It is our proposition that a reminder increases intention to attend (and, therefore, likelihood of attendance) when it (1) reduces patient-specific obstacles to attendance and/or (2) increases patient-specific enablers to attend. The patient will intend to attend when the enablers outweigh the obstacles. The following evidence statements relate to this proposition.
Evidence statement (A.1): there is strong consistent evidence that simple reminders that provide details of timing and location of appointments are effective at helping a (forgetful) patient to attend their appointment (evidence category Ia)
Findings from effectiveness review (systematic reviews and randomised controlled trials)
Freeet al.45reported that the pooled effect on appointment attendance using text message (SMS) reminders compared with no reminder was increased, with a relative risk (RR) of 1.06 [95% confidence interval (CI) 1.05 to 1.07]. Caret al.43provides moderate-quality evidence showing that mobile text message reminders improved the rate of attendance at health-care appointments compared with no reminders (RR 1.10, 95% CI 1.03 to 1.17). These findings suggest that a small percentage of individuals (estimated variously at between 3% and 17%) do genuinely forget and, therefore, benefit from receipt of a reminder.
The overwhelming pattern from the systematic reviews and included trials is that reminder systems reduce non-attendance rates. However, there are differences in what investigators perceive as a meaningful difference (figures such as a 10% or 15% reduction are cited when calculating a sample size) and so some studies fail to reach statistical significance.
Stubbset al.52conclude that telephone, mail and text/SMS interventions all improved attendance modestly, but at varying costs. Similarly, Jacobson Vann and Szilagyi49found that reminding people over the
telephone, sending a letter or postcard, or speaking to them in person increased vaccinations. Hasvold and Wootton47undertook a systematic review of 33 independent studies pertaining to telephone, SMS or automated telephone reminders found that all but one reported a benefit from sending reminders and suggested a weighted mean relative change of 34% from the baseline non-attendance rate.
Boset al.55tried three different types of reminder system and failed to confirm the hypothesis that a reminder would reduce the failed attendance rate. The explanation for this finding was that the clinic had a very high attendance rate with both a high perceived importance of the clinic and high levels of satisfaction with the orthodontist and the services being provided. Perronet al.78report that being part of a stepped approach intervention (telephone, text, mail) significantly decreased the risk of missing an appointment for all categories of patients found at risk [odds ratio (OR) 0.63, 95% CI 0.43 to 0.89]. A useful reminder function is served by whatever means is at a service’s disposal.
In their systematic review, Freeet al.45report no difference in attendance using SMS reminders compared with other reminders; however, these findings did not reach statistical significance (RR 0.98, 95% CI 0.94 to 1.02). Caret al.43identified two studies of moderate quality that showed that mobile phone text message reminders and telephone call reminders had a similar impact on health-care attendance (RR 0.99, 95% CI 0.95 to 1.03). This suggests that patient compatibility/preference, not the inherent advantage of any technology per se, should determine selection of the candidate reminder system. In contrast, Boset al.55found no differences between SMS, telephone and mail reminder when compared with no reminder. The authors concluded that the form of the reminder is irrelevant.
Findings from other studies
Evidence statement (A.2–A.6): there is weak consistent evidence that
‘reminder plus’is more effective than simple reminders at helping a patient to attend their appointment (evidence category IIIa)
Findings from effectiveness review (systematic reviews and randomised controlled trials)
There is weak consistent evidence from two reviews that show that reminders providing additional information (e.g. orientation information, health information, etc.) over and above details of timing and location (reminder plus) are more effective than simple reminders, which provide information about time date and location of an appointment.
In their Cochrane review, Reda and Makhoul51investigated the effects of reminders to encourage attendance at clinics for those with suspected serious mental illness. Of the four trials included in review, only one study87(n=120) compared a standard letter prompt with a letter‘orientation statement’. The results of this study favoured the orientation statement approach rather than the simple letter prompting attendance, but the results did not reach conventional levels of statistical significance (RR of missed appointment 1.6, 95% CI 0.9 to 2.9). There is a chance of type II error in this particular study and simply increasing the number of participants in this study may have resulted in a more favourable result. This review provides very weak evidence that a simple orientation-type letter may be more effective than a telephone prompt at promoting attendance at mental health clinics.
A systematic review48to assess the effectiveness of reminder systems as a means of increasing attendance and reducing‘did not attend’rates at all new outpatient appointments identified limited evidence, based on three studies, that‘reminder plus’were more effective than standard reminders. Postal reminders that offered a reward for attendance, threatened sanctions for non-attendance or provided orientation information about the clinic appeared to be more effective than standard reminders. In this review
‘warning reminders’contained warnings that patients would fall to the bottom of the waiting list following failure to attend (FTA),‘reward reminders’contained the offer of rewards should patients attend and
‘orientation reminders’contained information describing the clinic. There was an indication in this review, based on the findings of one study, that warning reminders were more effective than reward reminders.88 Canet al.56describe an intervention that requested that patients return a stamped addressed postcard, so that the appointment could be confirmed. It could be hypothesised that the action of returning the postcard might be construed as a symbolic‘contract’between patient and provider, reducing the subsequent likelihood of non-attendance. Whatever the reasons, return of the postcard resulted in an attendance rate of 83% compared with only 48% if the card was not returned.
This evidence indicates that‘reminder plus’may be more effective than simple reminders; however, as a result of the small number of studies which have systematically investigated this hypothesis, it is not possible to be conclusive about this. There is no evidence to show in what way the receipt of additional information as part of the reminder will shape patients’intentions to attend or their perceptions about the appointment. Further high-quality research is required to investigate these areas.
Findings from other studies
Several studies have utilised orientation strategies to apparent good effect. Kitchemanet al.69incorporated letter reminders on headed paper in their RCT explaining the time of the appointment, name of the doctor, description of the clinic and its routine, a map and a request to bring a list of medication and a friend or family member. This significantly reduced the numbers of people failing to attend a mental health clinic appointment. Booth and Bennett89conducted a comparative study utilising telephone reminders incorporating information about appointments, directions to the clinics and other relevant information that reduced non-attendance at first appointments at a specialist alcohol treatment clinic. However, neither of these studies incorporated control groups receiving a simple reminder only and, therefore, it is not possible to determine from these studies the additive effect of orientation information.