Which of the following is most likely a reason for the decline in the use of voicemail messaging?

Main findings

The objective of this project was to explore the differential effect of alternative types of reminders for scheduled health service encounters for different segments of the population on fulfilled or rescheduled appointments, substitutions and satisfaction. This study has presented the findings of three separate reviews in order to answer the more specific research questions outlined in this project [see Objectives]. A brief discussion of the literature as it relates to each of the questions is outlined below.

Which types of reminder systems are most effective in improving the uptake of health service appointments?

Simple reminders

All reminders are effective at improving attendance at appointment. Simple reminders, which provide details of timing and location of appointments, are effective at increasing attendance at appointment [see Chapter 4, Evidence statement [A.1]: there is strong consistent evidence that simple reminders which provide details of timing and location of appointments are effective at helping a [forgetful] patient to attend their appointment [evidence category Ia]]. Forgetfulness is reported by patients and by health professionals as the most common reasons for not attending a health-care appointment and accounts for between 8% and 44.8% of patients who did not attend their appointments, indicating that this is a substantial problem [see Chapter 5, Reported reasons for non-attendance]. Forgetfulness or confusion over date, time or location of the appointment appears to act as the theoretical basis for many reminder systems identified in this review.59,63,70,76,78,79,98,99,102,106,198–200 It has been suggested that simple reminders may be effective because they act as cues to counteract prospective memory failures.25 Numerous studies suggest that as many as 80–90% of patients have a positive attitude to receiving a reminder that jogs the memory.55,79,145,200 The evidence presented indicates that the use of simple reminders is both acceptable and feasible across a wide array of health-care settings. Although very few studies have investigated the influence of preference on reminder effectiveness [see Chapter 4, Evidence statement [B.4]: very few studies investigated whether or not the reminder preferences of the patient may influence the impact a reminder has on the patient's appointment behaviour [evidence category VIIa]], it may provide some indication about a patient’s ability to access the reminder, which may ultimately influence the effectiveness of the reminder [see Chapter 4, Evidence statement [B.1]: there is strong consistent evidence that the reminder may not be received by the patient [evidence category Ia]]. Therefore, the choice of reminder system remains an important consideration for health services. In an acquired immunodeficiency syndrome [AIDS] clinic serving young adult patients, a high percentage of whom were mobile phone users, SMS was the preferred option.200 In a different study of adolescents attending dental clinics, participants reported a significant preference for letter reminders [56.3%], followed by telephone reminders [26.0%] and SMS reminders [17.7%].55 Patient preferences for reminders appear to vary considerably, and we hypothesise that this may be related to sociodemographic factors such as age, employment status, etc. or possibly in relation to the health setting; patients attending sensitive health-care appointments may prefer a very confidential reminder, although this needs to be confirmed through research.

Although simple reminders are effective memory joggers for people who might otherwise forget, this does not explain why, in settings where reminders have been used, forgetfulness continues to be a commonly cited reason for non-attendance.74,136 Forgetfulness may also be a reason that is offered by patients, as it may be more convenient and easier than the truth. Murdock et al.12 have suggested that the underlying reason may be apathy; however, the truth may be considerably more complex and uncomfortable than that. Patients may be uncomfortable stating that they did not find the treatment helpful or that they did not like their doctor, etc. The implication of this is that ‘true forgetfulness’ may be over-rated, whereas other reasons may be under-rated or even unaccounted. Numerous other reasons have also been reported [see Chapter 5 for an account of these reasons]. It has been suggested that, for patients who receive, or expect to receive, some benefit from attending their appointment, reminders will be effective in increasing appointment attendance.25 Reminders will be effective in increasing appointment attendance provided the clients receive some benefit from their attendance, such as useful information, alleviation of symptoms or emotional support.201 If patients no longer find the treatment sessions rewarding, then the prompts will eventually be ignored by the client;201 therefore, clients may fail to attend after the initial appointment because the treatment is simply not meeting their expectations or needs.25 This suggest that reminders, even simple reminders, have a more complex mechanism than simply ‘jogging the memory’.

Reminder plus

There is currently weak evidence [category IIIa] that ‘reminder plus’, which provides additional information over and above the date, time and location of the appointment, are more effective than simple reminders at helping a patient to attend their appointment [see Chapter 4, Evidence statement [A.2–A.6]: there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment [evidence category IIIa]]. Many authors have suggested that the provision of additional information may reduce the number of perceived obstacles to patient attendance and, in this way, increase patient intentions to attend, thereby enhancing the effectiveness of a reminder system.

Gain-framed compared with loss-framed reminders

Specifically, it has been suggested that the provision of information that increases patient perceptions that attendance is important and will contribute positively to his/her well-being will be effective in increasing appointment attendance [gain-framed reminders].59,89,164 Alternatively, it has been suggested that the provision of information that increases patient perceptions that non-attendance will contribute negatively to his/her well-being will be effective in increasing appointment attendance [loss-framed reminders].86,89,202 Ersin et al.123 recommend a combination of the two. Patients themselves stated that they felt reassured and more confident about attending the appointment if they had received information that emphasised the importance or the benefit of the health check.203

The use of additional information as a way of increasing appointment uptake is supported in different contexts. Rutland et al.83 conducted a prospective randomised control study to determine whether or not SMS follow-up of patients who had not attended a booked GUM appointment would improve subsequent reattendance rates and to assess the impact of inclusion of a health promotional message on reattendance rates. Participants [n = 252] who did not attend a booked GUM appointment during the 6-month study period were randomised to [1] no intervention, [2] SMS notification of the defaulted appointment and invitation to attend clinic or [3] SMS notification of the defaulted appointment, invitation to attend clinic and a health promotional message about Chlamydia. All SMS messages were sent 1 week after the defaulted appointment. The reattendance rate was 4.5% in the control group compared with 8.2% in the group receiving a text reminder [p = 0.36] and 15.2% [12/79] in the group receiving a text reminder with a health promotional message [p = 0.032]. In this study, SMS messages with a health promotional message improved subsequent reattendance rates of clinic defaulters. However, not all studies support this finding. Marteau et al.204 found no significant difference in the uptake of appointments for diabetic screening appointments in their RCT when they compared an invitation letter promoting informed choice for screening presenting diabetes as a serious potential problem and providing details of possible costs and benefits of screening and treatment in text and pie charts, with a standard invitation describing diabetes as a serious potential problem.

There may be a contextual element around whether messages should be gain-framed, emphasising the advantages of adherence with recommendation, or loss-framed, emphasising the disadvantages of non-adherence. A meta-analytic review205 of 93 studies [n = 21,656] found that gain-framed messages advocating dental hygiene behaviours were effective, whereas there appeared to be less difference between gain- and loss-framed messages concerning other preventative actions such as safer gender behaviours, skin cancer prevention behaviours or diet and nutrition behaviours. More research is required to consider the influence of message framing.

Orientation information

There is weak evidence that reminders that provide orientation information [e.g. provision of maps, information about clinics and procedures, transport, etc.] may be more effective at increasing appointment attendance than simple reminders. It has been suggested69,89 that reminders of this nature may decrease patient perceptions that attendance at the appointment will be difficult and help patients to feel more confident about attending their appointment. Some authors25,140 have further speculated that orientation information is specifically effective for improving attendance at specific types of appointments, for example new patient appointments or screening appointments for which patients are likely to be attending the clinic for the first time.

Creating a positive perception of the appointment and health-care provider

Providing information that increases patient perceptions that the appointment will be a positive experience may increase appointment attendance. The act of simply sending a reminder may increase patient perceptions of the value of the appointment.80,145 Patients have also reported that receiving a reminder felt like a proactive, positive contact with the health-care provider, which left them feeling that their health-care provider was genuinely concerned about their health problem.145,203 The degree of alliance and quality of communication between patients and the health-care provider and health services impacts on patient attendance behaviour [see Chapter 5, Patient–provider ‘alliance’, communication and ‘engagement’] and a positive communication through reminder systems may lead to positive patient action to attend, cancel or change their appointment.80,203 However, if reminders are handled badly, some patients may feel disinclined to engage with health-care providers and appointments.145

Moral obligation to attend

Our review identified examples from the attendance literature to indicate that patients may not attend appointments if they feel morally obligated to undertake a higher-priority activity such as child care; or that they will attend an appointment if the patient feels morally obligated to perform that health behaviour [see Chapter 5, Norms, attitudes and understandings regarding whether or not attendance is the morally right thing to do]. It has been suggested that providing information that increases patient perceptions that attending the appointment is morally the right thing to do will be effective at increasing appointment attendance.104 Some authors102,123 suggest that the receipt of a reminder or influential wording of the reminder may compel some patients to attend their appointment. Some patients recognised and valued the extra time and effort taken by health services to send a reminder and, consequently, felt compelled to attend their appointment.115,203 Asking patients to enter into an agreement by sending back a confirmation of attendance or contracting to attend may further compel patients to attend their appointment.56,140,141

Although there is strong evidence to support the use of reminders, there is a need for high-quality studies investigating the differential influence of providing additional information as part of the reminder system in different contexts [first vs. follow-up appointment], particularly the use of loss-framed compared with gain-framed messages and orientation information for facilitating attendance behaviours.

Are there any systems that effectively support the cancellation of appointments?

Currently, there is strong evidence that a personal telephone reminder will increase patient cancellation/rescheduling rates [see Chapter 4, Evidence statement [E]: there is strong consistent evidence that reminder systems will promote cancellation of appointments [evidence category Ia]]. Reti80 suggests that one of the dominant benefits of telephone reminders may be the ‘promotion of suitable cancellation behaviours’. Telephone reminders carry the inherent advantage that patients who are unable to attend can cancel their appointment at the time of contact from staff. This advantage is further heightened if the same telephone interchange can be used either to rebook the appointment or to establish that the appointment is no longer required. There is less evidence to support the use of SMS messages to promote cancellation and rebooking [see Chapter 4, Evidence statement [E]: there is strong consistent evidence that reminder systems will promote cancellation of appointments [evidence category Ia]]; however, this may be because SMS reminders are frequently sent very close to the appointment time, which may leave insufficient time for patients to act on the prompt.78 A second reason that SMS may not optimise cancellations could be that when patients receive a reminder they are frequently asked to phone a telephone number rather than simply replying to the text [see Chapter 4, Evidence statement [E.2 and E.5]: there is strong evidence that whether or not a patient cancels and rebooks will be influenced by reminder system factors that facilitate/hamper patient intentions to rebook [e.g. nobody answers the telephone] [evidence category Ia]]. There is strong evidence that patients frequently encounter heath-care system factors such as difficulties accessing cancellation lines, which can hamper patient attempts and intention to cancel and rebook [see Chapter 4, Evidence statement [E.2 and E.5]: strong consistent evidence indicates that system factors related to appointment systems will hamper patient intentions to cancel/rebook [evidence level Ib]]. Better administrative processes in support of SMS may support cancellation more effectively.

Reminder systems are often employed with increased attendance rates in mind and relatively little attention is given to cancellation and/or rescheduling of appointments. Cancellation of appointments may be considered a desirable outcome, especially when the cancellation occurs in time for the appointment to be reallocated to another patient. Even under time-constrained conditions, cancellation without reallocation of the appointment may still be viewed as a favourable outcome as it reduces uncertainty about whether or not the patient will attend, allows clinical staff to assign the equivalent freed time to other patients or to alternative activities and, therefore, reduce the pressure on crowded appointment schedules. Rescheduling of appointments may also be a desirable outcome, especially when the health need of the patient is great. As there is strong evidence that the timing of a reminder, between 1 and 7 days prior to the scheduled appointment, has no effect on patient attendance behaviour [see Chapter 4,Evidence statement [B.5]: there is strong consistent evidence that the timing of a reminder, between 1 and 7 days prior to the scheduled appointment, has no effect on patient attendance behaviour [evidence category Ia]], it would seem appropriate to send all reminders with more time to allow patients to cancel their appointments and for health services to reallocate appointments to other patients. Although there are no studies investigating the framing of reminders [see Chapter 4, Evidence statement [A.2–A.6]: there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment [evidence category IIIa]], it is recommended that the reminder should be framed with cancellation and/or rescheduling in mind. How the request is framed may increase a patient’s sense of moral obligation to cancel;102 however, more robust structures to support cancellation are also required. Cancellation procedures that are easy and require minimal effort from the patients are important, e.g. automated responses to SMS messages rather than the patient having to phone a telephone number, or cancellation and rescheduling telephone lines with adequate administrative support so that patients can quickly leave a message. E-mail may also be a convenient cancellation medium for many patients, as there is no need to wait to get through to a receptionist.42 Automated methods of cancellation may be perceived as easier than methods that require direct contact, as they offer flexibility to cancel at a time convenient to the patient and also reduce the need to provide explanations for cancellation.42,206 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 to have central booking lines which are open 24 hours a day.

Kitcheman et al.69 observed that an effective reminder system will increase the ‘already heavy workload of psychiatric out-patient clinics’. The authors note that ‘even when appointments are missed clinicians do not, as a rule, waste their time’. Alternative activities include the fact that ‘patients are double-booked, dictation is completed, telephone calls made and colleagues consulted’.69 This highlights that increased attendance at appointments may be welcomed more by managers, primary carers and patients than by those working in outpatient clinics. As a consequence, each service faces the challenging dilemma of whether to build in assumptions of non-attendance without opportunity for appointment cancellation or reallocation or to build in processes that optimise cancellation and rescheduling. If building in processes to optimise cancellation and rescheduling, then services will also need to consider the impact on staff that frequently utilise non-attendance at appointments as an opportunity to catch up on other health-care-related activities.

Although reminder systems will increase attendance, full appointment attendance is unlikely to be an achievable outcome; therefore, cancellation and rescheduling of appointments should be seen as a desirable outcome. Reminders would appear to have considerably more potential for promoting cancellation of unwanted appointments to allow reallocation of cancelled appointments than the current evidence indicates. Researchers and health services seeking to optimise attendance should not only consider reminder solutions, but should also consider the supporting resources that would be required to facilitate patient cancellation and rescheduling, reallocation of appointments to other patients while simultaneously supporting hard-pressed clinicians to manage administrative tasks that are routinely carried out when a patient misses an appointment.

Do different reminder systems have differential effectiveness for particular subgroups of the population [e.g. by age group, ethnic group, socioeconomic status, gender, etc.]?

There is very little good-quality evidence investigating whether or not reminder systems have differential effectiveness for population subgroups [e.g. gender, socioeconomic status, ethnicity, employment status, mental health, other comorbidities, presence of symptoms, diagnosis, severity of condition] [see Chapter 4, Proposition F: distal/proxy individual attributes]. The majority of included studies have not been designed to perform secondary analysis to identify subgroups who are more or less likely to respond to reminders.

Age

There is weak evidence that age does not have a differential impact on the effectiveness of reminders [see Chapter 4, Evidence statement [F.1]: there is sufficient weak equivocal evidence to suggest that age does not have a differential effect, over and above pre-existing appointment behaviour, on reminder effectiveness [in terms of attendance, cancellations or rebooking] [evidence category IVa]], indicating that reminder systems can be employed across all age groups. Further investigation of wider attendance literature [see Chapter 5, Age] indicates that there is largely consistent evidence, across health and geographical settings, that higher rates of non-attendance is related to younger age, although this may not hold for paediatric patients who have greater parental involvement in the health care. However, older people tend to have multiple health problems or conditions that may be less likely to resolve and therefore take up the bulk of outpatient appointments. There is speculation surrounding the reasons why younger patients are at greater risk of not attending; however, there has been little solid exploration of the reasons. Therefore, there is little theoretical basis to inform reminder selection so we contend that there is no reason not to employ reminder systems equitably across all age groups. However, as discussed under Accessibility, there are important considerations to be made in relation to the type of reminder technology that would be most appropriate or acceptable for different age groups. Accessibility is a key issue in selection of reminder technology, and older populations are likely to have lower levels of accessibility to mobile phones and, therefore, SMS than younger people108 [see Accessibility]. Patient preferences for reminders are another key issue as it may be a proxy for acceptability, with patients unlikely to prefer reminder systems that they cannot access [see Other reminder characteristics].

Gender

There are no studies indicating that gender has a differential impact on the effectiveness of reminders [see Chapter 4, Evidence statement [F.2–F.11]: few studies investigate whether or not a range of distal/proxy individual attributes have a differential effect, over and above pre-existing appointment behaviour, on reminder effectiveness [in terms of attendance, cancellations or rebooking] [evidence category Va or VIIa]], suggesting that reminder systems can be employed regardless of gender [see Chapter 5, Gender]. There is conflicting evidence, across health and geographical settings, that gender predicts non-attendance at appointments. Half of the studies searched find that women are more likely to miss appointments and the other half find that women are more likely to attend their appointment. On this basis, we can see no reason for employing reminder systems differentially for male and female patients.

Deprivation

There are no studies indicating that deprivation has a differential impact on the effectiveness of reminders [see Chapter 4, Evidence statement [F.2–F.11]: few studies investigate whether or not a range of distal/proxy individual attributes have a differential effect, over and above pre-existing appointment behaviour, on reminder effectiveness [in terms of attendance, cancellations or rebooking] [evidence category Va or VIIa]]. There is weak but consistent evidence that deprivation is a factor in non-attendance [see Chapter 5, Deprivation]. This section reveals an array of suggested reason why patients from deprived backgrounds may not attend appointments and reveals a potentially complex set of circumstances that could make it difficult to engage with health-care systems in general, or appointment and reminder systems in particular. Although there has been little exploration of these circumstances in relation to appointment attendance behaviours, these circumstance explain why this group of patients may struggle to engage with complex appointment systems that require a relatively high degree of health literacy;207 they may also not receive appointment information or reminders and subsequently may find it difficult to attend, cancel or reschedule appointments. The available literature suggests that deprived populations face multiple obstacles to health-care appointment attendance.86,89,123,148,166 Health services providing care to deprived populations have a wide range of complex issues to consider in addition to thinking about strategies for improving attendance. Clinics that achieve high levels of attendance despite serving patients populations with high levels of socioeconomic deprivation would warrant close investigation, as they may have introduced ways of working that could be transferable to other settings. Reminder systems are likely to be indicated although, as discussed above, reminder systems are very dependent on accurate data from patients and so deprived populations with unstable contact details may be disadvantaged.103 Health services will need to give careful attention to having robust procedures for keeping patient contact details up to date and for providing easy to use systems for patients to make, cancel and reschedule appointments.

Ethnicity

There are no studies indicating that ethnicity has a differential impact on the effectiveness of reminders [see Chapter 4, Evidence statement [F.2–F.11]: few studies investigate whether or not a range of distal/proxy individual attributes have a differential effect, over and above pre-existing appointment behaviour, on reminder effectiveness [in terms of attendance, cancellations or rebooking] [evidence category Va or VIIa]]. Our evidence suggests that there may be a link between ethnicity and non-attendance, although this is not completely consistent. On the whole, studies in this review have failed to examine ethnicity and to understand the causal pathways that link ethnicity to non-attendance. Ethnicity is itself an umbrella term that covers multiple potentially relevant and inter-related factors that, by themselves, may be linked to non-attendance, e.g. socioeconomic or deprivation status [see Deprivation], language barriers [see Other reminder characteristics], health literacy [see Deprivation], issues of trust, mutual respect and cultural competency [see How do the perceptions and beliefs of patients, their carers and health professionals regarding specific types of reminder systems, and patient/carer resources and circumstances, influence their effectiveness?]. Several factors could interact to create difficulties with patient engagement and therapeutic relationships [see Characteristics of the appointment system]. Ethnic groups face multiple potential obstacles to health-care appointment attendance. Health services providing care to ethnic groups have a wide range of complex issues to consider in addition to thinking about wider strategies for improving attendance in this group. Reminder solutions are one possible way forward; however, owing to the likelihood of concurrent deprivation status, similar issues around accuracy of contact details and general accessibility of patients to reminder technologies are likely to exist. In addition, health services need to give consideration to having reminder systems, cancellation procedures and rescheduling procedures that suit the language requirements of their particular ethnic groups and are easy for this group of patients to understand and engage with.

Substance abuse/mental health/comorbidity and physical illness

There are no studies indicating that substance abuse, mental health or comorbidity has a differential impact on the effectiveness of reminders [see Chapter 4, Evidence statement [F.2–F.11]: few studies investigate whether or not a range of distal/proxy individual attributes have a differential effect, over and above pre-existing appointment behaviour, on reminder effectiveness [in terms of attendance, cancellations or rebooking] [evidence category Va or VIIa]]. High levels of non-attendance are found in patients who abuse drugs and alcohol [see Chapter 5, Substance abuse], patients with mental health problems [see Chapter 5, Mental health] and patients with comorbidities and illness [see Chapter 5, Physical illness/comorbidity]. Although forgetfulness may occur, it is likely that other, more substantial, problems may be acting as the obstacle to attendance. Non-attendance at the appointment is an indicator that there may be a deterioration of the mental health, drug and alcohol problems. In such cases, patients may need active follow-up in order to support them through their relapses and to re-engage them in their treatment programmes. Patients with other co-morbidities or illness may find themselves too ill to attend, too ill to cancel or may even be admitted to hospital. Health services serving large numbers of these patients need to be aware that this group are at high risk of not attending and to be aware that non-attendance may indicate an increased health need and will have a wide range of complex issues to consider in relation to finding wider strategies for improving attendance in this group. Simple reminders and automated reminders to attend may be ignored or overlooked, particularly when patients are experiencing an increased level of illness or substance abuse. In fact, the use of simple reminders may put these patient groups at a disadvantage compared with general outpatient populations. Reminders with direct personal contact might be appropriate in these groups [see Other reminder characteristics, Format of the reminder]. To facilitate attendance, a sequential reminder intervention such as that described by Perron et al.78 could be initiated: first a phone call to either landline or a mobile phone; second, a SMS message if participants do not answer the telephone after three attempts and have a mobile phone; and, finally, a postal reminder if participants do not answer the telephone, have no mobile phone for SMS, or had no phone at all. Such a design, although labour intensive, would reach the maximum number of participants and may increase attendance rates while still being cost-effective. A further consideration is how to re-engage patients with treatment after they have missed their appointment. Intensive approaches, such as ‘stepped reminders’46,195 and patient navigators,196,197 have been effective at increasing attendance at screening and immunisation programmes in disadvantaged and vulnerable populations and might also be effective at re-engaging similar groups of patients who have dropped out of treatment.

Symptomatology and severity

There are no studies indicating that symptoms or severity of a condition have a differential impact on the effectiveness of reminders [see Chapter 4, Evidence statement [F.2–F.11]: few studies investigate whether or not a range of distal/proxy individual attributes have a differential effect, over and above pre-existing appointment behaviour, on reminder effectiveness [in terms of attendance, cancellations or rebooking] [evidence category Va or VIIa]]. Our review does suggest that patients who have no symptoms, improved symptoms or low perception about the severity of the condition are more likely to not attend a scheduled appointment [see Chapter 5, Symptomatology and severity]. However, there will be patients in this bracket who do not have a life- or function-threatening condition who can manage their health condition satisfactorily for many years and for whom continued attendance is unnecessary. In this case, a reminder system could be used to promote cancellation without rescheduling leading to a negotiated discharge. Conversely, there may be patients or people in this bracket who do have a potentially serious health problem but who are either unaware of its potential severity and impact if it remains untreated or who do not know it because they have not attended a screening appointment. There is a huge amount of literature, which has not been investigated in this review, investigating strategies for increasing uptake of screening appointments. Some of these strategies, including stepped reminders and patient navigation, are labour intensive but might be relevant to consider for re-engaging patients with health-care procedures if they have dropped out [see Substance abuse/mental health/comorbidity and physical illness]. The end point of these kinds of processes is either rescheduling of further health-care appointments or a negotiated discharge.

Previous patterns of non-attendance

Previous patterns of attendance are often cited as indicators of future attendance; however, the evidence in this review presents a more unpredictable picture than this [see Chapter 5, Previous patterns of non-attendance]. In some studies, patterns of attendance and non-attendance can be variable, with no clear picture emerging of those patients who are ‘attenders’ or those who are ‘non-attenders’. In this review we have already identified that people may not attend for many different reasons and these may be variable over time. For anyone at any time, the appointment can be unsuitable from the outset or can become unsuitable because of a change of circumstances,101 indicating that all patients are likely, at some point, to be unable to attend an appointment. We recommend sending all patients reminders that include a message about cancelling an unwanted appointment and rescheduling for a future appointment if treatment is still required.

What factors influence the effectiveness of different reminder systems for particular population subgroups?

We have added no further comments to this section as we have discussed this under Previous patterns of non-attendance in the context that understanding patient non-attendance can provide insights into how reminder systems could be designed and deployed.

How do the perceptions and beliefs of patients, their carers and health professionals regarding specific types of reminder systems, and patient/carer resources and circumstances, influence their effectiveness?

In general, our review did not generate much information on the perceptions and beliefs of patients regarding specific reminder systems, as opposed to their preference for particular technologies, and we cannot say how perceptions and beliefs of patient or health professionals about reminder systems influence their effectiveness. This reflects the fact that most reminder-related research takes a rather narrow focus. There is evidence to suggest that a personalised interaction with a member of practice staff is perceived as more useful than an automated reminder system. However, there is also conflicting evidence as to whether this would make a patient more or less likely to communicate a cancellation than a less personalised method of delivery. Our review has also identified that an individual’s perception about health-care systems and professionals will influence patient attendance [see Chapter 5, Patient–provider ‘alliance’, communication and ‘engagement’]. This could be related to an individual’s view of the quality of care provided, trustworthiness, empathy and cultural sensitivity of staff and issues of mutual respect. However, individuals’ views may also be shaped by the surrounding community in which they live, through a process of ‘storytelling’ whereby negative storylines will contribute to the individual’s negative perceptions of the health system or health professionals.155 Patients may experience stigmatisation within individual relationships, such as those with family, GPs or other health professionals, which may directly influence an individual’s intention to attend or further colour the individual’s perception of the health service.143 This is a difficult area to manage, and wider solutions must also be considered, but there is greater scope to consider how these factors might influence the effectiveness or design of reminder systems interventions. The role of reminder systems in this context is potentially limited given the negative publicity that British health services and health professionals have received through the media. However, the small role that reminder systems might play here in positively influencing individual-level perceptions of health-care services is via their contribution to patient engagement and therapeutic alliances [see Characteristics of the appointment system]. Positively framed reminder messages, delivering appropriate and helpful information, could help to counter an individual’s negative perceptions of a health service.

How do external factors [e.g. content, delivery, setting, frequency, notice period] influence the effectiveness of reminder systems?

There are few studies that directly investigate the extent to which characteristics of the reminder system can influence the effectiveness of the reminder system; however, two characteristics stand out as being important. There is strong evidence that factors such as accessibility to the reminder will influence the effectiveness of the reminder and that the timing of the reminder, between 1 and 7 days prior to the appointment, will not influence the effectiveness of the reminder and we suggest that there are good reasons for sending reminders earlier than usual, i.e. 3–7 days prior to the appointment [see Timing of the reminder].

Accessibility

There is strong consistent evidence that the reminder may not be received by the patient [see Chapter 4, Evidence statement [B.1]: there is strong consistent evidence that the reminder may not be received by the patient [evidence category Ia]]. It is largely intuitive that if the patient does not receive the reminder, this may contribute to suboptimal effectiveness of the reminder. Several reasons for non-receipt of reminders are discussed in the literature. There appears to be a consistent amount of either technology error or human error associated with all reminder systems, and consequently many patients report not receiving a reminder or receiving it late. The reminder systems will be most effective when contact details are accurate and patients receive the reminder. It is therefore important for the health-care organisation to have systems in place to ensure that patient contact details are current and that reminders are successfully received by the patient.95,208

Telephone reminders [automated or manual]

One of the reasons that patients may not receive telephone reminders is that landline calls are often made during business hours, when it is most likely that patients will be out of the house.25 In our review, all the RCTs that reported procedures for making telephone contact attempted to contact patients within usual working hours [09.00–17.00 hours] during the working week [Monday to Friday] in a 1–7 day window prior to the clinic appointment.57,66,80,82,90,179 Many other reasons have also been frequently reported that further explain why patients may not be contactable using a telephone reminder system, e.g. the patient either did not have a telephone or had been disconnected, the patient never answers the telephone or the contact number provided was incorrect.91,92 Some patient groups, e.g. deprived populations and homeless groups, may not have equitable access to landline systems or mobile phone technology. Other groups may not answer the telephone and may let the telephone run to the answerphone, e.g. patients with mental health problems, deaf patients or those with poor mobility. However, for reasons of confidentiality, most telephone reminder systems do not leave messages on answerphones. Despite the relatively low contact rates reported, ranging from 30% to 60% [see Chapter 4, Evidence statement [B.1]: there is strong consistent evidence that the reminder may not be received by the patient [evidence category Ia]], there are also considerable potential advantages of interactive telephone calls, including allowing patients to verify and confirm their appointment, respond to instructions about logistics, request additional preparation materials, answer queries about their current health, request that information is repeated and ask for a summary of instructions.80 There is also an opportunity for receptionist or health-care professionals to resolve any misunderstandings, or to deliver educational information about procedures, as well as motivational messages that address the risks, benefits, barriers and self-efficacy associated with health-care procedures.80 If telephone reminder systems are to be the reminder of choice, then clinics using such systems should consider using both landline and mobile telephones in combination57 or out-of-hours reminder calls to maximise the contact rate.82

Short message service reminders

The recognised advantages of SMS reminders over telephone messages are that SMS reminders can be automated and the technology allows large batches of text messages to be delivered almost instantly, minimising labour costs.57 They do not require the mobile phone to be active or within range, messages can be sent after normal business hours and it does not matter whether the patient is at home or at work.53,57 A high rate of successful contact is assumed with SMS reminders, as indicated by most included RCTs for which success is based on a ‘message sent’ response being received by the sender. However, this does not recognise that many patients either may not receive their SMS reminder or may receive and ignore a reminder that was not intended for them as a result of incorrect data entry on hospital systems.95,100 However, some clients may not receive their text message until after their scheduled appointment because of delays in delivery of the text, because their telephones were switched off or because, in the case of individuals from poorer economic groups, they may have delayed purchase of pay-as-you-go tariffs at financially challenging times.119 One disadvantage of using SMS reminders is that patient groups are not equally likely to have a mobile phone. Although very popular among the young British population,101 mobile phone ownership declines sharply with increasing age;108 however, the total number of people > 60 years of age with a mobile phone is increasingly annually. In addition, patients with mental health problems appear to have a higher level of distrust of SMS, which means that they have a lower preference rate for SMS reminders than other patient groups.209 If SMS is considered to be the reminder of choice, then services that provide health care to older patients, patients from deprived backgrounds, patients with mental health problems or the homeless should carefully consider whether or not mobile phone technology is an appropriate medium for sending out reminders.

E-mail reminders

Although not yet rigorously tested, e-mail has been proposed as a suitable medium for appointment reminders.42 Bespoke secure e-mail programmes can incorporate special features such as standard forms guiding the use and content of the e-mail sent and the capacity to show read receipts [in order to confirm the patient has received the correspondence]. However, they are costly to set up and may require a greater degree of user skill than standard, unsecured mail.42 In addition, technological issues may occur, such as recipients having a full mailbox causing e-mails to bounce back to the sender.210 Systems may be at risk of failure owing to the loss of the link to a central server, delay in transmission of e-mails, power failure or, in worst-case scenarios, natural disasters. There is also potential for human error, which can lead to unintended content or e-mails being sent to incorrect recipients. Future research is required to consider the likely usefulness/availability/accessibility and practical implications of e-mail reminders.

The importance of successfully contacts through reminder systems is largely intuitive but should not be underestimated. For example, in their RCT secondary analysis, Chiu58 identified that non-attendance rates for successful and failed reminders were 3.86% and 18.68%, respectively. With any reminder system, there is likely to be a level of unsuccessful contact; however, poor selection of reminder systems will exacerbate this problem in to hard-to-reach groups, e.g. substance abusers,211 older patients108 and homeless populations.212

Timing of the reminder

There is strong evidence that the timing of a reminder, between 1 and 7 days prior to the scheduled appointment, has no effect on patient attendance behaviour [see Chapter 4,Evidence statement [B.5]: there is strong consistent evidence that the timing of a reminder, between 1 and 7 days prior to the scheduled appointment, has no effect on patient attendance behaviour [evidence category Ia]]. SMS or telephone reminders are typically sent either the day before or on the day of the health-care appointment.64,70,71,73,76,78,84,89,100,108 Reminders of this nature appear to be sent to benefit those patients who have genuinely forgotten about their appointment [see Chapter 4, Evidence statement [A.1]: there is strong consistent evidence that simple reminders which provide details of timing and location of appointments are effective at helping a [forgetful] patient to attend their appointment [evidence category Ia]]. For this reason, the reminder is not sent too far in advance as this may allow that patient to forget again.102 It might be supposed that if a reminder mainly serves as a memory prompt for the genuinely forgetful patient, then it is more likely to be effective at increasing attendance behaviour the closer it is to the date of the appointment. Although the evidence from our included studies does support the use of reminders for supporting forgetfulness [see Chapter 4, Evidence statement [A.1]: there is strong consistent evidence that simple reminders which provide details of timing and location of appointments are effective at helping a [forgetful] patient to attend their appointment [evidence category Ia]], it further indicates that reminders can be sent any time between 1 and 7 days, with no diminished effectiveness of the reminder at facilitating attendance at appointments. The evidence does not determine whether or not effectiveness of reminders is diminished beyond 7 days, but presumably a 1- to 7-day window is plenty of time in which to operate any kind of reminder system, e.g. SMS, telephone, letter, etc., with any kind of outcome in mind, e.g. attendance, cancellation, rescheduling, information sending, etc.

There are several advantages of sending out earlier reminders. First, there is strong evidence that reminders, particularly telephone reminders, increase cancellation and rescheduling of appointments [see Chapter 4, Evidence statement [E]: there is strong consistent evidence that reminder systems will promote cancellation of appointments [evidence category Ia]]. Earlier discussion also suggests that other types of reminders have the potential to increase cancellation and reallocation of appointments to other patients with the commensurate benefits that this can bring [see Are there any systems which effectively support the cancellation of appointments?]. Because the timing of appointment reminders makes no appreciable difference to the scale of attendance behaviour, it is sensible to send out reminders that are received by patients a minimum of 2–3 days prior to the appointment in order to take advantage of the efficiencies that can be gained through patient cancellations and health service reallocation of appointments. Second, earlier reminders allow for the patients to be provided with information leaflets about appointments or procedures, orientation information such as maps, etc. that patients can read prior to attending their appointment, which may also help to increase the effectiveness of the reminder [see Chapter 4, Evidence statement [A.2–A.6]: there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment [evidence category IIIa] and Chapter 6, Reminder plus for more detailed about provision of additional information].

Other reminder characteristics

There is either no evidence, weak evidence or conflicting evidence that a range of other reminder characteristics influence the effectiveness of the reminder. This includes language and framing of information [see Chapter 4, Evidence statement [B.2]: there are no studies investigating whether or not reminder factors [such as language, information provided, framing of information] influence the accessibility/comprehensibility of the reminder message for particular patient groups [evidence category VIIa]], content of the reminder [see Chapter 4, Evidence statement [B.3]: there are no studies to show that the content of the reminder may effectively address the obstacles/enablers experienced by the patient in question [evidence category VIIa]], personal reminders compared with automated reminders [see Chapter 4, Evidence statement [B.4]: there is controvertible evidence, based on multiple good-quality studies, that personal reminders have a greater impact on attendance rates than automated reminders [evidence category IIa]], the format of the reminder [see Chapter 4, Evidence statement [B.4]: the format of the reminder will compromise the amount, and type, of information that can be delivered to the patient [self-evident]] and patient reminder preferences [see Chapter 4, Evidence statement [B.4]: very few studies investigated whether or not the reminder preferences of the patient may influence the impact a reminder has on the patient's appointment behaviour [evidence category VIIa]].

Language and framing of information

None of the included studies explored the extent to which the language in which a reminder is framed influences its comprehensibility, although the scale of this potential problem would depend on the language demographic of the population served. One of the included RCTs based in Switzerland used a multilingual research assistant who spoke French, English and Spanish to make telephone calls;78 however, two RCTs81,141 involving telephone reminders excluded patients who did not speak English fluently. The majority of RCTs were silent on the issues of language. Health-care services do not have the luxury of being able to exclude sectors of the population based on English language and, therefore, should consider different suitable language options for their reminder systems. There is scope for catering for different languages with reminder systems.53,78 For a discussion about framing of information see Reminder plus.

Cognitive ability/literacy level will further determine whether or not a patient will understand the reminder, irrespective of format. These are important considerations for health services serving older populations, travelling communities and inner-city deprived populations, for example. The included studies did not explore this factor and were silent on this point, although two RCTs explicitly excluded those patients with dementia100 or with significant cognitive impairment.141 Boll et al.213 describe alternative ways in which reminders may be presented in users’ homes, e.g. using non-speech sound, ambient light and tactile feedback.

Content of the reminder

The addition of different types of content [e.g. orientation, etc.] may be appropriate as part of the reminder system in order to alleviate concerns, fears and anxieties that patients may have about attending an appointment [see Chapter 4, Evidence statement [A.2–A.6]: there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment [evidence category IIIa]] and Chapter 6, Reminder plus. SMS reminders have a limited amount of space in which to convey information and may, therefore, be better suited to simple reminders for follow-up appointments.59 E-mails and postal reminders may be well suited to encouraging attendance at first appointment reminders as these reminders can be automated and can contain extra orientation information at no extra, or minimal extra, cost.52,214 Personal telephone reminders have the advantage of being interactive such that specific information can be exchanged between patient and sender.80 There is little evidence to indicate what patients would find helpful by way of reminder content; however, it is likely that this will depend on the nature of the health service. Patient preferences for the type of information that would be helpful will potentially dictate the choice of reminder system.

Format of the reminder

The appointment reminder immediately prior to a first appointment may also be an appropriate time for patients to receive additional information, e.g. directions to the clinic, or information/reassurance about the procedure.69 Consequently, reminder systems that support the provision of extra information, e.g. personal telephone calls, e-mail and letter, may be most useful for supporting new patient attendance. Simple reminders, e.g. SMS, automated telephone calls, etc., may most useful for follow-up appointments.

There is generally inconsistent evidence that personal reminders are more effective than automated reminders [see Chapter 4, Evidence statement [B.4]: there is controvertible evidence, based on multiple good-quality studies, that personal reminders have a greater impact on attendance rates than automated reminders [evidence category IIa]]. However, on balance, the evidence appears to favour the use of personal reminders. In the larger of the reviews, based on data from 29 studies reporting a total of 33 estimates of reminder effectiveness, the difference between personal versus automated reminders in absolute reduction of non-attendance compared with baseline is around, on average, 10%.47 It is not known whether or not specific groups of patients, e.g. patients with mental health problems, etc., would show a greater differential increase in attendance as a specific result of the reminder system, but there is evidence to suggest that patients report greater positive perceptions to [and may prefer] personal contact, which may explain the increased level of attendance.66 It has been suggested by that patients may associate ‘a [personal] clinic staff reminder [compared with an automated reminder] with respect for their own time and higher quality of care’.77 But the authors continue that ‘. . . according to our survey results, patients found an appointment reminder helpful, but they could not accurately differentiate between a clinic staff reminder and an automated reminder.’77 A comparatively novel feature of reminder systems is the development of interactive automated reminders.66 This technology offers some of the features of direct contact reminders, e.g. patients can ask for information to be repeated, patients may be able to select from a range of options about specific types of information that they may want to hear about [e.g. appointment procedures or health service location], etc. Given that there is a considerable cost saving in using automated technologies compared with personal reminder technologies [see What are the likely economic impacts of reminder systems?], it would seem that interactive reminder technologies are worth further investigation.

Patient reminder preferences

The included studies do not directly explore the relationship between patient reminder preferences and the effectiveness of the reminder in impacting on patient appointment behaviour [see Chapter 4, Evidence statement [B.4]: very few studies investigated whether or not the reminder preferences of the patient may influence the impact a reminder has on the patient's appointment behaviour [evidence category VIIa]]. However, it can readily be postulated that the degree to which a patient is comfortable with the reminder technology used may have an impact on how well the reminder message is ‘received’ and, thus, whether or not the patient chooses to act on it. For instance, some population groups may not regularly use mobile phones and so SMS messages would not be welcome or useful.208 One study209 found that ‘the reported rates of mobile phone ownership and of the ability to use text messaging were significantly lower in patients with psychotic illness than in those with non-psychotic disorders.’ Therefore, preferences for SMS may be low in this group. A survey of patients attending a neurological outpatients clinic reported that ‘over half of the participants [55 per cent] said they would like a pre-appointment reminder by text message; 19 per cent said they would prefer a telephone reminder while another 19 per cent said they would prefer a reminder by e-mail’.111

How do organisational factors influence the effectiveness of reminder systems?

No studies investigating whether or not factors about health-care settings influence the effectiveness of reminder systems were identified from this review [see Chapter 4, Evidence statement [C.1–C.6]: there are no studies investigating whether or not factors about health-care settings influence the effectiveness of the reminder [evidence category VIIa]]. However, there is a wealth of research that shows that attendance behaviours are linked to health-care settings; however, often the findings are conflicting, indicating that contextual issues may contribute to complexity. Exploration of this evidence offers possible insights into how reminder systems and supporting processes should be designed in order to optimise attendance at outpatient appointments. This section will focus on specific organisational factors that impact on attendance and for which a reminder-based solution might contribute to reducing non-attendance. For clarity, this material is organised into four inter-related themes: [1] administrative errors, [2] characteristics of appointment systems, [3] patient–provider alliance and engagement and [4] clinic accessibility.

Administrative errors

There is strong evidence that reminders are not always received by patients [see Chapter 4, Evidence statement [B.1]: there is strong consistent evidence that the reminder may not be received by the patient [evidence category Ia]]. In Accessibility we focused primarily on patients’ ability to access reminder technology; however, health-care systems frequently have incorrect or out-of-date contact details for their patients.95,208 It is largely intuitive that incorrect patient contact details will lead to suboptimal reminder effectiveness and that the reminder system will be most effective when contact details are accurate and patients receive the reminder. This is a greater problem for health services that are dealing with less geographically stable communities, e.g. populations consisting mainly of students, young adults or socioeconomically deprived groups, who may frequently change address, mobile phones or landline telephone numbers.103 However, this population is also greatly at risk of non-attendance at appointments [see Chapter 5, Demographic and socioeconomic characteristics]. Although the use of reminders can be justified in all health services, there appears to be a particular need in health services dealing with geographically unstable populations. Nevertheless, the use of reminders could be considered redundant unless there are also robust processes in place that regularly check to ensure the accuracy of their patient contact details.

Characteristics of the appointment system

Although several characteristics of appointment systems were discussed in detail in Chapter 5, Characteristics of appointment systems, three main issues affecting appointment attendance are discussed because they are potentially modifiable through the use of reminder systems.

Compatibility of appointments with other commitments

The date and time of the appointment have been shown to be potentially less important than the compatibility of the appointment time and date with other commitments such as employment commitments or child care commitments [see Chapter 5, Timing of the appointment]. Such issues exist at an individual patient level and indicate that flexible appointment systems that can accommodate a variety of patient lifestyles are likely to have a lower rate of non-attendance. In this regard, flexibility may mean negotiated appointments for which patients have a say in the day and time of their appointment [e.g. partial booking systems, Choose and Book] or out-of-hours clinics, which may be popular with employed patients who may struggle with work commitments or carers who may then be able to find an alternative carer. Better engagement of patients with the health-care system allows patients to negotiate appropriate appointment dates and times and simultaneously to develop a positive relationship with the health service, which is likely to result in higher levels of attendance at appointments [see Chapter 5, Patient–provider ‘alliance’, communication and ‘engagement’]. It is difficult to envisage a justification of a system in which appointments are simply allocated to patients, as this does not recognise the important starting point that a reminder might have for promoting patient engagement and a therapeutic alliance [see Characteristics of the appointment system]. However, when this is the case, non-attendance is also likely to be particularly high and, therefore, robust procedures for reminders, cancellations and rescheduling will be warranted.

Long waiting times

There is strong consistent evidence that long waiting times for appointments are associated with higher non-attendance. The long wait could be between the date the appointment was scheduled and the date of the appointment or it could be a long delay between patient referral and the invitation to make an appointment [see Chapter 5, Time to wait to the appointment]. The longer the wait, the greater is the likelihood of the patient not attending. A variety of things may happen to patients while they are waiting for their appointment: they can forget, improve or recover, seek help elsewhere, lose motivation to attend or become committed to other more pressing issues. While the government’s priority is to provide non-emergency treatment within a maximum wait137 and, while patients report that short waiting times for treatment are important to them, it is likely that most health-care appointment systems will be exposed to the degrading effects of time on attendance. Therefore, reminder systems that promote attendance are warranted for all health-care appointments. For health-care systems that do have longer waits, particularly when patients have no symptoms [e.g. screening] [see Chapter 5, Symptomatology and severity], are likely to recover [e.g. acute injury and post-surgery clinics] or seek care elsewhere from an alternative health-care provider, we would suggest that reminders that encourage cancellation of unwanted appointments and rescheduling of inconvenient appointments would be useful. This would allow the health service to reallocate cancelled appointments to other patients. It would also be sensible to explain to patients why they have to wait and why the appointment is important.

First appointment compared with follow-up appointments

The studies investigating attendance at first appointment compared with follow-up appointment attendance are inconclusive. Approximately equal numbers of studies show higher non-attendance rates for first appointments or follow-up appointments [see Chapter 5, First versus follow-up appointments]. Whether or not patients attend their first appointment may depend on a variety of contextual factors, such as whether or not the appointment was prompted by the patient or the presence of symptoms. Follow-up appointments may not be as highly valued once the symptoms have been alleviated or the concerns dealt with and, therefore, non-attendance can result. However, continued treatment benefits, continuity of care and a valued relationship with the health-care provider may drive continued attendance at follow-ups. On balance, the findings in Chapter 5, First compared with follow-up appointments suggest that the use of reminders is equally valid for first appointments and follow-up appointments, although the reasons for non-attendance may vary between the two groups and may vary by health service. In the section Reminder plus, we suggest that the provision of additional information as part of the reminder system [or as part of appointment scheduling] may be beneficial for facilitating attendance at first appointments, particularly when such information addresses concerns about well-being, anxieties about procedures, concerns about location of the health service, etc. A simple reminder to attend, cancel unwanted appointments or to reschedule inconvenient appointments may be appropriate for follow-up appointments. However, this hypothesis remains untested at this time.

Patient–provider alliance and engagement

There is good evidence that the relationship between the patient and the health service may impact on patient attendance at appointments [see Chapter 5, Patient–provider ‘alliance’, communication and ‘engagement’]. Patients are less likely to attend appointments when they feel that staff are being judgemental or lack empathy.101,145 One interesting difference between patients who seek structured health care and those who do not is the apparent need for the support and reassurance that can be offered by health-care professionals.145 The provision of orientation information or ‘navigational support’, which is information and guidance regarding the way that the health service works and what to expect from treatment/care, is viewed by many patients to be a positive interaction that would encourage attendance at appointments.145 This has direct implications for utilisation of reminder systems and the simple act of sending a reminder may increase patient perceptions of the value of the appointment and of the interaction with the health service.80,145 The provision of information through automated systems is an opportunity to build on that [see Reminder plus]. It could be argued that the provision of individualised information to patients through direct regular patient contact would be specifically beneficial for some patients, such as those with long-term health problems and more vulnerable patients.61 The findings presented here would suggest that reminder messages which are gain-framed would be more welcome than those which are loss-framed and that may be perceived as pressurising, stressful or irritating [see Reminder plus for a brief discussion about message framing].

Clinic accessibility

The available evidence regarding the impact of service location and transport on attendance levels is equivocal and suggests clinic accessibility is not simply a function of travelling time or distance to the clinic [see Chapter 5, Service location and transport difficulties]. Some of the reported difficulties faced by patients trying to access clinics were difficulties with getting transport, parking, availability of public transport and cost of travelling, and the impact of these factors is likely to vary between service settings and within patient groups. The impact of transport issues is potentially greater for patients who are more socioeconomically deprived because they may be more reliant on public transport, which may be relatively and prohibitively expensive. Transport difficulties may also be more pertinent to patients with young children or for the elderly who may have problems negotiating public transport systems. Many of the issues discussed here require a broader solution to tackle the problems of patient accessibility in order to increase attendance. However, health services should consider whether or not they can include useful information that could aid the patient journey to an appointment within any reminder, e.g. availability and cost of parking, bus routes, etc., that may encourage patients to make the journey [see Reminder plus for information regarding orientation information]. In many cases, patients may know in advance that they will not be able to attend their appointment because of transport difficulties and a reminder that is framed to support cancellation of appointments and rescheduling to a more convenient time may reduce a proportion of travel-related non-attendance [see Are there any systems which effectively support the cancellation of appointments?]. It is unlikely to make much difference for patients who encounter travel difficulties while they are en route to their appointment.

What disadvantages [or challenges] should be considered when introducing reminder systems for specific populations for health care and health services?

The principal technologies should not only be considered in terms of their principal characteristics. Technologies may possess additional functionalities that, if activated, may have a differential effect on the effectiveness of the reminder. To take just two examples, SMS technology can be used to deliver a message [one way], to reply with a confirmation of attendance or, in some cases, to effect a cancellation and/or a rebooking. When evaluating text messaging reminders, Leong et al.72 did not require participants to confirm receipt of reminders. This carried the implication of uncertainty whether or not all participants had received the text messages. In this circumstance, they assumed that those who did not receive messages were more likely to be non-attenders and, therefore, concluded that their study would probably underestimate the effectiveness of text messaging reminder. Similarly, the effectiveness of a telephone-based reminder system, whether personal or automated, will depend on factors such as whether or not a patient possesses an answering machine and whether or not it is acceptable policy to leave a message without speaking to the patient themselves or to a nominated next of kin. Again, Leong et al.72 made no attempt to leave messages on the answerphone/voicemail, stating that the ‘investigators were of the opinion that most people do not check their voice-mail and there is no way to check if the participants had retrieved their messages’.

Accuracy of patients contact details/clerical errors

Reminder systems rely on accurate and stable data from their patients. Our review has highlighted that contact details of patients are frequently not up to date, incorrectly entered into the database or wrong contact details were given by patients [see Chapter 4, Evidence statement [B.1]: there is strong consistent evidence that the reminder may not be received by the patient [evidence category Ia]]. In addition, there can often be clerical errors in the sending out of appointments whereby a patient may receive a reminder intended for another patient. This raises possible implications for patient confidentiality, appointment non-attendance and increased cost and time implications of dealing with errors. Health services need to work hard to ensure that they have robust procedures for updating patient records in order to optimise attendance and cancellation/rebooking systems.103 An effective reminder system with appropriate cancellation and reminder systems will almost certainly increase attendance and utilisation of health-care appointments [see Are there any systems which effectively support the cancellation of appointments?], which will increase the workload of health-care clinicians.69 Health services will also need to consider the impact on staff that frequently use unattended appointments as an opportunity to catch up on other health-care-related activities [see Are there any systems which effectively support the cancellation of appointments?].

Inequitable access to reminder technologies

With any reminder system there is likely to be a level of unsuccessful contact; however, some patient groups, e.g. deprived populations and homeless groups, may not have equitable access to landline systems or mobile phone technology. Other groups may not answer the phone and may let the phone run to the answerphone, e.g. patients with mental health problems, deafness or those with poor mobility. Our review illustrates that reminder interventions are not being developed specifically to address inequalities in access to services between population subgroups, nor is consideration being given to whether or not interventions may actually serve to increase disparities [so-called intervention-generated inequalities]. Henderson48 observes that the impact of implementing initiatives on inequalities in access to services was not considered by any of the studies included in his review. Health services need to bear in mind the sociodemographic status of the population that they are serving and consider issues of accessibility to reminder technologies of all their patients otherwise they run the risk of increasing inequalities in access.

Reminder preferences

Although many patients indicate that they are happy to receive a reminder [see Other reminder characteristics], there is a risk of antipathy from a sizeable percentage of patients who feel negatively or very negatively about reminders.55 Those who were disturbed by the reminder gave the following reasons: telephone call too early in the morning, they were waiting for other important results, they were contacted at work, felt that were being treated as senile or felt that the reminder was unnecessary.78 Evaluations of reminders do not typically examine any inherently harmful effects of reminder systems and it is unclear how reminder preference might influence the effectiveness of the reminder [see Chapter 4, Evidence statement [B.4]: very few studies investigated whether or not the reminder preferences of the patient may influence the impact a reminder has on the patient's appointment behaviour [evidence category VIIa]]. We have postulated that how comfortable the patient is with the reminder technology used may have an impact on how well the reminder message is ‘received’ and, thus, whether or not the patient chooses to act on it. If the reminder is irritating, demeaning or badly done, then this could lead to a loss of faith or trust in the health-care service and for some patients, the effect of the reminder could be counter-productive. Potential negative impacts of reminders and reminder preferences should be considered in future evaluations.

Ceiling effects

Several studies suggest the presence of a ceiling effect, i.e. when the baseline attendance rates are already high the potential for improvement is correspondingly reduced.63 In such cases, the use of complex reminders may simply not be required. Recognising that all patients across all health services will occasionally forget or find that the appointment is no longer convenient, it is likely that simple reminders that encourage cancellation of unwanted appointments and rescheduling to a more convenient time may be all that is warranted in health services with an already high attendance rate.

What are the likely economic impacts of reminder systems?

A full economic analysis of reminder systems is beyond the scope of this review. In the majority of included studies, there is either no or minimal data capture on health economics. However, 11 studies25,43,47,53,57,72,100,102,108,208,215 discussed the cost of reminder systems, using different methods of calculating cost savings and providing sufficient data to create a picture of possible economic impacts. All 11 studies support the view that SMS messaging is a cheaper option than other type of reminders. Hasvold and Wootton47 conducted a systematic review of 14 studies and found that the mean cost of SMS reminders, although it varied from country to country, was €0.14 per patient, compared with €0.90 for telephone reminders. The cost-effectiveness analysis showed that the cost per attendance for the SMS group [¥0.31] was significantly less than that for telephone group [¥0.48].57 Leong et al.72 found that text messaging was the cheaper option, as suggested by the total costs, i.e. 87.66 Malaysian ringgit for text messaging reminders and 160.33 Malaysian ringgit for mobile phone reminders’ for clarity. When the authors compared the two reminder systems, the ratio of the cost of text messaging versus mobile phone was 0.55.72 A US trial in a physiotherapy setting calculated that 19 SMS reminders needed to be sent to prevent one missed appointment.85 The authors suggest that this system of sending reminders to patients may lead to economic savings when the relatively low cost of each SMS reminder is balanced against the cost of employing a physical therapist for the time of a non-attended appointment. However, they do point out that a formal economic evaluation is needed. Milne et al.108 calculated that the cost of SMS to reduce non-attendance was £7.50 [US$13.13, €10.88] per ‘no-show’ avoided. Based on number needed to text [NNT] analysis, approximately 14 people would need to be sent a SMS reminder to prevent one non-attendance.100 Perry et al.208 stated that the cost of the SMS reminder is minimal, considering the loss of revenue generated by failed appointments. Text reminders on a large scale would be a cost-effective strategy that could be improved. Battistotti et al.102 calculated costs on an annual basis and estimated that for 500 SMS/day at a unitary cost of €0.0065, the first-year cost will be €11,500, while next-year cost will be about €8200, accounting for SMS and maintenance. They calculated that this would average out at around €35 per day once the SMS system was established. As the average monetary loss of a dropout is €20 per appointment missed, recovering two dropouts per day would be to sufficient to pay for the system. The annual cost of missed appointments in England is estimated to be close to £575M and the use of SMS reminders could save £55.6–83.5M a year.165

Reminders over the telephone may be expensive when compared with other approaches.49 In a recent systematic review,47 the average estimated costs from 14 studies reporting phone reminders was €0.90 compared with €0.14 for SMS messages; however, costs of telephone calls vary from country to country.47 Chiu58 similarly found that with an absolute reduction in non-attendance rate of 9.4–14.82% as a result of telephone reminders, 7–11 telephone reminders were required to prevent one non-attendance. Computing the cost for each telephone reminder by clerical staff at HK$7.44–15.33, Chiu58 estimated that it cost HK$109.37–296.79 for clerical staff to prevent one non-attendance using telephone reminders. In his specific context of radiological procedures, Chiu58 estimated that the cost of wasted computerised tomographic scan appointments offset the cost for the delivery of telephone reminders. This cost–benefit ratio would naturally be less favourable for less expensive interventions.58 Robert et al.82 estimated that the cost of telephoning 200 patients could be offset by preventing one non-attendance.

Perron et al.78 reported results from a stepped approach to reminders, comprising telephone call, text and then postal reminders, and demonstrated that this generated 55 additional consultations. The intervention proved to be cost-effective in providing a total net benefit of €1846 per 3 months once the cost of the intervention had been deducted. Bech215 concludes that very few studies include more than one intervention. This, combined with the fact that very few report information on the cost of the intervention, enables only vague conclusions about the cost-effectiveness of the interventions to be made.

Charging a fine for missing appointments is unlikely to be cost-effective as the cost of charging and collecting a fine includes personnel time, setting up information technology [IT] facilities and accounting systems, postal and reminders cost.215 These costs have recently been estimated in Denmark to be around 40 Danish krone per fine at 2003 prices. At first glance this appears to be more costly per unit than letter and telephone reminders; however, these administrative costs are generated only for non-attendees whereas letter and telephone reminders by their very nature generate a cost for every scheduled patient; therefore, fines may very well be cost-effective because of their low average cost per patient. However, these estimates would need to be tested in various UK settings in order to determine whether such a system is feasible or, indeed, acceptable. Whether or not charging a fine is cost-effective would depend partly on the cost of the appointment and partly on whether or not non-attendances decrease. As non-attendances decrease, so the unit cost of administering the fine increases.

Methods: strengths and limitations of the review

When discussing the strengths and limitations of our review, it is necessary to highlight three complementary aspects. First we need to consider the strengths and limitations of the systematic review method, then we need to consider the strengths and limitations of the review informed by realist principles and, finally, by recognising that any review will only be as good as its included studies, we encounter the collective limitations of the evidence base. As the last of these has important implications, both for current practice and for future research, we have highlighted the limitations of the evidence base separately, in Limitations of the evidence base.

Strengths and limitations of the systematic review

Generally speaking, the systematic review method seeks to provide a precise answer to a tightly focused question. Such reviews tend to be most useful when there is a high degree of homogeneity around the five PICOS elements: the population, intervention, comparison, outcomes and study types. As can be seen from our description of findings in Chapter 5, such homogeneity is not present in this particular review. A wide range of population types is included within the RCTs we identified. This variation by population is seen in the clinical settings, countries and age groups studied in the included studies. Some populations are recruited completely randomly, increasing our confidence in the applicability of results in a real-world setting. However, others either established technology preferences prior to the study or excluded those who did not have a particular technology [e.g. mobile phones]. The reader should, therefore, carefully examine the number and nature of participants exiting the study prior to randomisation before drawing conclusions on real-world effectiveness. In addition, two studies targeted non-attenders, but not in comparison with a general population.64,83 As a consequence, we are unable to advise on specific strategies for the non-attending population – an otherwise viable decision alternative to blanket coverage.

Further variation is observable in the interventions. Although it is not unusual for a systematic review to examine, for example, different drugs within the same therapeutic class, this is quite different from appointment reminder systems for which different technologies employ vastly different mechanisms. Such variation is not simply evidenced in the technologies themselves [e.g. synchronous [SMS text] vs. asynchronous [letter]; interactive [personalised telephone call] vs. non-interactive [e.g. automated calls]; or mobile [SMS/mobile] vs. ‘static’ [letter/landline]]. Different studies use different features of the technologies, for example reply slips [post],56 acknowledgements/confirmations [SMS]56 or answerphones [for landlines].66,84 Included studies also follow different protocols with regard to, for example, the number of attempts to be made and whether or not leaving a message on an answerphone constitutes successful contact. Such heterogeneity makes it extremely challenging to attribute success to a particular technology and/or to a specific component feature.

Notwithstanding a fairly plentiful body of studies, the number of different interventions being compared and, in addition, the number of supplementary questions they simultaneously seek to answer [e.g. comparing nurse calls with doctor calls, 3-day with 7-day intervals, etc.] adds a vast array of comparators with only single studies occupying many of the intervention–comparator matrix cells. Some interventions compare adjunct interventions, e.g. postal reminder plus SMS text reminder, while one intervention in particular has a stepped approach proceeding through telephone, SMS then post.78

The domain probably experiencing least heterogeneity is that of outcomes. Attendance rate [expressed alternatively as its converse, the no-show rate] is ubiquitous among the studies. A limited number of studies report cancellations, and an even lower number examine rebookings. Clearly, all three are required for an understanding of interactions and ‘knock on’ effects. This commonality of outcome did help our review team in performing some preliminary comparisons that showed, for example, that attendance rates for non-diagnosis specific situations, such as blood donation, are generally lower and that paediatric studies tend to report higher attendance rates than other populations, particularly compared with adolescents. However, such apparent conformity belies variation in how attendance or cancellations are actually defined. In some cases, actual attendance is collected while, in other cases, an operational definition depends on the timeframe within which a particular service can respond.

With regard to study type, this particular area of investigation is well travelled by systematic reviews but is complicated by differential inclusion of study types. Our systematic review included only RCTs and, as a consequence, it became challenging to compare our included studies with those in several existing systematic reviews.

It is important to note that the scope of the review required a specific focus on appointment reminder systems. While this opened up a fairly substantial body of evidence, it did restrict the team by excluding studies about appointment behaviour. The focus on RCTs further restricted the number and types of question that these studies could address.

Our systematic review 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. Comparison with other systematic reviews demonstrates the improved currency and coverage of our review combined with a sole reliance on properly conducted RCTs, which led to increased rigour and robustness of studies. To extend our coverage in a field that is rapidly changing, we conducted various internet searches to identify new developments. While we acknowledge that innovation must be accompanied by evaluation, this at least ensured that the team was aware of the main directions for future travel. The rigour of the process was ensured by various mechanisms such as the use of multiple reviewers, regular consensus processes and checking of newly identified studies against original sift criteria.

There are also limitations to our review. Our review was limited to English-language literature, but we consider this acceptable given the intended audience for this review. However, it should be noted that published, non-English reports are not identified in our report. Our reporting and assessment of each study was limited to data in each published article with no attempt made to contact the authors for additional information or missing data. Assessments of quality are based on the reporting of study details, which is regarded as an adequate surrogate but may not equate to the quality of the conduct of each study. An additional limitation to this review stems from the potential for publication bias whereby studies that demonstrate positive results in favour of a particular technology are more likely to be published.

We can conclude that the systematic review component followed accepted guidelines for conducting such reviews. It utilised a clearly focused question that was easily operationalisable in terms of inclusion and exclusion criteria. However, as we freely acknowledge, the topic area itself possessed several complexities. Decisions we made at the systematic review stage therefore carry associated ‘knock on’ implications for the review informed by realist principles as discussed below under Strengths and limitations of the review informed by realist principles.

Strengths and limitations of the review informed by realist principles

Methods for realist review [also known as realist synthesis] are still in their relative infancy and standards for conduct and reporting are still subject to ongoing development. Our review team recognised the value of exploring the complexity of appointment behaviour as it determined interaction with appointment reminder systems. However, we had concerns that our overarching aim was to inform practical recommendations for appointment reminder systems, not only to generate explanatory theory. We followed realist principles by starting from outcomes and then seeking to identify upstream determinants that may have influenced appointment behaviour. We consider context to be informed by four principal considerations [personal, organisational, trial and problem context].216 Personal context includes personal characteristics such as age, gender, sociodemographic and employment status. These attributes can variously act as ‘baffles’ to damp down the signals from the appointment reminder or as ‘amplifiers’ to give a reminder additional urgency and/or importance. Health-care organisations can create a culture within which attendance, or indeed non-attendance, becomes the norm. Paradoxically, flexibility of appointment systems may be misinterpreted as either a ‘couldn’t care less’ or an ‘it’s not that important’ mentality and could aggravate non-attendance trends. All staff, clinical and administrative, have an influence in creating and/or communicating this culture. The trial context relates to some of the decisions that may be taken in the context of a trial protocol that might not be carried through in a real world situation. This might include the number of attempts that is reasonable or feasible to make to contact a patient via telephone or counting patients as non-attendances when they have actually used the opportunity to rebook. Finally, the problem context refers to the way in which the nature, scale and cause of the problem may shift [with varying and sometimes unknown impact on its size and frequency]. Other national and/or local policy factors may determine patterns of attendance, which may result in oversimplification of the mechanisms of effect. Even using the tools suggested by realist synthesis methods such contextual challenges continued to pose a significant challenge.

Realist synthesis itself poses a challenge to systematicity in that its processes are iterative, intuitive and often defy audit and transparency. We used the systematic review principles described above to ensure that we constructed a transparent and well-defined sampling frame. Characteristics of identified studies were plotted on our ‘PopInS’ matrix to map the landscape for our question; however, once we had extracted and analysed all systematic reviews and RCTs to address the questions relating to effectiveness, we faced a decision as to how to prioritise the remaining studies. We decided to focus on UK studies and, in particular, to pay closest attention to those studies that supplied data against the various aspects of the conceptual framework.

Several decisions made in connection with the earlier systematic review had implications for the subsequent review informed by the realist principles. These included:

1. Appointment systems for screening programmes for which a patient is required to respond by booking an appointment. These were characterised as ‘recall’ systems not ‘reminder’ systems and were therefore, excluded from the review. We argue that the action of booking indicates the presence of some extrinsic motivation for fulfilling the appointment thus making attendance atypical from appointments in general. However, such an exclusion may seem arbitrary alongside such systems as Choose and Book, which are included in our review, and indeed the extra interactions required by, for example, systems requiring postcard and/or reply-paid confirmations. It is possible, however, that an exploration of recall systems might contribute to our further understanding of motivations for appointment attendance and how these might be harnessed within a reminder system.

2. Interventions that include not simply a ‘reminder’ but also some therapeutic interaction, typically via the telephone. Clearly there is a substantive difference between a member of administrative staff telephoning with factual details of a time and location of appointment and a clinically qualified staff member offering reassurance, advice and treatment options, etc., along with an exhortation to attend a forthcoming appointment. Such therapeutic interactions may be particularly important in the contexts of counselling, health promotion and psychological therapies, etc. However, it is methodologically challenging to isolate the reminder component from the therapeutic component and, therefore, we chose to exclude such studies from our systematic review. Nevertheless, our review informed by realist principles identifies ‘engagement’ with treatment, service or health provider as a likely contributor to attendance behaviour. It is again possible that an exploration of therapeutic communication may contribute further insights and offer value added services that can be easily integrated with the basic reminder function. Indeed, such a distinction becomes even more blurred where health promotion information is included with a SMS reminder or when an orientation statement is included with a postal reminder [both included].

3. The content of SMS text messages, telephone calls and letters is poorly described in many included studies. Little attention is given to the ‘framing’ of any spoken or written communication. Framing is a significant area of research in disciplines such as psychology and information science and it is likely that assumptions on what is the default position [assume to attend or assume not to attend], to use one example, will have an effect on the effectiveness of reminder systems. We highlight the impact of such framing in our discussion on ‘nudge theory’ [see Nudge theory and custard creams], but only in connection with the collective behaviour of a practice population. However, there is clearly significant potential for further exploration in terms of effects on individual behaviour, both in terms of theory-building and subsequent empirical inquiry.

The strengths of our review informed by realist principles include the strong embedding of our propositions in the extracted data. This stems from the practical orientation of our review and facilitates the production of implications for practice.

A weakness of our review, and yet a corresponding strength, is the fact that, unlike realist synthesis, we did not settle on a single theory as an overarching explanation for what can be observed in the very complex situation of appointment attendance and non-attendance. We engaged with a full range of theory operating at different levels and originating from different disciplines, in a sense problematising the literature as a collective evidence base, analogous to critical interpretive synthesis methods. It is, therefore, not entirely coincidental that we discovered resonance with the work of Dixon-Woods et al.168 nor, indeed, that those authors chose appointment attendance as one case by which they explained their own findings. Our steering group encouraged us to identify a leading candidate theory in the quest to simplify the subsequent review process. However, the review team strongly believed that no single theory served to explain all aspects of the phenomenon of attendance and the effect of appointment reminder systems. To the contrary, we sincerely considered multiple theories, in total or in part, to stimulate our interpretation of the problem. This is but one reason why we prefer to describe our review as being ‘informed by realist principles’.

Scope

The scope of our review was limited by both practical and conceptual constraints. Our original intention was to characterise the response to appointment reminders by different population groups. We hoped to find RCTs that measured population differences at baseline and then again following completion of the intervention. Subsequently, it became clear that the research agenda privileged investigation of the technologies and of the reminder processes over and above exploration of population differences. We encountered numerous instances when investigators chronicled the baseline differences in attendance, but did not examine the differential effect of the intervention. As a consequence, we have gained valuable insights into what challenges exist for particular populations without being able to select the best candidate solutions. Such a finding leads us to a null hypothesis that there are no population-specific differences in the effect of an intervention other than those already observed in the population at baseline. A more sophisticated variation of this line of thought might suggest that rather than certain reminder interventions improving appointment attendance for particular groups, the reverse perspective is true, namely that these technologies carry intrinsic properties that impair the achievement of the full potential effectiveness achieved by the population on average. If this is indeed the case, then one might envisage that removal of such barriers, unless differentially targeted, would also benefit the population in general, thereby perpetuating, rather than removing, inequalities in access to health care.

When it became clear that our principal review question would not be answered by rigorously conducted RCTs, we faced the challenge of accessing a wider evidence base. However, clearly there is an expectation that we summarise the findings of systematic reviews and trials. As a consequence, we found ourselves expending significant resources exploring the trial literature with a reduced prospect of such sources answering our questions of principal interest. In turn, this had a cumulative effect on the review informed by realist principles for which, again, we prioritised studies of appointment reminder systems but increasingly found that useful insights were being generated by other bodies of literature [i.e. appointment behaviours, behavioural economics, communication and framing of health messages, interactions and consultations with health professionals, operational research and modelling, etc.]. We intend to continue making such productive connections over and above the resources of this project by exploring alternative funding for research projects and fellowships.

Limitations of the evidence base

It is a truism in review methodology that a systematic review is only as good as its included studies, and this has been our collective experience in relation to this review. On the positive side, interventions relating to appointment reminder systems are relatively straightforward to undertake as they typically involve either offering alternative routes for communication [a relative advantage model] or providing a system when one had not previously existed [a service enhancement model]. As a consequence, and partly because this particular form of experimentation is often integrated with routine administration, several included trials have succeeded in recruiting large study populations. However, motivation for change is frequently a ‘technical fix’, and this has several implications for the research evidence. There is little evidence of a systematic and priority-based pursuit of the research agenda, or even of a close-knit research community within this area, with most contributions being locally focused and opportunistic. Scant attention has been paid to those who are typically excluded from population-based solutions to attendance. For example, Neal et al.110 are among the few who observe the difficulty of studying attendance behaviour, specifically in the context of unmet mental health problems. They recommend that ‘more work needs to be done to engage people who miss appointments with research in a more meaningful way’.110 This requires creativity in the use of research methodologies, in recruiting participants and, subsequently, in devising appointment reminder or service solutions. There is a particular role for qualitative methods given the review team’s experience of the value of such studies to our understanding of appointment behaviour. Rather than the ‘averaging effect’ documented so thoroughly by systematic reviews and trials, there is a need to extend such work to ‘other “disengaged” or potentially vulnerable groups of patients’.110

Therefore, it is particularly worth highlighting additional complexity in that those who fail to engage with appointment systems, and, indeed, health services in general, will also represent those informants who are most challenging to access when performing observational [i.e. non-representative] or research studies [i.e. uneven recruitment] of appointment behaviour. Commissioners of health services, and specifically those designing appointment systems, should therefore be aware that, even if they take steps to investigate non-attendance behaviour, there is still a danger of creating solutions predicated on the views of a vocal ‘more easily researchable’ minority.

The most significant omission from all the effectiveness studies was contextual detail on the working assumptions under which each clinic or service scheduled its appointments. In applying the findings of research studies to their own practice, service managers would find it helpful to know whether the clinic was designed to operate at overcapacity, thereby bringing the actual rate down to 100% once non-attendances have been taken into account, or whether appointments were booked at 100% capacity with the consequence of underutilisation or scheduling of alternative activities in the light of subsequent no-shows.

Another important limitation of the evidence base relates to mobile phone ownership. Some studies, for example the RCT by Leong et al.,72 randomised patients after establishing mobile phone ownership. This is the technological equivalent of an efficacy trial that overestimates the effect of an intervention when compared with its real-world performance. To adequately explore the impact of reminder technologies in a health service setting, it is necessary to employ an intention-to-treat analysis approach for which patients are randomised before ascertaining mobile phone ownership. This would be analogous to taking lack of compliance into account when planning pharmaceutical trials; however, this creates both ethical and practical issues. As a result, the effect sizes achieved by many of the trials are seen to be artificially inflated.

Other emergent interpretations

In the absence of evidence on the differential impact of particular appointment reminder systems on different populations, aside from factors already present in the population preintervention, what valuable insights might we offer from the course of our review? Our own thinking has been enhanced with regard to the following:

1. That factors apparently indicated in leading to patients being more likely to attend their appointments are perceptions of importance, severity, timeliness, engagement with the service, clinician and/or clinical problem, and the perception of an appointment being an ‘event’ rather than something routine or mundane.

2. That ‘forgetting’ includes both genuine forgetting and forgetting as a non-judgement-laden excuse.

3. That conventional characterisation of attendance as an optimal outcome and non-attendance as a poor outcome are challenged by adopting and attempting to reconcile different perspectives, in particular those of the clinicians, the administrative staff and the patients.

4. That rather than problematising patients as being particularly poor attenders, those managing and delivering services could view non-attendance rates as key indicators of such aspects as lack of flexibility, inadequate allaying of anxiety or unwelcoming staff or premises. The challenge is diagnosing which of these pathologies is predominant in a particular setting.

5. That length of delay in appointments is a critical consideration that impacts across multiple aspects of attendance, including self-resolution of symptoms, perception of non-urgency or non-importance, inappropriate referral and disengagement from the service, clinician and/or clinical problem. Actual length of delay is exacerbated by undesirable connotations associated with periodic [i.e. non-patient determined] follow-up intervals bearing little relation to patient needs.

6. That patients may be encouraged to attend by employing principles from ‘nudge’ theory that includes reinforcing positive norms, use of service-enhancing not service-limiting defaults and memory retention strategies.

7. That feasible solutions to attendance problems may be best re-engineered if tackled within the overall context of integrated service delivery and not simply within the relatively stand-alone subroutine of appointment reminders.

The appointment as an event

Ambiguity: importance of appointment as an event will increase the likelihood that patients attend, up to a point. However, beyond this point it may simply increase anxiety. Similarly on the one hand doctors want to appear supportive, reassuring and alleviate anxiety; however, they may want to stress the importance of attending the appointment.

Lest we forget – or forget about forgetting

Forgetting consistently features as the most commonly cited reason for missing an appointment. However, results on reminders, e.g. 24-hour or 48-hour reminders, show no significant differences in effectiveness for these intervals. This suggests that the reminder function is not the most important consideration for the communication between service and patient. If timing of the message is not significant from a patient viewpoint then we can reverse the direction of the imperative and determine the reminder interval by the time period within which a service can best accommodate cancellations and rebooking. Such an approach does seem to fly contrary to the literature, which almost unanimously confirms the orthodoxy that reminder systems are for the express benefit of the forgetful patient. In fact, it is the service that stands to benefit most, not from the reminder itself but from the response that it triggers either in terms of notifying the service of cancellations or initiating rebooking at a more convenient time. However, such a response becomes useful only if notification is received in sufficient time for the service to reallocate the vacant slots to other areas of clinical need.

Further support for this counter-narrative that appointment reminders systems are primarily determined by considerations of service scheduling, not of assisting the forgetful patient, is seen by attitudes to late arrival, which were seen as more disruptive than non-attendance. In the study by Martin et al.,5 professionals felt that it was, in fact, even more disruptive if patients turned up late for an appointment than it was if they did not attend at all.

However, from a patient perspective it seemed that patients were unaware of the implications of turning up late for the practice. The impression, from previous experience, of waiting past their appointment time for their actual appointment had misled them into thinking that the practice would be quite relaxed to their late arrival. This reinforces the idea that norms around attendance may be either consciously or subconsciously reaffirmed by health service staff as much as by fellow patients. At this point it should be emphasised that health services staff working in the same service or at the same location will not necessarily communicate unambiguous messages regarding the values associated with attendance. For example, in the study by Martin et al.,5 receptionists were more concerned than GPs about missed appointments, possibly because of the greater disruptive effect that non-attendance had on reception staff. Hussain-Gambles et al.104 also found that receptionists felt that they were most affected by non-attendance and wanted GPs to address this in consultations with patients. GPs were more guarded about this, being more fearful of damaging the doctor–patient relationship.104

What are desirable outcomes?

Our review informed by realist principles yielded some interesting insights on what might be considered a good or bad outcome. First cancellation, although an irritation to administrative staff, could be seen as a desirable outcome provided that the system has the flexibility to compensate for the non-attendance of the particular patient and the welfare of the patient is not impaired, e.g. there is no disease window of opportunity that is missed by deferral.

A key variable that is not addressed by any of the studies is the underlying assumption around clinic capacity, i.e. is the clinic booked at 100% capacity with cancellations providing much needed respite or is a clinic booked at overcapacity to allow for 100% attendance following the inevitable withdrawals. All recommendations and planned interventions should be moderated by an understanding of this underpinning service rationale.

Such ambivalence could also be observed from the viewpoint of the individual clinician.5 Missing appointments may be seen to offer some respite from an often relentless stream of appointments and offered clinicians the chance to catch up with note writing or other administrative tasks.5

However, reception staff themselves found missed appointments more frustrating and irritating than GPs. They talked about how hard they had worked to find patients an appointment slot. If this appointment was then wasted, there were fewer appointments available to other patients.5

Reaction to a reminder in terms of cancellation can be considered a valuable trigger of a service response by reducing the uncertainty of whether or not the patient is going to attend. A system of telephone reminders, particularly because it offers interactivity, not only reduces the non-attendance rate, but also decreases the uncertainty associated with non-attendance. Therefore, health-care managers become more able to control the workload, plan duty rosters and allocate health-care resources.

There is some evidence to suggest that ‘forgetting’ is readily adopted as a ‘blame-free’ explanation for non-attendance and may therefore be used as an avoidance strategy against articulating other priorities or reasons that may not be so readily accepted.5,12,56 Qualitative evidence suggests that ‘forgetfulness’ is used as an umbrella explanation for non-attendance when subsequent explanation reveals other more tangible factors.5,12 For example, Martin et al.5 observed that, following an initial explanation of forgetfulness, numerous patients identified a variety of employment and family-related factors which might become a higher priority than attending the appointment.

Nevertheless, figures from our effectiveness review demonstrate a consistent effect of any reminder suggesting that genuine forgetfulness does indeed play a significant, if less prominent, part. Such a ‘smoke screen’, perhaps in response to perceived or actual judgemental behaviour from clinicians or administrative staff, ironically performs a disservice when it comes to understanding appointment behaviours and developing effective reminder strategies. Only if candour, in a non-judgemental blame-free context, can be elicited by researchers and replicated in interactions with health service staff will service managers be able to devise appropriate patient-focused solutions to problems of non-attendance. In the course of our review informed by realist principles we have found that the observations of Dixon-Woods et al.168 resonate with our own work, namely that attendance behaviour research displays a consistent tendency to problematise the patient, not the service. The phenomenon of ‘convenient forgetting’ should not be allowed to mask the fact that certain sections of the community are particularly prone to genuine forgetting, for example the elderly or those experiencing symptoms of dementia. Clearly it would be retrograde to imprint suspicion of the explanation of forgetting too vigorously in the minds of those managing appointment rescheduling.

Voting with their feet

Non-attendance rates can be viewed as a way of patients expressing their reaction to the perceived inaccessibility or inflexibility of the service. If cancellation is easy [and does not subject a patient to disapprobation], then a service will gain valuable opportunities to reschedule other patients or for clinicians to plan to utilise downtime effectively. If services are flexible in terms of good availability of clinical services then cancellations and rebookings will be low. Very little attention is paid in the literature to attendance and cancellation rates as a diagnostic indicator for a service manager in assessing how their service performs with regard to access and availability. Instead, the research literature focuses on ‘fixing’ the problem rather than on understanding it and re-engineering innovative service solutions.

Another way in which poor attendance rates can be seen as a diagnostic indicator relates to inappropriate referral. Patients may fail to attend an appointment because they no longer consider it necessary, a condition may be self-resolving, a crisis point may have passed and been successfully negotiated or a patient may have arrived at a view that their referral is no longer desirable or necessary. In health-care systems that maximise patient choice, through availability of other health-care providers, a patient may simply have gone elsewhere for resolution of their condition.

Inappropriate referral and self-resolution of symptoms are two possible explanations for the commonly reported phenomenon of high non-attendance for appointments located in the distant future from onset of symptoms. Another factor, which itself may lead to patients concluding that their visit to a clinician is not entirely necessary, relates to signals that conflict with a sense of urgency. As a result of our review informed by realist principles, we hypothesise that any single factor or combination of factors that attributes importance or significance to attendance at a particular appointment serves to create a sense of that appointment being an ‘event’ rather than being routine or mundane. These signals may emanate from the individual patient [e.g. the severity of the symptoms], from the disease trajectory [e.g. the sense of a limited ‘window of opportunity’], from the service [e.g. a battery of tests or procedures in close succession] or from the health staff [e.g. how urgently they treat scheduling of an appointment or how they react to cancellation of an appointment]. This ‘event’ hypothesis possesses explanatory power in terms of the frequent use of forgetfulness as a reason for non-attendance – in general, we are less likely to forget those occurrences that have acquired the status of an ‘event’.

A further hypothesis relates to the importance of creating a sense of ‘engagement’, whether this be engagement with the service, the treatment or the therapeutic relationship. Patients who are more engaged are more likely to prioritise their attendance at appointments and to take such appointments seriously. In terms of appointment reminder systems, various degrees of engagement are possible. These include speaking to a member of health service staff rather than an automated message, speaking to the clinician handling your case and interactively acknowledging that you will attend an appointment – the ‘symbolic contract model’ mentioned in Chapter 4, Evidence statement [A.2–A.6]: there is weak consistent evidence that ‘reminders plus’ are more effective than simple reminders at helping a patient to attend their appointment [evidence category IIIa].

Within the specific context of help-seeking for mental health problems, commentators have described the interplay of approach–avoidance conflict whereby an appointment holds both the potential of resolution of symptoms and exposure to a stressful situation.217 This tension neatly captures some of the ambiguities encountered in the course of the review informed by realist principles whereby an appointment can be seen as both a positive and a negative event leading to markedly alternative ‘futures’.

Carrots, sticks and sermons

It has been suggested that a three-part classification of carrots, sticks and sermons is one way of characterising three different approaches to changing behaviour. This classification could be applied to the content of the reminder messages and how they are framed. Carrots can refer either to financial or other tangible incentives or to positive ‘strokes’ aimed at appealing to personal reward [you will be treated in a timely fashion, you will reduce your uncertainty promptly, etc.] or social good. Sticks can again be tangible [as in financial penalties] or affective [e.g. if you don’t attend then . . .], perhaps in provoking a guilt response. In a health education context, sermons refer to information that tells patients why reminders are good for them. Appointment reminder messages would tell you the health consequences of missing the appointment, particular if there is a relatively narrow window of opportunity with regard to the particular condition. It is our perception that there is a considerable body of literature on these phenomena in a health education context and yet, except when health promotion messages are included with appointment reminders, this evidence is largely divorced from the reminder context.

Do I really need to go?

Except in a mental health context for which patients may have an impaired sense of determining their need for treatment, it may be reasonable to expect patients, particularly those with a chronic self-managed condition, to be able to judge when they need an appointment. However, certain conditions may have a brief and critical window of opportunity which, if missed, can lead to severe consequences in terms of patient health and/or health-care resource utilisation. In addition, if members of health service staff endorse inappropriate over-utilisation they may perpetuate such a situation. Alternatively, if they appear too judgemental, they may discourage utilisation all together. Regular, unmediated appointment intervals may be viewed as an alternative to more sophisticated communication and interaction between patient and clinician and to facilitate informed patient self-determination in decision-making. It also may be viewed as a defensive procedure to minimise risk of negligence. As mentioned under Carrots, sticks and sermons, patients may receive ambiguous messages about the importance of the appointment particularly if there is a juxtaposition of a ‘task-focused’ view from the administrative staff with a ‘person-focused’ perspective of the clinical task. Of course, these roles are equally problematic if the perspectives are reversed.

Nudge theory and custard creams

Current thinking on mechanisms for effecting behavioural change is heavily influenced by the so-called ‘nudge theory’. Nudge theory has its origins in behavioural psychology and economics and is currently being promoted by the ‘behavioural insights team’ at the UK Cabinet Office. Nudge theory suggests that making it easier for people to take a healthier or more socially acceptable course can prove more effective than introducing legislation or penalties. Of particular relevance to the problems associated with appointment attendance are experiments being trialled with regard to payment of taxes or fines. Initiatives, such as sending personalised text messages urging people to pay fines and including images of untaxed vehicles in demands for payment of duties, have demonstrated initial success. Other suggestions include highlighting key information in bold or ‘strong’ colours, using lotteries or prize draws as an incentive for prompt payment of taxes and sending ‘thank you’ letters to people. Clearly some, although not all, of these approaches have direct implications for appointment behaviour and appointment reminder systems. For example, Hayes et al.218 describe how they initiated a behavioural contract to increase appointment keeping among low-income families in a child and family therapy programme. Such families received US$30 in coupons at attendance at four consecutive appointments with costs offset against the potential cost of broken appointments.

This potential for social influence or ‘nudge’ theory has recently been explored in the specific context of those who did not attend appointments. Martin et al.142 describe three interventions tested in GP surgeries in NHS Bedfordshire that could be implemented quickly and appear to be cost neutral.

• Patients calling for an appointment should be asked to repeat back the time and date of their appointment before the call ends.

• When booking follow-up appointments, patients should write down the time and date on an appointment reminder card rather than health-care or reception staff doing it for them.

• Replacing common signs that communicate the number of patients who did not attend appointments in previous months with signs that conveyed the much larger number of patients who do turn up.

These first two interventions correspond to our ‘engagement’ hypothesis in that they seek to increase patient participation, thereby either reducing did-not-attends or at least increasing a sense of responsibility such that those subsequently unable to attend would call and cancel. Surgery staff booking appointments over the telephone asked patients to repeat back the time and date of their appointment before ending the call. This led to a 3.5% reduction in did-not-attends, which is comparable to the minimum gains made by moving from no reminder to using any form of appointment reminder system. The second intervention, asking patients to write the time and date of their follow-up appointment with a nurse on the appointment card themselves, rather than the nurse doing so, led to a reduction in did-not-attends of 18%. This figure equates to some of the highest gains made when introducing reminder systems.

Finally, Martin et al.142 turned their attention to the idea that publicising the number of patients who did not attend via posters on waiting room walls or TV monitors might increase rather than decrease did-not-attends. By drawing attention to the regrettable frequency of unwanted behaviours they understood that this would be likely to normalise such behaviours thereby resulting in increased occurrence. They replaced these signs with posters that conveyed the much larger number of patients who did attend. When this intervention was combined with the verbal and written commitment-led interventions described above, this resulted in a 31.7% reduction in did-not-attends compared with the average of the previous 12 months. While caution should be expressed at the use of relative, rather than absolute, figures for improvement, particularly when there is no way of knowing what the baseline rates were and whether they are high or low when compared with typical practices, it is clear that low-cost behavioural interventions should at least merit as prominent place in the future research agenda as high-technological ‘fixes’.

Service inertia

One of the attractions of the approaches by Martin et al.142 is involvement of practice staff in the diagnosis and resolution of problems associated with non-attendance over a coffee break, hence the ‘custard creams’ of the article title. This is particularly to be welcomed given that there is some evidence to suggest that health service staff may act as a barrier to the development of innovative patient-friendly solutions that overcome obstacles to their attendance. In the study by Martin et al.,5 patients described difficulties in getting through to the surgery by telephone, as lines were often busy. Interestingly patients did express the perception that getting through to the surgery might have enabled others to take advantage of a cancellation slot, although there was no evidence that the practice offered such flexibility. This suggests that if services were able to actively demonstrate that they were able to reutilise slots freed by cancellations, an ‘altruistic’ subset of patients might choose to phone in to cancel, providing that the structural barriers, such as engaged telephone lines, were removed. However, there was evidence from this particular study site that the surgery problematised the patients, not the service. This attitude may explain an apparent inertia from this surgery in response to the suggestion concerning a dedicated cancellation line or facility to use SMS text messaging as a means of cancelling an unwanted appointment. In fact, staff expressly rejected these suggestions from patients as being impractical to implement or difficult for existing staff to manage.5

Clinical implications

General implications

In this section we provide an overview of findings that are potentially relevant for all health services. All reminders are effective at improving attendance at appointment. Simple reminders which provide details of timing and location of appointments are effective at increasing attendance at appointments and would appear to be useful for all patients, across all health-care settings, who are at risk of forgetting their appointment [see Chapter 4, Evidence statement [A.1]: there is strong consistent evidence that simple reminders which provide details of timing and location of appointments are effective at helping a [forgetful] patient to attend their appointment [evidence category Ia]]. There is also weak evidence that ‘reminder plus’, which provides additional information over and above date, time and location of the appointment, is more effective than simple reminders at helping a patient to attend their appointment [see Chapter 4, Evidence statement [A.2–A.6]: there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment [evidence category IIIa]]. Orientation information and information about health services and procedures may be helpful at reducing perceived obstacles to attendance, although more high-quality research is required to confirm this. We speculate that ‘reminder plus’ may be particularly useful to facilitate first appointment attendance and attendance at screening appointments, and that simple reminders may be appropriate thereafter for most patients and most health services, most of the time [see Reminder plus], although this hypothesis requires further testing.

Appointments can be scheduled at inconvenient times, become inconvenient owing to a change of circumstances or no longer be required for very many reasons that have been discussed in this review. This indicates that all patients are likely to be unable to attend an appointment [whether it is a new appointment or a follow-up] at some point [see Previous patterns of non-attendance]. Unless patients indicate that they do not want to receive a reminder, we recommend that all patients should receive a reminder or ‘reminder plus’, which recognises this as true and actively encourages patients who are unable to attend to cancel their appointment and to reschedule if further appointments are required [see Are there any systems which effectively support the cancellation of appointments?]. We further recommend sending the reminder around 3 days in advance because although timing of a reminder between 1 and 7 days prior to the scheduled appointment has no effect on patient attendance behaviour, this will allow sufficient time for patients to cancel and health services to reallocate the cancelled appointment to another patient [see Chapter 4, Evidence statement [B.5]: there is strong consistent evidence that the timing of a reminder, between 1 and 7 days prior to the scheduled appointment, has no effect on patient attendance behaviour [evidence category Ia]] or allow the clinician to undertake care-related administrative tasks, e.g. telephone calls, discharge letters, etc. [see Are there any systems which effectively support the cancellation of appointments?].

We found many examples in the literature of inefficient reminder activity [e.g. poor patient accessibility to reminder technology, incorrect patient contact details and human error] leading to suboptimal reminder effectiveness [see Accessibility] and poor resourcing of reminder systems. To optimise attendance, cancellation and rescheduling, there needs to be robust procedures to ensure that patient contact details are up to date. There needs to be easy-to-use, probably multiple, systems for cancelling appointments that suit the needs of the patients and not just the needs of the service, e.g. automated SMS cancellation, answerphone, e-mail, etc. Robust rescheduling procedures need to be in place to allow easy rescheduling of appointments for patients, both within and outside normal working hours to provide patients with flexible opportunities. Finally, an effective reminder system will increase the workload on clinical staff and services will need to build in alternative administrative time for staff that frequently utilise non-attendance at appointments as an opportunity to catch up on other health-care-related activities [see Are there any systems which effectively support the cancellation of appointments?].

We found few studies investigating the differential effectiveness of reminder systems for population subgroups. Consequently, we have provided a narrative overview of literature generated by our review, to identify groups who are at higher risk of non-attendance. In general, contrary to the popular view, our review provides no evidence that age, gender and previous attendance patterns predicts non-attendance but it does show that key groups at high risk of non-attendance are related to deprivation status, ethnicity, substance abuse and comorbidity/illness [see Chapter 5, Patient characteristics]. Our findings suggest that reminder system choices need to be carefully considered in order to maximise accessibility for these key patient groups. Simple reminders and automated reminders to attend may be ignored or overlooked and may put these patient groups at a disadvantage compared with general outpatient populations. Reminders with direct personal contact might be appropriate in these groups [see Other reminder characteristics, Format of the reminder]. To facilitate attendance in the most at risk, vulnerable groups we have suggested that reminder systems of increasing intensity and interactivity could be introduced to ensure that disparities in health-care opportunities are not compounded. We have introduced the concept of a sequential reminder intervention in order to reach the most number of patients and maximise attendance78 [see Substance abuse/mental health/comorbidity and physical illness]. The re-engagement of patients with treatment after they have missed their appointment may be important if they have particular health problems that need ongoing treatment. Intensive approaches, such as ‘stepped reminders’ and patient navigators, have been effective at increasing attendance at screening and immunisation programmes in disadvantaged and vulnerable populations and might also be effective at re-engaging similar groups of patients who have dropped out of treatment [see Do different reminder systems have differential effectiveness for particular subgroups of the population [e.g. by age group, ethnic group, socioeconomic status, gender, etc.]?].

Specific implications

The general implications above should be considered by all health-care services; however, this review also identifies various reminder or appointment-related issues that may be relevant to specific health services. Therefore, along with the ideas outlined above, health service managers should consider the following issues that will add a layer of decision making to their choices about reminders. In essence, reminder systems are a complex intervention,219 because of the potential number of interacting components within the interventions, and so owing to the requirement for tailoring of the intervention to the health service and the number of difficulties and behavioural changes from those receiving and delivering the reminder to facilitate decision-making, we developed:

• a conceptual framework [see Figure 2]

• a set of clinical scenarios [see Appendix 7]

• reasons for non-attendance and possible reminder solutions and wider solutions [see Appendix 8]

• advantages/disadvantages for various reminder systems [see Appendix 9].

Conceptual framework: implications for practice

We examined existing conceptual frameworks to identify models that explain reasons for FTA appointments. No existing models explored the complexity of the different interactions between the patient, the service, the reminder system and the factors that support or inhibit attendance. Consequently, we developed a conceptual framework exploring FTA. This framework places patients at the centre, to convey their centrality in forgetting or deciding whether or not they will attend [or at least intend to attend]. The framework examines patient status when they receive the appointment notification in terms of obstacles or enablers to their attendance, ‘distal/proxy’ attributes that could characterise a patient group to predict the effectiveness of different types of reminder systems and the characteristics of the reminders.

Our study proposes five possible outcomes relating to appointment attendance, cancellation, rebooking and FTA [see Appendix 2]:

• outcome 1 – patient attends the original appointment

• outcome 2 – patient does not attend the original appointment but rebooks and attends

• outcome 3 – patient does not attend the original appointment, cancels, but does not rebook and attend

• outcome 4 – patient does not attend the original appointment and does not cancel

• outcome 5 – patient does not attend the original appointment and does not cancel, but is rebooked by the clinic.

The conceptual framework was further developed to propose a series of hypotheses with respect to the interaction between the patient and the reminder system [see Appendix 3]. These explore the patient–reminder interaction [A] and the attributes associated with increasing the likelihood of attendance, including reminding the forgetful patient to attend [A.1], providing information that attending the appointment will positively affect his/her well-being [A.2], providing information that non-attendance will negatively affect his/her well-being [A.3], that attendance will not be difficult [A.4], the experience will be positive [A.5], attendance is compatible with other commitments [A.6] and is morally the right thing to do [A.7].

The hypotheses further explored the relationship between the accessibility of the reminder [B] and the outcomes for the patient. In particular, the outcomes are more likely to be detrimental for the service if the reminder is not received [B.1] or understood [B.2] by the patient, does not overcome potential obstacles experienced by the patient [B.3], is not formatted appropriately [B.4] or timed appropriately to allow cancellation or rebooking [B.5].

Several components of the reminder can be varied to impact on the effectiveness of the reminder, specifically, the medium [e.g. telephone, SMS, letter, multiple modalities], timing, content, interactivity and intensity.

Further, we hypothesised that the impact and effectiveness of reminder systems vary by health-care settings [C], including the source of the original appointment [C.1], service location [C.3] and initial or follow-up appointment [C.5].

The study also hypothesised that the wider social systems in which the appointment is situated impacts on the likelihood of attendance [D] and that obstacles to attendance and rebooking impact on attendance [E].

Clinical scenarios: implications for practice

In response to the findings from this study, we have developed a series of clinical scenarios relating to the use of reminder systems [see Appendix 7] that synthesise the evidence presented into this report to address specific scenarios for service providers, outlined below:

1. if you want to optimise the likelihood of the patient attending the appointment

2. if you want to optimise the likelihood of attendance at an initial appointment

3. if you want to increase the rates of attendance at screening appointments

4. if you want to optimise the likelihood of attendance at follow-up appointments

5. if you want to optimise the likelihood of attendance of specific population groups

6. if you want minimise the number of unfilled, non-attendances on any one day [i.e. minimise unused capacity]

7. if it is a high priority that patients cancel then it is important that health-care services make it as easy as possible for patients to cancel

8. if it is a high priority that patients reschedule their unwanted appointment in order to receive priority treatment

9. if you want to make it easy for the patient to cancel or reschedule

10. if the health service has to reschedule an appointment.

Reasons for non-attendance

In addition, we have summarised below the major reasons proposed for missing appointments [see Appendix 8]. In particular, we propose solutions to address each of these issues based on the evidence presented in the report.

1. problems with appointment system

2. patient illness

3. patient perceptions and fears regarding the importance or value of appointment

4. timing and incompatibility of the appointment: planned [avoidable]

5. timing and incompatibility issues: unplanned [unavoidable]

6. issues to do with patient: practitioner relationship or interaction

7. issues to do with the accessibility of the appointment

8. patient attributes.

Advantages and disadvantages of different reminder systems

The advantages and disadvantages of the range of reminder systems are presented in Appendix 9, including a discussion of the costs and implications for cancellation and rebooking.

Practice guidelines

In our original proposal, we identified that one of the outcomes of the project would be a stand-alone practice guide based on the information provided in Appendices 7–9. Owing to the complexity of the information, we propose to create a web-based practice guide which will allow health service managers to negotiate the information more readily. A brief outline proposal of this is provided in Appendix 10.

Research implication

The gaps in the evidence point to three clear research priorities that could lead to increased effectiveness of reminder systems, more efficient use of appointment resources while simultaneously recognising the needs of specific patient groups who may be at higher risk of missing appointments. These research priorities are identified below:

• Although there is strong evidence to support the use of reminders, there is a need for high-quality studies investigating the differential influence of providing additional information as part of the reminder system in different contexts [first vs. follow-up appointment, particularly the use of loss- vs. gain-framed messages and orientation information for facilitating attendance behaviours] [see Which types of reminder systems are most effective in improving the uptake of health service appointments?].

• Reminder systems would appear to have considerably more potential for promoting cancellation of unwanted appointments to allow reallocation of cancelled appointments than the current evidence indicates. To optimise attendance, cancellation and rescheduling there needs to be robust procedures to ensure that patient contact details are up to date and that there are easy-to-use, probably multiple, systems for cancelling appointments that suit the needs of the patients, e.g. automated SMS cancellation, answerphone, e-mail, etc. Robust 24-hours-per-day rescheduling procedures should allow easy rescheduling of appointments for patients. Finally, an effective reminder system will increase the workload on clinical staff and alternative time will need to be scheduled for staff to undertake health-care-related administration. Further research is required to investigate the differential effectiveness and cost-effectiveness of an ‘optimised’ reminder system over and above usual reminder systems.

• This study set out to examine whether certain types of reminder systems are more effective for specific population subgroups; however, there was a lack of research in this area. Specifically, we have identified patient groups who are higher than average risk of non-attendance. For these groups, we have introduced the concept of a sequential reminder intervention in order to reach the maximum number of patients and to maximise attendance; however, the effectiveness of these reminders in this context needs to be established. The re-engagement of these patient groups with treatment after they have missed their appointment may be important if they have particular health problems that require ongoing treatment. Intensive approaches, such as ‘stepped reminders’ and patient navigators have been effective at increasing attendance at screening and immunisation programmes in disadvantaged and vulnerable populations; however, their effectiveness in this context also needs to be investigated.

Current and future developments [innovations]

Bech215 suggests the following interventions to combat non-attendance: information given to patients before appointments, reminder letters, telephone reminders, punishing non-attendees by discharging them from the waiting list or by assigning them to the bottom of the waiting list, and charging non-attendees a monetary fine. Some of these suggestions have been examined in the systematic review section of this report. Within our review team we have expanded the range of possible alternatives, as shown in Box 1. It should be emphasised that such potential solutions have been identified through narrow specific searches of the literature and are not intended as a systematic mapping of the area. Nevertheless, we are confident that we have identified the main choices available to those managing services.

BOX 1

Suggested approaches to issues of non-attendance Modify current ways of delivering appointment reminders.

Modify current ways of delivering appointment reminders

A study carried out last year at two Bedfordshire practices142 revealed how three simple and cost-effective measures could significantly reduce the number of appointments missed by patients. Asking patients to write down their appointments cut did-not-attends by 18% compared with the average of the previous 6 months. Asking patients who booked over the phone to repeat back the time and date of their appointments cut did-not-attends by 3.5% compared with the previous month. Displaying posters stating how many patients had attended their appointments in the previous month, in combination with the other two measures, cut did-not-attends by a total of 31% in comparison with the average for the previous 12 months.

Further recommendations about how services can cut did-not-attend rates are outlined in the ‘did not attends – Reducing Did Not Attends’ Quality and Service Improvement Tool from the NHS Institute for Innovation and Improvement.220

Another alternative is to integrate appointment reminders within a more wide-reaching approach to caring for the client by utilising other features of the chosen reminder technology. For example, NHS Bolton supplemented a text-based appointment reminder system within the context of an alcohol relapse prevention programme.221 In addition to allowing clients to confirm whether or not they will be attending their aftercare appointments, clients were contacted a few times a week via text message with simple questions about their feelings and emotional state. The response from the clients triggered, in turn, an appropriate service response depending on the answers given. This innovative use of mobile technology as an engagement strategy is concordant with our earlier observations and seeks to enhance self-sufficiency for clients through reminder and feedback on treatment success.

Utilise new ways of delivering appointment reminders

Intensive reminders

We have identified that high levels of non-attendance are found in patients who abuse drugs and alcohol [see Chapter 5, Substance abuse], patient with mental health problems [see Chapter 5, Mental health] and patients with comorbidities and illness [see Chapter 5, Physical illness/comorbidity]. For these groups, simple reminders and automated reminders to attend may be ignored or overlooked particularly when experiencing an increased level of illness or substance abuse. In fact, the use of simple reminders may put these patient groups at a disadvantage compared with general outpatient populations. Reminders with direct personal contact might be appropriate in these groups [see Other reminder characteristics, Format of the reminder]. To facilitate attendance, a sequential reminder intervention such as that described by Perron et al.78 could be initiated. First, a phone call to either landline or mobile; second, a SMS if participants do not answer the phone after three attempts and have a mobile phone and, finally, a postal reminder if participants did not answer the phone, had no mobile phone for SMS, or had no phone at all. Such a design, although labour intensive, would reach the maximum number of participants and may increase attendance rates while still being cost-effective. A further consideration is how to re-engage these groups with treatment after they have missed their appointment. Intensive approaches, such as ‘stepped reminders’46,195 and patient navigators,196,197 have been effective at increasing attendance at screening and immunisation programmes in disadvantaged and vulnerable populations, and might also be effective at re-engaging similar groups of patients who have dropped out of treatment.

E-mail reminders

E-mail has been proposed as a suitable medium for sending appointment reminders42 [see Accessibility]. Bespoke secure e-mail programmes can incorporate special features such as standard forms guiding the use and content of the e-mail sent and the capacity to show read receipts [in order to confirm the patient has received the correspondence]. However, they are costly to set up and may require a greater degree of user skill than standard unsecured mail.42 E-mail may also be a suitable medium for many patients to cancel appointments that are no longer convenient or no longer required. It is unlikely to be suitable for all patients, but does provide an automated mechanism for quick and easy cancellation. Future research is required to consider the likely usefulness/availability/accessibility and practical implications of e-mail reminders.

Utilise new ways of appointment booking

Booking/cancellation over the internet

Derby Hospitals NHS Foundation Trust uses online cancellation forms to make it easier for patients who do need to cancel to get in touch with the trust. This addresses difficulties, such as those identified by Martin et al.,142 in accessing, or indeed providing, staffing for a cancellation telephone line. A Department of Health press release222 indicates that because of projects to reduce missed appointments, the number of missed appointments in Derby between April and December 2011 fell by over 12,000 [2%] compared with the same period the previous year. A 2011 survey of 1700 patients by www.patient.co.uk showed that 85% wanted to book GP appointments online.223 Nearly half of patients surveyed [47%] were over 55 years of age and, therefore, challenged assumptions about the demographics for users of such technologies.223

Integrated care including appointment booking

University College London Partners has been working on an internet-based solution that allows a pregnant woman to automatically receive all the information she needs about her forthcoming 12-week scan. Appointments can be made online with the content being tailored to individuals [e.g. according to age group or language spoken].224

Utilise new ways of managing appointment systems

Charging for non-attendance

In their qualitative study, Martin et al.142 discuss the ramifications of charging for non-attendance. They describe how some patients held the view that that financial penalties for patients who did not attend appointments was justified. If this measure had an effect on attendance then it might seem justified; however, some patients indicated that this would not have prevented the non-attendance in their particular case. They further indicated that, in this context, a fine would not be an intervention to reduce non-attendance but would simply provide a financial reimbursement for the NHS or a penance for patients who did not attend.

They go on to compare this with the USA, where most appointments actually do involve a financial cost to the patient, and non-attendance rates are similar. They report an association with lack of insurance cover and Medicaid for which individuals often have to make some contribution to costs and are, by definition, poor. They conclude, as does Bech,215 that financial penalties would have some effect in reducing non-attendance, but that it would not be substantial.

Resistance to a system of financial penalties came from medical staff who were not only opposed to the system but who emphasised that implementation would prove difficult.142 A contrary view comes from the Developing Patient Partnerships Survey and Hussain-Gambles et al.104 qualitative study of primary care team members. However, there was common recognition of the administrative pitfalls and approval of fining was not universal. Martin et al.142 conclude by proposing that an evaluation of such a policy on health service efficiency, administrative staff burden, costs and patient–clinician relationships would be an important first stage that should precede any implementation of monetary penalties. We were unable to establish whether or not such a pilot has actually taken place.

The effectiveness of charging a fine for non-attendees was been debated in Denmark and the UK in the middle of the last decade, but has been investigated in very few studies.215 These studies225,226 reveal that a fine will, as most economists expected, reduce the non-attendance rate. The literature of non-attendance discloses ‘a significant need for studies addressing the non-attendance problem applying economic theory and standards of analysis’.215

Open access systems

A recent innovation, adopted by many primary care clinics, is the advanced or open-access system, credited to Murray and Tantau.227 In this approach, physicians attempt to accommodate patient requests for appointments on the day they call; this is not to be confused with walk-ins who do not call in advance. Future appointments at a time that is more convenient for the patient are also permitted. Service providers vary available capacity to meet the demand of each day. The ability of a patient to book an appointment on the day he or she calls is no longer a function of his/her medical condition and, in contrast, clinics that do not offer advanced access often employ a triage nurse to assess the urgency of medical need of a caller who requests an appointment without delay. Only callers whose need is deemed urgent are offered a slot reserved for urgent requests.

The impetus for adopting advanced access comes from the desire to make clinic practices more patient focused, to accommodate faster access for patients with urgent needs and to gain competitive advantage. St Levan Surgery in Plymouth won the Health Service Journal [HSJ] Award for a patient access system whereby patients phone the surgery and receptionists record all requests for doctor contact on the computer screens of the GPs.228 The GP phones the patient back, usually within an hour, to agree a plan. Options may include an appointment at a time convenient to the patient [70% of patients choose to be seen on the day], phone advice, investigations, appointments with other practice staff or directions to other services. Follow-ups are also often carried out by phone. However, the implementation of advanced access systems remains a challenge.

First, providers are limited in their capacity to absorb variations in daily demand. It may not be possible to accommodate all appointment requests on the day they originate. This leads to demand spill over to a future day, limiting the clinics ability to meet the demand of that future day.

Second, true demand for same-day service is not captured by the appointments data because it is difficult to tell whether a patient actually preferred to book an appointment on a future date or [s]he did so because a same-day appointment was not available. Same day services may prove particularly challenging for those managing appointment services who seek to determine approximately how much capacity should be available at the start of each day for the demand.

Third, in many clinics, different physicians’ patient list compositions and sizes are significantly different, with the result that some physicians have fewer available slots to accommodate same-day demand.228,229

The open-access policy that calls for ‘meeting today’s demand today’ has been demonstrated to be a reasonable choice when the patient load is relatively low.230

Luo et al.231 have shown that appointment scheduling policies that ignore interruptions for emergency requests perform quite badly in relation to patient waiting times, especially when the number of appointments to be scheduled is also a decision variable. They also found that policies requiring equally spaced appointments perform reasonably well when the interruption rate is constant; however, their performance worsens significantly when the interruption rate is time dependent.

Choose and Book

An important component of enhancing patient experience of care is to provide more flexibility to patients regarding how, when and where to receive treatment. In pursuit of this objective, the NHS in the UK launched its electronic booking system, Choose and Book, for outpatient appointments in January 2006.232 However, there is some evidence, mainly anecdotal, to suggest that this system will impair outpatient practice233 and, in particular, patient attendance is worse under a Choose and Book service.234 Commentators have suggested that part of the problem is that patients are given only one chance for booking with one phone call with the implication that a three contact system, at different times, of the day would prove more successful.235

Patient-initiated appointments

Patient-initiated appointments offer patients the opportunity to self-manage their disease by requesting specialist reviews at times of need instead of clinician-scheduled appointments. Claimed benefits for patient-initiated care, in comparison with traditional clinician-driven care, include reduction of unnecessary medical reviews, greater satisfaction to patients and staff and maintenance of the patient’s physical and psychological status.236 In a 2-year RCT, subsequently extended to 6 years, 209 consecutive patients with rheumatoid arthritis were assigned to either a direct access group or a control group receiving regular clinician-initiated care.236 Patients in the direct access group expressed significantly higher satisfaction and confidence in the system and also had significantly fewer [38%] hospital appointments [median 8 vs. 13 hospital appointments; p < 0.0001] than patients in the control group. This approach is regarded as particularly promising for other chronic diseases.

Systematic overbooking

Each service faces a challenging dilemma, i.e. whether to build in assumptions of ‘non-attendance without opportunity to reassign’ into their appointment schedules [i.e. overbooking] or whether to expect clinical staff to redeploy the freed time [with a consequent risk of underutilisation]. Flexibility to redeploy the time to the benefit of other patients will also be limited by factors relating to those patients themselves, i.e. if a patient turns up early [or is invited to turn up early] for their appointment, he or she may be able to occupy a previous slot. However, such patterns then drive future appointment behaviour with being seen early on one occasion being likely to modify expectations for future appointments and, conversely, perceived ‘idle time’ experienced by turning up early but being seen at the appointed time being likely to lead to presentation closer to the scheduled time on subsequent occasions. While service providers such as airlines respond to uneven attendance patterns by offering stand-by opportunities, they risk losing significant good will when overbooking flights.237 They similarly face a vicious cycle whereby a customer’s previous experience of the convenience of standby may modify their expectations that this option will then be available on a repeat occasion, thereby increasing demand and making such provisions less likely for the particular individual. In an award-winning paper, LaGanga and Lawrence237 show that a simple solution is to shorten the time between appointments relative to the average rate of no-shows. For example, if the average no-show rate is 30% and the average time allotted per visit is 15 minutes, a practice could reduce that 15 minutes by 30% and allow only 10.5 minutes per appointment, resulting in more appointment slots.

Utilise alternative ways of delivering health care

Teleconsultation

Newham University Hospital NHS Trust has reportedly started seeing diabetes patients who do not need a physical examination via Skype™ [Skype Ltd, Rives de Clausen, Luxembourg]. Results from a pilot suggest that this has caused missed appointments to fall by 11% because of the time saved in travelling, waiting and fewer patients attending A&E. Importantly, feedback from patients suggests that the quality of care was the same as with face-to-face appointments.222 The project had a significant impact on patients, particularly those who have difficulty accessing care because of their busy lifestyles or multiple commitments and those with limited mobility or who are housebound. For staff, it encouraged more focused consultations and better use of face-to-face time for clinical activities.238

Patient decision aids

There are also early indications that patient decision aids, given at an initial meeting with a nurse and followed up by a telephone consultation, may reduce the need for face-to-face appointments. A follow-up appointment is required only when the patient is struggling to make a decision. However, the need to respect patient choice means that such provision can only be offered as an alternative and not as a standard default.239

Changes to appointment opening times

Experience from the Royal Bolton Hospital NHS Trust,240 which responded to perceived capacity issues by holding extra outpatient clinics out of normal hours, at high cost, indicates the importance of a sophisticated understanding of appointment behaviours in using poor performance as an indicator of systemic issues. The trust encountered a significant number of cancellations and rescheduling of appointments, with the consequence that some clinics were under-running. Furthermore, it identified waste within the appointments themselves. As a consequence, the trust has been working with the Health Foundation to apply innovative ‘lean’ methods to the outpatient setting.