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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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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. By Email n =207

2. With the phone call of an operator n =200

3. Sending an SMS n =208

4. 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. By Email n =207

6. With the phone call of an operator n =200

7. Sending an SMS n =208

8. Sending an SMS and an Email n =182

9. 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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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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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] 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 non-

attendance 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 hmandirola@biocom.com Institución.UBA/ BIOCOM Dirección postal Amenabar 1645 Ciudad de Buenos Aires CP C1426AKE.