Does Prompting Reduce DNA Rates: BIPA Prize Presentation

Does prompting reduce non-attendance rate? Ranga Rattehalli – ST6 Mahesh Jayaram - Consultant Ihsan Kader - Consultant

My role in the project
Inspired by the Leeds PROMPTS trial
I took the lead in formulating and developing the idea, data collection, data analysis, writing up and publication
Research was conducted on my special interest day during my ST4 post

Background
Out-patient clinics- an important contact
Failed attendance adds to the cost of care
Adverse impact – missing medications
Delay in identifying relapses
Increases waiting time for others
It costed NHS 360 million pounds in 1997
? > 0.5 billion per year now

Causes of non-attendance?
Conscious decision (benefits vs risk)
Often have a treatable morbidity
Commonest – forgetting the appointment
Forgetting – medication non-adherence
Unrelated to severity (other specialities)
Severe mental illness – more likely

Implications of non-attendance
Delay in identifying EWS of relapse
Disengagement from services
Trust performance indicator- CQC report
Banded on a scale of 1 to 5 (high=better)
Rate < 11% considered acceptable
Financial penalties for high DNA rates?

Evidence for prompting
Leeds PROMPTS trial (N 764, RR 0.76, CI 0.59 to 0.98,NNT 16, 95% CI 10 to 187 )
- Psychological Medicine 2008
Systematic review (serious mental illness)
5RCTs, N 1184, RR 0.72, CI 0.59 to 0.89, NNT 6, CI 4 to 14
- Cochrane 2001 + PROMPTS Trial

Aim
To implement this evidence based intervention of sending prompt letters in our out-patient clinics in the pragmatic real world non-randomised setting & measure the non-attendance rate.
(Prompting works in trial settings but does it work in the real world?)

Methods
Prompting letter to all patients attending outpatient clinic in South Leeds (2 CMHT)
Letter sent one week before appointment
Royal mail First Class Post
Ongoing practice since June 2007
DNA- failed to attend & no message

Dear [Patient’s name] Re: Your appointment at Bridge House This is a short reminder of your appointment at Bridge House on the [Date at Time] . Your appointment will be with Dr. XX and will last for xx minutes. This interview will be private and confidential. It is often helpful if you bring a friend or family member and medications along. Our clinic has a reception and once the receptionist knows you have arrived, she will inform the doctor. Bridge House is located on Balm Road and a map with directions is enclosed with this letter. If you have forgotten about the appointment or made other plans, do not worry. Please let me know at the above telephone number and we will rearrange your appointment at a time which is convenient for you. [Name of Secretary]

Data analysis
Compared DNA rates before and after this intervention in 2007
Compared with DNA rates in the same months in 2006 (seasonal variation)
Trend across the whole year
Compared with DNA rates in West Leeds where no prompting was used

Results A total of 1433 letters were sent out in the study period. Average non-attendance rates across different periods 26% 27% 17% Jan-May 07 June-Nov 06 June – Nov 07

Prompting letters introduced

NNT 11, 95% CI 8 to 17 A Forest plot showing the effect size 0.5 0.7 1 1.5 2 Favours Prompts Favours Controls Study Prompt Group Control Group RR Weight RR (95% CI) n/N n/N % 243/1433 280/1074 Total N=2507 Total events: 243 (prompts group), 280 (control group) Test for heterogeneity: not applicable Test for overall effect Z=5.53 ( P<0.00001 ) 100.0 0.65 (0.56, 0.76)

Comparison with West Leeds So a reduction in the DNA rate in our study is unlikely to be due to a general reduction across the city! Average non-attendance rates 0.45 (NS) 23% 22% P value June-Nov 2007 June-Nov 2006

Were samples comparable? So a reduction in the DNA rate in our study is unlikely to be due to a having a different set of patients in 2007! 1433 appointments 575 patients (2007) 90% patients same as in 2006 10% patients new to 2007

Were the clinicians different?
Clinicians in 2007 may have acted differently toward patients compared to 06
Yes!
- one Consultant changed in Mar 2007
- SHOs, SpRs & Staff Grade changed
Drawback of pragmatic studies in NHS!

Patients getting better over time? Average non-attendance rates So a reduction in the DNA rate in our study is unlikely to be due to an improvement in their mental state! 0.79 to 1.74 1.17 17% 15% 95% CI RR Remained constant New for 2007

Conclusion
Prompting letters do reduce non-attendance rates even under non-trial conditions
Useful and easy to apply intervention with no implication on resources
£80 saved for every £3 spent (NNT 11)!!
(reference cost of each appointment - £80)

Does Prompting Reduce DNA Rates: BIPA Prize Presentation

by JP Rajendran on Aug 28, 2010

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Does Prompting Reduce DNA Rates: BIPA Prize Presentation — Presentation Transcript