Did not attends (DNAs) for outpatient hospital appointments can be reduced by 13% using behaviourally informed SMS reminders

DNAs could be reduced by over 60,000 annually, freeing up resources valued at €12 million which could be used to provide more care for patients each year.

The Minister for Health Stephen Donnelly today published “The Better Letter Initiative: An Evaluation of the Impact of Redesigned Appointment SMS Reminders on Outpatients DNAs”. This paper reports the impact of a collaborative quality improvement project between the Department of Health, the National Treatment Purchase Fund (NTPF), and the Health Service Executive (HSE). It shows that using amended SMS reminder content, informed by behavioural science, reduced DNA rates for outpatient hospital appointments by a substantial amount. The recommended SMS content from this current evaluation will be considered by the HSE for use as a template SMS / text to help implement the Outpatient DNA Strategy.

Commenting on the publication, Minister for Health Stephen Donnelly said:

What an Outpatient Did Not Attend (DNA) is

A “did not attend” (DNA) occurs when a patient unexpectedly does not attend an outpatient hospital appointment. This means that hospital staff expected the patient to attend but the patient did not attend and did not signal in advance that they would not attend.

The DNA rate is the number of did not attends divided by the total number of appointments offered for which a patient was expected to attend. That is the DNA rate = DNAs / (Attendances + DNAs).

Why Did Not Attends (DNAs) are important

International research shows that did not attends (DNAs) for hospital outpatient appointments can lead to the inefficient use of staff time, worse care for patients, and increase waiting times for patients.

In 2022 there were nearly half a million (481,432) DNAs for outpatient appointments and 3.4 million outpatient appointments where patients attended. By reducing the DNA rate for outpatient hospital appointments, it is possible to increase the number of appointments delivered within available resources. Reducing the DNA rate increases hospital productivity.

The purpose of this project/evaluation

This collaborative quality improvement project between the DoH, the NTPF and the HSE explored if using behavioural insights to re-design SMS reminders for hospital outpatient appointments would help more patients to attend.

Sending a text (SMS) reminder to patients a few days in advance of appoints has been found to reduce DNA rates. SMS reminders for outpatient appointments are currently utilised in Ireland. International evidence suggests the effectiveness of these reminders at reducing DNA rates can be further enhanced by applying findings from behavioural science to enhance the content of SMS reminder messages. The quality improvement project sought to identify the best performing SMS reminder for Ireland.

A randomised control trial (RCT) is used to test the impact of four re-designed SMS appointment reminders (interventions) against an existing SMS reminder (control) on patient DNA rates. The RCT took place in Naas General Hospital between August 2022 and July 2023.

SMS reminders that were tested

All interventions included personalisation, reciprocity, and the day of appointment in words. Intervention 2 onwards also included the name of the consultant and clinic. Intervention 3 additionally stated the importance of attendance for health. Intervention 4 referred to the avoided loss if patients who cannot attend signal this in advance. The specific control and intervention SMS reminders utilised for this evaluation are outlined below:

Control

REMINDER: NAAS HOSPITAL APPOINTMENT 7/09/2023 AT 15:00 IF YOU HAVE ANY COVID 19 SYMPTOMS OR UNABLE TO ATTEND CALL 045841111 AUTOMATED TEXT PLEASE DO NOT REPLY.

Intervention 1: Recall I = Personalisation, reciprocity & day

Robert, we are expecting you at your appointment on Thursday 7 September at 15:00 with Naas hospital. If you cannot attend or have any Covid 19 symptoms please phone 045841111.

Intervention 2: Recall II = Recall I + Clinic and consultant name

Robert, we are expecting you at your appointment on Thursday 7 September at 15:00 with Naas hospital Dr. Deirdre Robertson Pain Clinic. If you cannot attend or have any Covid 19 symptoms please phone 045841111.

Intervention 3: Recall II + Importance for health

Robert, we are expecting you at your appointment on Thursday 7 September at 15:00 with Naas hospital Dr. Deirdre Robertson Pain Clinic. Attending means you are looking after your health. If you cannot attend or have any Covid 19 symptoms please phone 045841111.

Intervention 4: Recall II + Avoided loss to patients and staff

Robert, we are expecting you at your appointment on Thursday 7 September at 15:00 with Naas hospital Dr. Deirdre Robertson Pain Clinic. If you cannot attend or have any Covid 19 symptoms please phone 045841111, let us know now so that we can give your appointment to another patient.

Rationale for selecting the particular SMS content tested

Previous international research shows that the most common reason reported by patients for not attending is that they forgot. All interventions aimed to help the patient remember better or to improve their recall.

Intervention 1 (Recall I) included two design elements reported to increase engagement, namely personalisation and reciprocity. It also included the day of the appointment in words to help with recall.

All other interventions included these three design elements of Intervention 1 along with additional design features. Intervention 2 (Recall II) additionally included the name of the consultant and clinic name on the basis that this might help patients to remember their appointment.

Another commonly reported reason for not attending is that a patient felt the appointment appeared to have no benefit. Therefore, Intervention 3 additionally stated the importance of attendance for health (Recall II + Importance for health). Some previous international trials show an effect on DNAs of including the cost to hospitals of non-attendance, so Intervention 4 included text on the avoided loss if patients who cannot attend signal this in advance (Recall II + Avoided loss to patients and staff).

Results of the impact evaluation

The redesigned SMS of Intervention 2 (Recall II) is the best performing reminder.

Those receiving Intervention 2 had a significantly lower DNA rate compared to the control group (z = 3.29, p < .001 ≤ 0.0125 threshold). Intervention 2 reduced the DNA rate from 18.72% to 16.35%, which is an absolute reduction of 2.37 percentage points.

In relative terms, Intervention 2 (Recall II) reduced DNA rates by 12.7% compared to the control reminder, resulting in one in eight non-attendees changing their behaviour.

Did Not Attend (DNA) rates Across Control and Intervention Groups

We suspect Intervention 2 reduced DNAs as it makes it easier to remember the appointment as it creates a stronger association with the appointment. Intervention 2 added personalisation, reciprocity, day in words, consultant name and clinic name. Adding additional information beyond that in intervention 2 did not reduce DNAs further.

Intervention 2 is highly cost effective with a benefit to cost gain of between €300 and €445 per 100 appointment offers.

How we know the intervention worked/had the reported impact

Because of the way the evaluation was designed and the statistical tests used we can assign the reduction in the DNA rate to Intervention 2. The evaluation used the gold standard method for impact evaluation.

To test the effectiveness of redesigned SMS communication, we utilise a randomised control trial (RCT). This involved randomly assigning patients into five different groups. Each group received a different SMS reminder. One group, the control group, received the SMS reminder that was already in use. The other four groups, the intervention groups, received one of four newly designed SMS reminders. We compared the DNA rates across these five groups to assess whether the intervention groups who received a newly designed SMS reminder had a lower DNA rate when compared to the control group who received the existing SMS reminder message. We can assign causation to an intervention if a significant reduction in the DNA rate is observed between control and intervention groups. This is because the only difference between the group is the content of the SMS reminder they received.

Compliance of the approach taken with GDPR

The HSE’s website provides a clear legal basis for processing of personal data and under a section relating to “What is my personal data used for?”, the HSE’s FAQ on GDPR states that “personal information” can be used to “Remind you of appointments by text.” All data for the evaluation is already collected as part of routine care / service management (no new data was collected on patients) and there is a clear legal basis under both the GDPR and the Data Protection Act 2018 for this by the HSE and the NTPF. The evaluation team in the Department of Health did not require access to personal data, only analysis of secondary non-personal data was required.

Compliance of the approach taken with HSE data handling issues

All 6 design elements used in the study in Naas General Hospital are compliant with the HSE data handling policy.

Nevertheless, when moving to a national recommendation which would involve a wider set of clinic types (than in this evaluation in Naas General Hospital) it is advisable in certain circumstances to remove design element 6 (Clinic Name). This is because when used for a wider set of clinic types the content could fall into the category of “restricted information”. For this reason two SMS template options are suggested, Option 1 which includes the clinic name and would apply in most situations and Option 2 which does not include the clinic name and is for clinics where the clinic name potentially falls into the HSE’s data handling category of “restricted information” such as reference to mental health, sexual health, addiction, disability (see the next question for the recommended templates).

Recommended SMS reminder templates

Two SMS template options are recommended. Option 1 includes the clinic name and is recommended for use with “standard” clinic names. Option 2 does not include the clinic name and is recommended for clinics where the clinic name potentially falls into the HSE’s data handling category of “restricted information” (for example, includes reference to mental health, sexual health, addiction, disability).

• Option 1 Recommended for “Standard” Clinic Names
• Option 2 Recommended if Clinic Name Potentially Falls into the “Restricted Information” Category (for example, includes reference to mental health, sexual health, addiction, disability)

Implications for policy and practice

From a policy perspective this study shows (using an RCT, the gold standard of impact evaluation) that using amended SMS reminder content reduced DNA rates by a substantial amount.

Applying the findings to 2022 national data suggests DNAs could be reduced by about 61,000 with a 2023 value of €11.6 million.

Widespread adoption of the recommended SMS templates as part of national practice could substantially reduce non-attendance and improve hospital productivity and efficiency.

In June 2023 the HSE produced an Outpatient DNA Strategy which included a toolkit. It includes a requirement to “send offer letters six weeks before the appointment, send letters or SMS text reminders two weeks before the appointment, and to send a SMS text a few days before the appointment”. It does not include a template for a SMS reminder. The recommended SMS content from this current evaluation should be considered by the HSE for use as a template SMS / text to help implement the Outpatient DNA Strategy. The Department of Health is committed to working with the HSE to support the wider implementation of the SMS templates recommended SMS by the evaluation.