In China, health promotion centers, orthodontic clinics, endoscopic clinics and many ophthalmic clinics rely on scheduled appointments, for which patient FTA is an area of concern. Indeed, the FTA rate reached 19.5% at the health promotion center of our hospital. Patient FTA wastes resources, frustrates staff, and may result in unmet health needs. Many appointment reminder studies have found reductions in FTA rates, including postcards, letters and telephone. Recently, there are some studies using SMS text messaging that has been found to be successful in improving attendance rate in some settings (Downer et al., 2006
; Geraghty et al., 2007
; Leong et al., 2006
; Milne et al., 2006
). However, very little progress has been made in China.
To our knowledge, this is the first study to examine the effect of telephone and SMS on absenteeism at a health promotion center in China. In this study, the percentage of attendance was significantly higher in SMS and telephone intervention groups compared to the control group. Participants assigned to appointment reminders were more likely to keep their appointments than controls. The effectiveness of both interventions, telephone and SMS, is reflected by the superior attendance rate among the patients.
Similar results have also been obtained in other studies. Haynes and Sweeney (2006
) studied the effect of telephone appointment reminder calls on absenteeism in a pulmonary function laboratory. The reminder calls reduced the absenteeism rate from 11.7% to 4%. Shoffner et al.(2007
) demonstrated that phone reminders were effective for intake appointments when therapists made direct contact with patients in an Appalachian Community mental health center. Used a historical control group, Geraghty et al.(2007
) found SMS reminder to be an effective means of improving outpatient attendance at the ear, nose and throat (ENT) outpatient clinic in Ireland, while Milne et al.(2006
) had done the same at outpatient clinics in the UK national health service. Leong et al.(2006
) performed a RCT of SMS reminder calls in comparison with mobile phone reminder calls to improve outpatient attendance in primary care in Malaysia. The study showed that the attendance rate of the SMS group was significantly higher than that of the control group, but there was no difference between SMS group and the telephone group. They also found that SMS reminder was more cost-effective compared with the telephone reminder. But no articles compared SMS reminder with traditional reminder techniques, including telephone.
In the present study, although the SMS reminder and telephone reminder were equally effective, the cost-effectiveness analysis showed that the cost per attendance for SMS group was significantly lower than that for telephone group, with the ratio of cost per attendance of SMS to telephone being 0.65. This finding may have a significant influence at a health promotion center, which has a heavy patient burden and calls for an active strategy to reduce FTA. In China, due to a reasonable cost (generally 0.10~0.15 Yuan per message), people widely use the SMS text messaging on mobile phones. According to the Ministry of Information Industry (MII) of the People’s Republic of China, China’s cell-phone user population hit 500 million in June 2007 (http://www.mii.gov.cn/art/2007/07/25/art_166_32599.html
). Chinese people sent 429.6 billion text messages through mobile phones in 2006 and the number of mobile phone users and the volume of short messages sent still show an upward trend (http://www.mii.gov.cn/art/2007/02/09/art_169_28756.html
). SMS messaging software allows large batches of text messages to be delivered almost instantly, minimizing labor costs (May and Hearn, 2005
). SMS messages do not require the mobile phone to be active nor necessarily within range and can be held for a number of days until the phone is active or within range (Virtanen et al., 2007
). Furthermore, SMS is also private in a way that voice calling is often not.
This study has several limitations that need to be considered. First, it lacks information on patient beliefs or intentions, and factors as income, education and information on other barriers (e.g., work-loss time) that are of considerable interest. Such data might help explain why some patients were still not present despite these interventions. Second, in China people frequently change their mobile phone numbers as they like and we did not know whether SMS messages were received by the correct recipients. Other authors have identified outdated telephone numbers as a problem for reminder study (Lee and McCormick, 2003
). Furthermore, in various countries cost-effectiveness of reminders would change in accordance with the prices of labor, telephone and text messaging costs. Finally, we also could not evaluate the effect of the time lapse between the reminder call and the appointment date on absenteeism. Further work is needed to explore the timing of patient contact, the use of SMS text messaging to other areas which include patient education, smoking cessation program and chronic disease intervention.