Improving out-patient attendance using postal appointment reminders

Previousstudies have demonstrated high rates of non-attendance among new referrals to psychiatric out patient clinics. Consistentfactors which distinguishnon-attenders have not been shown. Forgetting an appointment contributes towards non-attendance and offers potential for its reduction. The effect of sending patients an appointment reminder three working days prior to the appointment date wasexamined. Therate of attendance of those sent a reminder improved significantly.

The efficiency of out-patient clinics is reduced by high rates of non-attendance. Fatid & Alapont (1993), for example, reported a 'did not attend' (DNA)rate of 22% for new referrals to a psychiatric out-patient clinic. Factors differentiating those who DNA have repeatedly been examined and produced some conflicting results. Frankel et al (1989) consequently concluded that the form of service delivery is more important than patient factors in determining nonattendance. Forgetting the appointment has been reported in up to 24% of non-attenders (Sparr et al 1993), and provides potential for reducing DNA rates. Grover et al, (1993) reduced a 20% DNA rate in a general medical clinic to 12% by letter reminders and 10% by telephone reminders. This study examines the effect that sending an appointment reminder three working days prior to the appointment date has upon the DNA rate among new referrals to a psychiatric out-patient clinic.

The study
The study was conducted in an adult psychiatric out-patient clinic in a general hospital covering an urban population of 250,000 in the south of Sheffield. All new referrals were randomly allocated to one of two groups. Group 1 were sent a standard appointment letter within two weeks of referral giving an appointment up to 12 weeks later, i.e. the usual system. Group 2 were also sent a postal reminder of the appointment three working days prior to the appointment date. Only I knew the allocation of patients. The Student's t test was used to analyse the data on age and distance from the clinic, and %2test was used to analyse the remaining data.

Findings
The results are summarised in Table 1. The study ran for five months during which time there were 144 new referrals to the clinic; all were included in the study. The difference in the rates of attendance and non-attendance in the two groups is statistically significant at 0.05> P >0.01. There was no difference in age,

Comment
Non-attendance at out-patient clinics is wasteful of professional time and resources. Non-attenders among those referred are a mixed group in terms of sociodemographic factors, diagnosis and severity of symptoms. Although some non-attenders subsequently feel no longer in need of treatment, others present elsewhere or at a later date (Carpenter et al 1981). Therefore high DNA rates probably result in delay or absence of appropriate treatment for more patients. Organising a service to maximise the likelihood of attendance is, therefore, befitting. Our control group DNA rate of 28% is not high compared with many other studies, but it was nevertheless reduced to 13% in the group who were sent a letter reminder. Of greater importance was the corresponding increase in the number of original referrals being assessed in clinic, (from 51% to 61%), thus contributing to a better provision of service. The number of changed /cancelled appointments was high partly due to staff changes and sickness, but it was similar in the two groups and probably did not affect the results.
The two groups did not differ significantly in terms of their age, sex, marital status or distance from the clinic. However, information on previous and current mental health of the patients was not obtained or analysed, although it could be relevant to the results. It is concluded, nevertheless, that the sending of appointment reminders may be a cost-effective way of increasing attendance and reducing non-attendance for new referrals to a psychiatric out-patient clinic.