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Impact of appointment reminders Impact of appointment reminders via Short Message Service in a via Short Message Service in a
District HospitalDistrict Hospital
Introdução à Medicina’s Annual Assignment
2006/2007
Final Presentation
Class 4 - FMUP
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
2
Presentation Structure
Objective
Introduction
Methods
Results and Discussion
References
Acknowledgments
Authors
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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This study aims to measure the changes in outpatient’s non-attendance rate according
to the sending or not of an appointment reminder via Short Message Service in a
District Hospital.
Objective
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Introduction
Problem: failure to attend outpatients appointments.
[Hashim, 2001]
Reasons for non-attendance:
- Forgetfulness (which is the most important for our work);
- Long distance from home to health services and trip cost;
- Inconvenient time of appointment (incompatible with work
schedule).
[McClure, 1996]
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Consequences of non-attendance:
Missed opportunities for diagnosis and treatment; Reduced opportunities for hospital revenue; Extended time patients have to wait for an appointment booking.
[Downer, 2005]
Emerging technology of Short Message Service is starting to be
used to remind patients about their appointments...
Introduction
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Portugal: this method is starting to be used in some hospitals such as Santa Maria and the one of our study S. Sebastião. [http://www.telecom.pt/InternetResource/PTSite/PT/DestaquesHP/smsconsultas.htm]
Advantages of this method: it is cheap; it is computorized; no need for many human resources; easy to apply.
Introduction
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Hardware used by the hospital to send appointment reminders through the technology of SMS (Pictures taken in S. Sebastião Hospital)
Introduction
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Conclusions of previous studies conducted in Portugal
related to Hospital S. Sebastião
improving patients attendance, reflected by:
general reduction in the no-attendance rate of 14% in
general appointments;
most extreme case of Paediatrics with a reduction of 50%;
recovering of about 900 appointments per month;
account for nearly 15.000 euros per month. (information given by administrative services of Hospital S. Sebastião)
Introduction
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Participants and Methods
Population: All patients of S. Sebastião Hospital, who
have mobile phone number registered at the system.
Sample’s selection: The set of the Hospital’s patients
who have appointments in the days we perform the study.
Study design: Experimental and transversal study
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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SMS sent by the hospital:Outpatients visits
“Hospital São Sebastião. O utente NOME tem consulta de ESPECIALIDADE
em DATA as HORA. Compareça 20 min. antes.”
Exams
“Hospital São Sebastião. O utente NOME tem exame de ESPECIALIDADE em
DATA as HORA. Compareça 20 min. antes.”
Hospitalizations
“Hospital São Sebastião. O utente NOME tem internamento de
ESPECIALIDADE em DATA.”
Participants and Methods
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
11
Flowchart:
Selection of Participants
Participants and Methods
Start
Has an appointment?
Yes
No
End
List of patients who have an appointment
State = “Not sent”
State = “Not sent”?
Save
No SMS sendingYes
Save
State = “Sent”
Next episode
State = “Not sent”
Yes
Within the study criteria?
No
All SMS sent
List of patients who have mobile phone
number registered at the system
Has mobile phone number registered at
the sistem? Yes
No
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Methods:
Selection of the days for the study (6 working days) Messages sent from 8th to 15th March for the appointments on
days 12th to 19th March.
The hospital sends appointment reminders randomly and alternately to the participants of the sample.
The messages are sent two working days before the appointment.
Finally the results of those who attended the appointment and those who did not, in both groups, reminded and non-reminded, are collected.
Participants and Methods
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Data Analysis (using SPSS program):
1. Statistical analysis, comparing the percentage of attendances and non-attendances in reminded and non-reminded groups;
Participants and Methods
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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2. We are studying if the attendance rate varies according to
some of the following variables:
• Gender
• Age Groups
• Date of the appointment
• Hour of the appointment
• Previous contact with the system
• Type of Episode
• Mobile telephone network
• Speciality
Participants and Methods
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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3. Chi-square test for each of the variables mentioned before and contingency tables.
4. That will allow us to conclude if there is any relationship between the sending of text messages as appointment reminders and the patients’ non-attendance.
Participants and Methods
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Flowchart: description of methods
Participants and Methods
Start
Experimental study
Population: all the hospital’s patients
Sample: patients who have an
appointment in the days of the study
Algorithm aplication (flag)
Attendance and non-attendance rates gathering,
within the reminded and not remimded groups
Statistical analysis
End
SMS sending or not according to
flag
Define query
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Non-Attendance p
Age (Years Old)
Under 15 16,3
<0,0516 to 25 14,0
26 to 55 10,4
More than 55 9,9
GenderFemale 10,8
>0,05Male 12,3
Table 1 - Attendances (%) according to each variable individually
Considering the age of the patients, we verify that the non-attendance rate decreases along with age.
There isn’t any relation between gender and non-attendance.
Results and Discussion
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Non-Atendance p
Previous contact with the system
Yes 9,0>0,05
No 11,6
Type of Episode
Analysis 23,2
<0,05Outpatient 10,1
Exams 15,3
Inpation 18,0
Table 1 – Cont.
Results and Discussion
• There isn’t any relation between the previous contact with the system and the non-attendance
• Hospitalizations is the episode with the highest non-attendance rate, followed by exams, analyses and outpatients
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Results and Discussion
Non-attendance p
Day of the week
Monday 10,6
Tuesday 12,1
Wednesday 15,0 <0,05
Thursday 11,9
Friday 6,8
Table 1 – Cont.
• This table shows that on Wednesday people tend to fail appointments more than on any other day and on Friday
the non-attendance rate is the lowest.
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Non-attendance p
Time of the Day
Morning 11,4>0,05
Afternoon 10,9
Mobile Telephone Network
Vodafone 10,9
>0,05Optimus 12,9
TMN 11,3
Table 1 – Cont.
Results and Discussion
•There aren’t any relation between the non-attendance and time of the day and also mobile telephone network
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Results and Discussion
Table 1 – Cont.
Non-attendance p
Specialty
Medical 11,2
<0,05Medical-surgical 11,3
Surgical 5,0
Other 23,9
• it can be seen a relation between non-attendance and specialty. Surgical is the one with lowest non-attendance
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Table 2 – Attendances (%) according to the sending or not of SMS.
Attendance Non-Attendance p
Reminded 90,4 9,6<0,05
Non-reminded 86,9 13,1
Rate difference: 3,5%
Rate ratio: 26,7%.
Results and Discussion
Number of episodes = 3899
Missings = 537
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Results and Discussion
• it was conducted Logistics regressions for the variable attendance including in
each regression the variable in study, the variable state of SMS sending and
the interaction between the two variables to investigate the influence of the
different variables on the impact of the sending of a SMS appointment
reminder. This regressions, with a p>0,05, showed that there was no relation
between the variables studied and the impact of the SMS appointment
reminder, what means that there is no benefit to SMS relatively to the groups of
the variable in study.
Results and Discussion
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Comparison of data collected
Reference
Type of
sample
selection
Type of
reminder
Durability of
the study
Time between the
reminder and the
appointment
Dimension
of the sample
(number of
individuals)
Non-
attendance
rate in non-
reminded
group
Difference
of the non-
attendance
rate after
reminder
Ritchie PD
(2000)
Randomized Phone call Not
mentioned
1 to 3 days 400 45,6% 16,3%.
Hardy KJ
(2001)
Non-
randomized
Information
pack and
telephone
call
Not
mentioned
2 weeks
(information pack)
1 week (phone
call)
325 15% 10,4 %
O’Brien G
(1998)
Randomized Phone call 11 months 1 day 703 55,9% 11,5%
Sawyer SM
(2002)
Randomized Phone call Not
mentioned
1 day 171 20% 12%
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Comparison of data collected
Reference Type of
sample
selection
Type of
reminder
Durability
of the
study
Time between
the reminder
and the
appointment
Dimension
of the sample
(number of
individuals)
Non-attendance
rate in non-
reminded group
Difference of
the non-
attendance rate
after reminder
Haynes JM
(2006)
Non-
randomized
Phone
call
7 months Not mentioned 515 11,7% 7,7%
Downer SR
(2006)
Non-
randomized
SMS 3 months Not mentioned 45110 19,5% 9.7%
Downer SR
(2005)
Non-
randomized
SMS 1 month 3 working days 2864 23,4% 9.2%
Hashim MJ
(2001)
Randomized Phone
call
Not
mentioned
1 day 903 26% 7%
Leong KC
(2006)Randomized
phone
call and
SMS
3 months 1-2 days 993 51,9% SMS – 10,9%
Telephone call –
11,5%
Costa J
(2007)
Randomized SMS 6 working
days
2 days 3899 13,1% 3,5%
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Discussion
The results show a decrease in the non-attendance rate with the sending of a SMS appointment reminder, which is consistent with the effectiveness of the sending of SMS or other appointment reminders in previous studies [1,2,3,4,7]. Although the non-attendance rate difference of this study was lower than the ones obtained with the studies referred, the non-attendance rate without the sending of an appointment reminder was also lower, so it was already expected a lower reduction. Comparatively with other studies referred, this has the advantage of being randomized and having a big sample.
Considering all this, and seeing that the difference isn´t as striking as it was expected, the hospital could adopt other methods in order to obtain a greater reduction in the non-attendance rate.
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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References
References in order of appearance:
Hashim MJ, Franks P, Fiscella K. Effectiveness of Telephone Reminders in Improving
Rate of Appointments Kept at an Outpatient Clinic: A Randomized Controlled Trial. J
Am Board Fam Pract. 2001 May-Jun;14(3):193-6.
McClure RJ, Newell SJ, Edwards S. Patient characteristics affecting attendance at
general outpatient clinics. Abstract. 1996 Feb;74(2):121-5.
Downer SR, Meara JG, Da Costa AC. Use of SMS text messaging to improve
outpatient attendance. Med J Aust. 2005 Oct 3;183(7): Haynes 366-8.
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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References
• Downer SR, Meara JG, Da Costa AC. Use of SMS text messaging to improve
outpatient attendance. Med J Aust. 2005 Oct 3;183(7):366-8.
• Haynes JM, Sweeney EL. The Effect of Telephone Appointment-Reminder Calls on
Outpatient Absenteeism in a Pulmonary Function Laboratory. Respir Care. 2006
Jan;51(1):36-9.
• Hashim MJ, Franks P, Fiscella K. Effectiveness of Telephone Reminders in Improving
Rate of Appointments Kept at an Outpatient Clinic: A Randomized Controlled Trial. J
Am Board Fam Pract. 2001 May-Jun;14(3):193-6.
• Hardy KJ, O'Brian SV, Furlong NJ. Information given to patients before appointments
and its effect on non-attendance rate. Abstract. 2001 Dec 1;323(7324):1298-300.
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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References
• McClure RJ, Newell SJ, Edwards S. Patient characteristics affecting attendance
at general outpatient clinics. Abstract. 1996 Feb;74(2):121-5.
• 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. Abstract. 2005
Nov 7;6:47.
• Downer SR. Meara JG. Da Costa AC. Sethuraman K. SMS text messaging
improves outpatient attendance. Aust Health Rev.2006 Aug;30(3):389-96.
• http://download.microsoft.com/download/
6/4/1/64122b0868594d95b0241544e37afab5/Case_Study_
%20Hospital_Sao_Sebastiao.doc
• Contratos programa com hospitais --Rcorreia 15:15, 14 Novembro 2006 (WET)
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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References
•Tecnologia "made in" S. Sebastião Hospital 22:30, 5 Dezembro 2006
•“Gestão de consultas por SMS no Hospital Santa Maria”-
http://www.telecom.pt/InternetResource/PTSite/PT/DestaquesHP/smsconsultas.ht
m
• Portugal Telecom - consulted on April 3rd 2006
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Acknowledgments
Dr. Ricardo CorreiaProf. Dr. Altamiro da Costa PereiraDr. Alberto FreitasDr. Armando PintoDrª. Filipa Almeida
S. Sebastião Hospital, in particular Engº. Rui Gomes
:: Annual Assignment | Introdução à Medicina 2006-2007 | Class4
Impact of appointment reminders via Short Message Service in a District Hospital
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Authors
Class 4, Introdução à Medicina 2006-2007, Faculdade de Medicina UP
Cardoso, L.; Costa, A.; Costa, J.; Cunha, A.; Dias, C.; Lima, M.; Pacheco, P.; Silva, D.; Silva, I.; Sousa, D.; Tinoco, M.; Valente, L.; Viana, S.; Correia, R.
Contact: