Effect of a Mailed Appointment Reminder on Appointment Keeping

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Effect of a Mailed

Appointment

Reminder

on

Appointment

Keeping

Lawrence F. Nazarian, M.D., Judith Mechaber, R.N., Evan Charney, M.D.,

and Molly P. Coulter, M.D.

From the Anthony L. Jordan Health Center, and the Department of Pediatrics,

University of Rochester School of Medicine and Dentistry, Rochester, New York

ABSTRACT. Poor appointment keeping is a major problem in many health facilities. At The Anthony L. Jordan Health Center, we studied 670 pediatric appointments to see if a

postal card reminder mailed one week before the

appoint-ment would make a difference in the keep rate (kept plus

canceled appointments, divided by kept plus canceled plus

broken appointments ). The appointments studied were 12

days to eight weeks from the time of scheduling.

In the control group, the keep rate was 48%. Those

re-ceiving mailed reminders had a keep rate of 64%, a

signifi-cant difference (X2 16.92; p < 0.001).

The effects on the keep rate of age, interval to appoint-ment, time of day, referral pattern, reason for appointment, and prior keep rate were minor.

The use of a mailed reminder can improve appointment

keeping and facilitate better care and more efficient

schedul-ing and use of personnel. Pediatrics, 53:349, 1974,

APPOINT-MENT REMINDERS, COMPLIANCE, HEALTh CENTERS.

Broken appointments have been a major problem

at the Anthony L. Jordan Health Center, a

multi-specialty health facility which serves approximately 19,000 people in a low-income area of Rochester.

More than one out of every three appointments at

the center is not kept. This paper describes a study

in which reminder postal cards were sent, and their

effect on appointment keeping was measured. At

the same time, the influence of several other van-ables was studied.

At the time the appointment was made in the

clinical area, the mother was given a standard

ap-pointment slip. Each patient was then assigned to

one of three groups : one group was to receive no

reminder card; a second group would receive card

A, which gave only the date and time of the

ap-pointment; a third group would receive card B,

which gave the date, time, doctor or nurse to be

seen, and reason for the appointment. Assignment

to these groups were made sequentially. If two or

more children in the same family were given an

appointment for the same time, they were assigned

to the same category.

The cards were mailed by the investigators one

week prior to the appointments. A telephone

in-quiry of 20 patients indicated that 80% or more of

the cards were received.

Information was recorded on the patient’s age, the interval between appointment scheduling and the actual appointment, time of day of the appoint-ment, personnel referring and referred to, reason

for the appointment, and outcome. Where possible, the patient’s keep rate prior to the study was cal-culated, using the formula “kept appointments plus

canceled appointments, divided by kept plus

can-celed plus broken appointments”:

.

KA+CA

KA+CA+BA.

METHODS

The study ran from July 24, 1972, through

No-vember 10, 1972, and included only the pediatric service. All patients were included whose

appoint-ments were scheduled from 12 days to eight weeks

from the time they were made, with the exception

of children receiving allergy injections and those

whose appointments were made on weekends.

(Received July 9; revision accepted for publication

Novem-ber 5, 1973.)

The project herein was perfonned pursuant to grant #8771 from the Office of Economic Opportunity. The opinions ex-pressed herein are those of the authors and should not be

construed as representing the opinions or policy of any

agency of the United States Government.

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TABLE I

KEEP RA’rl BY REMINDER GRouPs*

J’/o Card Sent

Vumber Keep

Rate

123 46* 27 56

Reason for Appointment

Well child appointment Shots only Follow-up Ofl acute

infectious illness Follow-up on acute or

semi-acute non-infectious illness All others Card Sent J’/umber Keep Rate 249 62% 53 70 * p<0.00l.

38 63 50 70

a If one disregards the canceled appointments and

cal-2() 40 31 71 culates the appointment-keeping percentages with the

for-20 30 52 62 mula KA , the results are as follows : no card, 44%; either

KA+BA

card, 61% (X2 14.21; p < 0.001).

350 APPOINTMENT REMINDER

Vumber of

Group t Appointments Aeep Rate

No card sent 228 48

Card .\ 216 67

(date, time)

CardB 219 61

(date, time, doctor

nurse, reason)

Cards A & B combined 43 64

S Keep ratekcpt plus canceled appointments, divided by

kept plus canceled plus broken appointnents.

t Difference between control group and group receiving

cards is significant ( = 16.92; p <0.001 ). Difference between

card A and card B is not significant.

RESULTS

Six hundred and seventy appointments were

in-cluded in the study. Of these, 333 were kept, 274 were broken, and 56 were canceled. The remaining seven appointments were not used in the calcula-tions because of errors made in the scheduling process. The two groups receiving cards and the control group were compared with respect to age of patient and appointment interval, and had the same distribution. For half of the patients, a keep

rate prior to the study could be calculated, and the three groups were closely comparable.

Reminder Sent

As shown in Table I, the keep rate for patients

receiving no reminder

(

n=228

)

was 48%. Those

receiving card A

(

date and time; n=216

)

had a

keep rate of 67%, while those receiving card B (date, time, doctor or nurse, and reason; n=219) had a keep rate of 61%. Since the difference between card

A and card B is not statistically significant, those

two groups can be combined, and the keep rate

TABLE II

KEEP RATE BY REASON FOR APPOINTMENT

for those receiving either card was 64%. The

differ-ence between those receiving no card and those

receiving either card is significant

(

x216.92; p <

0.001).#{176}

Age

The patients ranged in age from 6 weeks to 16

years. Twenty-seven percent were under 1 year of age; 39% were 1 through 4 years old; 23% were 5

through 10 years old; and 11% were 11 or older. No

relationship was found between age and keep rate.

Interval

The interval to the subsequent appointment

ranged from 12 days to eight weeks. For those

re-ceiving no card, the keep rate was 50% to 56% for

intervals between 12 days and 28 days, and 62% to

71% for those receiving a reminder card

(

p = not

significant) . For the interval 29 through 35 days,

the keep rate for those not receiving cards dropped

to 33%, while those receiving cards kept their

ap-pointments 55% of the time (p < 0.001

)

. There were not sufficient numbers of patients with appoint-ments made after 35 days to merit statistical

in-terpretation, but 22 of 51 patients (43%

)

kept

appointments without card reminders, while 39 of

57 patients

(

68%) kept their appointments after

receiving a card. It would appear that the

re-minder card protects against the otherwise falling

keep rate as the subsequent appointment is made

later in time.

Reason for Appointment

Table II shows the reasons for the appointments and the keep rates for both groups in each category.

In all cases, the group receiving the card had a

higher keep rate. The difference was statistically significant for well-baby appointments-the largest

group-and for follow-up appointments on acute or

semiacute noninfectious illness.

Other Factors

Appointments scheduled for morning, afternoon,

and evening sessions had similar keep rates.

Re-ferral patterns, such as “doctor to himself,” “nurse

to doctor,” “nurse to other nurse,” etc., were not

markedly different with regard to keep rate. Prior keep rate bore little relationship to keep rate during

the study, and did not appear to be a good

pre-dictor of behavior.

The keep rate for those receiving cards was

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better than that of the control group, no matter

what else was being measured, in all but a few

instances. Table II is illustrative of that fact. Thus,

the only variable of those measured which seems to

affect keep rate appears to be the mailed reminder.

DISCUSSION

When a patient fails to keep a medical appoint-ment, he usually deprives himself of needed

atten-tion, and he definitely creates scheduling and

staffing problems for the health facility. High

broken appointment rates plague clinics and health

centers in particular, though other modes of

de-livering care are not immune.

Studies have been done to characterize and

ex-plain appointment behavior, and a body of

informa-tion is available relating appointment keeping and

breaking to social class, education, age of patient,

weather, reason for appointment, and other param-eters.18 Even where the information is consistent, however, one is hard put to translate it into concrete

methods for improving the situation.

This study, as originally conceived, was designed

to garner information on appointment behavior in

our own health center population. Our investigation ultimately took the more pragmatic form presented here, because we decided that potential remedies

were quite limited in number and that gathering

more detailed, local information on appointment

behavior would not be likely to expand our options

for modifying this behavior. For this reason we

chose to test the most direct and feasible course of action-notifying the patient a few days in advance

by mail. An alternative solution would have been telephone reminders, but most of our patients do

not have telephones. Personal reminders in all but

urgent cases are beyond our outreach potential.

Modification of staff attitudes and approaches to

the patient could conceivably affect appointment behavior’; this approach seemed too diffuse and im-practical to study at this time.

Though sending reminder cards is not a new idea

and is already practiced to varying degrees, our

results bear out the theory that a reminder card

can improve the keep rate to a signfficant degree. Apparently, reminding the patient of date and time alone is as helpful as supplying him with a fuller description of his appointment.

One implication of these results is that a card

reminder system can make caring for patients,

scheduling, and staffing more efficient. In addition, if a facility is being reimbursed by third parties on a per-visit basis, a modest expenditure on printing

and sending cards can reap a very good return in

additional fees.

We cannot tell whether the sending of cards will,

over time, have the same effect as during the study.

There were not sufficient repeat cases to judge whether the effect of the card diminishes over time,

or whether it might actually encourage better

at-tendance. We also know that people are not

con-stant in their behavior, as evidenced by our

sur-prising finding that the previous keep rate was not

a good predictor of present behavior. We also

cannot extrapolate these results to other clinical services since adults do not always treat themselves

as they do their children; however, it would

cer-tainly be reasonable to try the card system on

all services.

This study concentrated on appointments 12

days off or more. Mail reminders would not be

appropriate for intervals much less than that, but

other data from our center indicate that the

ap-pointments which are less than 12 days off have a

higher keep rate, probably related to the acuteness of the problems. Specifically, the overall keep rate

for the pediatric service, with all appointments

in-cluded, was about 65%.

Why the keep rates at the center are low can only

be conjectured. Probably the major factor is the

long-standing orientation of our patients to crisis care and fragmented medical attention. In the final

analysis, appointment behavior is determined by

the patient’s attitudes and motivation, which in

turn are dependent on a myriad of complex factors,

including staff attitudes While we are waiting for

the slow changes which, hopefully, will come in

these less tangible areas, we welcome any small

modifications which will make our appointment

keeping better.

SUMMARY

In a study of 670 pediatric appointments at the

Anthony L. Jordan Health Center, the use of a

reminder postal card was found to improve

signifi-cantly the appointment keeping. Other factors

studied were the patient’s age, the interval between

appointment scheduling and actual appointment,

time of day of the appointment, personnel

in-volved, and reason for the appointment. These

fac-tors had little effect on appointment behavior.

REFERENCES

1. Badgley, R., and Fumal, M. : Appointment breaking in

a pediatric clinic. Yale J. Biol. Med., 34: 117, 1967.

2. Alpert, J.: Broken appointments. Pediatrics, 34: 127, 1964.

3. Berkowitz, N., Malone, M., Klein, M., and Eaton, A.:

Patient follow-through in the outpatient depart-ment. Nurs. Res., 12: 16, 1963.

4. Ambuel, J., Cebulla, J., Watt, N., and Crowne, D.: Urgency as a factor in clinic attendance. Amer.

J. Dis. Child., 108:394, 1964.

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352 APPOINTMENT REMINDER

6. Clogow, E. : Effects of health education methods on

ap-pointment breaking. Public Health Rep., 85:441,

1970.

7. Stine, 0., Chuaqui, C., Jimenez, C., and Oppel, W.:

Broken appointments at a comprehensive clinic for

children. Med. Care, 6:332, 1968.

8. Plaut, T., and Alston, A.: Appointment failures: Whose

fault? Presented at the 1 ith annual meeting of the

Ambulatory Pediatric Association, Atlantic City, April 28, 1971.

ACKNOWLEDGMENT

We would like to thank Mrs. Mary Howard, Ms. Susan Rogers, Mrs. Gloria Arnell, and Ms. Janet Kurtz, as well as

many other staff members, for their help.

“All life is specialization . . . specialization is

biologically, socially and intellectually necessary . .

but some loss of versatility occurs as a result. We

must retain some capacity to function as a

gen-eralist and have the capacity to shift to new

special-ties as circumstances require. Whether a man can

function as both depends partly on his motivation,

partly on the manner in which he was educated

and partly on the nature of the organization in

which his abilities mature.” 1. W. Gardner

SELF RENEWAL: THE INDIVIDUAL AND

THE INNOVATIVE SOCIETY

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1974;53;349

Pediatrics

Lawrence F. Nazarian, Judith Mechaber, Evan Charney and Molly P. Coulter