Background To assess the effectiveness of text-messages in reducing the proportion of non-attendance in a youth clinic of a University Hospital.
Methods Patients who registered for an appointment and provided a mobile phone number were randomly selected to receive or not a text-message reminder before the planned appointment. A 10% reduction in the proportion of missed appointments was considered clinically and economically useful and the study was powered accordingly.
Results The proportion of missed appointments was 16.4% (95% CI 13.1% to 19.8%) in the text-message group (N 462) and 20.0% (95% CI 16.6% to 23.4%) in the control group (N 529), showing no significant effect of the intervention (p=0.346).
Conclusions In our primary care youth clinic, text-message reminders are not effective in reducing the proportion of missed appointments. This may in part be due to the fact that most patients are referred by a professional or by their parents and do not initiate appointments themselves.
- Adolescents CG
- Randomised Trials
- General Practice
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Non-attendance at outpatient clinics is an important obstacle to providing effective and efficient healthcare. Adolescents are known to be ‘poor attendees’: studies report missed appointment proportions between 10% and 20% in hospital adolescent clinics in Australia and Switzerland,1 ,2 and 18%–73% in the USA.3
Telephone and text-message reminders have been shown to significantly increase attendance proportions in adults and to be cost-effective.4–6 Telephone reminders on the family's telephone also appear to improve adolescent clinic attendance.1 The high uptake of mobile phones by young people suggests that text-message reminders might be particularly effective with adolescents. Yet, we found only one randomised controlled trial conducted in Australia in which text-message reminders were sent directly to the young people.7 The study included 362 appointments (183 in the intervention group) and the proportion of missed appointment (35.3% in the intervention and 42.9% in the control group) was not significantly different between the two groups.
Each year, approximately 20% of appointments scheduled in our youth clinic are missed. The aim of our study was to test the effectiveness of text-message reminders in reducing this proportion.
Design, setting and participants
This randomised trial was conducted at the youth clinic of Geneva University Hospitals between November 2010 and April 2011. This multidisciplinary clinic offers primary care, gynaecological and mental healthcare to young people between the ages of 12 and 24 years, delivering more than 5000 appointments a year. Most patients are referred by carers, school, social services, paediatricians or family doctors. In most cases, the person referring the young person helps to organise the appointment and only 10% of first appointments are booked by young people themselves.
Patients and those accompanying them were informed of the study when making the appointment and through posters in the waiting room. Adolescent patients who had been registered for an appointment at the clinic and whose mobile phone number had been recorded were randomly selected to receive a text-message reminder or not. They were automatically included in the study each time they came for an appointment but could opt out by informing the receptionist. The study protocol was approved by the ethical committee of Geneva University Hospitals and adhered to the CONSORT guidelines. It was funded by the Division of primary care medicine of Geneva University Hospitals.
Intervention and outcome
We used ‘Easy Smart Care’, a software product developed by EasyMed Services Inc. Phone numbers were entered into a secure web platform which automatically sent generic text-message reminders between 08:00 and 11:00 the day before the planned appointment, including on Sundays. The text, written in French, stated: ‘You have an appointment on… (date) at … (time) with Dr … (name) Please answer NO if you do not intend to come’. Patients in the control group received no reminder.
The outcome was the proportion of unexplained missed appointments, without prior notification. Appointments that were cancelled or rescheduled before the planned appointment were not considered as missed.
The research assistant (NC) used a computer generated randomisation list to allocate consecutive appointments into one or the other group using a printed version of the electronic appointment record. Patients could not be blinded to allocation, but it was concealed from the clinical and administrative staff, as well as from the researcher who conducted the analysis. Reminders were managed by a research assistant and the team of EasyMedmobile, independently from the clinic.
Through team discussions and a review of the literature we decided that an 8%–10% reduction in the proportion of missed appointments would justify investing in an automated text-messaging reminder service.1 We powered the study accordingly estimating that at least 468 appointments had to be included in each group to have a 90% power to detect such a difference at a 5% significant level. Since we anticipated that small sample sizes would limit our ability to interpret these, we planned subgroup analyses only to provide preliminary data on attendance in the different types of consultations in our clinic.
Stata software V.11.0 was used for the analyses which were performed according to the ‘intention to treat’, excluding appointments that were cancelled before or independently from the intervention. We analysed all appointments and then examined whether the results differed in three subgroups of appointments: primary care, gynaecological and mental health appointments.
We compared patient and healthcare providers’ baseline characteristics between groups by means of χ2 tests for categorical variables and Student t test for continuous variables. We compared the proportion of missed appointments between both groups and calculated ORs and CI. P values of 0.05 or less were considered statistically significant.
Figure 1 shows that 469 of the 999 eligible appointments were randomised to receive a text-message. Six appointments were excluded from the analysis as the patients had cancelled their appointment before the intervention could take place. The groups did not differ in mean age, sex and percentage of new patients (table 1).
Although the point estimate for the proportion of missed appointments was lower in the intervention compared with the control group, the difference was not statistically significant (p=0.15; table 2).
When we examined the difference among subgroups of appointment type, we found that the point estimate for the proportion of missed appointments was particularly lower for gynaecology and mental health appointments among those randomised to receive the text-message; however, this again did not reach statistical significance.
This is the largest randomised trial to be conducted to date investigating the use of text-message reminders for young people attending an adolescent health clinic. As opposed to results from studies involving adults,8 our findings do not confirm the effectiveness of text-message reminders to reduce missed appointments in our youth clinic. Our results are in line with those of the small previous randomised controlled trial conducted in Australia.7 These reminders may be more effective in reducing missed appointments for specialised care (gynaecological and mental health appointments) but our study was not sufficiently powered to confirm this.
Missed appointments are a complex and multi-factorial phenomenon. Patients’ forgetfulness emerges as the most commonly reported favouring factor.1 ,9 Forgetting may be related to lack of motivation and difficulties in planning related to adolescent lifestyle or cognitive development at that age.10 In some cases, being in opposition with the parent or the adult who initiated the appointment may be a predominant factor, underlying the importance of family connectedness and perceived support from both parents and relatives.11 During adolescence, gaining autonomy in planning appointments themselves is yet at an early stage and adolescents are often referred by adults as when they were children. Thus, their own motivation to attend healthcare may be less important, leading to discontinuation of healthcare. This may in part explain why our intervention failed to improve attendance proportions. Although text-messages to the young person rather than to their parents promote confidentiality, the results of this study suggest that sending a text-message to the adolescent is less effective than leaving a message on the family's telephone.1
More research is needed to investigate whether text-messages can improve gynaecological and mental health attendance in our clinic. Text-message reminders may be useful when the time between appointment scheduling and the actual appointment is long, as in appointments with the gynaecologist. Reminders may also be more effective for gynaecological appointments as they are more frequently booked by patients themselves. Similarly, as patients in our clinic only have mental health appointments if referred by a primary care physician in the clinic, patients agreeing to such appointments may have been more motivated to attend them.
Young people's receptiveness to text-messages may also depend on the way they manage the text-message system: some may not be using it every day, not looking at it because they are using other communication programmes on social network or because overuse of the text-message system obscures the reminder. The area of new digital media including text-messaging has changed everyone's communication style especially for young people and more research is needed to develop new tools to improve adolescent healthcare.12
Our study had some limitations. Due to small sample sizes, subgroup analyses for the mental health and gynaecological consultations could not provide conclusive information about the effectiveness of text-messaging in these subgroups.
With the Easy Smart Care software it was not possible to know whether patients in the intervention arm had truly received the text-message. Finally, we did not collect data about potential misreading/misinterpretation of written or oral information in text-messages or during recruitment. Neither did we record information in relation to issues of privacy and role of the parents (or other significant adult) involved in scheduling the appointment.
In our youth clinic, where few patients are self-referred, text-message reminders are not effective in significantly reducing the proportion of missed appointments. Further research is needed to confirm the extent to which text-messaging may be effective in reducing missed gynaecology and mental health appointments and to improve our knowledge in this new area.
What is already known on this subject
Young people are widely reported as being ‘poor attendees’ in medical ambulatory care, but we only found one randomised controlled trial using text-message reminders in adolescent health clinics. New digital media are increasingly used in young people's healthcare.
What does this study add
The findings from this randomised controlled trial suggest there are no benefits in using text-message reminders to reduce the proportion of missed appointments in a youth clinic. This emphasises the multifaceted aspect of continuity of healthcare in the adolescent years.
Contributors NJ: initiated the collaborative project. FN, NJP, MDD, NCR, J-PH, BB, DH: designed data collection tools. J-MG: provided financial and practical support for the project. NCR: monitored data collection for the whole trial. DH: wrote the statistical analysis plan, cleaned and analysed the data. FN: drafted the paper. NJP, MDD, NCR, J-PH, BB, J-MG, DH: revised the paper.
Funding This study was funded by the Division of primary care medicine of Geneva University Hospitals.
Competing interests None.
Ethics approval The study protocol was approved by the ethical committee of Geneva University Hospitals and adhered to the CONSORT guidelines.
Provenance and peer review Not commissioned; externally peer reviewed.
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