in three phases, see Table 1. In Phase 1, patients receiving standard appointments (control group) were compared with those receiving reminder letters, which were sent two weeks prior to the outpatient (OP) appointment. Only those patients who had an appointment at an interval of 3 months or longer were included in the study. In Phase 2, patients received telephone reminders from the medical secretary one week prior to their appointment and were compared with those who did not (control group). In Phase 3, text messages were sent to consenting patients 2 weeks and 2
General Adult Psychiatry Department, Leicestershire Partnership NHS Trust, Leicester, UK Corresponding author: Girish Kunigiri, Bradgate Mental Health Unit, Leicester LE3 9EJ, UK. Email: [email protected]
Downloaded from jtt.sagepub.com at Univ of Illinois at Chicago Library on May 3, 2015
Kunigiri et al.
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Table 1. Reminder methods.
Phase 1 (Letter)
Phase 2 (Telephone)
Phase 3 (Text)
Intervention group*
Control group
Reminder letter sent 2 weeks prior to OP appointment scheduled 3 months or later (8 December 2004 to 8 February 2005) Medical secretary telephoned one week prior to appointment. If unsuccessful after 2 attempts, a reminder letter was sent (1 July 2006 to 31 August 2006) All consenting patients received an automated text message sent 14 days and 2 days prior to appointment. The text read ‘‘This is a reminder that you have a hospital appointment on . . . (date) at . . . (time) with Dr . . . at . . . (venue). If unable to attend please contact . . . ’’ (1 September 2010 to 28 February 2011)
Standard appointment card issued after OP clinic followed by confirmation letter from medical secretary (7 September 2004 to 7 December 2004) Same as above (1 May 2006 to 30 June 2006)
Same as above (1 September 2010 to 28 February 2011)
*The reminder was in addition to standard procedure.
days prior to the appointment, and compared with those who did not receive such text reminders (control group). In each phase, appointments were recorded as attended, did not attend (DNA) or cancelled by the patient. This information was tabulated on a spreadsheet. The control group were compared with the intervention group in each phase and also with each other using a chisquared test.
Results
Table 2. Attendance rates in the two groups. Intervention group Control group Number (%) Number (%) P-value Letter Attended 44 (85) Did not attend 1 (2) Cancelled by patient 7 (14) Telephone Attended 71 (72) Did not attend 9 (9) Cancelled by patient 19 (19) Text Attended 155 (80) Did not attend 13 (7) Cancelled by patient 25 (13) Pooled Attended 270 (79) Did not attend 23 (7) Cancelled by patient 51 (15)
63 (62) 27 (27) 12 (12)
0.001
97 (73) 22 (16) 14 (11)
0.068
893 (72) 137 (11) 210 (17)
0.002
1053 (71) 186 (13) 236 (16)
0.005
In Phase 1, 62% of patients in the control group (n ¼ 102) attended their appointment. In the intervention group who received reminder letters (n ¼ 52), 85% attended, see Table 1. The attendance rate was significantly higher in the intervention group (P < 0.001). In Phase 2, 73% of patients in the control group (n ¼ 133) attended their appointment. In the intervention group, who received reminder telephone calls (n ¼ 99), 72% attended. The attendance rate was not significantly different between the two groups (P ¼ 0.068). In Phase 3, 72% of patients in the control group (n ¼ 1240) attended their appointment. A total of 248 patients opted for the text messaging reminder service, but there was failure to send a text message to 55 patients (22%). Thus in the intervention group, who received text reminders (n ¼ 193), 80% attended. The attendance rate was significantly higher in the intervention group (P < 0.002). When the three reminder systems were compared with each other using a chi-squared test, there was no difference between them (P ¼ 0.26). The pooled chi-squared test suggested that the pooled intervention group differed significantly from the pooled control group (P < 0.005), see Table 2.
using telephone prompts. When the three methods were compared with each other, no method was significantly different from any other in reducing non-attendance rates. Telephone prompts resulted in an 8% higher cancellation rate compared to controls. Although this difference was not significant, it helped to free up clinic space and so assisted in reducing the waiting lists. Sending the reminder letter and the first text message two weeks prior to the appointment allowed enough time for the treating team to schedule an appointment for another patient if a patient chose to cancel the appointment.
Discussion
Previous work
In the present study, non-attendance rates were reduced significantly by using letters and text messages, but not by
The results from our study are similar to those from other studies that used letter,9 telephone prompts10,11 and text
Downloaded from jtt.sagepub.com at Univ of Illinois at Chicago Library on May 3, 2015
466
Journal of Telemedicine and Telecare 20(8)
messages13 to remind patients about their appointments. In a recent study patients who received reminder letters demonstrated improved clinic attendance (72% vs 56%),9 although this was lower than the attendance rate in our sample. This study too lacked randomization. Letter reminders may be safe in terms of ensuring confidentiality compared to telephone or text messages, but this comes at an additional cost (administrative and postal charges). With regard to telephone reminders, some studies reported an improvement in the initial appointment10 while others did not when contacted by staff compared to therapists.11 The Cochrane review16 on the subject found that telephone prompting, although beneficial, had only a weak positive effect on attendance at the first appointment, in comparison to a letter (orientation statement). This is similar to the findings of the present study. Cancellation by patients was higher in our study when using telephone reminders. This may have been because patients had the option of rescheduling their next appointment directly when they were contacted by the administrative staff to confirm their attendance. One of the problems with telephone messages is with confidentiality, specifically when leaving messages on an answerphone. Consequently, many hospitals refuse to leave messages on such devices unless the patient has previously consented to this. A systematic review of text messaging found that it had positive results on attendance rates.19,20 Using an automated text messaging system avoids the administrative costs associated with sending reminder letters.21 An additional advantage of text message reminders is that it is compatible with electronic patient records and is very time efficient. A key limitation of this technique is that only about half of mobile phone owners agreed to be contacted in this way.12 A recent pilot study13 conducted over a 3-year period examining the effectiveness of text messages sent a couple of days prior to the appointments, found a reduction in non-attendance of 25–28% compared to those who had no reminders. The attendance rate over three successive years was 47%, 54% and 49%, i.e. the improvement in attendance rate was only 2% in year 3 compared to year 1, raising questions about the real benefits of text messages. However the high cancellation rate (21%) of appointments by clinic or clinicians in the final year of study could have contributed to this.
National context Non-attendance in clinics comes at a cost to both the patients and the NHS, particularly in mental health, where the non-attendance rate is twice that of medical clinics.2 The cost of each missed appointment in England was 61 in 1996–9722 amounting to about 760 million per year in total.20 Sims et al.13 estimated that a reduction in non-attendance by a quarter, using text messages, could save the NHS 150 million per year. The Department of Health in the UK encourages general
practices and hospitals to reduce non-attendance by various initiatives.23 Each mental health trust in UK has its own non-attendance policy. Non-attendance is associated with poor outcome in patient care. Investigation of both new and follow-up psychiatric patients’ reasons for non-attendance suggest that active symptoms of the illness are a major contributor to non-attendance.1,2 Lack of insight, apathy and reduced organisational skills also appeared to be linked to missed appointments.1 Patients who miss follow-up appointments after discharge are more unwell, have greater social impairment, have higher admission rates and are a risk to themselves and others.3,4,24 There are more indirect benefits of increasing attendance having a positive effect on patient care, such as reduced morbidity by providing continuity of care.1,2,4 Hence some authors have stressed the additional benefits beyond the pure economic evaluation of reminder systems.15
Clinical implications Reducing non-attendance rates in psychiatric outpatient clinics by using reminder systems should be advocated. No one particular reminder system appears to be superior, although Reda et al.16 found the (orientation) letter to be more effective than telephone prompts. Text messages are an inexpensive method of reminding patients, although appropriate safeguards for patient confidentiality are required.25 Clinicians should make efforts to reduce patient nonattendance as this is a predictor of patients being unwell and at higher risk of relapse.1,2 Clinicians need to establish a good therapeutic alliance, involve patients in care planning, psycho-education and pre-discharge contact between inpatient services and the community team.2,26 Other simple measures include offering appointments promptly and at a convenient time at the moment of cancellation by the patient.2 Reducing non-attendance will reduce waiting time for new and follow-up patients, allowing judicious use of resources.
Limitations The present study was confined to a single psychiatric outpatient clinic in a small geographical region of the UK. Therefore the results of this study may not be generalizable. Each reminder system was used over a different time period; there was significant delay in setting up the SMS reminders because of technical and governance problems. The study period was from 2004 until 2011, and during this time new teams (crisis resolution, assertive outreach and early intervention team for psychosis) were set up by the Trust; these may have altered the profile of the patients seen in the outpatient follow-up clinic. It is possible that some patients might have received more than one reminder. There was a relatively small sample size for the letter and telephone interventions, compared to the text message intervention. Also the results may have
Downloaded from jtt.sagepub.com at Univ of Illinois at Chicago Library on May 3, 2015
Kunigiri et al.
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been different if SMS had been used in 2004, when the percentage of SMS users in the population was lower. Mobile phones were then owned mainly by people from higher socioeconomic groups, whose attendance is generally better. A three-month criterion was chosen for sending reminder letters, although the interval between appointments is not known to affect non-attendance.4 There could be sampling bias in the text messaging reminders, as only those patients who gave consent received a text reminder. This might have indicated better engagement with the clinic and therefore greater likelihood of attendance, whether or not they received a reminder. A substantial proportion of patients (22%) did not receive text message reminders, which could have been due to reasons such as change of mobile number, poor signal coverage and keeping their mobile phone switched off. The study was not randomised and hence further work is required. The study did not examine if the non-attendance rate differed between psychiatric conditions, particularly schizophrenia, using different reminder system which is a potential topic for future research. Acknowledgements We thank Leicestershire Health Informatics System for setting up the automated text message system, Christine Green, Dr S Battacharya (Institute of Psychiatry, London) and Dr J Devapriam.
References 1. Killaspy H. Psychiatric out-patient services: origins and future. Adv Psychiatr Treat 2006;12:309–19. 2. Mitchell AJ, Selmes T. Why don’t patients attend their appointments? Maintaining engagement with psychiatric services. Adv Psychiatr Treat 2007;13:423–34. 3. Koch A, Gillis LS. Non-attendance of psychiatric outpatients. S Afr Med J 1991;80:289–91. 4. Killaspy H, Banerjee S, King M, Lloyd M. Prospective controlled study of psychiatric out-patient nonattendance. Characteristics and outcome. Br J Psychiatry 2000;176:160–5. 5. Nelson EA, Maruish ME, Axler JL. Effects of discharge planning and compliance with outpatient appointments on readmission rates. Psychiatr Serv 2000;51:885–9. 6. Murdock A, Rodgers C, Lindsay H, Tham TC. Why do patients not keep their appointments? Prospective study in a gastroenterology outpatient clinic. J R Soc Med 2002;95:284–6. 7. Neal RD, Hussain-Gambles M, Allgar VL, Lawlor DA, Dempsey O. Reasons for and consequences of missed appointments in general practice in the UK: questionnaire survey and prospective review of medical records. BMC Fam Pract 2005;6:47. 8. Zailinawati AH, Ng CJ, Nik-Sherina H. Why do patients with chronic illnesses fail to keep their appointments? A telephone interview. Asia Pac J Public Health 2006;18:10–5. 9. Krishna M, Amarjothi S. Reminder letters to improve rate of attendance at Community Mental Health Centre. British Journal of Medical Practitioners 2012;5:a502.
10. MacDonald J, Brown N, Ellis P. Using telephone prompts to improve initial attendance at a community mental health center. Psychiatr Serv 2000;51:812–4. 11. Shoffner J, Staudt M, Marcus S, Kapp S. Using telephone reminders to increase attendance at psychiatric appointments: findings of a pilot study in rural Appalachia. Psychiatr Serv 2007;58:872–5. 12. Donaldson A, Tayar Z. Mobile telephone text messaging of clinic appointments in psychiatry. Psychiatric Bulletin 2009;33:39. 13. Sims H, Sanghara H, Hayes D, et al. Text message reminders of appointments: a pilot intervention at four community mental health clinics in London. Psychiatr Serv 2012;63:161–8. 14. Irigoyen MM, Findley S, Earle B, Stambaugh K, Vaughan R. Impact of appointment reminders on vaccination coverage at an urban clinic. Pediatrics 2000;106:919–23. 15. Hasvold PE, Wootton R. Use of telephone and SMS reminders to improve attendance at hospital appointments: a systematic review. J Telemed Telecare 2011;17:358–64. 16. Reda S, Rowett M, Makhoul S. Prompts to encourage appointment attendance for people with severe mental illness (Review). Cochrane Database Syst Rev 2001;(2):CD002085. 17. Agyapong VIO, Farren CK, McLoughlin DM. Mobile phone text message interventions in psychiatry – what are the possibilities? Curr Psychiatry Rev 2011;7:50–56. 18. Mitchell AJ, Selmes T. A comparative survey of missed initial and follow-up appointments to psychiatric specialties in the United Kingdom. Psychiatr Serv 2007;58:868–71. 19. Guy R, Hocking J, Wand H, Stott S, Ali H, Kaldor J. How effective are short message service reminders at increasing clinic attendance? A meta-analysis and systematic review. Health Serv Res 2012;47:614–32. 20. Atun AR, Sittampalam SR, Mohan A. Uses and benefits of SMS in health care delivery. See http://www.sermos.nl/filesystem/downloads/imperial_college%20schotland.pdf (last checked 17 July 2014). 21. Chen ZW, Fang LZ, Chen LY, Dai HL. Comparison of SMS text messaging and phone reminder to improve attendance at a health promotion center: a randomized controlled trial. See http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2170466/pdf/JZUSB09-0034.pdf (last checked 25 June 2014). 22. Stone CA, Palmer JH, Saxby PJ, Devaraj VS. Reducing non-attendance at outpatient clinics. J R Soc Med 1999;92:114–8. 23. Department of Health. Hospitals and patients urged to take action on missed appointments. See https://www.gov.uk/ government/news/hospitals-and-patients-urged-to-takeaction-on-missed-appointments (last checked 25 June 2014). 24. Centre for Suicide Prevention. National confidential inquiry into suicide and homicide by people with mental illness: annual report 2013. See http://www.rcpsych.ac.uk/pdf/ 19%20Appleby%20KN9%20IC2013.pdf (last chedked 21 July 2014). 25. Department of Health Informatics Directorate. Guidance: Short Messaging System (SMS) and Texting. See http:// www.connectingforhealth.nhs.uk/systemsandservices/infogov/links/sms2010.pdf (last checked 21 July 2014). 26. Nose´ M, Barbui C, Gray R, Tansella M. Clinical interventions for treatment non-adherence in psychosis: meta-analysis. Br J Psychiatry 2003;183:197–206.
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