Good Afternoon, I am Ranga Rattehalli a final year SpR from Leeds. In the next 10 minutes I am going to present this real world pragmatic trial that was conducted at the two CMHTs covering South Leeds in the year 2007 during my ST4 post.
I was inspired by the Leeds PROMPTS trial which was conducted within the Leeds Trust while I was working there as an SHO. One of the recommendations which came out of this Trial was that more real world pragmatic trials were needed in this area. At the same time I got a ST4 post in Leeds. This project interested me a lot and I found it as a wonderful opportunity which I grabbed. So I took the lead in formulating and developing the idea, .......................................... The actual work was done during my Special Interest days, one day a week during my ST4 post.
I am sure out patient contacts are a very important for every client in our mental health services. Failing to turn up for an arranged appointment certainly adds to the cost of running the service but much more important that that, it causes an adverse impact on those patients. Research in this area has shown that most of the times it equates to missing medications which I am sure you will all agree that it will lead to relapse which will go unidentified. Its not just that but it also increases the waiting time for those patients who do want to come and see us. Failed attendance costed over 360 million in 1997 but my guess is that it costs over half a billion today. So it is really important we do something to reduce this cost and that is why we carried out this very simple piece of Research
I conducted a detailed literature review in this area and I should say most of the things I found came from UK. Its possibly less of a problem in other countries where individuals have to pay for their healthcare. Looking specifically at the causes of failed attendance, research has shown that it could well be a conscious decision by the patient after weighting up the benefits of attending with the risks of not attending. That is fine by us but we wish they had told us so that we can use our time for something else. The other argument is: do they not turn up because they suffer from an untreatable illness anyway? But no, researchers have investigated this and found that most of the times people who miss appointments do have a treatable illness. So what is the cause then? Well, it is very simple. The commonest reason is to forget which I would call as not bothering to remember! We also know that when people said they forgot, it was clearly linked to non-adherence with their prescribed medication whichever branch of medicine you take. Specific to mental health is that non-attendance is linked to the severity of mental illness even though this was not the case in other specialities.
So what are the implications of non-attendance? They are wide and varied. For patients it is delay in identifying the early warning signs which means more suffering and disengagement from services. But for the Trusts it is one of the performance indicator which both the Care Quality Commission and the Monitor would be interested in. So it is something which both our Regulators and the Commissioners would be interested in. And a rate of around 11% is considered acceptable. The day is not far when the Trusts could have financial penalties for high DNA rates.
We were interested to find out whether sending out a prompting letter just before the actual appointment does reduce non-attendance rate. Mind you, the non-attendance rate will go down even if the cancellation rate goes us, as the cancellations are not recorded at DNAs. So what was the already existing evidence when we conducted the trial. We had the Leeds PROMPTS study which showed that it did work but the results were not impressive as the confidence interval for NNT ranged anywhere between 10 to 187 which is very wide. But when we pooled this result with the existing Cochrane review we had 5 RCTs, NNT fell to 6 and the confidence interval got nicely narrowed down.
So we decided to implement this evidence based intervention of sending out a prompting letter to all the patients attending our out-patient clinics within the two CMHTs in South Leeds. So this was our real world, pragmatic, non-randomised setting. To put it in plain English, we knew that the prompting works in trial settings and we wanted to find our whether it works in the real world.
So the letters were sent out a week before the actual appointment in First Class post by the Team secretary and has been an ongoing practice since June 2007 till date. It was recorded as DNA on the Trust’s e-care when somebody did not turn up for their appointment and did not cancel it.
The letter was very simple and said it was just a reminder for their appointment at such and such a place with such and such a doctor. A map was enclosed with it and it encouraged them to ring if they had forgotten about it and can’t make it on that day.
We compared the DNA rates before and after the intervention in the year 2007. But we were very much aware of the possible seasonal variation specially in mental health and so we compared it with the DNA rates for the same months in 2006. We also looked at the trend across the whole year to see if the non-attendance rates were decreasing any which continued rather then reducing due to our intervention. We also compared the rate with another part of Leeds where prompting letters were not used to make sure it was not a trend across the city rather than a result of our intervention.
So the main result that we are interested in is the fact that DNA rate fell from 27% in 2006 to 17% in 2007 with the intervention. But we still don’t know whether the reduction is actually because of the intervention or something else. A question inherent to our study design! It is just a before and after study design and we need be careful about the potential confounders before jumping into conclusions.
This is a graphical representation of our main results and you can see that the diamond is clearly away from the line of no effect, clearly favouring the intervention.
When we compared to see what was happening in West Leeds in the same period, nothing had changed. So it was clearly not a general reduction in non-attendance rates across the city which make us think that the results we found may be a result of our intervention.
The very next question that would come to your mind is: was the DNA rate less in 2007 because we had a different sample in 2007? To answer this question we looked at who our patients were in both these years and found out that only 11% of the patients were new in 2007. The rest of the 89% were the same from 2006.
Is it possible that the Clinicians acted differently in 2007 which caused the reduction in non-attendance? The answer is: yes it is possible and the fact is that one of the Consultants changed in March 2007. Yes, the junior doctors, SpRs and the staff grades had changed. But unfortunately this is how helath care system works in the NHS and is a drawback of pragamtic studies within the NHS.
The next question that came to my mind is: Is it because the mental state of the patients improved over time and which then reduced the DNA rate? Well, we were able to answer this question by looking at the DNA rates for patients who were new to 2007 and compare it with the DNA rate for the group that remained constant. And we found no difference as the CI crossed 1. So we can say that the reduction in non-attendance rate is unlikely to be due to an improvement in the patient’s mental state over time and one more reason to believe that it is actually due to the intervention.
Thus we could make considerable efficiency savings if prompting letters were introduced across the entire service. The other significant secondary benefit would be improvement in the QoL for our patients which would be something important to measure in the future studies. I am aware that not everybody checks their mail as a lot of it is junk mail anyway for our patients, but this intervention has proved to be of benefit in the real world. So what is the next step? - rolling out prompting letters nationwide? -or is it to go one step ahead and send Text Messages to remind our patient as almost all our patients use mobile phone? I am pleased to say that our funding application for an SMS Trial has recently been successful and I will be able to answer this question soon!
Does Prompting Reduce DNA Rates: BIPA Prize Presentation
My role in the project <ul><li>Inspired by the Leeds PROMPTS trial </li></ul><ul><li>I took the lead in formulating and developing the idea, data collection, data analysis, writing up and publication </li></ul><ul><li>Research was conducted on my special interest day during my ST4 post </li></ul>
Background <ul><li>Out-patient clinics- an important contact </li></ul><ul><li>Failed attendance adds to the cost of care </li></ul><ul><li>Adverse impact – missing medications </li></ul><ul><li>Delay in identifying relapses </li></ul><ul><li>Increases waiting time for others </li></ul><ul><li>It costed NHS 360 million pounds in 1997 </li></ul><ul><li>? > 0.5 billion per year now </li></ul>
Causes of non-attendance? <ul><li>Conscious decision (benefits vs risk) </li></ul><ul><li>Often have a treatable morbidity </li></ul><ul><li>Commonest – forgetting the appointment </li></ul><ul><li>Forgetting – medication non-adherence </li></ul><ul><li>Unrelated to severity (other specialities) </li></ul><ul><li>Severe mental illness – more likely </li></ul>
Implications of non-attendance <ul><li>Delay in identifying EWS of relapse </li></ul><ul><li>Disengagement from services </li></ul><ul><li>Trust performance indicator- CQC report </li></ul><ul><li>Banded on a scale of 1 to 5 (high=better) </li></ul><ul><li>Rate < 11% considered acceptable </li></ul><ul><li>Financial penalties for high DNA rates? </li></ul>
Evidence for prompting <ul><li>Leeds PROMPTS trial (N 764, RR 0.76, CI 0.59 to 0.98,NNT 16, 95% CI 10 to 187 ) </li></ul><ul><li>- Psychological Medicine 2008 </li></ul><ul><li>Systematic review (serious mental illness) </li></ul><ul><li>5RCTs, N 1184, RR 0.72, CI 0.59 to 0.89, NNT 6, CI 4 to 14 </li></ul><ul><li>- Cochrane 2001 + PROMPTS Trial </li></ul>
Aim <ul><li>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. </li></ul><ul><li>(Prompting works in trial settings but does it work in the real world?) </li></ul>
Methods <ul><li>Prompting letter to all patients attending outpatient clinic in South Leeds (2 CMHT) </li></ul><ul><li>Letter sent one week before appointment </li></ul><ul><li>Royal mail First Class Post </li></ul><ul><li>Ongoing practice since June 2007 </li></ul><ul><li>DNA- failed to attend & no message </li></ul>
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 <ul><li>Compared DNA rates before and after this intervention in 2007 </li></ul><ul><li>Compared with DNA rates in the same months in 2006 (seasonal variation) </li></ul><ul><li>Trend across the whole year </li></ul><ul><li>Compared with DNA rates in West Leeds where no prompting was used </li></ul>
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
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? <ul><li>Clinicians in 2007 may have acted differently toward patients compared to 06 </li></ul><ul><li>Yes! </li></ul><ul><li>- one Consultant changed in Mar 2007 </li></ul><ul><li>- SHOs, SpRs & Staff Grade changed </li></ul><ul><li>Drawback of pragmatic studies in NHS! </li></ul>
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 <ul><li>Prompting letters do reduce non-attendance rates even under non-trial conditions </li></ul><ul><li>Useful and easy to apply intervention with no implication on resources </li></ul><ul><li>£80 saved for every £3 spent (NNT 11)!! </li></ul><ul><li>(reference cost of each appointment - £80) </li></ul>