HEALTH SERVICES AND DELIVERY RESEARCH

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1 HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 2 ISSUE 34 OCTOBER 2014 ISSN Targeting the Use of Reminders and Notifications for Uptake by Popuations (TURNUP): a systematic review and evidence synthesis Sionnadh McLean, Meanie Gee, Andrew Booth, Sarah Saway, Susan Nancarrow, Mark Cobb and Sadiq Bhanbhro DOI /hsdr02340

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3 Targeting the Use of Reminders and Notifications for Uptake by Popuations (TURNUP): a systematic review and evidence synthesis Sionnadh McLean, 1* Meanie Gee, 2 Andrew Booth, 3 Sarah Saway, 3 Susan Nancarrow, 4 Mark Cobb 5 and Sadiq Bhanbhro 2 1 Facuty of Heath and Webeing, Sheffied Haam University, Sheffied, UK 2 Centre for Heath and Socia Care Research, Sheffied Haam University, Sheffied, UK 3 Schoo of Heath and Reated Research, University of Sheffied, Sheffied, UK 4 Schoo of Heath and Human Sciences, Southern Cross University, East Lismore, NSW, Austraia 5 Sheffied Teaching Hospitas, Sheffied, UK *Corresponding author Decared competing interests of authors: none Pubished October 2014 DOI: /hsdr02340 This report shoud be referenced as foows: McLean S, Gee M, Booth A, Saway S, Nancarrow S, Cobb M, et a. Targeting the Use of Reminders and Notifications for Uptake by Popuations (TURNUP): a systematic review and evidence synthesis. Heath Serv Deiv Res 2014;2(34).

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5 Heath Services and Deivery Research ISSN (Print) ISSN (Onine) This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) ( Editoria contact: nihredit@southampton.ac.uk The fu HS&DR archive is freey avaiabe to view onine at Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: Criteria for incusion in the Heath Services and Deivery Research journa Reports are pubished in Heath Services and Deivery Research (HS&DR) if (1) they have resuted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficienty high scientific quaity as assessed by the reviewers and editors. HS&DR programme The Heath Services and Deivery Research (HS&DR) programme, part of the Nationa Institute for Heath Research (NIHR), was estabished to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Heath Services Research (HSR) programme and the Service Deivery and Organisation (SDO) programme, which were merged in January The HS&DR programme aims to produce rigorous and reevant evidence on the quaity, access and organisation of heath services incuding costs and outcomes, as we as research on impementation. The programme wi enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evauative research to improve heath services. For more information about the HS&DR programme pease visit the website: This report The research reported in this issue of the journa was funded by the HS&DR programme or one of its proceeding programmes as project number 10/2002/49. The contractua start date was in January The fina report began editoria review in March 2013 and was accepted for pubication in November The authors have been whoy responsibe for a data coection, anaysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors report and woud ike to thank the reviewers for their constructive comments on the fina report document. However, they do not accept iabiity for damages or osses arising from materia pubished in this report. This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views and opinions expressed by authors in this pubication are those of the authors and do not necessariy refect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. If there are verbatim quotations incuded in this pubication the views and opinions expressed by the interviewees are those of the interviewees and do not necessariy refect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Pubished by the NIHR Journas Library ( produced by Prepress Projects Ltd, Perth, Scotand (

6 Heath Services and Deivery Research Editor-in-Chief Professor Ray Fitzpatrick Professor of Pubic Heath and Primary Care, University of Oxford, UK NIHR Journas Library Editor-in-Chief Professor Tom Waey Director, NIHR Evauation, Trias and Studies and Director of the HTA Programme, UK NIHR Journas Library Editors Professor Ken Stein Chair of HTA Editoria Board and Professor of Pubic Heath, University of Exeter Medica Schoo, UK Professor Andree Le May Chair of NIHR Journas Library Editoria Group (EME, HS&DR, PGfAR, PHR journas) Dr Martin Ashton-Key Consutant in Pubic Heath Medicine/Consutant Advisor, NETSCC, UK Professor Matthias Beck Chair in Pubic Sector Management and Subject Leader (Management Group), Queen s University Management Schoo, Queen s University Befast, UK Professor Aieen Carke Professor of Pubic Heath and Heath Services Research, Warwick Medica Schoo, University of Warwick, UK Dr Tessa Criy Director, Crysta Bue Consuting Ltd, UK Dr Peter Davidson Director of NETSCC, HTA, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Professor Eaine McCo Director, Newcaste Cinica Trias Unit, Institute of Heath and Society, Newcaste University, UK Professor Wiiam McGuire Professor of Chid Heath, Hu York Medica Schoo, University of York, UK Professor Geoffrey Meads Professor of Heath Sciences Research, Facuty of Education, University of Winchester, UK Professor Jane Norman Professor of Materna and Feta Heath, University of Edinburgh, UK Professor John Powe Consutant Cinica Adviser, Nationa Institute for Heath and Care Exceence (NICE), UK Professor James Raftery Professor of Heath Technoogy Assessment, Wessex Institute, Facuty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Keijnen Systematic Reviews Ltd, UK Professor Heen Roberts Professor of Chid Heath Research, University Coege London, UK Professor Heen Snooks Professor of Heath Services Research, Institute of Life Science, Coege of Medicine, Swansea University, UK Pease visit the website for a ist of members of the NIHR Journas Library Board: Editoria contact: nihredit@southampton.ac.uk NIHR Journas Library

7 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 Abstract Targeting the Use of Reminders and Notifications for Uptake by Popuations (TURNUP): a systematic review and evidence synthesis Sionnadh McLean, 1* Meanie Gee, 2 Andrew Booth, 3 Sarah Saway, 3 Susan Nancarrow, 4 Mark Cobb 5 and Sadiq Bhanbhro 2 1 Facuty of Heath and Webeing, Sheffied Haam University, Sheffied, UK 2 Centre for Heath and Socia Care Research, Sheffied Haam University, Sheffied, UK 3 Schoo of Heath and Reated Research, University of Sheffied, Sheffied, UK 4 Schoo of Heath and Human Sciences, Southern Cross University, East Lismore, NSW, Austraia 5 Sheffied Teaching Hospitas, Sheffied, UK *Corresponding author Background: Missed appointments are an avoidabe cost and a resource inefficiency that impact on the heath of the patient and treatment outcomes. Heath-care services are increasingy utiising reminder systems to counter these negative effects. Objectives: This project expores the differentia effect of reminder systems for different segments of the popuation for improving attendance, canceation and rescheduing of appointments. Design: Three inter-reated reviews of quantitative and quaitative evidence reating to theoretica expanations for appointment behaviour (review 1), the effectiveness of different approaches to reminding patients to attend heath service appointments (review 2) and factors ikey to infuence non-attendance (review 3). Data sources: Database searches were conducted on Aied and Compementary Medicine, Cumuative Index to Nursing and Aied Heath Literature Pus with Fu Text, The Cochrane Library, EMBASE (via NHS Evidence from 1 January 2000 to January/February 2012), Heath Management Information Consortium database, Institute of Eectrica and Eectronics Engineers Xpore, The King s Fund Library Cataogue, Maternity and Infant Care, MEDLINE, Physiotherapy Evidence Database, PsycINFO, SPORTDiscus and Web of Science from 1 January 2000 to January/February Suppementary screening of references of incuded studies was conducted to identify additiona potentiay reevant studies. Conceptua papers were identified for review 1, randomised controed trias (RCTs) and systematic reviews for review 2 and a range of quantitative and quaitative research designs for review 3. Methods: We conducted three inter-reated reviews of quantitative and quaitative evidence, invoving a review of conceptua frameworks of reminder systems and adherence behaviours, a review of the reminder effectiveness iterature and a review informed by reaist principes to expain the contexts and mechanisms that expain reminder effectiveness. A preiminary conceptua framework was deveoped to show how reminder systems work, for whom they work and in which circumstances. Six themes emerged that potentiay infuence the effectiveness of the reminder or whether or not patients woud attend their appointment, namey the reminder patient interaction, reminder accessibiity, heath-care settings, wider socia issues, canceation and rebookings, and dista/proxy attributes. Standardised review methods were used to investigate the effectiveness of reminders to promote attendance, canceation or rebooking across a outpatient settings. Finay, a review informed by reaist principes was undertaken, using the conceptua Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v

8 ABSTRACT framework to expain the context and mechanisms that infuence how reminders support attendance, canceation and rebooking. Resuts: A tota of 466 papers reating to 463 studies were identified for reviews 2 and 3. Findings from 31 RCTs and 11 separate systematic reviews (review 2 ony) reveaed that reminder systems are consistenty effective at reducing non-attendance at appointments, regardess of heath-care setting or patient subgroups. Simpe reminders that provide detais of timing and ocation of appointments are effective for increasing attendance at appointments. Reminders that provide additiona information over and above the date, time and ocation of the appointment ( reminder pus ) may be more effective than simpe reminders at reducing non-attendance and may be particuary usefu for first appointments and screening appointments; simpe reminders may be appropriate thereafter for most patients the majority of the time. There was strong evidence that the timing of reminders, between 1 and 7 days prior to the appointment, has no effect on attendance; substantia numbers of patients do not receive their reminder; reminders promote canceation of appointments; inadequate structura factors prevent patients from canceing appointments; and few studies investigated factors that infuence the effectiveness of reminder systems for popuation subgroups. Limitations: Generay speaking, the systematic review method seeks to provide a precise answer to a tighty focused question, for which there is a high degree of homogeneity within the studies. A wide range of popuation types, intervention, comparison and outcomes is incuded within the RCTs we identified. However, use of this wider approach offers greater anaytica capabiity in terms of understanding contextua and mechanistic factors that woud not have been evident in a more narrowy focused review and increases confidence that the findings wi have reevance in a wide range of service settings. Concusions: Simpe reminders or reminder pus shoud be sent to a patients in the absence of any cear contraindication. Other reminder aternatives may be reevant for key groups of patients: those from a deprived background, ethnic minorities, substance abusers and those with comorbidities and/or inesses. We are deveoping a practice guideine that may hep managers to further taior their reminder systems for their service and cient groups. We recommend future research activities in three main areas. First, more studies shoud routiney consider the potentia for differentia effects of reminder systems between patient groups in order to identify any inequaities and remedies. Second, reminder pus systems appear promising, but there is a need for further research to understand how they infuence attendance behaviour. Third, further research is required to identify strategies to optimise reminder systems and compare performance with current approaches. Funding: The Nationa Institute for Heath Research Heath Services and Deivery Research programme. vi NIHR Journas Library

9 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 Contents List of tabes List of figures List of boxes List of abbreviations Pain Engish summary Scientific summary xiii xv xvii xix xxi xxiii Chapter 1 Background 1 Chapter 2 Objectives 3 Chapter 3 Methods 5 Overa rationae 5 Review questions 5 Literature searches (reviews 2 and 3) 6 Preiminary searches 6 Suppementary searches 6 Sifting/categorisation of search resuts (reviews 2 and 3) 7 Tite/abstract screening and categorisation of studies 7 Fu-text screening 7 Production of draft conceptua framework and draft propositions (review 1) 8 Preiminary data extraction: randomised controed trias (review 2) 10 Testing the draft propositions: further data extraction (reviews 2 and 3) 12 Synthesis (reviews 2 and 3) 13 Thematic synthesis 13 Consideration of meta-anaysis 13 Narrative synthesis 14 Quaity appraisa (reviews 2 and 3) 15 Review compexity 15 Deveopment of materias for heath service users 16 Invovement of patient steering group 16 Chapter 4 Resuts 17 Resuts of searches 17 Evidence from systematic reviews 17 Characteristics of incuded systematic reviews 19 Quaity of incuded systematic reviews 19 Evidence from randomised controed trias 20 Characteristics of incuded randomised controed trias 20 Quaity of incuded trias 20 Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii

10 CONTENTS Proposition A: the reminder patient interaction 34 Evidence statement (A.1): there is strong consistent evidence that simpe reminders that provide detais of timing and ocation of appointments are effective at heping a (forgetfu) patient to attend their appointment (evidence category Ia) 34 Evidence statement (A.2 A.6): there is weak consistent evidence that reminder pus is more effective than simpe reminders at heping a patient to attend their appointment (evidence category IIIa) 35 Proposition B: reminder accessibiity 36 Evidence statement (B.1): there is strong consistent evidence that the reminder may not be received by the patient (evidence category Ia) 36 Evidence statement (B.2): there are no studies investigating whether or not reminder factors (such as anguage, information provided, framing of information) infuence the accessibiity/comprehensibiity of the reminder message for particuar patient groups (evidence category VIIa) 37 Evidence statement (B.3): there are no studies to show that the content of the reminder may effectivey address the obstaces/enabers experienced by the patient in question (evidence category VIIa) 38 Evidence statement (B.4): there is controvertibe evidence, based on mutipe good-quaity studies, that persona reminders have a greater impact on attendance rates than automated reminders (evidence category IIa) 38 Evidence statement (B.4): the format of the reminder wi compromise the amount, and type, of information that can be deivered to the patient (sef-evident) 39 Evidence statement (B.4): very few studies investigated whether or not the reminder preferences of the patient may infuence the impact a reminder has on the patient s appointment behaviour (evidence category VIIa) 40 Evidence statement (B.5): there is strong consistent evidence that the timing of a reminder, between 1 and 7 days prior to the schedued appointment, has no effect on patient attendance behaviour (evidence category Ia) 40 Proposition C: heath-care settings 42 Evidence statement (C.1 C.6): there are no studies investigating whether or not factors about heath-care settings infuence the effectiveness of the reminder (evidence category VIIa) 42 Proposition D: wider socia systems 42 Evidence statement (D.1 D.9): there are no studies investigating whether or not wider socia systems infuence the effectiveness of the reminder (evidence category VIIa) 42 Proposition E: are there any systems that effectivey support the canceation of appointments? 42 Evidence statement (E): there is strong consistent evidence that reminder systems wi promote canceation of appointments (evidence category Ia) 43 Evidence statement (E.1 and E.4): there is indicative evidence to suggest that whether or not a patient cances and rebooks wi be infuenced by patient perceptions of how easy it is to rebook (evidence category Va) 44 Evidence statement (E.2 and E.5): there is strong evidence that whether or not a patient cances and rebooks wi be infuenced by reminder system factors that faciitate/hamper patient intentions to rebook (e.g. nobody answers the teephone) (evidence category Ia) 45 Evidence statement (E.2 and E.5): strong consistent evidence indicates that system factors reated to appointment systems wi hamper patient intentions to cance/ rebook (evidence eve Ib) 46 viii NIHR Journas Library

11 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 Evidence statement (E.3 and E.6): there is indicative evidence that for patients who intend to take up the offer of an appointment, whether or not a patient cances and rebooks wi be infuenced by structura factors that faciitate/hamper patient intentions to rebook (e.g. has to be done onine and no internet access) (evidence eve Va) 46 Evidence statement (E.7): there is no evidence that whether or not a patient cances the appointment wi be infuenced by patient perceptions that canceing the appointment is the moray right thing to do (evidence category VIIa) 47 Proposition F: dista/proxy individua attributes 47 Evidence statement (F.1): there is sufficient weak equivoca evidence to suggest that age does not have a differentia effect, over and above pre-existing appointment behaviour, on reminder effectiveness (in terms of attendance, canceations or rebooking) (evidence category IVa) 47 Evidence statement (F.2 F.11): few studies investigate whether or not a range of dista/proxy individua attributes have a differentia effect, over and above pre-existing appointment behaviour, on reminder effectiveness (in terms of attendance, canceations or rebooking) (evidence category Va or VIIa) 48 Chapter 5 Patterns and infuences on heath-care attendance behaviour: a narrative overview of key themes and issues 51 Reported reasons for non-attendance 52 Factors inked to the heath-care setting 52 Characteristics of appointment systems 52 Patient provider aiance, communication and engagement 61 Service features 63 Wider socia system (conceptua framework domain D) 67 Norms, attitudes and understandings regarding the (dis)benefits of heath care on offer 67 Norms, attitudes and understandings regarding condition/symptoms 67 Norms, attitudes and understandings regarding whether or not attendance is the moray right thing to do 68 Structura factors 68 Patient characteristics 68 Demographic and socioeconomic characteristics 69 Patient indicators of heath and we-being 74 Chapter 6 Discussion 79 Main findings 79 Which types of reminder systems are most effective in improving the uptake of heath service appointments? 79 Are there any systems that effectivey support the canceation of appointments? 81 Do different reminder systems have differentia effectiveness for particuar subgroups of the popuation (e.g. by age group, ethnic group, socioeconomic status, gender, etc.)? 83 What factors infuence the effectiveness of different reminder systems for particuar popuation subgroups? 86 How do the perceptions and beiefs of patients, their carers and heath professionas regarding specific types of reminder systems, and patient/carer resources and circumstances, infuence their effectiveness? 86 How do externa factors (e.g. content, deivery, setting, frequency, notice period) infuence the effectiveness of reminder systems? 86 How do organisationa factors infuence the effectiveness of reminder systems? 91 Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ix

12 CONTENTS What disadvantages (or chaenges) shoud be considered when introducing reminder systems for specific popuations for heath care and heath services? 93 What are the ikey economic impacts of reminder systems? 95 Methods: strengths and imitations of the review 96 Strengths and imitations of the systematic review 96 Strengths and imitations of the review informed by reaist principes 97 Scope 99 Limitations of the evidence base 100 Other emergent interpretations 101 The appointment as an event 101 Lest we forget or forget about forgetting 101 What are desirabe outcomes? 102 Voting with their feet 103 Carrots, sticks and sermons 104 Do I reay need to go? 104 Nudge theory and custard creams 104 Service inertia 105 Cinica impications 106 Genera impications 106 Specific impications 107 Research impication 109 Current and future deveopments (innovations) 110 Modify current ways of deivering appointment reminders 111 Utiise new ways of deivering appointment reminders 111 Utiise new ways of appointment booking 112 Utiise new ways of managing appointment systems 112 Utiise aternative ways of deivering heath care 114 Changes to appointment opening times 115 Chapter 7 Concusions 117 Acknowedgements 119 References 121 Appendix 1 Exampe search strategies 137 Appendix 2 Articuation of possibe causa pathways between eements of the conceptua framework 139 Appendix 3 Hypotheses associated with different eements of the conceptua framework 141 Appendix 4 Incuded and excuded systematic reviews and randomised controed trias for review Appendix 5 Reviews incuded in this review with an assessment of their quaity 151 Appendix 6 Judgement on quaity of incuded trias (not aready covered in incuded reviews) 157 x NIHR Journas Library

13 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 Appendix 7 Cinica scenarios 161 Appendix 8 Reasons for missing appointments 169 Appendix 9 Advantages and disadvantages of reminder systems 175 Appendix 10 Outine proposa for a web-based practice guide 181 Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xi

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15 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 List of tabes TABLE 1 Draft propositions from a preiminary conceptua framework identifying potentiay important infuences on patient attendance 12 TABLE 2 Summary categories for bodies of evidence 14 TABLE 3 Reminder technoogies covered by each review 19 TABLE 4 Technoogies covered by each RCT 21 TABLE 5 Settings and countries for incuded RCTs 23 TABLE 6 Reminder features: interactivity, frequency, timing and taioring of messages (according to conceptua framework by Coomes et a., 2012) 26 TABLE 7 Randomised controed trias: attendance outcomes and overa effect 32 TABLE 8 Studies examining the effectiveness of SMS reminders by popuation group 48 Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xiii

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17 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 List of figures FIGURE 1 Fow chart summarising the review process 5 FIGURE 2 Targeting the Use of Reminders and Notifications for Uptake by Popuations (TURNUP) conceptua framework 11 FIGURE 3 The PRISMA fow chart 18 Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xv

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19 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 List of boxes BOX 1 Suggested approaches to issues of non-attendance 110 Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xvii

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21 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 List of abbreviations A&E accident and emergency IT information technoogy AHP Aied Heath Professiona IVR interactive voice response CASP Critica Appraisa Skis Programme NNT number needed to text CI confidence interva OR odds ratio CINAHL CRD Cumuative Index to Nursing and Aied Heath Literature Centre for Reviews and Dissemination PopInS PRISMA Popuation/Intervention/Study type Preferred Reporting Items for Systematic Reviews and Meta-Anayses DARE Database of Abstracts of Reviews of Effects QIPP quaity, innovation, productivity and prevention FTA faiure to attend RCT randomised controed tria GP genera practitioner RR reative risk GUM genitourinary medicine SMS short message service HIV human immunodeficiency virus Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xix

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23 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 Pain Engish summary Missed hospita appointments are common and costy and can have a negative effect on the heath of patients. Hospitas use reminder systems to increase the ikeihood of patients attending their appointments. This study ooked into which reminder systems work best for which patients with regard to improving attendance, canceation or rescheduing of appointments. This review incuded any kind of study investigating any type of system used to remind patients that they have a booked hospita appointment. The resuts showed that a types of reminders can reduce non-attendance at heath appointments, regardess of the type of appointment or patient groups being treated. Standard reminders shoud be sent to a patients, uness there is a cear reason not to do so. The reminder can be sent to the patient any time within 7 days of the appointment and it is sti ikey to be effective. Hardy any studies ooked at whether or not certain reminders woud be better for certain patient groups. Patients who come from poor communities or ethnic backgrounds, who are addicted to drugs or acoho, or who have mutipe heath probems are at a high risk of not attending their appointment. More intensive reminders may hep these patients. Many patients never receive their reminder and do not cance appointments because they have probems getting in touch with the hospita. If it was made easier to contact the hospita, then more hospita appointments coud be canceed and reaocated to another patient. We are deveoping a practice guideine to hep managers to taior their reminder systems for their service and cient groups. Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxi

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25 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 Scientific summary Background Missed heath-care appointments are a major source of potentiay avoidabe cost and resource inefficiency that impact on the heath of the patient and treatment outcomes. Since 1999, the cost of missed appointments to the NHS has triped, and in 2009 was estimated to be more than 600M. In the UK, more than 24 miion appointments with the genera practitioner (GP) or consutant-ed cinics are missed each year. Non-attendance rates of between 6% and 30% are frequenty reported at outpatient cinics ed by Aied Heath Professionas (AHPs) and nurses. Non-attendance may aso ead to increased waiting times for appointments; increased cost of care deivery; under-utiisation of equipment, premises and personne; reduced numbers of appointments avaiabe for a patients; reduced patient satisfaction; and negative reationships between the patient and staff. They may aso predispose patients to exacerbations of their condition, eading to unnecessary suffering and possibe costy hospita admission. Reducing the number of missed appointments may be a reativey inexpensive way to reduce NHS costs, treat patients within 18 weeks of GP referra and improve treatment outcomes. In an attempt to manage the negative effects and improve the efficiency of the appointment system, many heath-care organisations are increasingy investing in short message service (SMS), teephone and e-mai reminder systems. However, they frequenty empoy a one-size-fits-a approach, with itte evidence of differentia effectiveness or acceptabiity for particuar popuations or subgroups. Objectives The aim of the project is to expore the differentia effect of aternative types of reminders (written and automated) for schedued heath service encounters for different segments of the popuation on fufied or reschedued appointments, substitutions and satisfaction. The foowing questions wi be addressed: 1. Which types of reminder systems are most effective in improving the uptake of heath service appointments? i. Do any systems effectivey support the canceation of appointments? 2. Do different reminder systems have differentia effectiveness for particuar popuation subgroups? 3. Which factors infuence the effectiveness of different reminder systems for particuar popuation subgroups? i. How do the perceptions and beiefs of patients, their carers and heath professionas regarding specific types of reminder systems, and patient/carer resources and circumstances, infuence their effectiveness? ii. How do reminder intrinsic factors (e.g. content, deivery, setting, frequency, notice period) infuence the effectiveness of reminder systems? iii. How do heath-care organisationa factors infuence the effectiveness of reminder systems? 4. What disadvantages shoud be considered when introducing reminder systems for specific popuations for heath care and heath services? 5. What are the economic impacts of reminder systems? Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxiii

26 SCIENTIFIC SUMMARY Methods The three inter-reated reviews of quantitative and quaitative evidence comprise three components: (1) a review of conceptua frameworks of reminder systems and attendance/adherence behaviours, (2) a review of the reminder effectiveness iterature and (3) a review informed by reaist principes to expain the contexts and mechanisms that ead to reminder effectiveness (and appointment attendance). Searches were conducted on the foowing databases: Aied and Compementary Medicine (via Ovid 1 January 2000 to 15 February 2012), Cumuative Index to Nursing and Aied Heath Literature Pus with Fu Text (via EBSCOhost, January 2000 to 11 January 2012), The Cochrane Library (1 January 2000 to 15 February 2012), EMBASE (via NHS Evidence, 1 January 2000 to 15 February 2012), Heath Management Information Consortium database (via NHS Evidence, 1 January 2000 to 15 February 2012), Institute of Eectrica and Eectronics Engineers Xpore (1 January 2000 to 15 February 2012), The King s Fund Library Cataogue (1 January 2000 to 8 February 2012), Maternity and Infant Care (via Ovid, 1 January 2000 to 15 February 2012), MEDLINE (via EBSCOhost, 1 January 2000 to 11 January 2012), Physiotherapy Evidence Database (1 January 2000 to 8 February 2012), PsycINFO (via ProQuest, 1 January 2000 to 8 February 2012), SPORTDiscus (via EBSCOhost, 1 January 2000 to 11 January 2012), Web of Science (1 January 2000 to 2 February 2012). The reference ists of incuded studies were screened for additiona reevant studies to inform the three review stages. Studies of various quantitative and quaitative designs, pubished from the year 2000 onwards, were incuded if they investigated the effectiveness of outpatient appointment reminders in any geographic context or investigated appointment attendance behaviour or adherence to treatment (if this incuded appointment attendance behaviour) in the UK or a comparabe heath context. Studies expicating theories/modes/frameworks reating to reminder systems or appointment attendance were specificay incuded in review 1. Studies were excuded if they investigated reminders sent to a patient to schedue an appointment. Comprehensive searches yieded 1200 citations. A members of the project team were invoved in screening and seection of studies and data extraction from incuded artices. The aim of review 1 was to deveop a conceptua framework to aid an understanding of the contexts and mechanisms that infuence reminder effectiveness. We identified no pre-existing conceptua modes or frameworks that directy expained the mechanisms by which reminder systems support appointment attendance; therefore, we broadened our review to encompass behavioura modes that infuence medica adherence. Reevant modes reated to the use of text messages to promote cinica outcomes, heath-care utiisation theory, the theory of panned behaviour, the transtheoretica mode, sef-determination theory, protection motivation theory, rationae choice theory and compexity theory. The conceptua framework emerged from an iterative process invoving examination of the various theories and discussions about context, mechanisms and outcomes that were important to expain how reminder systems works, for whom and in which circumstances. Our preiminary conceptua framework consisted of six draft propositions that woud potentiay infuence the effectiveness of the reminder and whether or not patients woud attend their appointment. These six propositions were the reminder patient interaction, reminder accessibiity, heath-care settings, wider socia issues, canceation and rebookings, and dista/proxy attributes. We used this preiminary conceptua framework to faciitate the deveopment of a data extraction tempate for review 3. In review 2, standardised methods, foowing Centre for Reviews and Dissemination (CRD) guideines, were used to seect, quaity assess, data extract and synthesise the findings of systematic reviews and randomised controed trias (RCTs). Quaity appraisa was carried out using the Critica Appraisa Skis Programme (CASP) appraisa too for RCTs for a RCTs not aready quaity assessed in a pre-existing systematic review. The aim of this systematic review was to investigate the effectiveness of reminder systems for improving attendance, canceations and rescheduing of appointments. A tota of 31 RCTs and 11 separate systematic reviews were incuded; however, most of these had aready been incorporated within one or more pre-existing systematic reviews. Ony 10 RCTs were uniquey identified for this review. xxiv NIHR Journas Library

27 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 For review 3, the framework for data extraction was deveoped empoying the important six eements of the conceptua framework described above. Studies were prioritised for data extraction based on study type and reevance to a UK NHS context. A RCTs about reminder systems and a reviews (systematic and otherwise) about reminder systems and appointment systems, previousy identified for review 2, were prioritised for fu extraction of contextua and expanatory variabes. This was foowed by quaitative, mixed-methods and non-rct quantitative studies about reminders and appointments for the UK, Ireand, Europe, Austraia and New Zeaand. Four members of the project team examined different sections of the data as they aigned with the conceptua framework and undertook thematic anaysis of the evidence avaiabe for that section of the framework. The reviewers formuated evidence statements using summary categories for bodies of evidence for each of the six eements of the framework. To support each evidence statement, the reviewers aso deveoped a narrative synthesis that sought to expain the context and mechanisms infuencing how reminders support attendance, canceation and rebooking. Reviewers aso provided a suppementary synthesis of evidence to expain emergent factors that expain patient attendance behaviours. The findings of each stage of the review were brought together to refine the preiminary framework and wi be used to produce practice guideines. The preiminary database searches yieded 1200 records and, foowing the screening stages, a tota of 466 records were incuded for reviews 2 and 3. Data extraction was prioritised according to study type and reevance to the UK context. Consequenty, in accordance with reaist principes, not a records contributed to the review. Resuts Review 2 There is overwheming evidence that a reminder systems are effective at improving attendance at appointments, regardess of heath-care setting or patient popuation subgroups. Ony one of the 31 RCTs did not show a significant reduction in non-attendance. Review 3 In genera, a reminders are effective at improving attendance at appointments. The imited poor-quaity evidence that is avaiabe suggests that reminders are aso cost-effective. Simpe reminders, which provide detais of timing and ocation of appointments, are effective at increasing attendance at appointments and woud appear to be usefu for a patients, across a heath-care settings, who they are at risk of forgetting their appointment. There is weak evidence that reminder pus, which provides additiona information over and above the date, time and ocation of the appointment, may be more effective than simpe reminders at reducing non-attendance. Additiona information may reduce perceived obstaces to attendance. Reminder pus may be usefu for first appointments and screening appointments and simpe reminders may be appropriate thereafter for most patients the majority of the time. There was strong evidence that: The timing of reminders, between 1 and 7 days prior to the schedued appointment, has no effect on attendance. A substantia number of reminders may not be received by patients. Reminders promote canceation of appointments. Patients cannot aways cance appointments because of structura factors affecting reminder systems (e.g. busy teephone ine, nobody answers the teephone). Reativey few studies investigated factors that infuence the effectiveness of different reminder systems for particuar popuation subgroups. Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxv

28 SCIENTIFIC SUMMARY Discussion Genera impications for heath services Uness patients indicate otherwise, the evidence suggests that a patients shoud receive a reminder or reminder pus, which activey encourages patients who are unabe to attend to cance their appointment and to reschedue if further appointments are required, and the reminder shoud be sent around 3 days in advance. Because timing of a reminder between 1 and 7 days prior to the schedued appointment has no effect on patient attendance behaviour, an interva of 3 days shoud aow sufficient time either for patient canceation and heath service reaocation of the appointment to another patient or to aow the cinician to undertake care-reated administrative tasks. For the most part, reminder systems are not being fuy expoited to maximum advantage. Optimisation of attendance, canceation and rescheduing rates requires (1) robust administrative procedures to ensure that patient contact detais are up to date, (2) easy-to-use, mutioption systems for canceing appointments matched to the needs of the patients, e.g. automated SMS canceation, answer teephone, e-mai, etc., and (3) robust 24 hours per day rescheduing procedures to aow easy rescheduing of appointments for patients. However, an effective reminder system wi increase the workoad of cinica staff and aternative time wi need to be schedued for staff to undertake heath-care-reated administration. We found few studies investigating the differentia effectiveness of reminder systems for popuation subgroups. However, findings suggest that reminder system choices need carefu consideration in order to maximise accessibiity for the foowing key patient groups: those from deprived communities or ethnic groups, substance abusers and those with comorbidities and/or inesses. Simpe reminders to attend may be overooked by patients in these vunerabe groups and may increase disadvantage in heath-care access in comparison with genera outpatient popuations. Reminders with direct persona contact might be appropriate in these groups. Intensive sequentia reminders may maximise contact in these difficut-to-reach groups and, therefore, may maximise attendance. Intensive approaches, such as stepped reminders and patient navigators, may be effective at re-engaging patients with ongoing heath needs who have dropped out of treatment. These genera recommendations are suitabe for a heath-care outpatient services. Specific impications Reminder systems are a compex intervention because of the potentia number of interacting components within the interventions, the requirement for taioring of the intervention to the heath service and the number of difficuties and behavioura changes from those receiving and deivering the reminder. Therefore, in addition to foowing the genera recommendations provided above, heath service managers wi need to taior their reminder systems to meet the needs of the service and the patient popuation that it serves. This review provides some findings that wi inform heath service managers decision-making processes. We are producing a practice guide to hep heath service managers consider specific issues that may be reevant to the design of reminder systems for their heath service. The practice guide consists of four sections: 1. a conceptua framework 2. a set of cinica scenarios 3. reasons for non-attendance and possibe reminder soutions and wider soutions 4. advantages/disadvantages for various reminder systems. xxvi NIHR Journas Library

29 DOI: /hsdr02340 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 34 Concusions A heath services shoud be using a reminder system for a patients, in the absence of any cear contraindication. This review has found strong, consistent evidence to support the use of a reminder systems for a patients in any outpatient setting for increasing attendance, canceation or rescheduing. There is additiona evidence that reminder pus, which provides additiona information over and above the date, time and ocation of the appointment, may be more effective than simpe reminders at reducing non-attendance, particuary at first appointments. However, there is imited evidence investigating the differentia effectiveness of aternative types of reminders for different segments of the popuation. Nevertheess, we have used the findings of our review to suggest important reminder aternatives for key groups of patients: those from deprived communities, ethnic minorities, substance abusers and those with comorbidities and/or inesses. Based on the findings of this review, we are producing a practice guideine to hep managers identify further important considerations when seecting the reminder system most ikey to be effective for reducing non-attendance rates for their service and cient groups. Many eements of the conceptua framework are hypothetica and, consequenty, eements of the practice guide are aso hypothetica and further research is required to investigate these eements. The gaps in the evidence point to the need for further research investigating (1) the differentia infuence of providing additiona information as part of the reminder system in different contexts, (2) the differentia effectiveness and cost-effectiveness of an optimised reminder system over and above usua reminder systems and (3) intensive approaches, such as stepped reminders and patient navigators in disadvantaged and vunerabe popuations. Funding Funding for this study was provided by the Heath Services and Deivery Research programme of the Nationa Institute for Heath Research. Queen s Printer and Controer of HMSO This work was produced by McLean et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxvii