appointment reminder systems are effective but not optimal
TRANSCRIPT
Appointment reminder systems are effective but not optimal: results of a systematic review and evidence synthesis employing realist principles
MCLEAN, Sionnadh <http://orcid.org/orcid.org/0000-0002-9307-8565>, BOOTH, Andrew, GEE, Melanie <http://orcid.org/0000-0001-9149-4314>, SALWAY, Sarah, COBB, Mark, BHANBHRO, Sadiq <http://orcid.org/0000-0003-0771-8130> and NANCARROW, Susan
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MCLEAN, Sionnadh, BOOTH, Andrew, GEE, Melanie, SALWAY, Sarah, COBB, Mark, BHANBHRO, Sadiq and NANCARROW, Susan (2016). Appointment reminder systems are effective but not optimal: results of a systematic review and evidence synthesis employing realist principles. Patient Preference and Adherence, 10, 479-499.
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http://dx.doi.org/10.2147/PPA.S93046
Appointment reminder systems are effective but not optimal: results of a systematic review and evidence synthesis employing realist principles
Sionnadh Mairi McLean1
Andrew Booth2
Melanie Gee3
Sarah Salway2
Mark Cobb4
Sadiq Bhanbhro3
Susan A Nancarrow5
1Faculty of Health and wellbeing, Sheffield Hallam University, Sheffield, UK; 2School of Health and Related Research, University of Sheffield, Sheffield, UK; 3Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK; 4Therapeutics & Palliative Care, Sheffield Teaching Hospitals, Sheffield, UK; 5School of Health and Human Science, Southern Cross University, east Lismore, NSw, Australia
Abstract: Missed appointments are an avoidable cost and resource inefficiency which impact
upon the health of the patient and treatment outcomes. Health care services are increasingly
utilizing reminder systems to manage these negative effects. This study explores the effectiveness
of reminder systems for promoting attendance, cancellations, and rescheduling of appointments
across all health care settings and for particular patient groups and the contextual factors which
indicate that reminders are being employed sub-optimally. We used three inter-related reviews
of quantitative and qualitative evidence. Firstly, using pre-existing models and theories, we
developed a conceptual framework to inform our understanding of the contexts and mechanisms
which influence reminder effectiveness. Secondly, we performed a review following Centre
for Reviews and Dissemination guidelines to investigate the effectiveness of different methods
of reminding patients to attend health service appointments. Finally, to supplement the effec-
tiveness information, we completed a review informed by realist principles to identify factors
likely to influence non-attendance behaviors and the effectiveness of reminders. We found
consistent evidence that all types of reminder systems are effective at improving appointment
attendance across a range of health care settings and patient populations. Reminder systems
may also increase cancellation and rescheduling of unwanted appointments. “Reminder plus”,
which provides additional information beyond the reminder function may be more effective than
simple reminders (ie, date, time, place) at reducing non-attendance at appointments in particular
circumstances. We identified six areas of inefficiency which indicate that reminder systems are
being used sub-optimally. Unless otherwise indicated, all patients should receive a reminder
to facilitate attendance at their health care appointment. The choice of reminder system should
be tailored to the individual service. To optimize appointment and reminder systems, health
care services need supportive administrative processes to enhance attendance, cancellation,
rescheduling, and re-allocation of appointments to other patients.
Keywords: attendance, cancellation, rescheduling, TURNUP
IntroductionMissed health care appointments are a major source of avoidable inefficiency that
impacts on patient health and treatment outcomes. Data on non-attendance vary,
however studies from around the world consistently report non-attendance rates of
between 15% and 30% in outpatient health clinics.1–4 In England, more than 12 million
appointments at consultant led clinics,5 and a similar number of general practice
appointments are missed each year.6 The cost of missed appointments to the UK
National Health Service (NHS) has tripled since 1999.7 In 2009, non-attendance was
estimated to cost over £600 million (around US$970 million).8
Correspondence: Sionnadh Mairi McLeanCollegiate Campus, Sheffield Hallam University, 38 Collegiate Crescent, Sheffield, S10 2BP, UKTel +44 114 225 2271email [email protected]
Journal name: Patient Preference and AdherenceArticle Designation: ReviewYear: 2016Volume: 10Running head verso: McLean et alRunning head recto: Effectiveness and optimization of appointment remindersDOI: http://dx.doi.org/10.2147/PPA.S93046
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McLean et al
The consequences of non-attendance include increased
appointment waiting times,9 increased costs of care delivery,10,11
underutilization of equipment and personnel,10 reduced
appointment availability,6,11 reduced patient satisfaction,12,13
and negative relationships between patients and staff.6,9 Missed
appointments may delay presentation at health services, result-
ing in a lack of follow-up of chronic conditions which may
ultimately lead to complications, unnecessary suffering, and
costly hospital admission.10,14 Pressures from referring agents
to manage waiting lists, can potentially increase staff stress,
anxiety, and fatigue levels.15 Reducing the number of missed
appointments may be a relatively inexpensive way to increase
health care efficiency, effectiveness, and quality.
Numerous reviews have demonstrated the effectiveness
of existing reminder systems in varied service settings.
However, research to-date focusses on the use of reminder
systems in particular service contexts or technologies,16–18
rather than synthesizing knowledge across different contexts
and patient groups. This study explores the effectiveness of
reminder systems for promoting attendance, cancellations,
and rescheduling of appointments across all health care set-
tings and for particular patient groups and the contextual
factors which indicate that reminders are being employed
sub-optimally.
Material and methodsOur project incorporated three components: the development
of a conceptual framework to provide an understanding of
the contexts and mechanisms which influence reminder
effectiveness (review 1); a systematic review (SR) of the
reminder effectiveness literature (review 2), and an evi-
dence synthesis informed by realist principles to explain
the contexts and mechanisms which influence reminder
effectiveness (review 3). We used realist inquiry because it
clarifies the context–mechanism–outcome relationships in an
attempt to understand better what works, for whom, under
what circumstances.19 Further detail on the methodology
employed is available in the TURNUP project report.20
Searches were conducted on 13 databases with date
limits of January 1, 2000 to February 15, 2012: AMED,
CINAHL Plus with Full Text, Cochrane Library, Embase,
HMIC, IEEE Xplore, Kings Fund Library Catalogue,
Maternity and Infant Care, MEDLINE, PEDro, PsycINFO,
SportDiscus, and Web of Science. The strategy used the
concept of (reminders/prompts/alerts) in proximity to
(appointments) (Figure 1). Where supported, appropriate
database headings/thesaurus terms were used. The refer-
ence lists of included randomized controlled trials (RCTs)
and SRs were screened for additional relevant studies and
citation (forward-) searches were performed in respect of
the included RCTs. English-language studies of various
quantitative and qualitative designs were included if they
investigated the effectiveness of outpatient appointment
reminders, appointment attendance behavior, or explicated
theories/models/frameworks relating to reminder systems
or appointment attendance. Studies were excluded if they
investigated reminders sent to a patient inviting them to
schedule an appointment. All members of the project team
were involved in screening and selection of studies and data
extraction from included studies.
Review 1We could find few pre-existing conceptual models or
frameworks that directly explain the mechanisms by which
CitationsS1 (MH “Reminder Systems”) 2,850S2 TI reminder* OR AB reminder* 8,104S3 TI appointment* OR AB appointment* 18,257S4 (MH “Appointments and Schedules”) 10,007S5 s3 OR s4 25,901S6 s5 AND s1 409S7 s1 OR s2 9,797S8 s7 AND s4 452S9 s6 OR s8 543S10 TI remind* n5 appointment* OR AB remind* n5 appointment* 277S11 TI prompt* n5 appointment* OR AB prompt* n5 appointment* 34S12 TI alert* n5 appointment* OR AB alert* n5 appointment* 6S13 S10 OR S11 OR S12 316S14 S9 OR S13 limiters – published date from: 20000101- 470
Figure 1 example search strategy.Note: example search strategy: CiNAHL Plus with Fulltext, MeDLiNe, SportDiscus (via eBSCO) 2000 to January 11, 2012.
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effectiveness and optimization of appointment reminders
reminder systems support appointment attendance.
We therefore drew on a variety of models that have been
developed to understand behavior in relation to medical
adherence. Included models related to use of reminders to
promote clinical outcomes;21 health care utilization theory;22
the theory of planned behavior;23 the trans-theoretical
model;24 self-determination theory;25 protection motivation
theory;26 rationale choice theory;27 and complexity theory.28
Our conceptual framework was developed through an itera-
tive process involving examination of the various theories
and discussions about context, mechanisms, and outcomes
that were important to explain how reminder systems work
to promote attendance, for whom, and in what circumstances.
The framework consisted of six broad factors that could
potentially influence the effectiveness of the reminder or
whether patients would attend, cancel or reschedule their
appointment, namely: the reminder-patient interaction,
reminder accessibility, health care settings, wider social
factors, cancellation and rebooking systems, and patient
attributes. This framework was then used to support data
extraction.
Review 2Our SR of effectiveness investigated the impact of reminder
systems on improvements in attendance, cancellations, and
rescheduling of appointments. The questions addressed in
this were: 1) how effective are reminder systems at reducing
non-attendance at appointments and increasing cancellation/
rescheduling of appointments? and 2) which types of reminder
systems are most effective in improving the uptake of health
service appointments? We used standardized methods to select,
quality assess, extract and synthesize the findings of SRs and
RCTs.29 The Critical Appraisal Skills Program appraisal tool
for RCTs was used to quality assess those RCTs not already
assessed in pre-existing SRs.30 The quality of the included
SRs was assessed against the criteria used by the Centre for
Reviews and Dissemination when evaluating reviews for
inclusion in the Database of Abstracts of Reviews of Effects.31
We used these quality assessments to moderate our interpreta-
tion of the review findings, not to exclude the papers.32
Review 3Our evidence synthesis aimed to explore the differential
effectiveness of reminder systems for particular population
sub-groups; to identify contexts and mechanisms which
influence the effectiveness of different reminder systems
for particular population sub-groups; and identify any
disadvantages which should be considered when introducing
reminder systems for specific populations. The data extrac-
tion framework used the six elements of the conceptual
framework. In accordance with realist principles, not all
potentially relevant papers identified from the screening con-
tributed to the synthesis.33 All RCTs investigating reminder
systems and all reviews (systematic and otherwise) about
reminder systems and appointment systems were prioritized
for full extraction of contextual and explanatory variables.
Whereas RCTs were required to meet minimum quality
standards in order to be included in the effectiveness SR,
the studies excluded from this SR still had the potential
to contribute to the evidence synthesis informed by realist
principles. In many cases findings from such studies con-
tributed to the evidence base regarding the mechanisms and
contexts that shape the operation of reminder systems in
real world settings. Examination of the trial evidence was fol-
lowed by exploration of qualitative, mixed-methods and non-
RCT quantitative studies about reminders and appointments
for Europe, America, Canada, Australia, and New Zealand.
Thematic analysis was used to examine the evidence avail-
able for each section of the framework. Subsequently a
narrative synthesis was developed that sought to explain the
context and mechanisms influencing how reminders support
attendance, cancellation, and rebooking.
ResultsThe PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) flowchart (Figure 2) shows
the numbers of included papers for review 2 and 3. Prelimi-
nary database searches yielded 638 unique papers; a further
139 were identified from subsequent searches. Following
the screening stages, 466 potentially relevant papers were
identified. Eleven SRs met the inclusion criteria for review 2
(Table 1).16–18,34–41 These SRs either examined a single tech-
nology, eg, an SR of short message service (SMS) reminder
systems,17 or explored the role of information technologies
along a patient care pathway, one of which might be appoint-
ment reminder systems.41 The quality of included reviews
was variable (Table 2). The five Cochrane reviews had been
scrutinized against the highest quality standards.16,18,34,36,40
Four reviews passed the Centre for Reviews and Dissemina-
tion SR quality threshold.17,35,39,41 Two reviews did not pass
the minimum standard for SRs.37,38
Of the 31 RCTs that met our inclusion criteria for
review2,4,42–72 only ten were uniquely identified by our
review. The included RCTs related to the use of systems
to remind patients to attend a health-related appointment
that had already been scheduled (Table 3). The majority of
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McLean et al
Figure 2 PRISMA flowchart for review 2 and 3.Abbreviations: PRiSMA, Preferred Reporting items for Systematic Reviews and Meta-Analyses; SRs, systematic reviews; RCTs, randomized controlled trials; Ti, titles; AB, abstracts.
Table 1 Reminder technologies covered by each review
Study Letter Manual telephone
Automated telephone
Mobile/SMS Voice messaging
Email Other
Atherton et al18 Car et al34 Free et al35 Glynn et al36
Guy et al17 Hasvold and wootton37 Henderson38 Jacobson vann and Szilagyi16 Krishna et al39 Reda and Makhoul40 Personal visitStubbs et al41 Open access
scheduling
Abbreviation: SMS, short message service.
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effectiveness and optimization of appointment reminders
Tab
le 2
Rev
iew
s in
clud
ed in
thi
s re
view
with
an
asse
ssm
ent
of t
heir
qua
lity
Stud
yR
evie
w q
uest
ion/
aim
sO
vera
ll re
view
qua
lity
Impl
icat
ions
for
tech
nolo
gies
Impl
icat
ions
for
spec
ific
popu
lati
ons
Ath
erto
n
et a
l18
To a
sses
s ef
fect
s of
usin
g em
ail
for
coor
dina
tion
of h
ealth
car
e ap
poin
tmen
ts a
nd a
tten
danc
e re
min
ders
, com
pare
d to
ot
her
form
s of
coo
rdin
atin
g ap
poin
tmen
ts a
nd r
emin
ders
, on
outc
omes
for
heal
th p
rofe
ssio
nals,
pa
tient
s an
d ca
rers
, and
hea
lth
serv
ices
, inc
ludi
ng h
arm
s.
Coc
hran
e em
pty
Rev
iew
with
no
elig
ible
stu
dies
. A
lim
itatio
n of
thi
s re
view
is t
he d
ate
of t
he s
earc
h.
The
sea
rch
was
con
duct
ed in
Janu
ary
2010
. Len
gth
of t
ime
betw
een
sear
ch d
ate
and
publ
icat
ion
of
revi
ew m
eans
it is
pos
sibl
e th
at r
elev
ant
stud
ies
have
be
en p
ublis
hed
in in
teri
m p
erio
d.
Not
app
licab
leN
ot a
pplic
able
Car
et
al34
To
asse
ss e
ffect
s of
mob
ile
phon
e m
essa
ging
rem
inde
rs
for
atte
ndan
ce a
t he
alth
car
e ap
poin
tmen
ts. S
econ
dary
ob
ject
ives
incl
ude
asse
ssm
ent
of
patie
nt a
nd h
ealth
car
e pr
ovid
er
eval
uatio
ns o
f int
erve
ntio
n; c
osts
; an
d po
ssib
le r
isks
and
har
ms
asso
ciat
ed w
ith in
terv
entio
n.
Coc
hran
e R
evie
w. i
nclu
ded
stud
ies
wer
e of
var
ying
m
etho
dolo
gica
l qua
lity;
mos
t pr
ovid
ed in
suffi
cien
t in
form
atio
n to
acc
urat
ely
asse
ss r
isk
of b
ias.
Se
quen
ce g
ener
atio
n fo
r ra
ndom
izat
ion
cons
ider
ed
adeq
uate
(al
thou
gh r
ando
miz
atio
n m
etho
d un
clea
r in
one
stu
dy)
but
in t
wo
stud
ies
it w
as n
ot c
lear
w
heth
er, a
nd h
ow, a
lloca
tion
was
con
ceal
ed. L
ack
of b
lindi
ng in
all
stud
ies
can
be p
artly
exp
lain
ed b
y in
tera
ctiv
e na
ture
of t
ext
mes
sage
inte
rven
tions
, w
hich
doe
s no
t pe
rmit
blin
ding
of p
artic
ipan
ts o
r he
alth
car
e pr
ovid
ers.
Pot
entia
l bia
s fr
om a
ppar
ent
lack
of b
lindi
ng o
f out
com
e as
sess
ors.
incl
uded
4 R
CT
s in
volv
ing
3,54
7 pa
rtic
ipan
ts.
Thr
ee s
tudi
es w
ith m
oder
ate
qual
ity e
vide
nce
show
ed
that
mob
ile t
ext
mes
sage
rem
inde
rs im
prov
ed r
ate
of
atte
ndan
ce c
ompa
red
to n
o re
min
ders
(R
R 1
.10
[9
5% C
i] 1.
03 t
o 1.
17).
One
low
qua
lity
stud
y re
port
ed th
at m
obile
text
m
essa
ge r
emin
ders
with
pos
tal r
emin
ders
, com
pare
d to
pos
tal r
emin
ders
, impr
oved
rat
e of
att
enda
nce
at h
ealth
car
e ap
poin
tmen
ts (R
R 1.
10 [9
5% C
i 1.0
2 to
1.1
9]).
How
ever
, tw
o st
udie
s of
mod
erat
e qu
ality
sh
owed
that
mob
ile p
hone
text
mes
sage
rem
inde
rs
and
phon
e ca
ll re
min
ders
had
a s
imila
r im
pact
on
heal
th c
are
atte
ndan
ce (R
R 0.
99 [9
5% C
i] 0.
95 to
1.0
3).
Cos
ts/a
tten
danc
e of
SM
S lo
wer
com
pare
d to
pho
ne
rem
inde
rs. N
o st
udie
s re
port
ed h
arm
s or
adv
erse
ef
fect
s of
the
inte
rven
tion,
nor
hea
lth o
utco
mes
or
user
per
cept
ion
of s
afet
y re
late
d to
the
inte
rven
tion.
Furt
her
rese
arch
sho
uld
focu
s on
old
er
patie
nts,
giv
en t
hat
this
pop
ulat
ion
has,
on
aver
age,
mor
e he
alth
car
e ap
poin
tmen
ts a
nd u
ses
mob
ile p
hone
s le
ss fr
eque
ntly
tha
n th
e yo
unge
r po
pula
tion.
Free
et
al35
To
quan
tify
effe
ctiv
enes
s of
m
obile
tec
hnol
ogy
base
d in
terv
entio
ns d
eliv
ered
to
heal
th
care
pro
vide
rs o
r to
sup
port
he
alth
car
e se
rvic
es, o
n an
y he
alth
or
heal
th c
are
serv
ice
outc
ome.
Iden
tified
as
mee
ting
CR
D c
rite
ria.
No
full
eval
uatio
n ye
t av
aila
ble.
Pool
ed e
ffect
on
appo
intm
ent a
tten
danc
e us
ing
text
m
essa
ge (S
MS)
rem
inde
rs v
s no
rem
inde
r in
crea
sed,
w
ith R
R of
1.0
6 (9
5% C
i 1.0
5–1.
07, I2 =
6%).
Pool
ed
effe
cts
on n
umbe
r of
can
celle
d ap
poin
tmen
ts w
as n
ot
signi
fican
tly in
crea
sed
RR 1
.08
(95%
CI 0
.89–
1.30
). N
o di
ffere
nce
in a
tten
danc
e us
ing
SMS
rem
inde
rs
vs o
ther
rem
inde
rs (R
R 0.
98, 9
5% C
i 0.9
4–1.
02,
resp
ectiv
ely)
. SM
S re
min
ders
no
mor
e ef
fect
ive
than
po
stal
or
phon
e ca
ll re
min
ders
, and
text
ing
rem
inde
rs to
pa
tient
s w
ho p
ersis
tent
ly m
issed
app
oint
men
ts d
id n
ot
signi
fican
tly c
hang
e nu
mbe
r of
can
celle
d ap
poin
tmen
ts.
SMS
appo
intm
ent r
emin
ders
hav
e m
odes
t ben
efits
and
m
ay b
e ap
prop
riate
for
impl
emen
tatio
n.
(Con
tinue
d)
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McLean et al
Tab
le 2
(Co
ntin
ued)
Stud
yR
evie
w q
uest
ion/
aim
sO
vera
ll re
view
qua
lity
Impl
icat
ions
for
tech
nolo
gies
Impl
icat
ions
for
spec
ific
popu
lati
ons
Gly
nn
et a
l36
To
eval
uate
the
effe
ctiv
enes
s of
rem
inde
rs o
n im
prov
ing
the
follo
w-u
p of
pat
ient
s w
ith
hype
rten
sion
.
Coc
hran
e R
evie
w. i
nclu
ded
RC
Ts
with
a
cont
empo
rane
ous
cont
rol g
roup
. The
met
hodo
logi
cal
qual
ity o
f inc
lude
d st
udie
s w
as g
ener
ally
poo
r to
m
oder
ate
with
40%
of i
nclu
ded
artic
les
desc
ribi
ng
thei
r ra
ndom
izat
ion
proc
esse
s an
d on
ly 1
9%
desc
ribi
ng a
dequ
ate
conc
eale
d al
loca
tion
proc
esse
s.
incl
uded
8 R
CT
s in
vest
igat
ing
appo
intm
ent
rem
inde
r sy
stem
s. A
ll bu
t on
e of
the
RC
Ts
wer
e as
soci
ated
w
ith im
prov
ed o
utco
mes
. The
poo
led
resu
lts fa
vore
d ap
poin
tmen
t re
min
der
syst
ems
for
follo
w-u
p of
pa
tient
s (o
dds
ratio
of b
eing
lost
to
follo
w-u
p 0.
4,
95%
Ci 0
.3 t
o 0.
5).
Guy
et
al17
To
asse
ss t
he e
ffect
iven
ess
of
SMS
rem
inde
rs a
t in
crea
sing
the
up
take
of a
ppoi
ntm
ents
in h
ealth
ca
re s
ettin
gs.
Alth
ough
gra
y lit
erat
ure
was
sea
rche
d, it
was
stil
l po
ssib
le t
hat
som
e ev
alua
tions
wer
e no
t id
entifi
ed,
part
icul
arly
tho
se w
ith a
neg
ativ
e ou
tcom
e. U
nabl
e to
ass
ess
poss
ibili
ty o
f effe
ct a
ccor
ding
to
clin
ical
re
ason
s fo
r at
tend
ing,
as
few
pap
ers
pres
ente
d th
is in
form
atio
n. C
linic
al p
rese
ntat
ion
coul
d af
fect
pr
iori
ty p
lace
d by
pat
ient
s on
the
nee
d fo
r ke
epin
g an
app
oint
men
t.T
o m
axim
ize
valu
e of
futu
re e
valu
atio
ns, s
tudi
es
shou
ld c
olle
ct a
nd r
epor
t in
form
atio
n on
clin
ical
re
ason
for
atte
ndan
ce a
s w
ell a
s th
e vi
sit
stat
us
(new
, fol
low
-up)
.
Sum
mar
y ef
fect
from
RC
Ts
was
1.4
8 (9
5% C
i: 1.
23–1
.72)
. No
sign
ifica
nt s
ub-g
roup
diff
eren
ces
by
clin
ic t
ype
(pri
mar
y ca
re c
linic
s, h
ospi
tal o
utpa
tient
cl
inic
s) o
r m
essa
ge t
imin
g (2
4, 4
8, a
nd 7
2+ h
ours
be
fore
sch
edul
ed a
ppoi
ntm
ent)
.SM
S re
min
ders
sub
stan
tially
incr
ease
like
lihoo
d of
at
tend
ing
clin
ic a
ppoi
ntm
ents
. SM
S re
min
ders
app
ear
to b
e si
mpl
e an
d ef
ficie
nt o
ptio
n fo
r he
alth
ser
vice
s to
impr
ove
serv
ice
deliv
ery,
as
wel
l as
brin
ging
hea
lth
bene
fits
for
patie
nts
who
rec
eive
the
rem
inde
rs.
No
sign
ifica
nt s
ub-g
roup
diff
eren
ces
by
targ
et a
ge g
roup
(pe
diat
ric,
adul
t, ol
der)
. A
ge c
lass
ifica
tion
base
d on
med
ian
age
of p
atie
nt r
ecei
ving
SM
S re
min
ders
, or
spec
ifica
tion
of c
linic
typ
e as
ped
iatr
ic.
RC
Ts
dem
onst
rate
d SM
S re
min
ders
ef
fect
ive
in w
ide
age
rang
e fr
om
pedi
atri
c to
old
er. M
obile
usa
ge
data
dem
onst
rate
tha
t ov
er 9
0% o
f po
pula
tion
in m
any
coun
trie
s ow
n m
obile
pho
nes,
but
upta
ke is
hig
her
in
youn
ger
peop
le.86
As
youn
ger
patie
nts
have
hig
her
non-
atte
ndan
ce r
ates
at
clin
ical
ser
vice
s,10
0 SM
S re
min
ders
m
ay b
e m
ore
bene
ficia
l in
this
gr
oup.
How
ever
, old
er p
atie
nts
have
co
nsid
erab
ly m
ore
heal
th a
ppoi
ntm
ents
ea
ch y
ear,
ofte
n at
out
patie
nt c
linic
s w
here
non
-att
enda
nce
cost
s U
K N
HS
estim
ated
£79
0 m
illio
n pe
r ye
ar.10
1
Has
vold
and
w
oott
on37
1) w
hat
is t
he b
est
estim
ate
of
effe
ct o
f sen
ding
rem
inde
rs
on n
on-a
tten
danc
e ra
tes?
2) A
re t
here
any
diff
eren
ces
in
non-
atte
ndan
ce w
hen
usin
g re
min
ders
sen
t m
anua
lly (
ie,
from
pho
nes
oper
ated
by
a hu
man
) or
aut
omat
ical
ly (
ie,
by S
MS
text
mes
sage
s or
by
auto
mat
ed v
oice
rec
ordi
ngs)
?3)
Doe
s tim
e at
whi
ch t
he
rem
inde
r is
sen
t in
fluen
ce
the
effe
ct o
n no
n- a
tten
danc
e ra
tes?
4) W
hat
are
cost
s an
d be
nefit
s of
us
ing
rem
inde
rs?
Not
cla
ssed
as
syst
emat
ic r
evie
w b
y D
AR
e (C
RD
). Pu
bMed
onl
y se
arch
ed.
wei
ghte
d m
ean
rela
tive
chan
ge in
non
-att
enda
nce
was
34%
of b
asel
ine
non-
atte
ndan
ce r
ate.
Aut
omat
ed r
emin
ders
less
effe
ctiv
e th
an m
anua
l ph
one
calls
(29
% v
s 39
% o
f bas
elin
e va
lue)
.N
o di
ffere
nce
in n
on-a
tten
danc
e ra
te, w
heth
er
rem
inde
r se
nt d
ay b
efor
e or
wee
k be
fore
.C
ost
and
savi
ngs
not
mea
sure
d fo
rmal
ly, b
ut a
lmos
t ha
lf in
clud
ed c
ost
estim
ates
. Ave
rage
cos
t of
usi
ng
eith
er S
MS,
aut
omat
ed p
hone
cal
ls o
r ph
one
calls
was
0.
41 e
uros
per
rem
inde
r.
All
stud
ies
exce
pt o
ne10
2 sho
wed
po
sitiv
e ef
fect
from
usin
g re
min
ders
. (P
atie
nts
them
selv
es c
hose
in a
dvan
ce
whe
ther
the
y w
ished
to
rece
ive
rem
inde
r or
not
– p
oten
tial b
ias
in
inte
rven
tion
grou
p.) O
vera
ll no
-sh
ow r
ate
(out
patie
nts
in v
ascu
lar
labo
rato
ry) w
as 1
2% (a
vera
ge 7
.6
miss
ed a
ppoi
ntm
ents
/wee
k: gr
oss
annu
al
reve
nue
loss
of U
S$89
,107
bas
ed o
n ul
tras
ound
cos
ts).
Of 8
,766
pat
ient
s of
fere
d au
tom
ated
rem
inde
rs, o
nly
53%
agr
eed
to r
ecei
ve c
alls.
No-
show
ra
te s
igni
fican
tly g
reat
er fo
r pa
tient
s ch
oosin
g au
tom
ated
rem
inde
rs
(8.9
% v
s 5.
9%, P
,0.
0001
).
Patient Preference and Adherence 2016:10 submit your manuscript | www.dovepress.com
Dovepress
Dovepress
485
effectiveness and optimization of appointment reminders
Hen
ders
on38
To
asse
ss t
he e
ffect
iven
ess
of
appo
intm
ent
rem
inde
rs a
s a
mea
ns o
f inc
reas
ing
atte
ndan
ce
and
redu
cing
DN
A r
ates
at
new
ou
tpat
ient
app
oint
men
ts.
Not
cla
ssed
as
syst
emat
ic r
evie
w b
y D
AR
e (C
RD
). U
nder
take
n by
sin
gle
revi
ewer
, with
pos
sibi
lity
of r
evie
wer
bia
s. H
and-
sear
chin
g no
t pe
rfor
med
. N
on-e
nglis
h la
ngua
ge p
aper
s no
t in
clud
ed. R
elev
ant
mat
eria
l may
hav
e be
en m
isse
d.M
etho
dolo
gica
l qua
lity
of e
vide
nce
base
gen
eral
ly
poor
. Sev
eral
tri
als
faile
d to
des
crib
e ra
ndom
izat
ion.
in
man
y st
udie
s bl
indi
ng w
as p
oorl
y ad
dres
sed,
stu
dy
part
icip
ants
wer
e in
adeq
uate
ly d
escr
ibed
and
onl
y a
smal
l num
ber
of p
artic
ipan
ts w
ere
recr
uite
d.
Tel
epho
ne r
emin
ders
, if r
ecei
ved,
can
hav
e a
posi
tive
impa
ct o
n at
tend
ance
and
DN
A r
ates
.Po
stal
rem
inde
rs fo
und
to b
e ef
fect
ive.
Alth
ough
lim
ited,
lite
ratu
re s
ugge
sts
that
the
impa
ct o
f “s
tand
ard”
rem
inde
rs is
sim
ilar
to t
hat
of t
elep
hone
re
min
ders
. Sug
gest
s th
at “
Rem
inde
r pl
us”
is m
ore
effe
ctiv
e th
an “
stan
dard
” re
min
ders
.
impa
ct o
f im
plem
entin
g in
itiat
ives
on
ineq
ualit
ies
in a
cces
s to
ser
vice
s no
t co
nsid
ered
by
any
stud
ies
incl
uded
in
revi
ew.
Maj
ority
of i
nclu
ded
stud
ies
cond
ucte
d in
psy
chia
tric
set
tings
out
side
the
UK
, ra
isin
g is
sues
of g
ener
aliz
abili
ty.
Jaco
bson
v
ann
and
Szila
gyi16
To
asse
ss o
vera
ll ef
fect
iven
ess
of p
atie
nt r
emin
der
or r
ecal
l sy
stem
s, o
r bo
th, i
n im
prov
ing
imm
uniz
atio
n ra
tes;
com
pare
ef
fect
iven
ess
of d
iffer
ent
type
s of
re
min
der
or r
ecal
l int
erve
ntio
ns
(eg,
pos
tcar
d, le
tter
, tel
epho
ne),
or c
ombi
natio
n of
bot
h re
min
der
and
reca
ll.
Coc
hran
e R
evie
w.
Rem
indi
ng p
eopl
e ov
er t
elep
hone
, sen
ding
a le
tter
or
pos
tcar
d, o
r sp
eaki
ng t
o th
em in
per
son
incr
ease
d va
ccin
atio
ns. P
rovi
ding
num
erou
s re
min
ders
was
m
ore
effe
ctiv
e th
an s
ingl
e re
min
ders
. Rem
indi
ng
peop
le o
ver
tele
phon
e m
ore
effe
ctiv
e th
an p
ostc
ard
or le
tter
rem
inde
rs. R
emin
ders
ove
r te
leph
one
may
be
exp
ensi
ve c
ompa
red
with
alte
rnat
ive
appr
oach
es.
Rem
inde
rs w
orke
d w
heth
er fr
om p
riva
te d
octo
r’s
offic
e, m
edic
al c
ente
r, o
r pu
blic
hea
lth d
epar
tmen
t cl
inic
. Stu
dies
all
from
dev
elop
ed c
ount
ries
.
Rem
indi
ng p
eopl
e to
hav
e va
ccin
atio
ns
incr
ease
d th
e nu
mbe
r of
peo
ple
vacc
inat
ed, w
heth
er t
he p
eopl
e w
ere
due
or o
verd
ue fo
r va
ccin
atio
ns.
incr
ease
s w
ere
obse
rved
in b
oth
child
ren
and
adul
ts fo
r al
l typ
es
of v
acci
nes,
but
not
am
ong
urba
n ad
oles
cent
s in
one
stu
dy.
Kri
shna
et
al39
To
inve
stig
ate
role
of c
ell p
hone
s an
d te
xt m
essa
ging
inte
rven
tions
in
impr
ovin
g he
alth
out
com
es a
nd
proc
esse
s of
car
e.
Res
earc
h qu
estio
n su
ppor
ted
by in
clus
ion
crite
ria
for
stud
y de
sign
, int
erve
ntio
n an
d ou
tcom
es.
Aut
hors
did
not
rep
ort
sear
ches
of u
npub
lishe
d da
ta. O
nly
stud
ies
publ
ishe
d in
eng
lish/
engl
ish-
lang
uage
abs
trac
ts e
ligib
le fo
r in
clus
ion.
Pub
licat
ion/
lang
uage
bia
s co
uld
not
be r
uled
out
. Aut
hors
did
no
t re
port
rev
iew
pro
cess
, so
not
know
n w
heth
er
step
s ta
ken
to r
educ
e po
ssib
le e
rror
and
bia
s (s
uch
as p
erfo
rmin
g pr
oces
ses
in d
uplic
ate)
. Stu
dy
qual
ity n
ot a
sses
sed,
so
unkn
own
whe
ther
res
ults
of
incl
uded
stu
dies
wer
e re
liabl
e. M
any
stud
ies
had
smal
l sam
ple
size
s. N
arra
tive
synt
hesi
s w
as
appr
opri
ate
give
n di
vers
ity o
f inc
lude
d st
udie
s.
Due
to
poss
ibili
ty o
f bia
s an
d er
ror
in r
evie
w
proc
ess
and
unkn
own
qual
ity o
f inc
lude
d st
udie
s,
auth
ors’
con
clus
ions
may
not
be
relia
ble.
Tex
t m
essa
ging
ass
ocia
ted
with
few
er d
ays
to
diag
nosi
s (o
ne s
tudy
). Fa
ilure
-to-
atte
nd r
ates
si
gnifi
cant
ly im
prov
ed in
tw
o st
udie
s, b
ut d
id n
ot d
iffer
si
gnifi
cant
ly b
etw
een
inte
rven
tion/
cont
rol g
roup
s in
tw
o ot
her
stud
ies.
Mob
ile p
hone
rem
inde
r, d
isea
se
mon
itori
ng a
nd m
anag
emen
t, an
d ed
ucat
ion
can
impr
ove
heal
th o
utco
mes
and
car
e pr
oces
ses.
Text
mes
sagi
ng a
ssoc
iate
d w
ith
impr
oved
com
mun
icat
ion
in p
artic
ipan
ts
with
dis
abili
ties
(one
stu
dy).
Red
a an
d M
akho
ul40
To
estim
ate
the
effe
cts
of s
impl
e pr
ompt
ing
by p
rofe
ssio
nal c
arer
sto
enc
oura
ge a
tten
danc
e at
cl
inic
s fo
r th
ose
with
sus
pect
ed
seri
ous
men
tal i
llnes
s.
Coc
hran
e R
evie
w.
No
clea
r di
ffere
nce
betw
een
thos
e pr
ompt
ed b
y te
leph
one
1 or
2 d
ays
befo
re a
ppoi
ntm
ent v
s th
ose
give
n st
anda
rd a
ppoi
ntm
ent m
anag
emen
t sys
tem
(2
RC
Ts, n
=457
, RR
miss
ed a
ppoi
ntm
ent 0
.84
95%
C
i 0.7
–1.1
). Tex
t-ba
sed
prom
pts
such
as
a le
tter
, a fe
w
days
bef
ore
the
appo
intm
ent d
ay, m
ay in
crea
se c
linic
at
tend
ance
vs
indi
catio
n th
at fo
r se
riou
s m
enta
l illn
ess
it m
ay b
e im
port
ant
to p
rovi
de t
extu
al
rem
inde
r pl
us o
rien
tatio
n st
atem
ent
(a
sho
rt p
arag
raph
, tak
ing
abou
t
30 se
cond
s to
read
, exp
laini
ng th
e pr
ogra
m
of c
are,
the
fee
syst
em, a
nd p
rovid
ing
(Con
tinue
d)
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Dovepress
Dovepress
486
McLean et al
Tab
le 2
(Co
ntin
ued)
Stud
yR
evie
w q
uest
ion/
aim
sO
vera
ll re
view
qua
lity
Impl
icat
ions
for
tech
nolo
gies
Impl
icat
ions
for
spec
ific
popu
lati
ons
no p
rom
pt (3
RC
Ts, n
=326
, RR
miss
ed a
ppoi
ntm
ent 0
.76
95%
Ci 0
.43–
1.32
). O
ne s
mal
l stu
dy (n
=61)
com
bine
d te
leph
one/
text
-bas
ed p
rom
pts
vs n
o pr
ompt
, no
real
di
ffere
nce
betw
een
grou
ps (R
R m
issed
app
oint
men
t 0.
7 95
% C
i 0.4
–1.2
). Tel
epho
ne p
rom
pts
vs te
xt-b
ased
pr
ompt
s (1
RC
T, n=
75),
the
latt
er, a
s an
“orie
ntat
ion
stat
emen
t” m
ay b
e m
ore
effe
ctiv
e th
an te
leph
one
prom
pt (R
R m
issed
app
oint
men
t 1.9
95%
Ci 0
.98–
3.8)
. O
ne s
tudy
(n=1
20) c
ompa
red
stan
dard
lett
er p
rom
pt
vs a
lett
er o
rient
atio
n st
atem
ent.
Ove
rall,
resu
lts te
nded
to
favo
r or
ient
atio
n st
atem
ent v
s sim
ple
lett
er b
ut n
ot
stat
istic
ally
sig
nific
ant (
RR m
issed
app
oint
men
t 1.6
95%
C
i 0.9
–2.9
). Fo
r pr
ompt
s re
gard
less
of t
ype,
resu
lts o
f gr
eate
r sig
nific
ance
sug
gest
incr
ease
d at
tend
ance
(RR
m
issed
app
oint
men
t 0.8
0 95
% C
i 0.6
5–0.
98).
gent
le e
ncou
rage
men
t).65
Con
tras
ts
with
gen
eral
tren
d in
favo
r of
tele
phon
e re
min
ders
.
Stub
bs
et a
l41
To
com
pare
tel
epho
ne, m
ail,
text
/SM
S, e
lect
roni
c m
ail
and
open
-acc
ess
sche
dulin
g to
det
erm
ine
whi
ch is
bes
t at
red
ucin
g ou
tpat
ient
non
-at
tend
ance
and
pro
vidi
ng n
et
finan
cial
ben
efit.
Revi
ew a
ddre
ssed
bro
ad r
esea
rch
ques
tion
to e
valu
ate
impa
ct o
f all
met
hods
for
redu
cing
out
patie
nt n
on-
atte
ndan
ce. M
etho
ds u
sed
to id
entif
y an
d se
lect
stu
dies
fo
r in
clus
ion
gene
rally
cle
ar, b
ut p
ublic
atio
n bi
as c
anno
t be
rul
ed o
ut. N
o at
tem
pts
to a
sses
s st
udy
qual
ity o
r m
inim
ize
erro
rs a
nd b
ias
in r
evie
w p
roce
ss m
entio
ned.
incl
uded
stu
dies
ext
rem
ely
dive
rse
in p
opul
atio
ns,
sett
ings
, and
res
earc
h m
etho
ds. A
naly
sis b
ased
on
simpl
e w
eigh
ted
aver
age
for
each
app
roac
h (t
elep
hone
, te
xt, p
ost,
or o
pen
acce
ss).
Influ
ence
of o
ther
rel
evan
t fa
ctor
s on
non
-att
enda
nce
not e
xplo
red.
Aut
hors
ac
know
ledg
e th
at o
nly
mor
e re
cent
stu
dies
(ele
ctro
nic
rath
er th
an p
aper
rem
inde
rs) l
ikel
y to
be
rele
vant
now
.Po
tent
ial p
ublic
atio
n bi
as n
otw
ithst
andi
ng, a
utho
rs
conc
lude
tha
t m
ost
incl
uded
inte
rven
tions
mod
estly
im
prov
ed a
tten
danc
e. A
ppea
rs r
elia
ble,
but
did
not
in
vest
igat
e fa
ctor
s th
at m
ight
influ
ence
effe
ctiv
enes
s of
the
se in
terv
entio
ns in
diff
eren
t po
pula
tions
and
se
ttin
gs. D
iffer
ent
rem
inde
rs n
ot c
ompa
red
with
eac
h ot
her.
Con
clus
ion
that
tel
epho
ne r
emin
ders
wer
e be
tter
tha
n te
xt a
nd p
ost
rem
inde
rs m
ay n
ot b
e re
liabl
e. N
o fo
rmal
eva
luat
ion
of c
ost-
effe
ctiv
enes
s, so
con
clus
ion
on r
elat
ive
cost
-effe
ctiv
enes
s of
in
terv
entio
ns a
lso m
ay n
ot b
e re
liabl
e.
Tel
epho
ne, m
ail,
and
text
/SM
S in
terv
entio
ns a
ll im
prov
ed a
tten
danc
e m
odes
tly b
ut a
t va
ryin
g co
sts.
T
ext
mes
sagi
ng m
ost
cost
-effe
ctiv
e of
the
thr
ee, b
ut
its a
pplic
abili
ty m
ay b
e lim
ited.
Few
dat
a av
aila
ble
rega
rdin
g el
ectr
onic
mai
l rem
inde
rs, w
here
as o
pen-
acce
ss s
ched
ulin
g is
are
a of
act
ive
rese
arch
.
Not
e: w
e ac
know
ledg
e th
e as
sist
ance
of t
he C
entr
e fo
r R
evie
ws
and
Dis
sem
inat
ion
in p
rovi
ding
qua
lity
asse
ssm
ents
for
incl
uded
rev
iew
s, in
clud
ing
the
Stub
bs e
t al
41 r
evie
w w
hich
was
pro
vide
d on
dem
and.
Abb
revi
atio
ns: R
CT
, ran
dom
ized
con
trol
led
tria
l; R
R, r
elat
ive
risk
; CI,
confi
denc
e in
terv
al; C
RD
, Cen
tre
for
Rev
iew
s an
d D
isse
min
atio
n; S
MS,
sho
rt m
essa
ge s
ervi
ce; D
AR
E, D
atab
ase
of A
bstr
acts
of R
evie
ws
of E
ffect
s; D
NA
, did
not
att
end;
N
HS,
UK
Nat
iona
l Hea
lth S
ervi
ce.
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487
effectiveness and optimization of appointment reminders
Tab
le 3
Rem
inde
r te
chno
logi
es a
sses
sed
and
outc
omes
rep
orte
d by
eac
h R
CT
Stud
ySt
udy
char
acte
rist
ics
Lett
erP
erso
naliz
ed
tele
phon
e ca
llA
utom
ated
te
leph
one
Mob
ile/
SMS
Voi
ce
mes
sagi
ngE
mai
lO
ther
Com
para
tor
Att
enda
nce
outc
omes
Ove
rall
effe
ct
Bos
et a
l42th
e N
ethe
rlan
ds,
orth
odon
tic c
linic
, (N
=301
)
N
o re
min
der
Stan
dard
ized
failu
re r
ate;
re
spon
dent
s’ a
ttitu
des
to r
ecei
ving
rem
inde
r;
resp
onde
nts’
rem
inde
r pr
efer
ence
s
Non
-att
enda
nce
rate
red
uced
by
4.5
%
Can
et
al43
UK
, ort
hodo
ntic
clin
ic,
(N=2
31)
i
No
rem
inde
rA
tten
danc
e ra
tes
Non
-att
enda
nce
rate
red
uced
by
4.2
%C
hen
et a
l44Pe
ople
’s R
epub
lic o
f C
hina
, hea
lth p
rom
otio
n ce
nter
, (N
=1,8
59)
No
rem
inde
rA
tten
danc
e ra
tes;
cos
t pe
r at
tend
ance
of i
nter
vent
ion
Non
-att
enda
nce
rate
red
uced
by
7%
Chi
u45H
ong
Kon
g, r
adio
logy
ou
tpat
ient
s, (
N=3
11)
No
rem
inde
rA
tten
danc
e ra
tes
Non
-att
enda
nce
rate
red
uced
by
9.4
%C
ho e
t al
46K
orea
, hos
pita
l-ba
sed
fam
ily p
ract
ice
outp
atie
nts,
(N
=918
)
No
rem
inde
rA
tten
danc
e ra
tes;
cos
t pe
r at
tend
ance
Non
-att
enda
nce
rate
red
uced
by
3.4
% (
SMS)
and
by
1.1%
(t
elep
hone
cal
l)C
hris
tens
en
et a
l47
USA
, chi
ldre
n’s
dent
al
clin
ic, (
N=3
13)
ii
No
rem
inde
rPu
nctu
ality
for
appo
intm
ent
(15
min
utes
); ra
te o
f mis
sed
appo
intm
ents
Non
-att
enda
nce
rate
red
uced
by
21%
(48
hou
rs)
and
by 2
6%
(24
hour
s)C
omfo
rt
et a
l48
USA
, sub
stan
ce a
buse
cl
inic
, (N
=102
)
No
enga
gem
ent
enga
gem
ent
with
ser
vice
sN
o st
atis
tical
ly s
igni
fican
t di
ffere
nces
Cos
ta e
t al
,49
Cos
ta e
t al
50
Port
ugal
, out
patie
nts
clin
ics,
(N
=3,3
62)
N
o re
min
der
Non
-att
enda
nce
rate
Non
-att
enda
nce
rate
red
uced
by
3.5
%Fa
irhu
rst
and
Shei
kh51
UK
, inn
er-c
ity g
ener
al
prac
tice,
(N
=418
)
No
rem
inde
rN
on-a
tten
danc
e ra
tes
Non
-att
enda
nce
rate
red
uced
by
5.3
%G
olde
nber
g et
al52
USA
, tea
chin
g cl
inic
, (N
=723
)
iiiN
o re
min
der
Att
enda
nce
(sho
w)
rate
sN
on-a
tten
danc
e ra
te r
educ
ed
by 1
0%G
riffi
n
et a
l53
USA
, col
posc
opy
clin
ic,
(N=1
,876
)
iv
No
rem
inde
rA
ppoi
ntm
ent
non-
atte
ndan
ce; p
atie
nt
perc
eptio
ns a
bout
the
cal
l
38%
, 42%
, and
41%
did
not
at
tend
in iv
R7,
ivR
3, a
nd N
DC
ar
ms,
res
pect
ivel
y; 3
3% (
FS)
and
38%
(co
lono
scop
y) n
on-
atte
ndan
ce a
t ba
selin
eH
ashi
m
et a
l54
USA
, urb
an fa
mily
pr
actic
e, (
N=9
30)
N
o re
min
der
Out
com
e of
cal
l (c
onfir
med
, una
ble
to le
ave
mes
sage
, app
oint
men
t ca
ncel
led
by p
atie
nt/fa
mily
, ap
poin
tmen
t re
-sch
edul
ed
by p
atie
nt/fa
mily
, or
no
activ
e te
leph
one
num
ber)
; co
st o
f rem
inde
rs
Non
-att
enda
nce
rate
red
uced
by
6.9
% (
95%
Ci,
1.5%
–12%
)
(Con
tinue
d)
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488
McLean et al
Tab
le 3
(Co
ntin
ued)
Stud
ySt
udy
char
acte
rist
ics
Lett
erP
erso
naliz
ed
tele
phon
e ca
llA
utom
ated
te
leph
one
Mob
ile/
SMS
Voi
ce
mes
sagi
ngE
mai
lO
ther
Com
para
tor
Att
enda
nce
outc
omes
Ove
rall
effe
ct
irig
oyen
et
al55
USA
, ped
iatr
ic
vacc
inat
ion
clin
ic,
(N=1
,273
)
v
N
o re
min
der
App
oint
men
t ra
tes;
va
ccin
atio
n co
vera
ge; c
ost
of r
emin
ders
Non
-att
enda
nce
rate
red
uced
by
6.7
%
Kitc
hem
an
et a
l56
UK
, inn
er-c
ity
outp
atie
nts,
(N
=764
)
No
rem
inde
rA
tten
danc
e at
firs
t ap
poin
tmen
t; co
ntin
uing
at
tend
ance
; hos
pita
lizat
ion,
tr
ansf
er o
f car
e, d
isch
arge
, pr
esen
tatio
n at
acc
iden
t an
d em
erge
ncy
and
deat
h by
1 y
ear
Non
-att
enda
nce
rate
red
uced
by
6.5
%
Kou
ry a
nd
Fari
s57
UK
, ear
, nos
e an
d th
roat
clin
ics;
(N
=291
)
N
o re
min
der
Non
-att
enda
nce
rate
; w
illin
gnes
s to
rec
eive
SM
SN
on-a
tten
danc
e ra
te r
educ
ed
by 8
%K
won
et
al58
USA
, ele
ctro
diag
nost
ic
labo
rato
ry; (
N=4
04)
N
o re
min
der
Non
-att
enda
nce
with
out
prio
r no
tifica
tion
Non
-att
enda
nce
redu
ced
by
2.6%
but
not
sig
nific
antly
. Fo
r ap
poin
tmen
ts o
f par
ticul
ar
test
eg,
ele
ctro
myo
grap
hy,
non-
atte
ndan
ce r
ate
redu
ced
by 2
1.7%
Leon
g et
al59
Mal
aysi
a, p
rim
ary
care
cl
inic
s, (
N=9
93)
No
rem
inde
rA
tten
danc
e ra
tes;
cos
ts o
f in
terv
entio
nsN
on-a
tten
danc
e ra
te r
educ
ed
by 1
0.9%
(SM
S); n
on-a
tten
danc
e ra
te r
educ
ed b
y 11
.5%
(m
obile
); co
st o
f SM
S re
min
der
low
er
than
mob
ile p
hone
rem
inde
rLi
ew e
t al
60M
alay
sia,
pri
mar
y ca
re
clin
ics,
(N
=931
)
N
o re
min
der
Non
-att
enda
nce
rate
sN
on-a
tten
danc
e ra
te r
educ
ed
by 9
.3%
(te
leph
one
call)
; non
-at
tend
ance
rat
e re
duce
d by
7.
4% (
SMS)
Max
wel
l et
al61
USA
, inn
er-c
ity c
linic
s,
(N=2
,304
)
N
o re
min
der
App
oint
men
t ad
here
nce
rate
sN
on-a
tten
danc
e ra
te r
educ
ed
by 3
.2%
(m
aile
r). N
on-
atte
ndan
ce r
ate
redu
ced
by
2.1%
(te
leph
one
call)
Nel
son
et
al62
USA
, ped
iatr
ic d
enta
l cl
inic
s, (
N=3
18)
S
MS
Mob
ileA
tten
danc
e ra
tes
8.97
% im
prov
emen
t in
voi
ce
over
tex
tO
ladi
po
et a
l63
UK
, col
posc
opy
clin
ic,
(N=1
89)
N
o re
min
der
Att
enda
nce
rate
Non
-att
enda
nce
rate
red
uced
by
22%
Pari
kh
et a
l64
USA
, aca
dem
ic
outp
atie
nt c
linic
s,
(N=9
,835
)
No
rem
inde
rN
on-a
tten
danc
e ra
te;
canc
ella
tion
rate
; pat
ient
sa
tisfa
ctio
n
Non
-att
enda
nce
rate
red
uced
by
9.5
% (
pers
onal
ized
); no
n-at
tend
ance
rat
e re
duce
d by
5.
8% (
auto
mat
ed)
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489
effectiveness and optimization of appointment reminders
Perr
on
et a
l65
Switz
erla
nd, H
iv/
prim
ary
care
clin
ics,
(N
=2,1
23)
N
o re
min
der
Rat
e of
mis
sed
appo
intm
ents
, cos
t of
in
terv
entio
n, a
nd p
rofil
e of
pat
ient
s m
issi
ng t
heir
ap
poin
tmen
ts
Non
-att
enda
nce
rate
red
uced
by
3.6
%
Pras
ad a
nd
Ana
nd66
indi
a, d
enta
l pre
vent
ive
care
, (N
=206
)
No
rem
inde
rA
tten
danc
e ra
teN
on-a
tten
danc
e ra
te r
educ
ed
by 4
3.7%
Ret
i67N
ew Z
eala
nd, h
ospi
tal
outp
atie
nts
depa
rtm
ent,
(N=1
09)
vi
No
rem
inde
rN
on-a
tten
danc
e ra
tes
Non
-att
enda
nce
rate
red
uced
by
22%
Ritc
hie
et
al68
Aus
tral
ia, h
ospi
tal
outp
atie
nts
depa
rtm
ent,
(N=4
00)
N
o re
min
der
Mak
ing
the
reco
mm
ende
d ap
poin
tmen
t; at
tend
ance
at
sche
dule
d ap
poin
tmen
t; an
d re
ason
s fo
r no
n-at
tend
ance
at
sch
edul
ed a
ppoi
ntm
ent
Non
-att
enda
nce
rate
red
uced
by
16.
2%
Rob
erts
and
Pa
rtri
dge69
UK
, res
pira
tory
clin
ics,
(N
=504
)
Usu
al c
are
Att
enda
nce
rate
; cos
t of
in
terv
entio
nN
on-a
tten
danc
e ra
te r
educ
ed
by 1
5% c
ompa
red
with
con
trol
(7
1%, n
=258
) an
d w
ith p
atie
nts
who
cou
ld n
ot b
e co
ntac
ted
(68%
, n=1
42)
(P=0
.007
; P=0
.004
)R
utla
nd
et a
l70
UK
, gen
itour
inar
y m
edic
ine
clin
ic, (
N=2
52)
SM
S pl
us h
ealth
pr
omot
ion
mes
sage
and
no
rem
inde
r
Re-
atte
ndan
ce r
ates
Non
-re-
atte
ndan
ce r
ate
redu
ced
by 3
.7%
for
text
rem
inde
r on
ly.
Non
-re-
atte
ndan
ce r
ate
redu
ced
by 1
0.7%
whe
n re
min
der
acco
mpa
nied
by
heal
th
prom
otio
nal m
essa
geSa
wye
r
et a
l71
Aus
tral
ia, a
dole
scen
t cl
inic
s (N
=53)
No
rem
inde
rC
linic
non
-att
enda
nce,
reas
on fo
r no
n-at
tend
ance
, an
d sa
tisfa
ctio
n w
ith t
he
book
ing
syst
em
Non
-att
enda
nce
rate
red
uced
by
12%
Tay
lor
et a
l4A
ustr
alia
, phy
sica
l th
erap
y cl
inic
, (N
=679
)
No
rem
inde
rR
ate
of n
on-a
tten
danc
e w
ithou
t ca
ncel
latio
n;
canc
ella
tion
and
atte
ndan
ce
rate
s; fa
ctor
s as
soci
ated
w
ith n
on-a
tten
danc
e
Non
-att
enda
nce
rate
red
uced
by
5%
Tom
linso
n et
al72
UK
, col
posc
opy
clin
ic,
(N=5
00)
vi
iSt
anda
rd
info
rmat
ion
– no
rem
inde
r
Att
enda
nce
and
defa
ult
rate
sN
on-a
tten
danc
e ra
te r
educ
ed
by 1
7%
Not
es: i P
lus
repl
y sl
ip; ii te
leph
one
call
at 2
4 ho
urs
and
48 h
ours
pri
or to
app
oint
men
t; iiite
leph
one
call
(doc
tor)
and
tele
phon
e ca
ll (s
ecre
tary
); ivin
tera
ctiv
e vo
ice
resp
onse
at 3
and
7 d
ays
prio
r to
app
oint
men
t, v p
ostc
ard
and
post
card
/tel
epho
ne
call;
vite
leph
one
call
from
hos
pita
l and
tel
epho
ne c
all f
rom
doc
tor;
vii p
osta
l rem
inde
r an
d le
aflet
.A
bbre
viat
ions
: N, n
umbe
r of
par
ticip
ants
in s
tudy
; RC
T, r
ando
miz
ed c
ontr
olle
d tr
ial;
SMS,
sho
rt m
essa
ge s
ervi
ce; C
I, co
nfide
nce
inte
rval
; IV
R, i
nter
activ
e vo
ice
resp
onse
; FS,
flex
ible
sig
moi
dosc
opy;
ND
C, N
urse
-del
iver
ed c
alls
.
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490
McLean et al
the included RCTs examined either automated telephone
reminders (15/31) or SMS texting services (12/31). Seven
RCTs examined personalized telephone calls and 9/31 studies
examined postal (letter/postcard) reminders. In most studies
the comparator was no intervention. The principal func-
tions of the various reminder systems were reminder only,
reminder requiring confirmation, reminder plus orientation
or reminder plus supporting clinical information. A variety of
attendance related outcomes were measured. These included
attendance, cancellation, rescheduling, and patient satisfac-
tion. A judgement of the quality of the uniquely identified
RCTs is shown in Table 4.
Reminders increase attendance at appointmentsThere was consistent evidence that reminder systems improve
appointment attendance across a range of health care settings
and patient population sub-groups. Only one of the 31 RCTs
did not show a significant reduction in non-attendance.48
“Simple reminders”, which provide details of date, time, and
location of appointments, were most frequently investigated.
“Reminder plus”, which provides additional information
(eg, orientation information, health information, etc) over
and above date, time, and location of the appointment, was
less commonly investigated. Both were effective at reducing
non-attendance.
There was consistent, strong evidence from SRs16,34,35,37,41
and RCTs32,65 that simple reminders are effective at increasing
attendance at appointments compared with no reminder. In
SRs, the pooled effects of simple reminders on appointment
attendance vs no reminder indicated significant increases in
attendance, with relative risks ranging between 1.06–1.10.34,35
One SR reported a weighted mean relative change of 34%
from the baseline non-attendance rate.37 In RCTs the differ-
ence in attendance between subjects who received remind-
ers and those who did not ranged from 5% in an Australian
physiotherapy clinic to 44% in an Indian dental preventive
care clinic.4,66 There was strong evidence from SRs16,34,35 and
RCTs42,65 that there is no differential effectiveness between
different reminder technologies, eg, SMS reminders, phone
call reminders or other reminders.
There was weak, but consistent evidence from five studies
that “Reminder plus” is more effective than simple remind-
ers at reducing non-attendance. Examples of “Reminder
plus” interventions include SMS notification of appointment
with a health promotional message or postal reminders
with additional information about medical procedures and
the importance of follow-up.70,72 A Cochrane Review40 of Tab
le 4
Judg
emen
t on
qua
lity
of in
clud
ed t
rial
s (n
ot a
lrea
dy c
over
ed in
incl
uded
rev
iew
s)
Stud
yR
evie
w q
uest
ion/
aim
sO
vera
ll re
view
qua
lity
Impl
icat
ions
for
tech
nolo
gies
Impl
icat
ions
for
spec
ific
popu
lati
ons
Com
fort
et
al48
To
exam
ine
the
effe
ct o
f the
pro
visi
on o
f “t
angi
ble”
eng
agem
ent
serv
ices
dur
ing
the
inta
ke p
erio
d to
wom
en’s
out
patie
nt s
ubst
ance
ab
use
trea
tmen
t on
rat
es o
f adm
issi
on,
rete
ntio
n, a
nd s
ervi
ce u
tiliz
atio
n.T
he e
ngag
emen
t gr
oup
rece
ived
add
ition
al
serv
ices
suc
h as
tra
nspo
rt a
nd c
hild
car
e to
hel
p w
ith t
he u
ptak
e an
d su
stai
nabi
lity
of s
ervi
ce u
se.
Poor
qua
lity
of r
epor
ting
of t
he
stud
y de
sign
mak
es it
diffi
cult
to
judg
e qu
ality
. No
repo
rtin
g of
bl
indi
ng, a
lloca
tion
to g
roup
s, fo
llow
-up
of a
ll pa
rtic
ipan
ts. T
he s
ampl
e si
ze w
as v
ery
smal
l, w
hich
may
hav
e le
d to
the
lack
of s
igni
fican
t re
sult.
Nil
Thi
s w
as a
stu
dy a
bout
wom
en r
ecei
ving
ou
tpat
ient
sub
stan
ce a
buse
pro
gram
s, b
ut
did
not
prod
uce
any
sign
ifica
nt fi
ndin
gs.
Cos
ta e
t al
,49
Cos
ta e
t al
50
Red
uce
rate
s of
FT
A b
y se
ndin
g SM
S 2
days
be
fore
app
oint
men
t. Se
nt b
y iT
dep
artm
ent.
Pers
onal
ized
to
exte
nt t
hey
incl
uded
: nam
e of
in
stitu
tion,
pat
ient
nam
e, t
ype
of a
ppoi
ntm
ent,
date
and
tim
e. w
hen
nece
ssar
y, in
clud
ed a
dvic
e to
arr
ive
earl
ier.
Lack
of r
epor
ting
on a
lloca
tion
to
inte
rven
tion
grou
ps, b
lindi
ng o
f pa
rtic
ipan
ts, a
nd la
ck o
f rep
ortin
g on
fo
llow
-up
of a
ll pa
rtic
ipan
ts. S
ampl
e si
ze c
alcu
latio
ns u
nder
take
n. S
eem
s re
ason
ably
rob
ust
stud
y, b
ut n
ot
wel
l rep
orte
d.
SMS
impr
oves
att
enda
nce
rate
s co
mpa
red
with
no
rem
inde
r.R
ates
of n
on-a
tten
danc
e hi
ghes
t in
yo
unge
r ag
e gr
oups
(un
der
15, a
nd
decr
ease
s w
ith a
ge);
in m
ales
; peo
ple
atte
ndin
g fo
r th
e fir
st t
ime;
peo
ple
atte
ndin
g fo
r te
sts;
high
est
on w
edne
sday
s; hi
gher
in t
he m
orni
ng; v
arie
s by
mob
ile
phon
e ne
twor
k; a
nd is
hig
her
for
med
ical
th
an s
urgi
cal s
peci
altie
s, bu
t ev
en h
ighe
r in
“ot
hers
” (a
nd s
peci
alty
is t
he m
ost
sign
ifica
nt d
iffer
ence
). A
ll P,
0.5.
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Dovepress
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491
effectiveness and optimization of appointment reminders
Gol
denb
erg
et a
l52
impr
ove
adhe
renc
e to
new
pat
ient
app
oint
men
ts;
asse
ss e
ffect
iven
ess
of te
leph
one
rem
inde
rs o
n co
mpl
ianc
e; to
iden
tify
othe
r fa
ctor
s af
fect
ing
patie
nt a
dher
ence
to a
ppoi
ntm
ents
.
Con
fere
nce
abst
ract
onl
y, s
o la
cks
deta
il, R
CT,
sam
ple
size
393,
inte
ntio
n to
trea
t use
d. U
nabl
e to
com
men
t on
blin
ding
or
proc
ess
of r
ando
miz
atio
n.
Dir
ect
pers
onal
con
tact
with
pat
ient
incr
ease
s lik
elih
ood
of a
tten
danc
e.Pr
ivat
ely
insu
red
patie
nts
mor
e lik
ely
to
atte
nd t
han
Med
icai
d pa
tient
s (6
1% v
s 46
%).
Mor
e de
priv
ed c
omm
uniti
es le
ss
likel
y to
att
end.
Pras
ad a
nd
Ana
nd66
To
eval
uate
the
effi
cacy
of a
ppoi
ntm
ent
rem
inde
rs, s
ent
as S
MS
text
mes
sage
s to
pa
tient
s’ m
obile
tel
epho
nes,
in c
ompa
riso
n w
ith
no r
emin
ders
giv
en t
o pa
tient
s, a
t ou
tpat
ient
cl
inic
s at
the
iTS
Cen
tre
for
Den
tal S
tudi
es a
nd
Res
earc
h, M
urad
naga
r, G
hazi
abad
, Utt
arPr
ades
h, in
dia.
Ran
dom
ized
at
depa
rtm
enta
l, ra
ther
th
an p
atie
nt le
vel,
so d
iffer
ence
s m
ay b
e du
e to
diff
eren
t tr
eatm
ent
type
/pat
ient
gro
ups.
No
blin
ding
, no
inte
nt t
o tr
eat
anal
ysis
pro
vide
d.
SMS
may
impr
ove
atte
ndan
ce r
ate
in c
ompa
riso
n w
ith n
o re
min
der
(alth
ough
evi
denc
e w
eak)
.w
hen
appo
intm
ent
rem
inde
rs w
ere
bein
g sc
hedu
led,
22
patie
nts
stat
ed t
hat
they
di
d no
t un
ders
tand
the
eng
lish
lang
uage
. R
emin
ders
for
thes
e su
bjec
ts w
ere
sent
in
the
loca
l lan
guag
e on
the
mob
ile p
hone
. in
add
ition
, a p
ictu
re m
essa
ge o
f the
in
stitu
tion
was
sen
t to
sev
en p
atie
nts.
Tay
lor
et a
l4T
o de
term
ine
whe
ther
SM
S re
duce
s ra
tes
of
non-
atte
ndan
ce in
phy
siot
hera
py o
utpa
tient
ap
poin
tmen
ts. S
econ
dary
aim
s w
ere
to e
valu
ate
effe
ct o
f SM
S re
min
ders
on
canc
ella
tion
and
atte
ndan
ce r
ates
and
exp
lore
fact
ors
asso
ciat
ed
with
non
-att
enda
nce.
Goo
d qu
ality
, wel
l pow
ered
, wel
l co
nduc
ted
RC
T.
Stro
ng e
vide
nce
to s
how
tha
t pe
ople
who
wer
e no
t se
nt a
n SM
S w
ere
1.77
tim
es m
ore
likel
y no
t to
att
end
thei
r ap
poin
tmen
t (in
clud
es a
djus
ting
for
othe
r fa
ctor
s).
Oth
er s
tatis
tical
ly s
igni
fican
t co
ntri
buto
rs t
o th
e m
odel
wer
e he
alth
co
nditi
on/d
iagn
osis
of n
eck
and
trun
k m
uscu
losk
elet
al d
isor
der
(OR
, 2.8
6; 9
5%
Ci,
1.53
–5.3
2), n
euro
mus
cula
r di
sord
er
(OR
, 3.2
7; 9
5% C
i, 1.
17–9
.17)
, and
age
(O
R, 0
.98;
95%
Ci,
0.97
–0.9
95).
Gri
ffin
et a
l53T
o te
st w
heth
er a
n in
tera
ctiv
e vo
ice
resp
onse
(iv
R)
syst
em p
hone
cal
l was
equ
ally
effe
ctiv
e as
nur
se-d
eliv
ered
pho
ne c
all a
t ed
ucat
ing
and
prep
arin
g pa
tient
s fo
r fle
xibl
e si
gmoi
dosc
opy
(FS)
and
col
onos
copy
exa
min
atio
ns. O
utco
mes
w
ere
appo
intm
ent
non-
atte
ndan
ce a
nd
prep
arat
ion
non-
adhe
renc
e.N
on-a
tten
danc
e de
fined
as
canc
ellin
g ap
poin
tmen
t or
not
att
endi
ng a
ppoi
ntm
ent.
App
oint
men
ts c
ance
lled
by c
linic
not
con
side
red
as n
on-a
tten
danc
e. P
repa
ratio
n no
n-ad
here
nce
asse
ssed
whe
ther
pat
ient
s ha
d ad
equa
tely
pr
epar
ed t
o co
mpl
ete
proc
edur
e.
wel
l-con
stru
cted
stu
dy w
ith s
ampl
e si
ze c
alcu
latio
n an
d in
tent
to
trea
t, ra
ndom
izat
ion
not
spec
ified
.
Thr
ee a
rm R
CT;
nur
se p
hone
cal
l 7 d
ays
befo
re
proc
edur
e, iv
R s
yste
m c
all 7
day
s be
fore
pr
oced
ure,
and
ivR
sys
tem
cal
l 3 d
ays
befo
re
proc
edur
e. A
ll ca
lls in
clud
ed a
n ap
poin
tmen
t re
min
der,
info
rmat
ion
abou
t pr
epar
atio
n fo
r ex
amin
atio
n, a
nd e
ncou
rage
men
t to
pre
pare
fo
r an
d at
tend
the
exa
min
atio
n. iv
R s
yste
m
was
effe
ctiv
e at
rem
indi
ng p
atie
nts
of t
heir
ap
poin
tmen
ts. i
vR
sys
tem
can
effe
ctiv
ely
deliv
er c
ompl
ex in
form
atio
n, e
g, pr
epar
atio
n in
form
atio
n; e
qual
ly e
ffect
ivel
y as
pho
ne c
alls
fr
om c
linic
nur
ses
at d
eliv
erin
g in
form
atio
n;
patie
nts
rece
ivin
g iv
R m
essa
ges
repo
rted
mor
e “n
eutr
al”
perc
eptio
ns a
bout
pho
ne c
alls
; pat
ient
s re
ceiv
ing
calls
from
nur
ses
repo
rted
mor
e “v
ery
posi
tive”
per
cept
ions
abo
ut p
hone
cal
ls.
Nil
Rut
land
et
al70
To
dete
rmin
e w
heth
er S
MS
follo
w-u
p of
pa
tient
s w
ho D
NA
boo
ked
GU
M a
ppoi
ntm
ents
im
prov
es s
ubse
quen
t re
-att
enda
nce
rate
s an
d to
ass
ess
the
impa
ct o
f inc
lusi
on o
f a h
ealth
pr
omot
iona
l mes
sage
on
re-a
tten
danc
e ra
tes.
Con
fere
nce
abst
ract
onl
y, s
o la
cks
deta
il, R
CT
, sam
ple
size
252
, una
ble
to c
omm
ent
on b
lindi
ng, p
roce
ss o
f ra
ndom
izat
ion
or in
tent
ion
to t
reat
an
alys
is.
SMS
mes
sage
to c
linic
def
aulte
rs im
prov
es r
e-at
tend
ance
rat
es c
ompa
red
with
no
rem
inde
r. A
n SM
S re
min
der
with
the
addi
tion
of a
hea
lth
prom
otio
nal m
essa
ge S
MS
follo
w-u
p of
clin
ic
defa
ulte
rs im
prov
es s
ubse
quen
t re-
atte
ndan
ce r
ates
co
mpa
red
with
a r
emin
der
alone
. The
add
ition
of
a he
alth
prom
otio
nal m
essa
ge to
cur
rent
rou
tine
clin
ic r
emin
der
text
s m
ay r
educ
e D
NA
rat
es a
nd
war
rant
s fu
rthe
r st
udy
(alth
ough
evi
denc
e w
eak)
.
Patie
nts
with
a G
UM
hea
lth p
robl
em
did
not
re-a
tten
d a
clin
ical
app
oint
men
t, un
less
a r
emin
der
was
sen
t. R
emin
ders
an
d re
min
ders
with
an
addi
tiona
l hea
lth
prom
otio
nal m
essa
ge m
ay in
crea
se
the
likel
ihoo
d of
pat
ient
s w
ith a
GU
M
heal
th p
robl
em r
e-at
tend
ing
a cl
inic
al
appo
intm
ent.
(Con
tinue
d)
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Dovepress
492
McLean et al
Tab
le 4
(Co
ntin
ued)
Stud
yR
evie
w q
uest
ion/
aim
sO
vera
ll re
view
qua
lity
Impl
icat
ions
for
tech
nolo
gies
Impl
icat
ions
for
spec
ific
popu
lati
ons
Kw
on e
t al
58T
o m
easu
re t
he e
ffect
of t
elep
hone
rem
inde
rs
on e
lect
rodi
agno
stic
labo
rato
ry a
tten
danc
e.
elec
trod
iagn
ostic
labo
rato
ry b
ooki
ngs
of
patie
nts
wer
e ra
ndom
ly a
ssig
ned
to e
ither
a
tele
phon
e re
min
der
1 da
y pr
ior
to t
heir
ap
poin
tmen
t, or
a r
outin
e bo
okin
g (n
o re
min
der)
. Non
-att
enda
nce
was
the
pri
mar
y ou
tcom
e m
easu
re, d
efine
d as
non
-att
enda
nce
with
out
prio
r no
tifica
tion.
Con
fere
nce
abst
ract
onl
y, s
o la
cks
deta
il, R
CT
, sam
ple
size
404
, una
ble
to c
omm
ent
on b
lindi
ng, p
roce
ss o
f ra
ndom
izat
ion
or in
tent
ion
to t
reat
an
alys
is.
Tel
epho
ne r
emin
ders
red
uced
non
-att
enda
nce
at a
ll ap
poin
tmen
ts b
y 2.
6% b
ut n
ot s
igni
fican
tly.
For
appo
intm
ents
of p
artic
ular
tes
t eg
, el
ectr
omyo
grap
hy, n
on-a
tten
danc
e ra
te r
educ
ed
by 2
1.7%
. Thi
s m
ay in
dica
te t
hat
spec
ific
type
s of
te
chni
cal a
ppoi
ntm
ents
may
be
mor
e ef
fect
ivel
y ta
rget
ed (
alth
ough
evi
denc
e w
eak)
.
Patie
nts
who
may
be
conc
erne
d th
at t
hey
have
a g
enui
ne h
ealth
pro
blem
may
be
mor
e ef
fect
ivel
y ta
rget
ed b
y te
leph
one
rem
inde
rs.
Chi
u45T
o in
vest
igat
e th
e ef
fect
iven
ess
of t
elep
hone
re
min
ders
on
atte
ndan
ce a
t C
T s
can
appo
intm
ents
. The
pri
mar
y ou
tcom
e m
easu
re
was
non
-att
enda
nce
at C
T s
can
appo
intm
ents
.
Goo
d qu
ality
, wel
l pow
ered
, wel
l co
nduc
ted
RC
T.
Tel
epho
ne r
emin
ders
wer
e ef
fect
ive
at
redu
cing
non
-att
enda
nce
rate
for
radi
olog
ical
ap
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tmen
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who
wer
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sful
ly
cont
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sign
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mor
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to
atte
nd t
han
thos
e pa
tient
s w
ho w
ere
not
succ
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ully
con
tact
ed.
Nil
Kou
ry a
nd
Fari
s57
To
inve
stig
ate
the
effe
ctiv
enes
s of
usi
ng a
n SM
S re
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com
pare
d w
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sual
pro
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. Pri
mar
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as a
tten
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tes
in e
ach
of t
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grou
ps.
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of r
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ando
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oced
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, allo
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terv
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oups
, blin
ding
of
part
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, and
lack
of r
epor
ting
on fo
llow
-up
of a
ll pa
rtic
ipan
ts.
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info
rmat
ion
abou
t sa
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ze
calc
ulat
ions
und
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ken.
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ly
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S re
min
ders
w
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ctiv
e at
red
ucin
g no
n-at
tend
ance
rat
es
at e
NT
app
oint
men
ts.
Nil
Abb
revi
atio
ns: F
TA
, fai
led
to a
tten
d; S
MS,
sho
rt m
essa
ge s
ervi
ce; I
T, i
nfor
mat
ion
tech
nolo
gy; R
CT
, ran
dom
ized
con
trol
led
tria
l; O
R, o
dds
ratio
; CI,
confi
denc
e in
terv
al; I
VR
, int
erac
tive
voic
e re
spon
se; F
S, fl
exib
le s
igm
oido
scop
y;
DN
A, d
id n
ot a
tten
d; G
UM
, gen
itour
inar
y m
edic
ine;
CT
, com
pute
rize
d to
mog
raph
y; N
HS,
UK
Nat
iona
l Hea
lth S
ervi
ce; e
NT
, ear
, nos
e an
d th
roat
.
Patient Preference and Adherence 2016:10 submit your manuscript | www.dovepress.com
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493
effectiveness and optimization of appointment reminders
the effects of reminders on clinic attendance for those with
suspected serious mental illness, identified one small study
favoring a letter with an orientation statement (ie, a short
paragraph, taking about 30 seconds to read, explaining
the program of care, the fee system, and providing gentle
encouragement) over a simple letter prompting attendance.73
A second SR to assess the effect of reminder systems on
non-attendance rates at new outpatient appointments, found
limited evidence in three studies, that “Reminder plus” was
more effective than simple reminders.38 In these studies, the
reminders threatened sanctions for non-attendance, offered
rewards for attendance or provided orientation information
about the clinic.
Reminders promote cancellation/reallocation of appointmentsThere is evidence from three RCTs that personal phone
reminders significantly increase patient cancellation and
rescheduling rates.54,64,67 Patients who received a telephone
reminder were more likely to cancel or reschedule their
appointment (17%–26%) compared with a control group
who had received no reminder (8%–12%).54,67,74 Clinics
were then able to re-allocate between 27% to 40% of the
cancelled appointment slots.54,65,74 Telephone reminders
carry the inherent advantage that patients who are unable
to attend can cancel and/or reschedule their appointment at
the time of their contact with staff.67 We also found strong
evidence that SMS reminders do not increase appointment
cancellation or rescheduling,75–77 however this may be
because SMS reminders are not conventionally deployed
with this in mind.
Reminder systems are not optimally employedOur review found sufficient strong consistent evidence
to indicate that the performance of reminders, and there-
fore appointment systems, is suboptimal. Six key areas
which lead to sub-optimal reminder effectiveness were
identified.
Accuracy of patient recordsPatient contact details are frequently incorrect or out-of-
date.78,79 The likelihood of inaccurate patient records corre-
sponds with populations at greater risk of non-attendance,80
including less geographically stable communities such as
students, young adults or socio-economically deprived
groups who may frequently change address or telephone
numbers.81
Reminders may not be receivedSuccessful contact rates for telephone reminders are low
ranging from 30% to 60% in most health care settings.
Reasons for non-receipt of telephone reminders are that land-
line calls are often made during business hours (9 am–5 pm),
during the working week (Monday to Friday), when it is
likely that patients will be out.82 In addition, non-receipt may
occur because patients do not have a telephone, they do not
answer the telephone or the contact number was incorrect.74,83
Most telephone reminder systems do not leave messages for
reasons of confidentiality.
SMS reminders are reported to have successful contact
rates of 97%–99%.79,84 Successful contact is assumed when
the mobile phone indicates “message sent” being received
by the sender.44,59,66 However, many patients may either not
receive their SMS reminder or may receive and ignore a
reminder that was not intended for them due to incorrect data
entry on hospital systems.77,79 Some clients may not receive
their text message until after their scheduled appointment
because of delays in delivery of the text or because their
phones were switched off, out of battery or out of credit.85
One disadvantage of using SMS reminders alone is the dif-
ferent levels of access to a mobile telephone. Mobile phone
ownership declines sharply with increasing age,86,87 although
the total numbers of older people with mobile phone are
increasing annually.
Understanding the reminderCognitive ability, literacy level, and language determine
patient comprehension of reminders, irrespective of format.
These are important considerations for health services serv-
ing older populations, travelling communities, inner-city
deprived populations, and multilingual communities. The
studies included in our review did not explore these factors.
Two RCTs explicitly excluded patients who did not speak
the official language (English) fluently, those with dementia,
or with significant cognitive impairment.68,88 Only one RCT
used multilingual research assistants to make the reminder
phone call.65 Reminder systems can cater for different
languages.41,66
Timing of remindersWe found strong evidence that the timing of reminders,
between 1 and 7 days prior to the scheduled appointment, has
no adverse effect on patient attendance behavior.37,89 SMS or
telephone reminders are typically sent either the day before
or on the day of the health care appointment.49,57,63 Sending
the reminder close to the appointment means that the patient
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McLean et al
may either not have time to act on it or they may receive
the reminder after the allotted appointment time.65 Sending
reminders early allows patients to re-arrange commitments,
which may increase the likelihood of a patient attending,
cancelling or rescheduling.54,64,67
Patient does not cancel or re-schedule the appointmentThere are numerous reasons why patients fail to either
cancel or reschedule their appointment. Simple reminders
rarely ask patients to cancel appointments, particularly SMS
reminders where space for text is limited.46,62 Some SMS
reminders ask patients to call a telephone number rather
than replying to the text.4,57 Patients frequently encounter
problems accessing health care systems which can thwart
their intention to cancel and rebook.86,90 Problems include
difficulties accessing central booking lines, including the
phone being engaged, having to wait a long time to speak
to someone or the call being disconnected with no option
to wait or leave a message.91,92 In some cases, patients were
warned by others of the difficulties of accessing a central
booking line, which deterred them from making contact.86
In two studies, patients who failed to attend stated that they
had already phoned or written to cancel their appointment,
indicating difficulties with cancellation systems or internal
hospital communication prevented cancellations being passed
on to the relevant clinic.81,86
Lack of tailoring to high risk groupsThere was weak evidence that patient age has no impact on
reminder effectiveness, suggesting reminder systems can
be employed across all age groups.18 However, few studies
have investigated the differential impact of reminder systems
between population sub-groups. There was weak but consis-
tent evidence that deprivation, minority ethnicity, substance
abuse, mental health problems, and comorbidities/illness are
associated with non-attendance at appointments.93,94 There
was little evidence of tailoring of reminder systems to meet
the needs of these groups of patients.
DiscussionThis review found consistent, strong evidence that all reminder
systems are effective at reducing non-attendance at appoint-
ments across diverse service contexts and patient populations.
There is no clear indication of differential effectiveness
between different simple reminder systems. However, there
is some evidence that “Reminder plus” interventions can
be more effective than simple reminders. Our review of the
available evidence suggests that “Reminder plus” may result
in higher attendance than simple reminders for first appoint-
ments and screening appointments and that for subsequent
follow-up appointments simple reminders and “Reminder
plus” may produce comparable increases in attendance for
most patients most of the time. However, further research
employing appropriate comparative designs is needed before
firm conclusions can be drawn.
There is also strong consistent evidence that reminders
can increase patient cancellation/rebooking rates, however
the success may depend to some extent upon the nature and
the timing of the reminder. We found only three studies
investigating this area of effectiveness,54,64,67 therefore further
research exploring the effectiveness of reminder systems to
promote cancellation/rebooking and rescheduling of appoint-
ments is warranted.
Based on the findings presented in this review, the small
amount of evidence that some patients find reminders intru-
sive or confusing is outweighed by the benefits.95 The use of
reminders appears to be both acceptable and feasible across
a range of health care settings,42,65 and we therefore propose
that all patients should receive a reminder and that all health
care services operating outpatient appointment systems
should employ reminder systems.
Whilst reminder systems can increase attendance, cancel-
lation, rescheduling and reallocation of appointments, this
review identified six key factors which limit the efficiency of
both reminder and appointment systems. Reminder systems
are often employed with the objective of increasing atten-
dance rates, with limited attention given to cancellation and/or
rescheduling of appointments. Full attendance at appoint-
ments is unlikely to be achievable; therefore appointment
cancellation and rescheduling should be seen as desirable
outcomes. Appointment systems can be optimized if patients
cancel and reschedule unwanted appointments, allowing
health care services to re-allocate the cancelled appointment
to a different patient. If appointment and reminder systems
are to realize their full potential this will require a whole
systems approach to looking at the characteristics of cur-
rent systems for attendance, cancellation, rescheduling and
re-allocation of appointments to other patients. A summary
of proposed strategies is outlined in Figure 3 and discussed
in greater detail to follow.
Optimization strategiesHealth services, particularly those serving geographically
less stable communities, should have robust procedures for
maintaining and updating patient records.81
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effectiveness and optimization of appointment reminders
In many health services it will be relevant to consider the
use of both simple reminders and “Reminder plus”. Depend-
ing on the nature of the information provided, “Reminder
plus” may help patients to feel more confident about attend-
ing their appointment, particularly for first appointments and
screening appointments.56,96 Thereafter, the use of simple
reminders may be sufficient for increasing attendance at
follow-up appointments in most health care settings.
Since the timing of appointment reminders appears to
have no appreciable impact on attendance behavior when
delivered up to 7 days before an appointment, we propose
that reminders should be delivered early enough to allow
patients to re-arrange commitments so that they can attend
the appointment and receive the care that they need. Alter-
natively, if unable to attend, patients will have sufficient
time to cancel and reschedule their appointments and allow
health services to re-allocate and rebook appointments.54,64,67
To support and enhance rescheduling it is appropriate to
frame reminders to ask patients to cancel and rebook incon-
venient appointments. In addition, robust structures, which
are easy to navigate and which require minimal effort from
the patient, are required to support cancellation. Automated
methods of cancellation, eg, SMS messages or email, are
perceived by many patients as easier than methods which
require direct contact since they offer flexibility to cancel
at a time convenient to the patient and reduce the need to
provide explanations for cancellation.18,34 Following cancel-
lation of appointments, rescheduling of the appointment, if
it has not occurred synchronously, also needs to be easy for
the patient. For example it may be sensible, in some health
care settings, to have central booking lines which are open
24 hours a day.
There is little evidence of tailoring of reminder systems
to meet the needs of vulnerable groups of patients who are
at high risk of non-attendance; this includes deprived and
ethnic groups, substance abusers, and populations with co-
morbidity and illness.93,94 Given the likely coincidence of
higher levels of non-attendance and health need, it is in the
interests of health services to monitor whether specific groups
of patients are being disadvantaged by the chosen reminder
systems. Simple reminders and automated reminders may
be ignored, overlooked or misunderstood, particularly if
patients are experiencing an increase of their health prob-
lem. We therefore hypothesize that reminders with direct
personal contact might be appropriate in these groups, since
the flexibility of information, advice or support which can
be offered may help to overcome barriers to attendance or
to cancel unwanted appointments. To facilitate attendance in
these groups more intensive reminder systems are advocated.
Examples of this include sequential reminders which were
effective at improving attendance in a Swiss AIDS clinic.65
This consisted of: first, a phone call to either landline or
mobile; second, an SMS if participants do not answer the
phone after three attempts and have a mobile phone; and
finally a postal reminder if participants do not answer the
phone, have no mobile phone or landline at all. Intensive
approaches, such as “stepped reminders” and patient navi-
gators have also been effective at increasing attendance at
screening and immunization programs in disadvantaged and
vulnerable populations and might also be effective at re-
engaging similar groups of patients who have dropped out of
treatment.36,97–99 Such designs, though labor intensive would
reach the maximum number of participants and may increase
attendance rates and simultaneously have a cost benefit.
An effective reminder and cancellation system will in crease
the already heavy workload of outpatient clinics.52 Clinicians
frequently fill missed appointments with alternative activi-
ties such as completing dictation, making telephone calls or
1) Maintain accurate patient contact details (with alternative contact routes wherever possible). 2) Select reminder technologies that are suitable for the needs of the population; possibly more than one. 3) Where appropriate use "Reminder plus" technologies to overcome common barriers to attendance. 4) Send reminder a minimum of 2–3 days in advance of the appointment. 5) Frame reminders to ask patients to cancel and reschedule unwanted appointments. 6) Employ multiple systems for cancelling appointments which suit the needs of the patients, not the needs of the
service eg, automated SMS cancellation, answer-phone, email etc. 7) Have robust rescheduling procedures in place to allow easy rescheduling of appointments for patients, both within
and out of normal working hours. 8) Monitor whether any specific groups of patients are being disadvantaged by the chosen reminder systems. 9) Employ personalized or intensive reminder strategies for groups of patients at high risk of non-attendance.10) Build in administrative time for clinicians to manage tasks which were previously routinely carried out when a
patient missed an appointment.
Figure 3 Summary of strategies to optimize reminder systems.Abbreviation: SMS, short message service.
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McLean et al
consulting with colleagues.56 If building in processes to opti-
mize cancellation and rescheduling, then health services will
need also to consider the impact on staff that frequently utilize
non-attendance at appointments as an opportunity to catch up
on other health care related activities.
Strengths and limitationsOur approach to this review, which combined an SR with
an evidence synthesis informed by realist principles, has
numerous strengths, including a structured search protocol
requiring thorough searches of electronic databases, reference
lists, and citations. As a consequence we believe that we have
assembled the widest possible body of relevant knowledge
which has relevance across all health care services which
use appointment systems. In addition, our review informed
by realist principles includes the strong embedding of our
findings in the extracted data. This stems from the practical
orientation of our review and facilitates the production of
implications for practice. There are also limitations to our
review. Generally speaking the SR method seeks to provide
a precise answer to a tightly focused question. Such reviews
are most useful where there is a high degree of homogeneity
around the five PICOS elements, namely the Population,
Intervention, Comparison, Outcomes, and Study types.
A wide range of population types, intervention, compari-
son, and outcomes is included within the RCTs we identified.
However, use of this wider approach offers greater analytical
capability in terms of understanding contextual and mecha-
nistic factors that would not have been evident in a more
narrowly focused review and increases confidence that the
findings have relevance in a wide range of service settings.
Research implicationsWe recommend future research activities in three main
areas. Firstly, more studies should routinely consider
the potential for differential effects of reminder systems
between patient groups in order to identify any inequali-
ties and remedies. Secondly, “Reminder plus” systems
appear promising but there is a need for further research
to understand how they influence attendance behavior.
Finally, further research is required to identify strategies
to “optimize” reminder systems and compare performance
against current approaches.
ConclusionIn the absence of clear contraindications all health services
should use simple reminders or “Reminder plus” for all
patients. More intensive reminder alternatives may be relevant
for key groups of patients: deprived, ethnic, substance abusers,
and those with comorbidities and illness.
There is evidence that reminders are used sub-optimally.
To optimize appointment and reminder systems, health
services should tailor reminder systems and adopt supportive
administrative processes to enhance attendance, cancel-
lation, rescheduling, and reallocation of appointments to
other patients.
AcknowledgmentsThe TURNUP project was funded by the National Insti-
tute for Health Research Health Services and Delivery
Research Program (project number 10/2002/49). The
views and opinions expressed are those of the authors and
do not necessarily reflect those of the HS&DR program,
NIHR, NHS or the Department of Health. This paper or
the abstract of this paper has been presented as a platform
presentation at the World Congress of Physical Therapy,
Singapore in May 2015 and will also be presented as a plat-
form presentation at Physiotherapy UK in October 2015,
Liverpool UK. The abstract was published in Physiotherapy
Journal: http://www.physiotherapyuk.org.uk/presentation/
appointment-reminder-systems-are-effective-not-optimal-
results-systematic-review-and. The actual paper, however,
has never been published.
DisclosureThe authors report no conflicts of interest in this work.
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