| Problems with appointment system |
|---|
| Appointment not received or received too late; being unable to cancel or reschedule; did attend (clerical error); did cancel (clerical error); scheduling of appointments with long delay (perception of importance of appointment) | Sending a reminder between 1 and 7 days in advance would provide patients with an opportunity to rearrange their schedule or to cancel and reschedule to a more convenient appointment (CS 7–9) | Send appointment letters/information letter in advance. Up to 2 weeks in advance is potentially adequate. Procedures for updating patient contact details are important to prevent patients from not receiving appointment information. Dedicated telephone lines. Link on web site. Improved clerical systems. Provide appointments in the near future | Having correct contact details would ensure that appointment information arrives with more patients in a time frame that allows patients to attend, or cancel and reschedule if the appointment is inconvenient. Receipt of a reminder up to 7 days in advance of the appointment will allow patients to attend, cancel or reschedule |
| Patient illness |
|---|
| Too ill to attend | Reminder systems which promote cancellation and rescheduling | Cancellation and rescheduling procedures need to be in place especially when rescheduling of appointments is an important priority | A reminder which encourages cancellation and rescheduling would reduce wasted appointments and allow the service to reallocate the appointment (CS 9,10) |
| Too ill to cancel | Reminders could be sent, but it is quite likely that patients and relatives/carers may not receive or respond to reminders | Easy cancellation for patients’ relatives to navigate (e.g. automated SMS reply). Consider whether or not it is very important for a patient to reschedule their health appointment when they are feeling better (CS 10). Send a reminder asking patients to reschedule when they are feeling better | In this case, it seems likely that the appointment will be missed, and that cancellation will not occur. A reminder (SMS, letter) could be effective at encouraging rescheduling behaviour when the patient is better |
| In hospital at time | For planned hospital admissions, a reminder shortly before the appointment could trigger cancellation/rescheduling. In the case of unplanned (emergency) hospital admissions, cancellation or rescheduling is unlikely to occur | Cancellation and rescheduling procedures in place (CS 7, 8). Linked record keeping | A reminder that encourages cancellation and rescheduling would reduce wasted appointments and allow the service to reallocate the appointment (CS 9,10). In the case of emergency admission, it is unlikely that cancellation will occur |
| Patient perceptions and fears regarding the importance or value of appointment |
|---|
| Anxiety about procedures | Provision of information that reduces anxiety (see Appendix 3, themes A.3 and B.3) (CS 3) | Provide full information about the screening program, including details of how and when the results will be reported to the patient (Public Governors’ Comments, see Chapter 3, Involvement of patient steering group). Provide information that increases patient perceptions that the appointment will be positive (see Appendix 3, theme A.5). Provide a follow-up reminder to patients who reschedule their appointment (Public Governors’ Comments, see Chapter 3, Involvement of patient steering group) | Likely to increase attendance |
| More important health concerns (comorbidities) (see Appendix 3, theme F.8) | When health services are dealing with populations with multiple health problems, e.g. older patients, reminder systems that encourage cancellation and rebooking might be an appropriate way to manage non-attendance (CS 7–9) | Open recognition that other health problems can get in the way of attending the current health appointment, may alleviate concerns or embarrassment about cancelling (see Chapter 5, Physical illness/comorbidity). Easy cancellation for patients or relatives/carers to navigate (e.g. automated SMS reply). Consider whether or not it is very important for a patient to reschedule their health appointment when they are feeling better (CS 8). Send a reminder asking patients to reschedule when they are feeling better.83 Assuming that patients are actually well enough to attend, consider batching of health-care appointments for people who are receiving treatment for multiple health problems simultaneously | A reminder may prompt an individual or carer to cancel an unwanted appointment that they might have forgotten about. A reminder (SMS, letter) could be effective at encouraging rescheduling behaviour when the patient is better.83 Batching of appointments may make it easier for patient to attend appointments |
| Asymptomatic health status, e.g. screening appointments or symptom resolution following treatment; not understanding the importance of the appointment; could not be bothered; patients do not find the appointments helpful or rewarding, etc. | Provide information that reinforces the importance of continued treatment through reminder systems (CS 3). Reminder systems should also positively promote cancellation (and rescheduling if it is indicated). Provision of information that increases understanding (reminder plus) (see Appendix 3, themes A.3 and B.3) | Provision of information that reinforces the importance of the screening procedure through appointment letters (see Appendix 3, theme A.2, and Chapter 4, Evidence statement (A.2–A.6): there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment (evidence category IIIa)]. Health-care providers check whether or not patients would like to continue with appointments or not or discuss the importance of continuing with treatment if this is indicated or negotiate a discharge if patients no longer want to continue with treatment | Promotes attendance at follow appointments through provision of information (see Appendix 3, themes A.2 and A.3). Good communication with patient to encourage attendance at appointments if this is required or self-management without wasted appointments if that seems more appropriate for the patient. Patients may feel reassured, more confident about attending |
| Low perceived severity of condition | This is likely to result in higher than usual non-attendance, consider using reminder plus or more intensive reminders (see Chapter 6, Symptomatology and severity). Consider whether or not the message should be gain-framed (benefits of attending) or loss-framed (consequences of non-attendance) (CS 3) | When patients actually have non-severe health conditions are self-managing or have reduced symptoms and no longer wish to attend, provision of information that reinforces the importance of relevant self-management strategies and what to do when/if the patient relapses negotiated discharge [see Appendix 3, theme A.2, and Chapter 4, Evidence statement (A.2–A.6): there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment (evidence category IIIa)]. When patients actually have severe health conditions and low level of symptoms, provision of information about management processes that reinforces the importance of continued treatment may be helpful to promote attendance [see Appendix 3, theme A.2, and Chapter 4, Evidence statement (A.2–A.6): there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment (evidence category IIIa)]. Reminder systems should promote attendance and the importance of rescheduling to maximise positive outcomes and minimise negative outcomes, and to address fears that are relevant to the health service, etc. (see Appendix 3, theme A – several may be relevant; and see Appendix 3, theme E). Negotiate a discharge if patients no longer want to continue with treatment | Patients with actual low severity conditions could be encouraged to self-manage for as long as possible and encouraged to reschedule via appropriate scheduling mechanisms when they feel that they need further input. May facilitate attendance and may lead to an informed decision to stop treatment. May also facilitate cancellation or rescheduling |
| Lower actual severity of condition (see Appendix 3) | Simple reminders are potentially useful in promoting attendance. Consider reminders that incorporate messages to cancel if patient no longer intends to attend treatment, and reminders to reschedule if patient simply unable to attend but wishes to continue with treatment | Prepare patients for self-management of condition as a part of the overall management strategy | Promotes attendance: allows patients to self-manage beyond the period of treatment decreasing the requirement for patients to attend. Promotes cancellation: promotes rescheduling for patients who do wish to continue with treatment. Patients can be referred for treatment if the patient feels that they need further treatment |
| Timing and incompatibility of the appointment: planned (avoidable) |
|---|
| Employment status – work commitments; inconvenient time; unable to get time off work | Reminder systems which promote cancellations and rescheduling | Easy cancellation and rescheduling procedures (CS 9); more flexible scheduling (see Appendix 3, theme F.4); provision of evening clinics; consider issues to do with accessibility, such as child care, transport, work commitments (see Appendix 3, theme A.6) (CS 4, 5) | A reminder that encourages cancellation would reduce wasted appointments and allow the service to reallocate the appointment (CS 8, 9). It is possible that more patients will be able to attend their appointments if there is greater flexibility in the appointments system. There is some evidence that patients would welcome this179 (see Appendix 3, theme F.4) |
| Timing and incompatibility issues: unplanned (unavoidable) |
|---|
| Other family commitments – sick child | Reminder systems which promote cancellations and rescheduling | Easy cancellation procedures (CS 9), more flexible scheduling (see Appendix 3, theme F.4) (CS 8) | A reminder that encourages cancellation would reduce wasted appointments and allow the service to reallocate the appointment (CS 8, 9). It is possible that more patients will be able to attend their appointments if there is greater flexibility in the appointments system. There is some evidence that patients would welcome this179 (see Appendix 3, theme F.4) |
| Forgetting | Send a simple reminder, it does not appear to matter what type of reminder is sent in this situation. Send reminder 1–7 days in advance | Cancellation and rescheduling procedures need to be in place, especially when rescheduling of appointments is an important priority (CS 7–9) | Simple reminders are effective at helping forgetful patients to attend (see Appendix 3, theme A.1) (CS 1). A reminder that encourages cancellation and rebooking would reduce wasted appointments and allow the service to reallocate the appointment (CS 8, 9) |
| Overslept | Reminder unlikely to be effective unless on same day, prior to appointment | Consider whether or not it is very important for a patient to reschedule their health appointment when they are feeling better (CS 8). Send a reminder asking patients to reschedule.83 Consider making appointments later in the day; evening clinics | A reminder (SMS, letter) could be effective at encouraging rescheduling behaviour when the patient is better.83 An appointment later in the day would prevent similar problems arising in the future |
| Issues to do with patient: practitioner relationship or interaction |
|---|
| Appointment not with doctor of choice; poor therapeutic relationship with HCP (see Appendix 3, theme C.4); accessing alternative health provider (e.g. doctor shopping in Hong Kong) | Ensure reminders contain appointment cancellation requests and procedures. Let patients know that the appointment can be given to someone else (see Appendix 3, theme E, and Chapters 5–7) | More flexible scheduling; constructive, open, non-judgemental communication and behaviour from HCP; provide option of appointment with alternative HCP | Allow rescheduling with other practitioner. Encourage resolution of issue |
| Issues to do with the accessibility of the appointment |
|---|
| Unable to get transport; unable to park; distance to clinic | Include information about transport and accessibility in reminder/appointment invitation: ‘reminder plus’ (see Chapter 6,Reminder plus) | Transport provision; provide health care in more accessible location | No strong evidence from the literature around reminder systems |
| Financial reason: cost of transport (costs of health care not so relevant in a UK context) | | | Privately insured patients more likely to attend than Medicaid patients65 |
| Patient attributes |
|---|
| Age (adolescents and young adults) (see Appendix 3, theme F.1) | Reminders are indicated for all age groups but for different reasons; younger people more likely to miss appointments, but older patients take up the bulk of the appointment. Consider reminder accessibility (see Chapter 6, Accessibility) | Age appropriate technologies could be considered – no evidence to support or describe this | The evidence strongly suggests that reminders will impact upon attendance62 and that this is likely to be the case regardless of age. We do not know how age impacts the effectiveness of reminders to increase cancellation figures |
| Too embarrassed to call clinic to cancel | Provide solutions that reduce patient: clinic interaction, such as SMS, answerphone (CS 7, 8) | | Facilitates cancellation/rebooking without need for explanation or interaction |
| Gender | There is no evidence that gender influences a person’s attendance at appointments therefore a reminder solution does not need to consider gender | No general recommendations can be offered, consider local health service needs | |
| Deprivation status (or problems arising from deprivation status) | Provide multiple methods of cancelling and rescheduling appointments. Consider a range of reminder technologies appropriate to the audience | Accuracy of contact details; ease of understanding health-care literature; easy and inexpensive ways to make, cancel, reschedule appointments (CS 1, 5, 7–9); transport; appointment batching (see Appendix 3, theme F.3) | Inability to access a population (for instance, owing to lack of telephones) makes cancellation and rebooking less likely and more difficult |
| Ethnicity: there is no clear evidence to suggest that ethnicity influences attendance; there is also equivocal evidence that language difficulties may lead to non-attendance | Consider the appropriateness of different technologies (e.g. SMS, phone uptake). Language needs to be considered and pictorial messages may be appropriate in some circumstances (see Appendix 3, theme B.2, and Chapter 5, Ethnicity) | It is hypothesised that sending appointment letters and reminders in a language that is understood by the patient would be an appropriate thing to do; although there is no evidence to suggest that this increase attendance, cancellation or rebooking | |
| Substance abuse: see Appendix 3, themes F.6 and D.3 and Chapter 5, Substance abuse) | Simple reminders and automated reminders to attend may be ignored or overlooked particularly when are experiencing an increased level of illness or substance abuse. In fact, the use of simple reminders may put these patient groups at a disadvantage as compared with general outpatient populations. Reminders with direct personal contact might be appropriate in these groups (see Chapter 6, Other reminder characteristics, Format of the reminder). A sequential reminder intervention78 would reach the maximum number of participants but may increase attendance rates and still be cost-effective (CS 5) (see Chapter 6, Substance abuse/mental health/comorbidity and physical illness) | A further consideration is how to re-engage patients with treatment after they have missed their appointment. Intensive reminder approaches might also be effective at re-engaging similar groups of patients who have dropped out of treatment (C8) (see Chapter 6, Substance abuse/mental health/comorbidity and physical illness) | Maximise attendance in a generally low-attending group. Re-engage patients following non-attendance |
| Mental health service users | As above in row Substance abuse | As above in row Substance abuse | Maximise attendance in a generally low-attending group. Re-engage patients following non-attendance |
