1. IT Technologies to reduce the rate of absenteeism
at the outpatient
*1,2 Dr. Humberto F. Mandirola Brieux, *2 Sebastián Guillén, *2 Pablo Laguzzi
1 Master career in Internal Medicine in Buenos Aires University, Argentina
Universidad de Buenos Aires, Argentina, 2 BIOCOM Argentina.
Summary
The percentage of absenteeism in external consulting rooms in many institutions ranges from 15 to 30%- By applying information
technologies it can be reduced considerably. The absenteeism in medical appointments has a high incidence in administrative and care
cost and efficiency in ambulatory attention not only in the first consultation but also in complementary studies, so it is very important to
measure it and to take steps to reduce it. 20% of absenteeism considerably increases waiting times in the assignment of new
appointments. The usual form to reduce waiting times for new consultations is to hire new professionals but this can be avoided if we
diminish said absenteeism and if we make the staff of external consulting rooms more efficient and productive. In this work we measure
the efficiency of the appointment confirmation methodology in four different ways: Email sent to patient, phone call made to patient by an
operator, sending an SMS to patient and the last one, combining SMS with an email. In our study, phone calls and SMS reduce
absenteeism in a significant way p<0,001regarding Control Group, it cannot be said the same in the case of reminders of appointments
by Emails.
Key words:
Reminder, Information Technology (IT), Short messaging service (SMS), Randomized controlled trial (RCT),
Telephone, Failure to attend (FTA), appointment-reminder, outpatient absenteeism.
Introduction
The percentage of absenteeism in external consulting rooms in many institutions ranges from 20 to 30%. By
applying information technologies it can be reduced considerably. Information technologies (IT) constitute a
big help to diminish absenteeism impact in external consultation. Failure to attendance has big incidence in
cost and efficiency in ambulatory attention not only in the first consultation but also in complementary studies
so it is very important to measure it and to take steps to reduce it. Many medical centers, considering this cost
and quality impact, implement different technologies efficiently as the so called personalized reminder of
appointment, this is the case of an absenteeism reduction from 11, 6% to 4,7% in breathing functional studio
at St Joseph Hospital. They didn’t find significant differences in absenteeism between reminders thru direct
conversation vs. a message left in an answering machine. [1], [5], [6] ,[8], so in this way it can be proved
that a message is an important means to avoid absenteeism
Standards with HL7 can be used to interoperate between systems in an automatic way [2]. A technology
which has been proved to be very efficient and, above all, economical is sending a SMS message, such is the
case of the work at the Royal Children’s Hospital, Melbourne, Victoria; this group compared two series of
patients, one was reminded by a phone call and the other by SMS. The first group reduced absenteeism 12%
to 16% and the other 19% to 39% [3]. Percentage of absenteeism does not affect productivity of the institution
but the opportunities of diagnosis and treatment in a timely manner and reduces the efficiency of health
systems [4]. 25% of absenteeism increases considerably waiting times for assignment of new appointments.
To reduce waiting times for new appointments the tendency is to hire new professionals but this could be
avoided if we succeed in diminishing absenteeism and in making more efficient and productive the staff in
external consulting rooms.
We measure the efficiency of the methodology of appointments confirmation thru 4 different ways: Email
sent to patient, phone call to patient by an operator, sending an SMS and the last one, combining SMS with an
email
Elements of Work and Methodology
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2. This study was made on the basis of data of appointments at a Private Hospital. 1000 data obtained at random
from ambulatory appointments in January 2011 were analyzed. At the beginning of the study, appointments
were assigned in 5 groups at random by computer. In samples 1 to 4 confirmation or cancellation of the
appointment was requested 72 hours before it. The four samples were obtained at random from the data base.
1. To send the Email to patients the notification was made by electronic mail thru a BIOCOM
appointments reminder module 72 hours before the assigned appointment.
2. A group of patients were called by phone operators (72 hours before the assigned appointment)
without distinguishing if the messages were received by the patient, a relative or an answering
machine.
3. To send SMS messages it was used: a conventional SIM module of Movistar mobile system, a GSM
modem which was connected to a computer with the appointment confirmation module thru a USB
port, then the BIOCOM appointments reminder module thru an asynchrony transference using AT
commands to activate GSM modem and in this way send the SMS messages.
4. In this group, thru the system, they were sent automatically (an Email and SMS 72 hours before)
with the methodology described before in samples 1 and 3.
The whole sample obtained belongs to 1000 patient appointments and the sub-samples prospectively obtained
at random for the analysis are the following:
1.
2.
3.
4.
By Email n =207
With the phone call of an operator n =200
Sending an SMS n =208
Sending an SMS and an Email n =182
The whole sample obtained belongs to 1000 patient appointments and the sub-samples prospectively obtained
at random for the analysis are the following
5.
6.
7.
8.
9.
By Email n =207
With the phone call of an operator n =200
Sending an SMS n =208
Sending an SMS and an Email n =182
CONTROL GROUP: Procedure of conventional appointment without previous reminder n =203
Inclution Criteria in the study: all the patients included in the data base in May 2011 (elected at
random in the four groups before mentioned) were added.
Exclution Criteria: all the patients who did not receive the message by Email, phone or SMS were
excluded from the study.
The population organization chart in study appears in figure 1 where it is shown the quantity of
excluded ones in each sample
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3. Figure 1
Data analysis was made transferring data extracted from data base to an Excel and adding a “1” if the patient
attended the appointment and a “0” if he/she failed. On these data different tests to calculate percentage, rates
and signification and comparative statistics between samples were made thru T test, distribution in two tails to
compare two samples of equal variance.
Results
From the analysis of data obtained, significant differences turned up with P<0.001 in the attendance to the
appointment of phone reminder patients with SMS and SMS plus Email (See table 1). Email reminders,
though they show more patient attendance, did not show significant differences with respect to the Control
Group p=0,046. When we compare SMS interventions vs. phone calls, SMS plus Email vs. Phone calls and
SMS plus email vs. SMS, we did not obtained significant differences either. We observed that appointment
reminders thru SMS achieve a 22% attendance increase with respect to the sample without reminder. (See
table 2).
Table 1
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4. Table 2
In figure 2 behavior of all variable analyzed
Figure 2
Discussion
Mobile phone is a very popular devise which is already part of our life. To use it for different actions related
to health is a valid option even better than other means of communication. This is not the first study which
examines the effect of communication tools as the phone, Emails and SMS on absenteeism in medical
appointments. In our study, though SMS reminders are more effective than phone call reminders, this
difference is not significantly higher. However in other studies other groups registered a significant difference
in favor of SMS [4]. Patients who received a reminder thru Email, phone or SMS tended to keep their
appointments compared to Control Group. Similar studies were obtained by other investigators: Haynes y
Sweeney’s studies (2006) [1]. They showed appointment reminders reduced absenteeism rate from 11,7% to
4% .Shoffner et al. (2007) [6], [8].
References
[1] Haynes, J.M., Sweeney, E.L., 2006. The effect of telephone appointment-reminder calls on outpatient absenteeism in a pulmonary
function laboratory. Respir. Care, 51(1):36-39.
[2] EHR IMPACT European Commission, DG INFSO & Media, The socio-economic impact of interoperable electronic health record
(EHR) and ePrescribing systems in Europe and beyond.
[3] Sean R Downer, John G Meara and Annette C Da Costa Use of SMS text messaging to improve outpatient attendance MJA 2005;
183: 366–368.
[4] Zhou-wen Chen, Li-zheng Fang, Li-ying Chen and Hong-lei Dai, Comparison of an SMS text messaging and phone reminder to
improve attendance at a health promotion center: A randomized controlled trial Journal of Zhejiang University – 2008 Science B
Volume 9, Number 1, 34-38, DOI: 10.1631/jzus.B071464.
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5. [5] Roberts, N., Meade, K., Partridge, M., 2007. The effect of telephone reminders on attendance in respiratory outpatient clinics. J.
Health Serv. Res. Policy, 12(2):69-72. [doi:10.1258/135581907780279567]
[6] Shoffner, J., Staudt, M., Marcus, S., Kapp, S., 2007. Using telephone reminders to increase attendance at psychiatric appointments:
findings of a pilot study in rural Appalachia. Psychiatr. Serv., 58(6):872-875. [doi:10.1176/appi. ps.58.6.872].
[7] Geraghty, M., Glynn, F., Amin, M., Kinsella, J., 2007. Patient mobile telephone ‘text’ reminder: a novel way to reduce nonattendance at the ENT out-patient clinic. J. Laryngol. Otol., 1:1-3.
[8] The Effectiveness of Outpatient Appointment Reminder Systems in Reducing No-Show Rates The American Journal of Medicine,
Volume 123, Issue 6, June 2010, Pages 542-548 Amay Parikh, Kunal Gupta, Alan C. Wilson, Karrie Fields, Nora M. Cosgrove,
John B. Kostis
Datos de Contacto:
Dr. Humberto Fernán Mandirola Brieux, Email
1645 Ciudad de Buenos Aires CP C1426AKE.
hmandirola@biocom.com Institución.UBA/ BIOCOM Dirección postal Amenabar
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