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Missed appointments are an avoidable cost and resource inefficiency which impact upon the health of the patient and treatment outcomes. Health care services are increasingly utilizing reminder systems to manage these negative effects. This study explores the effectiveness of reminder systems for promoting attendance, cancellations, and rescheduling of appointments across all health care settings and for particular patient groups and the contextual factors which indicate that reminders are being employed sub-optimally. We used three inter-related reviews of quantitative and qualitative evidence. Firstly, using pre-existing models and theories, we developed a conceptual framework to inform our understanding of the contexts and mechanisms which influence reminder effectiveness. Secondly, we performed a review following Centre for Reviews and Dissemination guidelines to investigate the effectiveness of different methods of reminding patients to attend health service appointments. Finally, to supplement the effectiveness information, we completed a review informed by realist principles to identify factors likely to influence non-attendance behaviors and the effectiveness of reminders. We found consistent evidence that all types of reminder systems are effective at improving appointment attendance across a range of health care settings and patient populations. Reminder systems may also increase cancellation and rescheduling of unwanted appointments. “Reminder plus”, which provides additional information beyond the reminder function may be more effective than simple reminders (ie, date, time, place) at reducing non-attendance at appointments in particular circumstances. We identified six areas of inefficiency which indicate that reminder systems are being used sub-optimally. Unless otherwise indicated, all patients should receive a reminder to facilitate attendance at their health care appointment. The choice of reminder system should be tailored to the individual service. To optimize appointment and reminder systems, health care services need supportive administrative processes to enhance attendance, cancellation, rescheduling, and re-allocation of appointments to other patients.
Missed health care appointments are a major source of avoidable inefficiency that impacts on patient health and treatment outcomes. Data on non-attendance vary, however studies from around the world consistently report non-attendance rates of between 15% and 30% in outpatient health clinics.1–4 In England, more than 12 million appointments at consultant led clinics,5 and a similar number of general practice appointments are missed each year.6 The cost of missed appointments to the UK National Health Service (NHS) has tripled since 1999.7 In 2009, non-attendance was estimated to cost over £600 million (around US$970 million).8
The consequences of non-attendance include increased appointment waiting times,9 increased costs of care delivery,10,11 underutilization of equipment and personnel,10 reduced appointment availability,6,11 reduced patient satisfaction,12,13 and negative relationships between patients and staff.6,9 Missed appointments may delay presentation at health services, resulting in a lack of follow-up of chronic conditions which may ultimately lead to complications, unnecessary suffering, and costly hospital admission.10,14 Pressures from referring agents to manage waiting lists, can potentially increase staff stress, anxiety, and fatigue levels.15 Reducing the number of missed appointments may be a relatively inexpensive way to increase health care efficiency, effectiveness, and quality.
Numerous reviews have demonstrated the effectiveness of existing reminder systems in varied service settings. However, research to-date focusses on the use of reminder systems in particular service contexts or technologies,16–18 rather than synthesizing knowledge across different contexts and patient groups. This study explores the effectiveness of reminder systems for promoting attendance, cancellations, and rescheduling of appointments across all health care settings and for particular patient groups and the contextual factors which indicate that reminders are being employed sub-optimally.
Our project incorporated three components: the development of a conceptual framework to provide an understanding of the contexts and mechanisms which influence reminder effectiveness (review 1); a systematic review (SR) of the reminder effectiveness literature (review 2), and an evidence synthesis informed by realist principles to explain the contexts and mechanisms which influence reminder effectiveness (review 3). We used realist inquiry because it clarifies the context–mechanism–outcome relationships in an attempt to understand better what works, for whom, under what circumstances.19 Further detail on the methodology employed is available in the TURNUP project report.20
Searches were conducted on 13 databases with date limits of January 1, 2000 to February 15, 2012: AMED, CINAHL Plus with Full Text, Cochrane Library, Embase, HMIC, IEEE Xplore, Kings Fund Library Catalogue, Maternity and Infant Care, MEDLINE, PEDro, PsycINFO, SportDiscus, and Web of Science. The strategy used the concept of (reminders/prompts/alerts) in proximity to (appointments) (Figure 1). Where supported, appropriate database headings/thesaurus terms were used. The reference lists of included randomized controlled trials (RCTs) and SRs were screened for additional relevant studies and citation (forward-) searches were performed in respect of the included RCTs. English-language studies of various quantitative and qualitative designs were included if they investigated the effectiveness of outpatient appointment reminders, appointment attendance behavior, or explicated theories/models/frameworks relating to reminder systems or appointment attendance. Studies were excluded if they investigated reminders sent to a patient inviting them to schedule an appointment. All members of the project team were involved in screening and selection of studies and data extraction from included studies.
We could find few pre-existing conceptual models or frameworks that directly explain the mechanisms by which reminder systems support appointment attendance. We therefore drew on a variety of models that have been developed to understand behavior in relation to medical adherence. Included models related to use of reminders to promote clinical outcomes;21 health care utilization theory;22 the theory of planned behavior;23 the trans-theoretical model;24 self-determination theory;25 protection motivation theory;26 rationale choice theory;27 and complexity theory.28 Our conceptual framework was developed through an iterative process involving examination of the various theories and discussions about context, mechanisms, and outcomes that were important to explain how reminder systems work to promote attendance, for whom, and in what circumstances. The framework consisted of six broad factors that could potentially influence the effectiveness of the reminder or whether patients would attend, cancel or reschedule their appointment, namely: the reminder-patient interaction, reminder accessibility, health care settings, wider social factors, cancellation and rebooking systems, and patient attributes. This framework was then used to support data extraction.
Our SR of effectiveness investigated the impact of reminder systems on improvements in attendance, cancellations, and rescheduling of appointments. The questions addressed in this were: 1) how effective are reminder systems at reducing non-attendance at appointments and increasing cancellation/rescheduling of appointments? and 2) which types of reminder systems are most effective in improving the uptake of health service appointments? We used standardized methods to select, quality assess, extract and synthesize the findings of SRs and RCTs.29 The Critical Appraisal Skills Program appraisal tool for RCTs was used to quality assess those RCTs not already assessed in pre-existing SRs.30 The quality of the included SRs was assessed against the criteria used by the Centre for Reviews and Dissemination when evaluating reviews for inclusion in the Database of Abstracts of Reviews of Effects.31 We used these quality assessments to moderate our interpretation of the review findings, not to exclude the papers.32
Our evidence synthesis aimed to explore the differential effectiveness of reminder systems for particular population sub-groups; to identify contexts and mechanisms which influence the effectiveness of different reminder systems for particular population sub-groups; and identify any disadvantages which should be considered when introducing reminder systems for specific populations. The data extraction framework used the six elements of the conceptual framework. In accordance with realist principles, not all potentially relevant papers identified from the screening contributed to the synthesis.33 All RCTs investigating reminder systems and all reviews (systematic and otherwise) about reminder systems and appointment systems were prioritized for full extraction of contextual and explanatory variables. Whereas RCTs were required to meet minimum quality standards in order to be included in the effectiveness SR, the studies excluded from this SR still had the potential to contribute to the evidence synthesis informed by realist principles. In many cases findings from such studies contributed to the evidence base regarding the mechanisms and contexts that shape the operation of reminder systems in real world settings. Examination of the trial evidence was followed by exploration of qualitative, mixed-methods and non-RCT quantitative studies about reminders and appointments for Europe, America, Canada, Australia, and New Zealand. Thematic analysis was used to examine the evidence available for each section of the framework. Subsequently a narrative synthesis was developed that sought to explain the context and mechanisms influencing how reminders support attendance, cancellation, and rebooking.
The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart (Figure 2) shows the numbers of included papers for review 2 and 3. Preliminary database searches yielded 638 unique papers; a further 139 were identified from subsequent searches. Following the screening stages, 466 potentially relevant papers were identified. Eleven SRs met the inclusion criteria for review 2 (Table 1).16–18,34–41 These SRs either examined a single technology, eg, an SR of short message service (SMS) reminder systems,17 or explored the role of information technologies along a patient care pathway, one of which might be appointment reminder systems.41 The quality of included reviews was variable (Table 2). The five Cochrane reviews had been scrutinized against the highest quality standards.16,18,34,36,40 Four reviews passed the Centre for Reviews and Dissemination SR quality threshold.17,35,39,41 Two reviews did not pass the minimum standard for SRs.37,38
Of the 31 RCTs that met our inclusion criteria for review2,4,42–72 only ten were uniquely identified by our review. The included RCTs related to the use of systems to remind patients to attend a health-related appointment that had already been scheduled (Table 3). The majority of the included RCTs examined either automated telephone reminders (15/31) or SMS texting services (12/31). Seven RCTs examined personalized telephone calls and 9/31 studies examined postal (letter/postcard) reminders. In most studies the comparator was no intervention. The principal functions of the various reminder systems were reminder only, reminder requiring confirmation, reminder plus orientation or reminder plus supporting clinical information. A variety of attendance related outcomes were measured. These included attendance, cancellation, rescheduling, and patient satisfaction. A judgement of the quality of the uniquely identified RCTs is shown in Table 4.
There was consistent evidence that reminder systems improve appointment attendance across a range of health care settings and patient population sub-groups. Only one of the 31 RCTs did not show a significant reduction in non-attendance.48 “Simple reminders”, which provide details of date, time, and location of appointments, were most frequently investigated. “Reminder plus”, which provides additional information (eg, orientation information, health information, etc) over and above date, time, and location of the appointment, was less commonly investigated. Both were effective at reducing non-attendance.
There was consistent, strong evidence from SRs16,34,35,37,41 and RCTs32,65 that simple reminders are effective at increasing attendance at appointments compared with no reminder. In SRs, the pooled effects of simple reminders on appointment attendance vs no reminder indicated significant increases in attendance, with relative risks ranging between 1.06–1.10.34,35 One SR reported a weighted mean relative change of 34% from the baseline non-attendance rate.37 In RCTs the difference in attendance between subjects who received reminders and those who did not ranged from 5% in an Australian physiotherapy clinic to 44% in an Indian dental preventive care clinic.4,66 There was strong evidence from SRs16,34,35 and RCTs42,65 that there is no differential effectiveness between different reminder technologies, eg, SMS reminders, phone call reminders or other reminders.
There was weak, but consistent evidence from five studies that “Reminder plus” is more effective than simple reminders at reducing non-attendance. Examples of “Reminder plus” interventions include SMS notification of appointment with a health promotional message or postal reminders with additional information about medical procedures and the importance of follow-up.70,72 A Cochrane Review40 of the effects of reminders on clinic attendance for those with suspected serious mental illness, identified one small study favoring a letter with an orientation statement (ie, a short paragraph, taking about 30 seconds to read, explaining the program of care, the fee system, and providing gentle encouragement) over a simple letter prompting attendance.73 A second SR to assess the effect of reminder systems on non-attendance rates at new outpatient appointments, found limited evidence in three studies, that “Reminder plus” was more effective than simple reminders.38 In these studies, the reminders threatened sanctions for non-attendance, offered rewards for attendance or provided orientation information about the clinic.
There is evidence from three RCTs that personal phone reminders significantly increase patient cancellation and rescheduling rates.54,64,67 Patients who received a telephone reminder were more likely to cancel or reschedule their appointment (17%–26%) compared with a control group who had received no reminder (8%–12%).54,67,74 Clinics were then able to re-allocate between 27% to 40% of the cancelled appointment slots.54,65,74 Telephone reminders carry the inherent advantage that patients who are unable to attend can cancel and/or reschedule their appointment at the time of their contact with staff.67 We also found strong evidence that SMS reminders do not increase appointment cancellation or rescheduling,75–77 however this may be because SMS reminders are not conventionally deployed with this in mind.
Our review found sufficient strong consistent evidence to indicate that the performance of reminders, and therefore appointment systems, is suboptimal. Six key areas which lead to sub-optimal reminder effectiveness were identified.
Patient contact details are frequently incorrect or out-of-date.78,79 The likelihood of inaccurate patient records corresponds with populations at greater risk of non-attendance,80 including less geographically stable communities such as students, young adults or socio-economically deprived groups who may frequently change address or telephone numbers.81
Successful contact rates for telephone reminders are low ranging from 30% to 60% in most health care settings. Reasons for non-receipt of telephone reminders are that landline calls are often made during business hours (9 am–5 pm), during the working week (Monday to Friday), when it is likely that patients will be out.82 In addition, non-receipt may occur because patients do not have a telephone, they do not answer the telephone or the contact number was incorrect.74,83 Most telephone reminder systems do not leave messages for reasons of confidentiality.
SMS reminders are reported to have successful contact rates of 97%–99%.79,84 Successful contact is assumed when the mobile phone indicates “message sent” being received by the sender.44,59,66 However, many patients may either not receive their SMS reminder or may receive and ignore a reminder that was not intended for them due to incorrect data entry on hospital systems.77,79 Some clients may not receive their text message until after their scheduled appointment because of delays in delivery of the text or because their phones were switched off, out of battery or out of credit.85 One disadvantage of using SMS reminders alone is the different levels of access to a mobile telephone. Mobile phone ownership declines sharply with increasing age,86,87 although the total numbers of older people with mobile phone are increasing annually.
Cognitive ability, literacy level, and language determine patient comprehension of reminders, irrespective of format. These are important considerations for health services serving older populations, travelling communities, inner-city deprived populations, and multilingual communities. The studies included in our review did not explore these factors. Two RCTs explicitly excluded patients who did not speak the official language (English) fluently, those with dementia, or with significant cognitive impairment.68,88 Only one RCT used multilingual research assistants to make the reminder phone call.65 Reminder systems can cater for different languages.41,66
We found strong evidence that the timing of reminders, between 1 and 7 days prior to the scheduled appointment, has no adverse effect on patient attendance behavior.37,89 SMS or telephone reminders are typically sent either the day before or on the day of the health care appointment.49,57,63 Sending the reminder close to the appointment means that the patient may either not have time to act on it or they may receive the reminder after the allotted appointment time.65 Sending reminders early allows patients to re-arrange commitments, which may increase the likelihood of a patient attending, cancelling or rescheduling.54,64,67
There are numerous reasons why patients fail to either cancel or reschedule their appointment. Simple reminders rarely ask patients to cancel appointments, particularly SMS reminders where space for text is limited.46,62 Some SMS reminders ask patients to call a telephone number rather than replying to the text.4,57 Patients frequently encounter problems accessing health care systems which can thwart their intention to cancel and rebook.86,90 Problems include difficulties accessing central booking lines, including the phone being engaged, having to wait a long time to speak to someone or the call being disconnected with no option to wait or leave a message.91,92 In some cases, patients were warned by others of the difficulties of accessing a central booking line, which deterred them from making contact.86 In two studies, patients who failed to attend stated that they had already phoned or written to cancel their appointment, indicating difficulties with cancellation systems or internal hospital communication prevented cancellations being passed on to the relevant clinic.81,86
There was weak evidence that patient age has no impact on reminder effectiveness, suggesting reminder systems can be employed across all age groups.18 However, few studies have investigated the differential impact of reminder systems between population sub-groups. There was weak but consistent evidence that deprivation, minority ethnicity, substance abuse, mental health problems, and comorbidities/illness are associated with non-attendance at appointments.93,94 There was little evidence of tailoring of reminder systems to meet the needs of these groups of patients.
This review found consistent, strong evidence that all reminder systems are effective at reducing non-attendance at appointments across diverse service contexts and patient populations. There is no clear indication of differential effectiveness between different simple reminder systems. However, there is some evidence that “Reminder plus” interventions can be more effective than simple reminders. Our review of the available evidence suggests that “Reminder plus” may result in higher attendance than simple reminders for first appointments and screening appointments and that for subsequent follow-up appointments simple reminders and “Reminder plus” may produce comparable increases in attendance for most patients most of the time. However, further research employing appropriate comparative designs is needed before firm conclusions can be drawn.
There is also strong consistent evidence that reminders can increase patient cancellation/rebooking rates, however the success may depend to some extent upon the nature and the timing of the reminder. We found only three studies investigating this area of effectiveness,54,64,67 therefore further research exploring the effectiveness of reminder systems to promote cancellation/rebooking and rescheduling of appointments is warranted.
Based on the findings presented in this review, the small amount of evidence that some patients find reminders intrusive or confusing is outweighed by the benefits.95 The use of reminders appears to be both acceptable and feasible across a range of health care settings,42,65 and we therefore propose that all patients should receive a reminder and that all health care services operating outpatient appointment systems should employ reminder systems.
Whilst reminder systems can increase attendance, cancellation, rescheduling and reallocation of appointments, this review identified six key factors which limit the efficiency of both reminder and appointment systems. Reminder systems are often employed with the objective of increasing attendance rates, with limited attention given to cancellation and/or rescheduling of appointments. Full attendance at appointments is unlikely to be achievable; therefore appointment cancellation and rescheduling should be seen as desirable outcomes. Appointment systems can be optimized if patients cancel and reschedule unwanted appointments, allowing health care services to re-allocate the cancelled appointment to a different patient. If appointment and reminder systems are to realize their full potential this will require a whole systems approach to looking at the characteristics of current systems for attendance, cancellation, rescheduling and re-allocation of appointments to other patients. A summary of proposed strategies is outlined in Figure 3 and discussed in greater detail to follow.
Health services, particularly those serving geographically less stable communities, should have robust procedures for maintaining and updating patient records.81
In many health services it will be relevant to consider the use of both simple reminders and “Reminder plus”. Depending on the nature of the information provided, “Reminder plus” may help patients to feel more confident about attending their appointment, particularly for first appointments and screening appointments.56,96 Thereafter, the use of simple reminders may be sufficient for increasing attendance at follow-up appointments in most health care settings.
Since the timing of appointment reminders appears to have no appreciable impact on attendance behavior when delivered up to 7 days before an appointment, we propose that reminders should be delivered early enough to allow patients to re-arrange commitments so that they can attend the appointment and receive the care that they need. Alternatively, if unable to attend, patients will have sufficient time to cancel and reschedule their appointments and allow health services to re-allocate and rebook appointments.54,64,67 To support and enhance rescheduling it is appropriate to frame reminders to ask patients to cancel and rebook inconvenient appointments. In addition, robust structures, which are easy to navigate and which require minimal effort from the patient, are required to support cancellation. Automated methods of cancellation, eg, SMS messages or email, are perceived by many patients as easier than methods which require direct contact since they offer flexibility to cancel at a time convenient to the patient and reduce the need to provide explanations for cancellation.18,34 Following cancellation of appointments, rescheduling of the appointment, if it has not occurred synchronously, also needs to be easy for the patient. For example it may be sensible, in some health care settings, to have central booking lines which are open 24 hours a day.
There is little evidence of tailoring of reminder systems to meet the needs of vulnerable groups of patients who are at high risk of non-attendance; this includes deprived and ethnic groups, substance abusers, and populations with co-morbidity and illness.93,94 Given the likely coincidence of higher levels of non-attendance and health need, it is in the interests of health services to monitor whether specific groups of patients are being disadvantaged by the chosen reminder systems. Simple reminders and automated reminders may be ignored, overlooked or misunderstood, particularly if patients are experiencing an increase of their health problem. We therefore hypothesize that reminders with direct personal contact might be appropriate in these groups, since the flexibility of information, advice or support which can be offered may help to overcome barriers to attendance or to cancel unwanted appointments. To facilitate attendance in these groups more intensive reminder systems are advocated. Examples of this include sequential reminders which were effective at improving attendance in a Swiss AIDS clinic.65 This consisted of: first, a phone call to either landline or mobile; second, an SMS if participants do not answer the phone after three attempts and have a mobile phone; and finally a postal reminder if participants do not answer the phone, have no mobile phone or landline at all. Intensive approaches, such as “stepped reminders” and patient navigators have also been effective at increasing attendance at screening and immunization programs in disadvantaged and vulnerable populations and might also be effective at reengaging similar groups of patients who have dropped out of treatment.36,97–99 Such designs, though labor intensive would reach the maximum number of participants and may increase attendance rates and simultaneously have a cost benefit.
An effective reminder and cancellation system will increase the already heavy workload of outpatient clinics.52 Clinicians frequently fill missed appointments with alternative activities such as completing dictation, making telephone calls or consulting with colleagues.56 If building in processes to optimize cancellation and rescheduling, then health services will need also to consider the impact on staff that frequently utilize non-attendance at appointments as an opportunity to catch up on other health care related activities.
Our approach to this review, which combined an SR with an evidence synthesis informed by realist principles, has numerous strengths, including a structured search protocol requiring thorough searches of electronic databases, reference lists, and citations. As a consequence we believe that we have assembled the widest possible body of relevant knowledge which has relevance across all health care services which use appointment systems. In addition, our review informed by realist principles includes the strong embedding of our findings in the extracted data. This stems from the practical orientation of our review and facilitates the production of implications for practice. There are also limitations to our review. Generally speaking the SR method seeks to provide a precise answer to a tightly focused question. Such reviews are most useful where there is a high degree of homogeneity around the five PICOS elements, namely the Population, Intervention, Comparison, Outcomes, and Study types. A wide range of population types, intervention, comparison, and outcomes is included within the RCTs we identified. However, use of this wider approach offers greater analytical capability in terms of understanding contextual and mechanistic factors that would not have been evident in a more narrowly focused review and increases confidence that the findings have relevance in a wide range of service settings.
We recommend future research activities in three main areas. Firstly, more studies should routinely consider the potential for differential effects of reminder systems between patient groups in order to identify any inequalities and remedies. Secondly, “Reminder plus” systems appear promising but there is a need for further research to understand how they influence attendance behavior. Finally, further research is required to identify strategies to “optimize” reminder systems and compare performance against current approaches.
In the absence of clear contraindications all health services should use simple reminders or “Reminder plus” for all patients. More intensive reminder alternatives may be relevant for key groups of patients: deprived, ethnic, substance abusers, and those with comorbidities and illness.
There is evidence that reminders are used sub-optimally. To optimize appointment and reminder systems, health services should tailor reminder systems and adopt supportive administrative processes to enhance attendance, cancellation, rescheduling, and reallocation of appointments to other patients.
The TURNUP project was funded by the National Institute for Health Research Health Services and Delivery Research Program (project number 10/2002/49). The views and opinions expressed are those of the authors and do not necessarily reflect those of the HS&DR program, NIHR, NHS or the Department of Health. This paper or the abstract of this paper has been presented as a platform presentation at the World Congress of Physical Therapy, Singapore in May 2015 and will also be presented as a platform presentation at Physiotherapy UK in October 2015, Liverpool UK. The abstract was published in Physiotherapy Journal: http://www.physiotherapyuk.org.uk/presentation/appointment-reminder-systems-are-effective-not-optimal-results-systematic-review-and. The actual paper, however, has never been published.
The authors report no conflicts of interest in this work.