Short message service cancellation intervention to reduce integrated sexual health and HIV ‘did not attend’ appointment rates

Abstract

Did not attend (DNA) appointments create a significant impact upon resource and finance efficiency in the NHS. Despite introduction of short-message service (SMS) reminders to our patients, DNA rates remained persistently high. An option to send an SMS to cancel a booked appointment was piloted from 15 January to 16 April 2018 for integrated sexual health and human immunodeficiency virus (HIV) appointments. Absolute monthly mean DNA rates as a proportion of total bookable appointments fell by 2.24% (14.42% pre-intervention [95% CI: 13.15–15.79%] to 12.18% post-intervention [95% CI: 10.98–13.50%]). Cancellation rates increased proportionally by 14.28% from 24.4% to 38.68% (786/3224 pre-intervention [95% CI: 22.70%–26.15%] to 1184/3061 post-intervention [95% CI: 36.52–40.93%]). Findings suggest that SMS cancellations are a viable solution to reduce DNA rates in this setting.

Keywords

Equipment screening human immunodeficiency virus diagnosis

Introduction

‘Did not attend’ (DNA) appointments cost the NHS almost £1 billion in the last year (2016/2017).¹ Approximately one in every ten outpatient appointments in England are being missed annually.² Missed appointments have negative impacts upon patient care, through longer appointment access times and inefficiency of staff time and resources. Sexual health services are under increasing financial pressure, with many services facing significant cuts to resources and budgets.³ Subsequently, the importance of prioritising resources to ensure those requiring care have access has never been of greater significance.

Short message service (SMS) text reminders are being increasingly used in health care settings as a method to reduce DNA rates.¹ Previous research has reviewed their use in the sexual health setting, with generally positive outcomes.^4,5 The Royal Bolton NHS Foundation Trust Integrated HIV, Sexual and Reproductive Health Service offers a combination of walk-in and bookable appointments for integrated sexual health and human immunodeficiency virus (HIV) patients. We have been sending SMS reminders 24 h prior to appointments for the past two years. Wording of the text message aligns with previously published research which identified the most effective phrasing for text reminders.² Reminders state the following: ‘You have an appointment at SHINE Bolton on <date> at <time>. Forgetting to cancel costs the NHS approx. £160. To cancel/rearrange call <clinic number>’. Despite the introduction of text reminders, DNA rates remained high, with mean monthly rates of 14.5%. Accordingly, we introduced a simultaneous SMS reminder and cancellation service from January 2018. This study’s objective was to identify whether this intervention led to improvements in bookable appointment DNA rates.

Methods

Our clinic uses electronic patient records, utilising the Blithe ‘Lilie’ system for both computerised booking, internet booking and clinical note recording. Explicit consent is obtained to contact patients via SMS, which is used as our main contact source for distribution of negative results. Our service is allocated a set bundle of SMS per month, with SMS reminders being an integral aspect of the patient management system. SMS text reminders are sent 24 h prior to patient appointments which are easily distributed by administration staff. Since January 2018, we added the following option to the reminder text, ‘Please text 1 to cancel your appointment’. SMS responses are emailed directly to our administration team, who then cancel the appointments, thus making these re-available. We conducted a review over three months pre- and post-SMS cancellation service implementation (pre-intervention 25 September 2017 to 18 December 2017; post-intervention 15 January 2018 to 16 April 2018) to identify the impact on DNA rates. Statistical analysis was conducted using the Wald method to calculate 95% confidence intervals and Chi squared test to calculate p-values. Ethical approval was not deemed necessary, as this was classed as a service improvement project.

Results

The DNA rates pre- and post-intervention are demonstrated in Table 1. Absolute monthly mean DNA rates as a proportion of total bookable appointments fell by 2.24%, from 14.42% (95% CI: 13.15–15.79%) to 12.18% (95% CI: 10.98–13.50%). Median number of SMS cancellations across the three-month period was 76 (interquartile range: 25th percentile 60, 75th percentile 78). Between the time periods, cancellation rates increased by 14.28% from 24.4% to 38.68% (786/3224 pre-intervention [95% CI: 22.70%–26.15%] to 1184/3061 post-intervention [95% CI: 36.52–40.93%]).

Table 1.

Pre- and post-intervention DNA and cancellation rates.

	Rate pre-intervention(95% confidence intervals)	Rate post-intervention(95% confidence intervals)	Two-tailed p-value using Chi squared
DNA appointment	465/3224 (14.42%) (13.15–15.79%)	373/3061 (12.18%) (10.98–13.50%)	0.0091
Cancellations	786/3224 (24.40%) (22.70–26.15%)	1184/3061 (38.68%) (36.52–40.93%)	<0.0001

DNA: did not attend.

Discussion

The SMS cancellation implementation service was associated with reduced DNAs and increased appointment cancellations in our department. Using SMS as a reminder and cancellation service has several advantages, including the ability to easily distribute reminders to simultaneous patients, improve cost-efficiency and time-efficiency.^4,5 Whilst the intervention required administration time to cancel appointments, it reduced administration time associated with DNAs and opened bookable appointments. Despite extensive reviews into SMS reminders in the outpatient setting, we believe this to be the first review of SMS cancellation service in the sexual health setting. Our findings may be of benefit to other sexual health clinics who have access to a similar electronic system and SMS availability. Limitations of this study include the study design being a ‘before and after’ study, which introduces the potential for other confounding variables to have influenced the results, not directly related to SMS cancellations. This includes factors relating to administration and ease of contacting the department via telephone to cancel appointments. Additionally, it is possible that time of year, accuracy of recording of DNAs and cancellations and external factors such as weather may impact numbers of DNAs. This was the only intervention implemented during the defined timescale, and no changes in the administration team were made during this time. Additionally, we excluded the two-week holiday period in our pre-intervention figures to minimise any potential confounding impact this could have had on results. We plan to make further improvements through ensuring all administration staff have access to cancel appointments, and further promote the SMS cancellation service in the clinic waiting areas. Our findings may be generalisable to other sexual health clinics offering a similar model of bookable appointments and using an electronic system which allows the distribution and return of SMS reminders and cancellations.

Footnotes

Acknowledgements

We would like to acknowledge the hard work of the administration team led by Helen Walker at The Royal Bolton NHS Foundation Trust Integrated HIV, Sexual and Reproductive Health Service who were key to the success of text cancellation intervention. We would like to thank Dr Ryan George, Manchester University Hospitals NHS Foundation Trust, for assistance with statistical analysis.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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