In healthcare, non-attendance for appointments is a main cause of inefficiency in wasted resources and disturbs the planned work schedules. Moreover, in several countries, optimising the anaesthesia medical time is important because the anaesthesiologist's resources are limited. Mobile phones and text messages (short message service, SMS) are of growing use in the medical field. Several studies, excluding anaesthesia, showed that SMS reminders increase attendance at healthcare appointments.1 Therefore, we hypothesised that SMS reminders could reduce the rate of non-attendance for preoperative anaesthesia clinics (PAC).
The current single centre, retrospective study was conducted at Rouen University Hospital from January 2013 to March 2015. Two stages were determined: before the use of SMS reminders, from January 2013 to April 2014, and after using SMS reminders (sent to patients’ mobile phones the day before an appointment), from May 2014 to March 2015. Ethical approval for this study (protocol no. E2015-38) was provided by the ethics committee for non-interventional research (CERNI = Comité d’Ethique de la Recherche Non-Interventionnelle) at Rouen University Hospital, Rouen, France (Chairperson: Prof LM Joly; [email protected]). The primary endpoint was the non-attendance rate. The secondary endpoint was the cancellation and the new appointment rates. Direct costs relating to efficiency were calculated.
Values presented are as percentages. Pearson's Chi-square test (df = 1) was used to determine statistically significant differences for qualitative variables (α risk of 5%). Statistics were performed using GraphPad Prism (GraphPad Software; La Jolla, California, USA) software.
A total of 14 316 patients were included in the study over a 26-month period. In the first stage (before SMS) 7177 patients were included and 7139 in the second (after the SMS). The total number of non-attenders from January 2013 to march 2015 was occurred in 719 patients (5%). The SMS reminder decreased the rate from 6.2% (n = 448) to 3.8% (n = 271) (P < 0.001). Moreover, there was a lower cancellation rate (P < 0.001) in the group with SMS (9.1%, n = 652) compared with the control group without SMS (10.4%, n = 745). A new appointment occurrence decreased (P < 0.001) in SMS group (14.8%, n = 1058) compared with the control group (19.7%, n = 1415). No efficiency for PAC is expensive (about 27 000 Euros for first stage), and the cost decreased by 10 791 Euros with SMS reminder.
In our study, the overall rate of non-attendance was 5% (719/14 316), and it decreased from 6.2 to 3.8% with an SMS reminder. Moreover, the cancellation and new appointment rates were also improved after an SMS reminder. It could be estimated that SMS reminders resulted in 900 Euros saved every month. Our results deserve several comments. The lack of randomisation and the potential for bias must be taken into account. Despite its retrospective design, the current study included 14 316 patients (fourth biggest study according to a systematic review).2 In addition, the study was conducted over a short period of time, which allowed us to observe the direct impact of the SMS reminders and limits other compounding factors. Another bias was the single-centre design. This study took place in the anaesthesia department of the Rouen University Hospital, which benefits from a central board of consultation, thus limiting bias during the period of the study such as changes in scheduling policy, as this would impact all the patients included in the study.
The rate of non-attendance in the control group (before SMS reminder) was lower than those found in previous studies (ranging from 23 to 32% and even up to 72.5%)1 but these included mainly follow-up consultations and screening consultations and not the PAC. The factors usually causing non-attendance are forgetfulness and erroneous scheduling.3 Hasvold and Wootton2 showed that appointment reminders (operator messaging, automated voice message or SMS) decreased the non-attendance rate from a median of 23.1% to 12.5%. In our study, the SMS reminders also decreased the non-attendance rate at the PAC. This result is in agreement with a recent meta-analysis that focussed on SMS reminders and other means of communication such as phone calls or postal reminders.1 The better results of SMS reminders versus postal reminders could be explained by the risk of incorrectly addressing printed reminders. SMS are generally perceived as less intrusive and thus may be better accepted by patients.
The effect on non-attendance rate is critical for efficiency and implies a better optimisation of the medical time at the consultation, a lower waiting time for the patients and an overall better satisfaction for both physicians and patients. Some studies described different ways to improve efficiency at PAC. A new organisation of the appointments with a dedicated structure for PAC instead of ward assessment is effective in reducing the consultation time.4 The scheduling pattern can be optimised to take into account the mean consultation time of each anaesthesiologist, and in this case computerised tools can be useful.5 We also showed that SMS reminders decreased the new appointment and cancellation rates This lower rate probably allows a better use of non-medical time as the department secretary's office does not need to re-schedule appointments.
In our study, SMS reminders generated an income of about 10 000 Euros for the second stage of our study (13 months). This estimation is for the financial cost of non-attendance (Fig. 1). The social cost must be included and involves the non-use or the misuse of personnel time, equipment or ward capacity in a period of shortage of resources and a political will to restrain the costs of the healthcare services.6 Furthermore, the need for re-scheduling lengthens the waiting list for the other patients and may result in a delay in the treatment that may endanger other users of the medical system.
In conclusion, this work shows that SMS reminders increases attendance and decreases cancellation and new appointment rates at PAC with a positive effect on costs. This supports the use of SMS reminders to improve the efficiency and organisation of a PAC.
Acknowledgements relating to this article
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Conflicts of interest: none.
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