1. Impact of appointment reminders via Short Message Service in a District Hospital Introdução à Medicina’s Annual Assignment 2006/2007 Final Presentation Class 4 - FMUP

2. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 2 Presentation Structure Objective Introduction Methods Results and Discussion References Acknowledgments Authors

3. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 3 This study aims to measure the changes in outpatient’s non-attendance rate according to the sending or not of an appointment reminder via Short Message Service in a District Hospital. Objective

4. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 4 Introduction Problem: failure to attend outpatients appointments. [Hashim, 2001] Reasons for non-attendance: - Forgetfulness (which is the most important for our work); - Long distance from home to health services and trip cost; - Inconvenient time of appointment (incompatible with work schedule). [McClure, 1996]

5. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 5 Consequences of non-attendance: Missed opportunities for diagnosis and treatment; Reduced opportunities for hospital revenue; Extended time patients have to wait for an appointment booking. [Downer, 2005] Emerging technology of Short Message Service is starting to be used to remind patients about their appointments... Introduction

6. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 6 Portugal: this method is starting to be used in some hospitals such as Santa Maria and the one of our study S. Sebastião. [http://www.telecom.pt/InternetResource/PTSite/PT/DestaquesHP/smsconsulta s.htm ] Advantages of this method: it is cheap; it is computorized; no need for many human resources; easy to apply. Introduction

7. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 7 Hardware used by the hospital to send appointment reminders through the technology of SMS (Pictures taken in S. Sebastião Hospital) Introduction

8. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 8 Conclusions of previous studies conducted in Portugal related to Hospital S. Sebastião  improving patients attendance, reflected by: general reduction in the no-attendance rate of 14% in general appointments; most extreme case of Paediatrics with a reduction of 50%; recovering of about 900 appointments per month; account for nearly 15.000 euros per month. (information given by administrative services of Hospital S. Sebastião) Introduction

9. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 9 Participants and Methods Population: All patients of S. Sebastião Hospital, who have mobile phone number registered at the system. Sample’s selection: The set of the Hospital’s patients who have appointments in the days we perform the study. Study design: Experimental and transversal study

10. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 10 SMS sent by the hospital: Outpatients visits “Hospital São Sebastião. O utente NOME tem consulta de ESPECIALIDADE em DATA as HORA. Compareça 20 min. antes.” Exams “Hospital São Sebastião. O utente NOME tem exame de ESPECIALIDADE em DATA as HORA. Compareça 20 min. antes.” Hospitalizations “Hospital São Sebastião. O utente NOME tem internamento de ESPECIALIDADE em DATA.” Participants and Methods

11. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 11 Flowchart: Selection of Participants Participants and Methods

12. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 12 Methods: Selection of the days for the study (6 working days)  Messages sent from 8th to 15th March for the appointments on days 12th to 19th March. The hospital sends appointment reminders randomly and alternately to the participants of the sample. The messages are sent two working days before the appointment. Finally the results of those who attended the appointment and those who did not, in both groups, reminded and non-reminded, are collected. Participants and Methods

13. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 13 Data Analysis (using SPSS program): 1.Statistical analysis, comparing the percentage of attendances and non-attendances in reminded and non- reminded groups; Participants and Methods

14. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 14 2. We are studying if the attendance rate varies according to some of the following variables: Gender Age Groups Date of the appointment Hour of the appointment Previous contact with the system Type of Episode Mobile telephone network Speciality Participants and Methods

15. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 15 3.Chi-square test for each of the variables mentioned before and contingency tables. 4.That will allow us to conclude if there is any relationship between the sending of text messages as appointment reminders and the patients’ non-attendance. Participants and Methods

16. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 16 Flowchart: description of methods Participants and Methods

17. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 17 Non-Attendancep Age (Years Old) Under 1516,3 <0,05 16 to 2514,0 26 to 5510,4 More than 559,9 Gender Female10,8 >0,05 Male12,3 Table 1 - Attendances (%) according to each variable individually  Considering the age of the patients, we verify that the non- attendance rate decreases along with age.  There isn’t any relation between gender and non-attendance. Results and Discussion

18. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 18 Non-Atendancep Previous contact with the system Yes9,0 >0,05 No11,6 Type of Episode Analysis23,2 <0,05 Outpatient10,1 Exams15,3 Inpation18,0 Table 1 – Cont. Results and Discussion There isn’t any relation between the previous contact with the system and the non-attendance Hospitalizations is the episode with the highest non- attendance rate, followed by exams, analyses and outpatients

19. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 19 Results and Discussion Non-attendancep Day of the week Monday10,6 Tuesday12,1 Wednesday15,0<0,05 Thursday11,9 Friday6,8 Table 1 – Cont. This table shows that on Wednesday people tend to fail appointments more than on any other day and on Friday the non-attendance rate is the lowest.

20. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 20 Non-attendancep Time of the Day Morning11,4 >0,05 Afternoon10,9 Mobile Telephone Network Vodafone10,9 >0,05 Optimus12,9 TMN11,3 Table 1 – Cont. Results and Discussion There aren’t any relation between the non-attendance and time of the day and also mobile telephone network

21. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 21 Results and Discussion Table 1 – Cont. Non-attendance p Specialty Medical11,2 <0,05 Medical-surgical11,3 Surgical5,0 Other23,9 it can be seen a relation between non-attendance and specialty. Surgical is the one with lowest non-attendance

22. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 22 Table 2 – Attendances (%) according to the sending or not of SMS. AttendanceNon-Attendancep Reminded 90,49,6 <0,05 Non-reminded 86,913,1 Rate difference: 3,5% Rate ratio: 26,7%. Results and Discussion Number of episodes = 3899 Missings = 537

23. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 23 Results and Discussion it was conducted Logistics regressions for the variable attendance including in each regression the variable in study, the variable state of SMS sending and the interaction between the two variables to investigate the influence of the different variables on the impact of the sending of a SMS appointment reminder. This regressions, with a p>0,05, showed that there was no relation between the variables studied and the impact of the SMS appointment reminder, what means that there is no benefit to SMS relatively to the groups of the variable in study. Results and Discussion

24. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 24 Comparison of data collected Reference Type of sample selection Type of reminder Durability of the study Time between the reminder and the appointment Dimension of the sample (number of individuals) Non- attendance rate in non- reminded group Difference of the non- attendance rate after reminder Ritchie PD (2000) RandomizedPhone call Not mentioned 1 to 3 days40045,6%16,3%. Hardy KJ (2001) Non- randomized Information pack and telephone call Not mentioned 2 weeks (information pack) 1 week (phone call) 32515%10,4 % O’Brien G (1998) RandomizedPhone call11 months1 day70355,9%11,5% Sawyer SM (2002) RandomizedPhone callNot mentioned 1 day17120%12%

25. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 25 Comparison of data collected Reference Type of sample selection Type of reminder Durability of the study Time between the reminder and the appointment Dimension of the sample (number of individuals) Non-attendance rate in non- reminded group Difference of the non- attendance rate after reminder Haynes JM (2006) Non- randomized Phone call 7 monthsNot mentioned51511,7%7,7% Downer SR (2006) Non- randomized SMS 3 monthsNot mentioned4511019,5%9.7% Downer SR (2005) Non- randomized SMS1 month3 working days286423,4%9.2% Hashim MJ (2001) Randomized Phone call Not mentioned 1 day90326%7% Leong KC (2006)Randomized phone call and SMS 3 months1-2 days99351,9% SMS – 10,9% Telephone call – 11,5% Costa J (2007) RandomizedSMS6 working days 2 days389913,1%3,5%

26. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 26 Discussion The results show a decrease in the non-attendance rate with the sending of a SMS appointment reminder, which is consistent with the effectiveness of the sending of SMS or other appointment reminders in previous studies [1,2,3,4,7]. Although the non-attendance rate difference of this study was lower than the ones obtained with the studies referred, the non-attendance rate without the sending of an appointment reminder was also lower, so it was already expected a lower reduction. Comparatively with other studies referred, this has the advantage of being randomized and having a big sample. Considering all this, and seeing that the difference isn´t as striking as it was expected, the hospital could adopt other methods in order to obtain a greater reduction in the non-attendance rate.

27. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 27 References References in order of appearance:  Hashim MJ, Franks P, Fiscella K. Effectiveness of Telephone Reminders in Improving Rate of Appointments Kept at an Outpatient Clinic: A Randomized Controlled Trial. J Am Board Fam Pract. 2001 May-Jun;14(3):193-6.  McClure RJ, Newell SJ, Edwards S. Patient characteristics affecting attendance at general outpatient clinics. Abstract. 1996 Feb;74(2):121-5.  Downer SR, Meara JG, Da Costa AC. Use of SMS text messaging to improve outpatient attendance. Med J Aust. 2005 Oct 3;183(7): Haynes 366-8.

28. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 28 References Downer SR, Meara JG, Da Costa AC. Use of SMS text messaging to improve outpatient attendance. Med J Aust. 2005 Oct 3;183(7):366-8. Haynes JM, Sweeney EL. The Effect of Telephone Appointment-Reminder Calls on Outpatient Absenteeism in a Pulmonary Function Laboratory. Respir Care. 2006 Jan;51(1):36-9. Hashim MJ, Franks P, Fiscella K. Effectiveness of Telephone Reminders in Improving Rate of Appointments Kept at an Outpatient Clinic: A Randomized Controlled Trial. J Am Board Fam Pract. 2001 May-Jun;14(3):193-6. Hardy KJ, O'Brian SV, Furlong NJ. Information given to patients before appointments and its effect on non-attendance rate. Abstract. 2001 Dec 1;323(7324):1298-300.

29. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 29 References McClure RJ, Newell SJ, Edwards S. Patient characteristics affecting attendance at general outpatient clinics. Abstract. 1996 Feb;74(2):121-5. Neal RD, Hussain-Gambles M, Allgar VL, Lawlor DA, Dempsey O. Reasons for and consequences of missed appointments in general practice in the UK: questionnaire survey and prospective review of medical records. Abstract. 2005 Nov 7;6:47. Downer SR. Meara JG. Da Costa AC. Sethuraman K. SMS text messaging improves outpatient attendance. Aust Health Rev.2006 Aug;30(3):389-96.Meara JGDa Costa ACSethuraman K http://download.microsoft.com/download/6/4/1/64122b0868594d95b0241544e3 7afab5/Case_Study_%20Hospital_Sao_Sebastiao.doc Contratos programa com hospitais --Rcorreia 15:15, 14 Novembro 2006 (WET)

30. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 30 References Tecnologia "made in" S. Sebastião Hospital 22:30, 5 Dezembro 2006 “Gestão de consultas por SMS no Hospital Santa Maria”- http://www.telecom.pt/InternetResource/PTSite/PT/DestaquesHP/smsconsultas.htm http://www.telecom.pt/InternetResource/PTSite/PT/DestaquesHP/smsconsultas.htm Portugal Telecom - consulted on April 3rd 2006

31. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 31 Acknowledgments Dr. Ricardo Correia Prof. Dr. Altamiro da Costa Pereira Dr. Alberto Freitas Dr. Armando Pinto Drª. Filipa Almeida S. Sebastião Hospital, in particular Engº. Rui Gomes

32. :: Annual Assignment | Introdução à Medicina 2006-2007 | Class4 Impact of appointment reminders via Short Message Service in a District Hospital 32 Authors Class 4, Introdução à Medicina 2006-2007, Faculdade de Medicina UP Cardoso, L.; Costa, A.; Costa, J.; Cunha, A.; Dias, C.; Lima, M.; Pacheco, P.; Silva, D.; Silva, I.; Sousa, D.; Tinoco, M.; Valente, L.; Viana, S.; Correia, R. Contact: turma4.2006fmup@gmail.com