J Witter, A Steele, D McEwen, P Mehler
J Witter, A Steele, D McEwen, P Mehler. The Effect of Computer Generated Appointment Reminders On Compliance With Clinic Appointments. The Internet Journal of Healthcare Administration. 2001 Volume 8 Number 2.
Missed medical appointments are an important obstacle to the provision of effective health care. By failing to keep their appointments, patients disrupt the doctor-patient relationship, adversely affect clinic efficiency, and erode continuity of care. The benefits of continuity of care include a decrease in emergency department visits 1234 , a decrease in the likelihood of future hospitalizations 56 , an increase in patient satisfaction 78 and the use of preventive health services 9 , and ultimately a decrease the cost of health care 10 . Moreover, there is decreased use of diagnostic tests and more reliance on judicious expectant management when as the result of the provision of continuity of care practitioners have a high level of accumulated knowledge regarding their patients 11 . Decreasing the missed appointment rate can therefore be expected to improve continuity of care and the provision of effective health care.
Failure to keep appointments leads to increased administrative complexity and decreased revenues. Missed appointments also decrease access to care for other patients needing health care. Practitioners and administrators struggle with the resultant unpredictable patient volume, and often resort to overbooking patients in an attempt to maintain productivity. This in turn can lead to patient and staff dissatisfaction. All of these factors indirectly increase the cost of care. Unfortunately, missed appointments are common in many different health care settings; a review by Oppenheim et al found missed appointment rates ranged from 19% to 52% in a large variety of health care settings 12 . Increased missed appointments were noted in young adults, adults with young children, and low socioeconomic groups.
Several interventions, with varying degrees of success, have been designed and described in the medical literature in order to improve compliance with appointment keeping and decrease clinic no-show rates. Computer generated telephone messages may provide an inexpensive and effective means to improve clinic attendance. Evaluation of these systems has shown that they can improve immunization rates 1314 and increase attendance in some public health clinics 15 . We decided to evaluate the effectiveness of a computer generated reminder system on kept appointment rates in an inner city public hospital system. Our hypothesis was that such a system would positively impact the kept appointment rates in primary care clinics in our integrated public health system.
(Note: BRITE is manufactured by InterVoice of Dallas, Tx. The scheduling system used was INVISION Resource Scheduling from Seimens Medical Solutions Corporation, Malvern, PA. Denver Health and Hospital Authority has purchased both of these systems. No financial support was provided to the authors.)
The demographics of the study patients in each of the appointment groups are shown in Table 1. Patients who were assigned to the reminder group were younger slightly younger and were more likely to be African American, although the great majority of the patients were Hispanic. Gender was similar between the two groups.
The kept appointment rates at each of the clinic sites, according to intervention group, are shown in Table 2. Also shown are the kept appointment rates for patients who were actually contacted by the voice messaging system. A total of 5,717 patients were eligible for the study, of which 3,048 were randomized to the reminder group and 2,669 to the control group. 2,617(86%) of the 3,048 patients in the “reminder” group were eligible to receive the reminder. The remaining 431 patients did not give permission to be contacted by the appointment system. Overall, the kept appointment rate was 69.2% in the reminder group compared to a kept appointment rate of 64.1% in the control group. This represents an 8% positive increase (p<0.01) and a large absolute increase in the numbers of kept appointments.
These results occurred even though only 1,192 of the 2,617 eligible reminder group patients were contacted by the system. The kept appointment rate among those patients who actually received the reminder was 71%, an increase of 10.8%.
The results of this study suggest that use of a computer generated appointment reminder system modestly increases the kept appointment rate in an urban community health environment. This increase occurred in a setting where kept appointment rates have traditionally been very low. Data from our institution and many other public hospital systems show a historical kept appointment rate of 68% to 72%. This low rate of kept appointments likely represents a combination of factors, including low socioeconomic status and lack of urgency relating to keeping the appointment (primary care visit versus urgent/emergency care visit), factors which have been shown to predict missed appointments in other studies 16 . It is precisely this historically difficult to reach population that our study addressed. The intervention did increase the kept appointment rate, albeit to a modest extent.
The magnitude of increase in the kept appointment rate was somewhat less than reported in other studies 1718 . These studies addressed mostly pediatric populations, while our study addressed patients of all ages. It is possible that this intervention would have different effects on different age populations and is a potential area for future investigation.
Another potential reason for the lower than expected increase in the kept appointment rate was the failure of our system to actually contact a significant proportion of the patients who were called. Failure to contact a patient could represent several possibilities, including incorrect phone numbers in our system, disconnected phones, computer errors in processing phone calls, and contact attempts being made while the patient was unavailable. Difficulties interfacing the CTI system with the existing scheduling computer were encountered. Increased familiarity with the CTI system would be expected to resolve this problem and improve the efficiency of the system.
Finally, the patients in this study may not have been receptive to receiving an impersonal computer generated appointment reminder. Patients may therefore have chosen to ignore the message when answering their telephones. Some providers anecdotally reported patients who complained about the message that was received, although information about patient acceptance of the reminder system was not systematically collected. This study was not able to determine if the younger mean age (29.15 years vs. 31.28 years) and slight African-American prevalence in the reminder group affected the response to the computer message. Further investigation regarding patient acceptance of such a system would be helpful.
One of the limitations of this study included the diverse age range of the patients. While we chose to study the effects of this system in patients of all ages and in different clinic locations (representative of our clinic system as a whole), there were considerable variations in the effect of this system among the different clinics. While the results may be applicable to broad populations, the effect of the CTI system in a specific clinic may not be predictable. Another limitation was the performance of the CTI system. Although we estimate that about 90% of our patients have telephones, only about 50% of the eligible patients were actually contacted. We would expect that improved system performance could be achieved with increased familiarity with the system and would result in even higher kept appointment rates, although the net effect of a well functioning system remains to be seen.
Mailed reminders and telephone prompts have been found to be somewhat effective interventions in many outpatient settings 1920 ; however, the high cost of mailings and the amount of labor involved prevent their widespread use by private clinics and public health systems. The use of a computer generated appointment reminder system resulted in an increase in the kept appointment rate of 8%. This increase could have considerable economic impact. In our community health system, there are about 300,000 patient visits a year, of which 57% are made 72 hours ahead of time. Thus 171,000 visits could potentially be impacted by implementation of the CTI system. An 8% increase in the kept appointment rate in 171,000 scheduled visits would represent almost 9,000 additional visits. If the average charge for an outpatient visit is $177.35, the increase in visits represents about $1.5 million in increased charges. Unfortunately, charges do not necessarily represent receipts. This analysis does not take into account the additional indirect benefits of an increased rate of kept appointments such as improved health of a patient population and more efficient staffing and overall clinic administration.
The decision to implement such a system would have to be made on a site-specific basis. Telephone ownership in the target population, population acceptance of recorded messages, and a cost/benefit analysis would have to be taken into account. The cost of implementing this system in our large public health system was not insignificant; about $325,000 initially and an expected $125,000 a year for maintenance and upkeep. We calculate that a clinic would need to have patient base of about 40,000 patients in order to break even. These costs would probably be significantly less in smaller clinics.
In summary, missed appointments in primary care practice continue to have a deleterious effect on clinic efficiency along with a negative impact on healthcare revenues. Additional studies are warranted in an attempt to further the kept appointment rate. The introduction of a computerized reminder system had a modest beneficial effect on decreasing no show rates. A comparison of the demographic characteristics of the patients who continue to miss appointments with those who did not as a result of the computerized reminder might provide additional worthwhile information.
Joel Witter, MD Eastside Clinic 501 28 th St. Denver, CO 80205 Phone (303)436-4604 Fax (303)436-4610 firstname.lastname@example.org