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Journal of the New Zealand Medical Association, 06-June-2003, Vol 116 No 1175

Improving outpatient department efficiency: a randomized controlled trial comparing hospital and general-practice telephone reminders

Shane Reti

Abstract

Aims This study aimed to ascertain whether or not telephone reminders reduce non-attendance at hospital outpatient clinics and whether telephone reminders from general practitioners are more effective than those made from hospitals.

Methods Outpatient department appointments for three general practitioners (GPs) over a three-month period, were randomized into three groups: ‘Hospital’, ‘GP’, and ‘Control’. Patients in the Hospital and the GP groups were reminded of their appointment by telephone 24 hours beforehand, by a hospital waiting-list clerk or their general practitioner respectively. Information was recorded on appointment awareness and subsequent attendance history.

Results A total of 109 patients were included in the study. The three study groups had ‘no show’ rates of 3% (GP), 8% (Hospital), and 27% (Control). The combined ‘no show’ rate for the groups reminded by telephone was 5%. The combined telephone-reminded group was statistically different from the Control group (p = 0.004). There was no statistical difference between the GP group and the Hospital group (p = 0.764).

Conclusions In this study, telephone reminders significantly decreased outpatient department ‘no show’ rates. The source of the telephone reminder made no difference to non-attendance.

There are few published New Zealand studies recording multi-specialty outpatient department (OPD) ‘no show’ rates. In this article, ‘no show’ is used as the preferred term to represent patients who were expected to turn up but did not. This differentiates from the popular usage of ‘DNA’ (did not attend) which sometimes includes patients who cancel their appointment and hospital-cancelled clinics. A literature review and survey by the author of sector-wide OPD non-attendance rates in 2002 showed a range for non-attendance of between 5.5% and 15%.1

Telephone reminders are one of many interventions that have been used to improve OPD attendance. International studies have demonstrated a reduction in ‘no show’ rates of as much as 26%.2,3 The only published New Zealand telephone-reminder study, was a single specialty study in 2000 demonstrating a 20% improvement in attendance for patients attending a community mental health centre.4

Most OPD telephone-reminder studies are hospital sourced. There are no New Zealand studies that have compared the effects of general-practice-based and hospital-based telephone reminders on multi-specialty OPD non-attendance rates. It is hypothesised that general practice reminders are more effective on the basis that general practices offer more regular opportunities to update contact information, a more extensive contact knowledge base, positive doctor/referrer reinforcement and ongoing doctor/patient relationships.

The hypotheses being tested are that OPD telephone reminders are effective, and that general-practice telephone reminders are more effective than hospital telephone reminders in reducing OPD ‘no shows’.

Methods

Ethical approval was received from the Auckland Ethical Committee, approval AKX/02/00/066.
Over the three-month period April to June 2002, this study engaged general practice patients registered with three GPs in a group practice in Whangarei who were also booked to attend an OPD appointment at Northland Base Hospital. Northland Base Hospital is a level 3–4 regional hospital servicing approximately 150 000 people.
Each month, patients with OPD appointments for that month (new patient, follow-up, consultant, non-consultant) were randomly allocated by the author to a ‘Hospital’, ‘GP’, or a ‘Control’ group. Randomization occurred by simple consecutive allocation to one of the three groups from the OPD appointment list provided by Northland Health. Twenty four hours before their appointment (Friday for Monday appointments), a hospital waiting-list clerk or the patient’s GP, made up to three attempts to contact patients in their respective groups by telephone. Calls were made between 0830 and 1700 hours using telephone contact details on the respective medical records. Contact was made with the patient or caregiver, or a call-back message left. Where the patient was unaware of their next-day appointment, reasons for this were recorded as: ‘forgot’, ‘no appointment received’, or ‘misunderstanding’. Eventual attendance details were recorded, with changed appointments included in the same category as cancelled appointments.
Statistical analysis used Fisher’s Exact Test to form contingency tables comparing any two of the three study groups at any one time. A combined telephone-reminded group was also compared with the non-reminded Control group. This methodology was also used for assessing the independence or otherwise of receiving a telephone reminder and subsequent attendance.

Results

A total of 109 patients were included in the study, 35 in the GP group, 37 in the Hospital group, and 37 in the Control group. Differences in numbers were due to patients no longer being registered with the GP. The clinics involved were general surgery, paediatrics, general medicine, obstetrics, gynaecology, colposcopy, opthalmology, ENT, neurology, orthopaedics, rheumatology, dental, retinopathy, dietitian, audiology, diabetes nurse clinic, and venesection clinic. A total of 85/109 (78%) clinics were specialist consultant clinics.

Table 1 summarises the attendance data. The three study groups had ‘no show’ rates of GP 3%, Hospital 8%, Control 27%, and a combined telephone-reminded group a rate of 5%. Cancellation rates for these groups were GP 20%, Hospital 22%, Control 8%, and Combined 21%.

Table 1. Attendance outcome

	Attend n (%)	No show n (%)	Cancel n (%)	Total n
GP Hospital Control Combined reminded	27 (77) 26 (70) 24 (65) 53 (74)	1 (3) 3 (8) 10 (27) 4 (5)	7 (20) 8 (22) 3 (8) 15 (21)	35 37 37

The Combined group was statistically different from the Control group (p = 0.004). There was no statistical difference between the GP group and the Hospital group (p = 0.764).

The telephone contact rates were not statistically significant between the GP group 31/35 (OR 89%, 95% CI 79–99%) and the Hospital group 26/37 (OR 70%, 95% CI 55–85%). The combined telephone-contact rate was 57/72 (79%).

All those patients contacted by telephone either attended, cancelled or changed their appointments. The association between being contacted and subsequently attending was statistically significant (p = 0.002).

Table 2 shows 7/72 (OR 10%, 95% CI 5–18%) of patients in the combined GP and Hospital group prospectively misunderstood their appointment date or time, and 2/72 (OR 3%, 95% CI 1–9%) failed to receive their appointment notification.

Table 2. Explanations from reminded group for potential non-attendance

	Forgot n (%)	No appointment received n (%)	Misunderstanding n (%)
Combined reminded	0 (0)	2 (3)	7 (10)

Assessment of the power of the study design to detect statistical differences between the groups (recognising the lack of formal formula for trinomial assessment, which, therefore, required binomial calculations) was undertaken by modelling observed proportions against a hypothetical 50% increase in study numbers. Under this assumption, the power of the analysis ranged from 0.82–0.89.

Discussion

The results of this study confirm the effectiveness of telephone reminders. Everybody contacted made a positive action to either attend, cancel, or change their appointment. A number of mechanisms may be responsible for the observed effectiveness. These include appointment value reinforcement, promotion of suitable cancellation behaviours, and correction of incorrect details. In this study, a significant role was played by the overall 2.6-fold increase in cancellations in the telephone-reminded groups. Incorrect appointment notification or details are often put forward as a major cause for non-attendance; however, in this study they accounted only for a potential 10% of non-attendance. On this evidence, then, it is suggested that the dominant benefits of telephone reminders may be appointment value reinforcement and the promotion of suitable cancellation behaviours.

Telephone reminders are but one form of reminder mechanism. Macharia reviewed 26 reminder studies that utilised letter prompt, calendar prompt, invitation letter, reminder to physician, and telephone prompts.5 All reminders were effective, with telephone reminders the most effective, and physician reminders the least.

Comparisons of interventions for improving OPD attendance should include a cost-benefit analysis. Several authors have noted that telephone reminders are significantly more expensive than other reminders, especially in terms of staff time.6,7 Further studies with specific cost-benefit analysis need to be undertaken.

In this study, the GP group and the Hospital group were not statistically different. The hypothesised advantages for reminders to come from a general practice can be put into two categories. The first encompasses the advantages of more up-to-date and far-reaching patient contacts that general practices have over hospitals, and the second, improved compliance resulting from the patient’s doctor (and usually the referrer) making the telephone call. In this study, there was no evidence that telephone reminders from GPs were more effective than those from hospitals. This rejection of the hypothesis could be explained by stable populations, and short waiting times between referral and appointment. However, OPD waiting times and population demographics in Northland give no support to these factors being significant in this study.

Several studies have shown the effect of doctor reinforcement on patient compliance, but this may not be as significant as thought for telephone reminders.8 Telephone-reminder studies using automated telephone reminders have also been effective.9 In this study, there was a difference in ‘no show’ rates between the GP group (3%) and the Hospital group (8%), but this difference was not statistically significant. Even though the numbers in this study design are consistent with others reviewed in the literature,6 larger studies may more clearly define whether or not a difference in effectiveness actually exists.

In summary, outpatient department ‘no shows’ have a significant influence on the patient and health-system resources. There are no winners when a patient fails to attend an OPD appointment. This study showed that a telephone reminder 24 hours before an appointment is effective in reducing ‘no shows’ regardless of whether a GP or hospital initiated the reminder. Greater use of general-practice resources in a collaborative manner with hospitals is likely to enhance the effectiveness of reminder-type interventions. Further work is required to assess the cost benefits of telephone reminders and to examine the opportunities that telephone reminders provide for the management of cancellations.

Author information: Shane Reti, Medical Practitioner, Whangarei

Acknowledgments: The general practitioners involved were Dr Shane Reti (author), Dr Allistair Whitton and Dr Graham Corbett. Acknowledgment is also made to Waiting List Clerk Leanne Jones, Elective Services Manager Pauline Fell, General Manager Medicine & Surgery (NBH) David Meates, and Information Systems Data Analyst Viviene Marshall. Statistical analysis was provided by Alistair Gray.

Correspondence: Dr Shane Reti, 15 Rust Ave, Whangarei. Fax: (09) 438 2011; email: dna@selectpost.com

References:

Reti S. Outpatient department attendance in New Zealand hospitals. NZ Health & Hospital September/October 2002. p. 14.
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MacDonald J, Brown N, Ellis P. Using telephone prompts to improve initial attendance at a community mental health center. Psychiatr Serv 2000;51:812–4.
Macharia WM, Leon G, Rowe BH, et al. An overview of interventions to improve compliance with appointment keeping for medical services. JAMA 1992;267:1813–7.
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