Does prompting reduce non-attendance rate?

Ranga Rattehalli – ST6Mahesh Jayaram - ConsultantIhsan 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 contactFailed attendance adds to the cost of careAdverse impact – missing medicationsDelay in identifying relapsesIncreases waiting time for othersIt 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 reportBanded on a scale of 1 to 5 (high=better)Rate < 11% considered acceptableFinancial 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

June – Nov 07 June-Nov 06 Jan-May 07

17% 27% 26%

A total of 1433 letters were sent out in the study period.

Average non-attendance rates across different periods

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DNA Rate

Prompting letters introduced

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=2507Total events: 243 (prompts group), 280 (control group) Test for heterogeneity: not applicableTest for overall effect Z=5.53 (P<0.00001)

100.0 0.65 (0.56, 0.76)

NNT 11, 95% CI 8 to 17

A Forest plot showing the effect size

Comparison with West Leeds

June-Nov 2006 June-Nov 2007 P value

22% 23% 0.45 (NS)

So a reduction in the DNA rate in our study is unlikely to bedue to a general reduction across the city!

Average non-attendance rates

Were samples comparable?

1433 appointments575 patients (2007)

90% patients sameas in 2006

10% patients new to 2007

So a reduction in the DNA rate in our study is unlikely to bedue to a having a different set of patients in 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?

New for 2007

Remained constant

RR 95% CI

15% 17% 1.17 0.79 to 1.74

Average non-attendance rates

So a reduction in the DNA rate in our study is unlikely to bedue to an improvement in their mental state!

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)