The first time 83-year-old Graham realised that he had missed his podiatry appointment was when he received a letter from the health service. They said that they had tried to text him to remind him, but he had not replied and not turned up. The letter threatened him with having to pay a fee for non-attendance and being taken off the practice list if he failed to turn up to subsequent appointments without notifying them.
The cost of non-attendance at health care appointments
Missed health care appointments cost health services many hundreds of millions of dollars a year. At the same time, missed appointments can prevent access to others waiting for health care.
In 2009, the cost of missed appointments was estimated to be more than £600M in the UK and more than 24 million appointments with the general practitioner (GP) or consultant-led clinics are missed each year. Allied health and nursing report non-attendance rates of between 6% and 30%
Other problems with non-attendance can include longer waiting times for appointments; increased health care cost; under-use of medical equipment, premises and workers; reduced numbers of appointments available for all patients; less patient satisfaction; and poor relationships between patients and staff.
Graham lives alone and easily loses track of the days. He rarely, if ever, checks his mobile phone and doesn’t know how to use SMS. He was horrified to find out that he had missed his appointment, and was alarmed at the threatening tone of the letter.
A low cost way to increase service efficiency and effectiveness
Reducing the rates of missed appointments is an inexpensive way for health service managers to increase service productivity and reduce unnecessary delays in health care delivery.
Organisations are increasingly investing using text, telephone and email reminder systems, generally using a ‘one-size-fits-all’ approach. However there is little evidence on either their overall effectiveness or their acceptability for particular population groups.
What the research tells us
To find out what types of reminder systems work best for different patient groups, our research team undertook three separate reviews to examine all of the findings from 463 research studies published between 2000 and 2012 on the use of reminders in outpatient populations, including general practice, allied health, hospital outpatient departments and specialist medical consultants. The full report is available here. While the data are relatively old, the findings are still relevant.
Reminders are effective, but not one-size-fits-all
All but one study found that reminders are an effective way of reducing patient non-attendance, regardless of the type of patient or health service.
Simple reminders that give the details of the time and location of the appointment are effective at increasing appointment attendance.
Reminders that provide additional information over and above the date, time and location of the appointment (‘reminder plus’) may be more effective than simple reminders at reducing non-attendance. These may be particularly useful for first appointments and screening appointments. Simple reminders are likely to be appropriate for most patients in all other situations.
However, the traditional simple reminder approach is less likely to be effective on its own for certain patient groups, in particular: people from deprived communities; minority ethnic groups; substance abusers; and those with comorbidities and/or illnesses.
Simple reminders to attend may be overlooked by patients in these vulnerable groups and may increase their disadvantage in health-care access in comparison with general outpatient populations. Reminders with direct personal contact might be appropriate in these groups.
Intensive sequential reminders may increase contact for these hard-to-reach groups and, therefore, may increase attendance. Intensive approaches, such as ‘stepped reminders’ and patient navigators, may be effective at re-engaging patients with ongoing health needs who have dropped out of treatment. These general recommendations are suitable for all health-care outpatient services.
There was strong evidence that reminders sent between 1 and 7 days prior to the appointment will be equally effective at increasing attendance.
Six factors that reduce the effectiveness of patient reminders
1. Inaccurate patient records
2. Patients not receiving their reminder
3. Patients not understanding their reminder
4. Poor timing of reminders
5. Patients do not cancel or re-schedule the appointment
6. Reminders are not tailored to the needs of high risk groups or hard to reach groups
Ten ways to increase the effectiveness of patient reminders
Based on the findings above, we propose the following ten strategies to increase the effectiveness of reminders:
1. Maintain accurate patient contact details (with alternative contact details wherever possible).
2. Use reminder technologies that are suitable for the needs of the population. It might be necessary to use more than one type of reminder system.
3. Where appropriate use “Reminder Plus” approaches mentioned above to overcome common barriers to attendance.
4. Send reminder a minimum of 2-3 days in advance of the appointment.
5. Ensure that reminders ask patients to cancel and reschedule unwanted appointments.
6. Use multiple different systems to let the patient cancel their appointments. The systems should suit the needs of the patients, not the needs of the service e.g. automated SMS cancellation, answer-phone, email etc.
7. Have robust rescheduling procedures in place to allow easy rescheduling of appointments for patients, both within and out with normal working hours.
8. Monitor whether any specific groups of patients are being disadvantaged by the chosen reminder systems.
9. Use personalised or intensive reminder strategies for groups of patients at high risk of non-attendance.
10. Build in administrative time for clinicians to manage tasks which were previously routinely carried out when a patient missed an appointment.
For someone like Graham, an older person who is not confident with technology, the use of a SMS was clearly not an appropriate choice. Instead, the use of a different approach, probably a telephone call, with a ‘reminder plus’ would have ensure that he had personal contact and the opportunity to reschedule if necessary.
A simple reminder is a good “one-size-fits-most” approach to patient appointment reminders, however for those from marginalised and harder to reach populations, other reminder systems need to be employed. Those who are hardest to reach are also likely to those with more complex health needs.