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McLean S, Gee M, Booth A, et al. Targeting the Use of Reminders and Notifications for Uptake by Populations (TURNUP): a systematic review and evidence synthesis. Southampton (UK): NIHR Journals Library; 2014 Oct. (Health Services and Delivery Research, No. 2.34.)

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Targeting the Use of Reminders and Notifications for Uptake by Populations (TURNUP): a systematic review and evidence synthesis.

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Appendix 9Advantages and disadvantages of reminder systems

Simple reminderReminder plus (brief orientation)Other reminder systems 1Other reminder systems 2
ExamplesSMS/letter: provides details of time, date, venueLetter/e-mail/telephone plus orientation informationReminder plus encouragement to cancel/rescheduleTelephone calls
AdvantagesMost people will get SMS reminder provided contact details have not changed or are inaccurate – delays in text are possible (see Appendix 3, theme B.1). Can encourage attendance in those who simply forget (see Appendix 3, theme A.1). SMS is popular and most widely welcomed mode of reminder amongst adolescents and young adults.101 There is strong consistent evidence that mobile text message reminders improved rate of attendance compared with no reminders (RR 1.10, 95% CI 1.03 to 1.17).43,85 IVR system can deliver complex information and is equally as effective as nurses at delivering information; however, patients who receive nurse phone calls report more positive interactions than those receiving IVR.66 SMS software allows large batches of text messages to be delivered almost instantly, minimising labour costs. SMS messages do not require the mobile phone to be active nor necessarily within range and can be held for a number of days until the phone is active or within range. Furthermore, SMS is also private in a way that voice calling is often not57The review by Car et al.43 finds conflicting evidence that favours the effectiveness of ‘reminder plus’. They report that one low-quality study245 reported that mobile text message reminders with postal reminders, compared with postal reminders, improved rate of attendance at healthcare appointments (RR 1.10, 95% CI 1.02 to 1.19). However, three studies of moderate quality showed that mobile phone text message reminders and phone call reminders had a similar impact on health-care attendance (RR 0.99, 95% CI 0.95 to 1.03)246248Can encourage attendance in those who simply forget (see Appendix 3, theme A.1). Can encourage patients who can no longer attend or no longer want to attend their appointment to cancel their appointment, making the appointment available for others (see Appendix 3, themes E.1 and E.4). Can encourage those patients who need to reschedule to make another appointment (see Appendix 3, theme E.1). Multimodal reminders (e.g. written invitation, phone call, reminder, home visit) increase attendance for disadvantaged populations with diabetes in comparison with standard reminder (written invitation and two reminders)Personal telephone calls have a higher rate of attendance in comparison with leaving a message or not reaching the patient at all65
DisadvantagesDoes not encourage cancellation or rescheduling in patients who cannot attend or who no longer wish to attend. Some patients reported that they never received a SMS reminder. It is possible that mobile phone numbers were entered incorrectly on patient records, or that those patients changed their phone numbers during the study.208 Patients may not receive the SMS reminders due to incorrect data entry. Older patients were considerably less likely to own a mobile phone, making them harder to access using reminder technology.100,108 People may not be willing to disclose their mobile phone numbers and record them in patient notes.91 High rate of 10% of clerical errors.111 Some clients expressed concern over having received a copy of a referral letter of another patient in ‘error’; therefore, negatives associated with this approach include the possible implications for client confidentiality, and the increased cost and time implication. One-third of patients gave incorrect contact details when booking the appointment.129 Inner city populations may have less stable contact details (either address or phones) and this may put these patients at a specific disadvantage.103 A potential disadvantage of the system was that 2–3% of people failed to receive their text reminder as a result of incorrect data entry. Patients with mobile phones are most likely to change their contact number.94 Use of this emerging technology disadvantages those who do not have a mobile telephone. 35% patients of this study did not give their mobile phone number.106 Problem in retrieving mobile phone numbers of the citizens, only 12% of the registered citizens did have a mobile phone; thus the initial sample of people eligible for reminders was 66,000 out of 544,000. Wrong phone numbers can result in the SMS reaching someone other than the patient.102 A limitation in the application of this reminder process to the wider hospital community is the degree to which different patient groups are familiar with SMS messaging.106 Issues with SMS: incidence of incorrect mobile telephone numbers; 92 (0.4%) of the 22,658 recipients contacted outpatient services stating that they had no knowledge of the scheduled appointments in the reminder message. It is possible that this value was higher but the recipients did not take any action. The high prevalence with which consumers change their mobile telephone and or mobile telephone service is another issue with SMS.95 Patients with mental health problems have a lower preference rate for SMS reminders than other patient groups.209 Older age groups are less likely to own mobile phone: 61% of 71- to 90-year-olds reported ‘no mobile’.198 90% of the population in many countries own mobile phones, but the uptake is higher in younger people.108 A concern often cited by both patients and physicians is the security of e-mail messaging206 and so this should be addressed specifically (by future research) to allay or confirm fears that may be influencing its use42E-mail is a relatively untested reminder method42May not promote attendance who are anxious about the intervention or who are not sure how to access the health-care service. Computerised appointment system: a disadvantage to this system is the automated call does not specify the clinic in which the patient has an appointment. Hard for some patients to understand and operate practice computer appointment systems249Telephone reminders have particularly poor contact rates – need to consider when calls are made (see Appendix 3, theme B.1). Need to ensure patient records are up to date. Telephone reminders are problematic for groups of the population who have no telephone or who have been disconnected (i.e. deprived populations). Of people in this audit, 23% did not have a telephone or their telephone was disconnected.91 The disadvantage of telephone reminder is that several calls may be needed and this increases the cost of this type of intervention215
CostThe cost of the SMS reminder is minimal, considering the loss of revenue generated by failed appointments. Text reminders on a large scale would be cost-effective strategy could be improved.208 Annual cost of missed appointments in England is estimated to be close to £575M. The use of SMS reminders could save £55.6–83.5M a year.165 Costs/attendance of mobile phone text message reminders have been shown to be lower compared with phone call reminders.43 Based on NNT analysis, approximately 14 people would need to be sent a SMS reminder to prevent one non-attendance.100 The average estimated costs in these 14 studies was €0.41 per patient. The mean cost of phone reminders was €0.90, while the mean cost of SMS or automated phone call reminders was €0.14. The three highest reported costs were from phone reminders.47 This study found that the impact is modest, but also is the cost about £7.50 (US$13.13, €10.88) per ‘no-show’ avoided.108 Considering 500 SMS/day at a unitary cost of €0.0065, the first year cost will be €11,500 while next year cost will be about €8200, accounting for SMS and maintenance. Reasoning on a daily basis, this amounts to €35 in the future. As the average monetary loss of a dropout is €20, it’s sufficient to recover 2–3 dropouts/day to amortise the system.102 The cost of sending the SMS reminder during the trial period amounted to 5164 Australian dollars. Attendance rate achieved estimated 11.5% (273,993 Australian dollars).95 Although the attendance rate was similar, the cost-effectiveness analysis showed that the cost per attendance for SMS group was significantly less than that for telephone group. The ratio of cost per attendance of SMS text messaging to that of phone was 0.65 : 1.57 Text messaging reminder is cheaper than mobile phone reminder. The ratio of cost per unit attendance of text messaging vs. mobile phone was 0.55 : 172
Implications for attendanceOne systematic review conducted by Car et al.43 found moderate-quality evidence showing that mobile text message reminders improved the rate of attendance at health-care appointments compared with no reminders (RR 1.10, 95% CI 1.03 to 1.17). [See Chapter 4, Evidence statement (A.1): there is strong consistent evidence that simple reminders which provide details of timing and location of appointments are effective at helping a (forgetful) patient to attend their appointment (evidence category Ia)]
Implications for cancellation and/or rebookingThere is strong evidence that a personal phone reminder will increase patient cancellation rates,67,77,80 but can be problematic when people do not have phone access. SMS can increase cancellations in comparison with no reminder.100 Telephone reminders are more effective than SMS reminders at facilitating cancellation and rebooking.80 The convenience of e-mail for cancellation, insofar as there is no need to wait to get through to a receptionist, is discussed by Atherton et al.42 The evidence for different technologies on rebooking is weak; however, the evidence suggests that cancellation and rebooking will be influenced by the simplicity ease of access to cancellation/rebooking systems101

RR, risk ratio.

Copyright © Queen’s Printer and Controller of HMSO 2014. This work was produced by McLean et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

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