Using SMS reminders in psychology clinics: a cautionary tale

Behavioural economic interventions to reduce health care appointment non-attendance: a systematic review and meta-analysis

BACKGROUND

Appointment non-attendance - often referred to as "missed appointments", "patient no-show", or "did not attend (DNA)" - causes volatility in health systems around the world. Of the different approaches that can be adopted to reduce patient non-attendance, behavioural economics-oriented mechanisms (i.e., psychological, cognitive, emotional, and social factors that may impact individual decisions) are reasoned to be better suited in such contexts - where the need is to persuade, nudge, and/ or incentivize patients to honour their scheduled appointment. The aim of this systematic literature review is to identify and summarize the published evidence on the use and effectiveness of behavioural economic interventions to reduce no-shows for health care appointments.

METHODS

We systematically searched four databases (PubMed/Medline, Embase, Scopus, and Web of Science) for published and grey literature on behavioural economic strategies to reduce no-shows for health care appointments. Eligible studies met four criteria for inclusion; they were (1) available in English, Spanish, or French, (2) assessed behavioural economics interventions, (3) objectively measured a behavioural outcome (as opposed to attitudes or preferences), and (4) used a randomized and controlled or quasi-experimental study design.

RESULTS

Our initial search of the five databases identified 1,225 articles. After screening studies for inclusion criteria and assessing risk of bias, 61 studies were included in our final analysis. Data was extracted using a predefined 19-item extraction matrix. All studies assessed ambulatory or outpatient care services, although a variety of hospital departments or appointment types. The most common behaviour change intervention assessed was the use of reminders (n = 56). Results were mixed regarding the most effective methods of delivering reminders. There is significant evidence supporting the effectiveness of reminders (either by SMS, telephone, or mail) across various settings. However, there is a lack of evidence regarding alternative interventions and efforts to address other heuristics, leaving a majority of behavioural economic approaches unused and unassessed.

CONCLUSION

The studies in our review reflect a lack of diversity in intervention approaches but point to the effectiveness of reminder systems in reducing no-show rates across a variety of medical departments. We recommend future studies to test alternative behavioural economic interventions that have not been used, tested, and/or published before.

Reasons for non-attendance in youth mental health clinics: Insights from mobile messaging communications

AIM

Non-attendance at appointments in youth mental health services is a common problem which contributes to reduced service effectiveness and unmet needs. Reasons cited by young people for non-attendance are poorly understood. Information derived from short-message-service (SMS) conversations about appointments between patients and clinicians can uncover new insights about the circumstances leading to 'did not attend' events.

METHODS

Text messages between young people and clinicians were examined in a retrospective audit of medical records in two youth mental health services in Perth, Australia. Frequently non-attending young people aged 16-24 (n = 40) engaged in 302 SMS message chains about appointments. Mixed methods included quantitative data and qualitative thematic analysis of textual data.

RESULTS

Medical reasons (32/190, 16.8%) and forgetfulness (20/190, 10.5%) were the most frequent reasons for non-attendance. Major issues included non-avoidable events while others were potentially preventable and could be addressed by the service.

CONCLUSIONS

The analysis of mobile communications in clinical practice can be used for service evaluation and to reveal barriers that impede attendance to ongoing care.

Automated Text Messaging During COVID-19: Patient Feedback to Increase Adoption

Automated text messaging interventions can effectively improve self-care and were used to support the U.S. Veterans Health Administration's (VHA) public health outreach during the COVID pandemic. Currently, significant gaps exist in knowledge about VHA patients' texting protocol preferences that may impact user receptivity, engagement, and effectiveness. This study qualitatively evaluated patient suggestions to improve two VHA Covid-related texting interventions and preferences for future text message protocols. We reviewed cross-sectional type-written survey responses from patients receiving either the "Coronavirus Precautions" or the "Coping During COVID" multi-week text protocols. Two team members independently and inductively coded all responses allowing for an upward abstraction of qualitative data. Nine hundred five patients (72.8% male) responded to the open-response item questions targeted by this research. An item that sought feedback to improve protocol acceptability generated thirteen distinct descriptive categories (inter-rater reliability 83.5%). Codable feedback showed, for example, that patients desired to manipulate message frequency and to have a more sophisticated interaction with messages. Patients' suggestions for future automated text messaging protocols yielded nine distinct topic areas. Patients offered suggestions that may impact receptivity and engagement of future automated text message protocols, particularly as they relate to outreach during a public health crisis. In addition, patients offered specific topics they would like to see in future text message protocols. We discuss how the findings can be used to increase engagement in current and post-pandemic public health interventions.

How scheduling systems with automated appointment reminders improve health clinic efficiency

Missed clinic appointments or no-shows burden health care systems through inefficient use of staff time and resources. Scheduling software with automatic appointment reminders shows promise to improve clinics' management through timely cancellations and re-scheduling, but at-scale evidence is missing. We study a nationwide text message appointment reminder program in Chile implemented at primary care clinics for patients with chronic disease. Using longitudinal clinic-level data, we find that the program did not change the number of visits by chronic patients eligible to receive the reminder but visits from other patients ineligible to receive reminders increased by 5.0% in the first year and 7.4% in the second. Clinics treating more chronic patients and those with a relatively younger patient population benefited more from the program. Scheduling systems with automatic appointment reminders were effective in increasing clinics' ability to care for more patients, likely due to timely cancellations and re-scheduling.

Digital privacy in mental healthcare: current issues and recommendations for technology use

Mental healthcare providers increasingly use technology for psychotherapy services. This progress enables professionals to communicate, store information, and rely on digital software and hardware. Emails, text messaging, telepsychology/telemental health therapy, electronic medical records, cloud-based storage, apps/applications, and assessments are now available within the provision of services. Of those mentioned, some are directly utilized for psychotherapy while others indirectly aid providers. Whereas professionals previously wrote notes locally, technology has empowered providers to work more efficiently with third-party services and solutions. However, the implementation of these advancements in mental healthcare involves consequences to digital privacy and might increase clients' risk of unintended breaches of confidentiality. This manuscript reviews common technologies, considers the vulnerabilities therein, and proposes suggestions to strengthen privacy.

Lay health supporters aided by mobile text messaging to improve adherence, symptoms, and functioning among people with schizophrenia in a resource-poor community in rural China (LEAN): A randomized controlled trial

BACKGROUND

Schizophrenia is a leading cause of disability, and a shift from facility- to community-based care has been proposed to meet the resource challenges of mental healthcare in low- and middle-income countries. We hypothesized that the addition of mobile texting would improve schizophrenia care in a resource-poor community setting compared with a community-based free-medicine program alone.

METHODS AND FINDINGS

In this 2-arm randomized controlled trial, 278 community-dwelling villagers (patient participants) were randomly selected from people with schizophrenia from 9 townships of Hunan, China, and were randomized 1:1 into 2 groups. The program participants were recruited between May 1, 2015, and August 31, 2015, and the intervention and follow-up took place between December 15, 2015, and July 1, 2016. Baseline characteristics of the 2 groups were similar. The patients were on average 46 years of age, had 7 years of education, had a duration of schizophrenia of 18 years with minimal to mild symptoms and nearly one-fifth loss of functioning, and were mostly living with family (95%) and had low incomes. Both the intervention and the control groups received a nationwide community-based mental health program that provided free antipsychotic medications. The patient participants in the intervention group also received LEAN (Lay health supporters, E-platform, Award, and iNtegration), a program that featured recruitment of a lay health supporter and text messages for medication reminders, health education, monitoring of early signs of relapses, and facilitated linkage to primary healthcare. The primary outcome was medication adherence (proportion of dosages taken) assessed by 2 unannounced home-based pill counts 30 days apart at the 6-month endpoint. The secondary and other outcomes included patient symptoms, functioning, relapses, re-hospitalizations, death for any reason, wandering away without notifying anyone, violence against others, damaging goods, and suicide. Intent-to-treat analysis was used. Missing data were handled with multiple imputations. In total, 271 out of 278 patient participants were successfully followed up for outcome assessment. Medication adherence was 0.48 in the control group and 0.61 in the intervention group (adjusted mean difference [AMD] 0.12 [95% CI 0.03 to 0.22]; p = 0.013; effect size 0.38). Among secondary and other outcomes we noted substantial reduction in the risk of relapse (26 [21.7%] of 120 interventional participants versus 40 [34.2%] of 117 controls; relative risk 0.63 [95% CI 0.42 to 0.97]; number needed to treat [NNT] 8.0) and re-hospitalization (9 [7.3%] of 123 interventional participants versus 25 [20.5%] of 122 controls; relative risk 0.36 [95% CI 0.17 to 0.73]; NNT 7.6). The program showed no statistical difference in all other outcomes. During the course of the program, 2 participants in the intervention group and 1 in the control group died. The limitations of the study include its lack of a full economic analysis, lack of individual tailoring of the text messages, the relatively short 6-month follow-up, and the generalizability constraint of the Chinese context.

CONCLUSIONS

The addition of texting to patients and their lay health supporters in a resource-poor community setting was more effective than a free-medicine program alone in improving medication adherence and reducing relapses and re-hospitalizations. Future studies may test the effectiveness of customization of the texting to individual patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-ICR-15006053.

Using text message reminders in health care services: A narrative literature review

INTRODUCTION

Despite the extensive use of mHealth behavior change interventions, questions remain about the use of technology-based reminders in delivering health care services. Text messaging, or short message service (SMS), is one reminder method that has been extensively researched. Most SMS-reminder research is distributed across a range of health care outcomes. The aim of this article is to systematically review the aggregate impact of these reminders on overall health care outcomes.

METHODS

A systematic literature review was conducted and yielded 2316 articles. Studies were included if they used SMS reminders to support patient health care outcomes. Study methodology was aligned with the PRISMA guidelines for systematic reviews.

RESULTS

Following screening, 162 articles met inclusion criteria. Of these studies, 93 investigated medical compliance reminders and 56 investigated appointment reminders. The review found that nearly all the SMS-reminder studies helped improve patient medical compliance and appointment reminders. Additionally, researchers reported numerous benefits from using SMS reminders, including ease of use, relative inexpensiveness, and rapid and automated message delivery. Minimal risks were reported and most participants found the reminders to be acceptable.

DISCUSSION

Text messages appear to be an effective reminder mechanism to promote improved patient appointment and medical compliance. Reminders should continue to be evaluated and improved to determine the most effective timing and frequency of messages for improving outcomes.

Reducing Non-Attendance Rates for Assessment at an Eating Disorders Service: A Quality Improvement Initiative

Rates of non-attendance at initial appointments within community eating disorder (ED) services are frequently high, although this has received relatively little research attention and no reports of interventions designed to address this. The current report describes outcomes following a change of procedure introducing a 'partial booking' system. Attendance rates at first appointments (N = 1260) were audited following introduction of a system designed to reduce non-attendance in January 2013 within a UK ED service. Rates were compared following implementation of the new system, using a historical control group for comparison, and showed a decline from 20.4 to 15.1%, a medium-sized effect. Use of a system asking patients to book an appointment reduced non-attendance at initial appointments and may be of use to similar services experiencing high non-attendance rates. Opt-in initiatives can reduce burden resulting from long waiting times and can be easily adapted to individual services.

Automated Text Messaging as an Adjunct to Cognitive Behavioral Therapy for Depression: A Clinical Trial

Background

Cognitive Behavioral Therapy (CBT) for depression is efficacious, but effectiveness is limited when implemented in low-income settings due to engagement difficulties including nonadherence with skill-building homework and early discontinuation of treatment. Automated messaging can be used in clinical settings to increase dosage of depression treatment and encourage sustained engagement with psychotherapy.

Objectives

The aim of this study was to test whether a text messaging adjunct (mood monitoring text messages, treatment-related text messages, and a clinician dashboard to display patient data) increases engagement and improves clinical outcomes in a group CBT treatment for depression. Specifically, we aim to assess whether the text messaging adjunct led to an increase in group therapy sessions attended, an increase in duration of therapy attended, and reductions in Patient Health Questionnaire-9 item (PHQ-9) symptoms compared with the control condition of standard group CBT in a sample of low-income Spanish speaking Latino patients.

Methods

Patients in an outpatient behavioral health clinic were assigned to standard group CBT for depression (control condition; n=40) or the same treatment with the addition of a text messaging adjunct (n=45). The adjunct consisted of a daily mood monitoring message, a daily message reiterating the theme of that week’s content, and medication and appointment reminders. Mood data and qualitative responses were sent to a Web-based platform (HealthySMS) for review by the therapist and displayed in session as a tool for teaching CBT skills.

Results

Intent-to-treat analyses on therapy attendance during 16 sessions of weekly therapy found that patients assigned to the text messaging adjunct stayed in therapy significantly longer (median of 13.5 weeks before dropping out) than patients assigned to the control condition (median of 3 weeks before dropping out; Wilcoxon-Mann-Whitney z=−2.21, P=.03). Patients assigned to the text messaging adjunct also generally attended more sessions (median=6 sessions) during this period than patients assigned to the control condition (median =2.5 sessions), but the effect was not significant (Wilcoxon-Mann-Whitney z=−1.65, P=.10). Both patients assigned to the text messaging adjunct (B=−.29, 95% CI −0.38 to −0.19, z=−5.80, P<.001) and patients assigned to the control conditions (B=−.20, 95% CI −0.32 to −0.07, z=−3.12, P=.002) experienced significant decreases in depressive symptom severity over the course of treatment; however, the conditions did not significantly differ in their degree of symptom reduction.

Conclusions

This study provides support for automated text messaging as a tool to sustain engagement in CBT for depression over time. There were no differences in depression outcomes between conditions, but this may be influenced by low follow-up rates of patients who dropped out of treatment.

Using digital notifications to improve attendance in clinic: systematic review and meta-analysis

OBJECTIVES

Assess the impact of text-based electronic notifications on improving clinic attendance, in relation to study quality (according to risk of bias), and to assess simple ways in which notifications can be optimised (ie, impact of multiple notifications).

DESIGN

Systematic review, study quality appraisal assessing risk of bias, data synthesised in meta-analyses.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, Web of Science and Cochrane Database of Systematic Reviews (01.01.05 until 25.4.15). A systematic search to discover all studies containing quantitative data for synthesis into meta-analyses.

ELIGIBILITY CRITERIA

Studies examining the effect of text-based electronic notifications on prescheduled appointment attendance in healthcare settings. Primary analysis included experimental studies where randomisation was used to define allocation to intervention and where a control group consisting of 'no reminders' was used. Secondary meta-analysis included studies comparing text reminders with voice reminders. Studies lacking sufficient information for inclusion (after attempting to contact study authors) were excluded.

OUTCOME MEASURES

Primary outcomes were rate of attendance/non-attendance at healthcare appointments. Secondary outcome was rate of rescheduled and cancelled appointments.

RESULTS

26 articles were included. 21 included in the primary meta-analysis (8345 patients receiving electronic text notifications, 7731 patients receiving no notifications). Studies were included from Europe (9), Asia (7), Africa (2), Australia (2) and America (1). Patients who received notifications were 23% more likely to attend clinic than those who received no notification (risk ratio=1.23, 67% vs 54%). Those receiving notifications were 25% less likely to 'no show' for appointments (risk ratio=.75, 15% vs 21%). Results were similar when accounting for risk of bias, region and publication year. Multiple notifications were significantly more effective at improving attendance than single notifications. Voice notifications appeared more effective than text notifications at improving attendance.

CONCLUSIONS

Electronic text notifications improve attendance and reduce no shows across healthcare settings. Sending multiple notifications could improve attendance further.

Can Low-Cost Strategies Improve Attendance Rates in Brief Psychological Therapy? Double-Blind Randomized Controlled Trial

OBJECTIVES

To assess if telephone text message appointment reminders and orientation leaflets can increase the proportion of patients who attend brief interventions after being assessed as suitable for guided self-help following cognitive behavioral therapy principles.

METHOD

Attendance was operationally defined as having accessed at least 1 therapy appointment. A secondary outcome was the proportion of attenders who completed or dropped out of therapy. After initial assessment, 254 patients with depression and anxiety disorders were randomly assigned to 1 of 3 groups: (a) usual waitlist control, (b) leaflet, (c) leaflet plus text message. Differences in the proportions of patients who started and completed therapy across groups were assessed using chi-square and logistic regression analyses.

RESULTS

Overall, 63% of patients in this sample attended therapy. Between-group differences were not significant for attendance, x(2) (2) = 3.94, p = .14, or completion rates, x(2) (2) = 2.98, p = .23. These results were not confounded by demographic or clinical characteristics.

CONCLUSIONS

Low-cost strategies appear to make no significant difference to therapy attendance and completion rates.

Short message service can be a promising tool for psychiatric patients and clinicians

Short message service (SMS), commonly referred to as text messaging, allows instantaneous communication between mobile telephones and other systems via 160-character messages. SMS has a wide reach, and thus researchers and public health officials have considered using this platform for health-related communication. Today, as our society continues to integrate components of automation in various forms and levels of human interaction, and with the increasing ubiquity of mobile technology in health care, technology-delivered health interventions such as SMS offer a creative alternative that can be a valuable tool to assist mental health patients in their own treatment and recovery and for the mental health clinicians who are responsible for providing care and its delivery.

Evaluating an e-mental health program ("deprexis") as adjunctive treatment tool in psychotherapy for depression: design of a pragmatic randomized controlled trial

BACKGROUND

Major depressive disorder (MDD) places a significant disease burden on individuals as well as on societies. Several web-based interventions for MDD have shown to be effective in reducing depressive symptoms. However, it is not known whether web-based interventions, when used as adjunctive treatment tools to regular psychotherapy, have an additional effect compared to regular psychotherapy for depression.

METHODS/DESIGN

This study is a currently recruiting pragmatic randomized controlled trial (RCT) that compares regular psychotherapy plus a web-based depression program ("deprexis") with a control condition exclusively receiving regular psychotherapy. Adults with a depressive disorder (N = 800) will be recruited in routine secondary care from therapists over the course of their initial sessions and will then be randomized within therapists to one of the two conditions. The primary outcome is depressive symptoms measured with the Beck Depression Inventory (BDI-II) at three months post randomization. Secondary outcomes include changes on various indicators such as anxiety, somatic symptoms and quality of life. All outcomes are again assessed at the secondary endpoint six months post randomization. In addition, the working alliance and feasibility/acceptability of the treatment condition will be explored.

DISCUSSION

This is the first randomized controlled trial to examine the feasibility/acceptability and the effectiveness of a combination of traditional face-to-face psychotherapy and web-based depression program compared to regular psychotherapeutic treatment in depressed outpatients in routine care.

TRIAL REGISTRATION

ISRCTN20165665.

Intervention strategies for improving patient adherence to follow-up in the era of mobile information technology: a systematic review and meta-analysis

BACKGROUND

Patient adherence to follow-up plays a key role in the medical surveillance of chronic diseases and affects the implementation of clinical research by influencing cost and validity. We previously reported a randomized controlled trial (RCT) on short message service (SMS) reminders, which significantly improved follow-up adherence in pediatric cataract treatment.

METHODS

RCTs published in English that reported the impact of SMS or telephone reminders on increasing or decreasing the follow-up rate (FUR) were selected from Medline, EMBASE, PubMed, and the Cochrane Library through February 2014. The impacts of SMS and telephone reminders on the FUR of patients were systematically evaluated by meta-analysis and bias was assessed.

RESULTS

We identified 13 RCTs reporting on 3276 patients with and 3402 patients without SMS reminders and 8 RCTs reporting on 2666 patients with and 3439 patients without telephone reminders. For the SMS reminders, the majority of the studies (>50%) were at low risk of bias, considering adequate sequence generation, allocation concealment, blinding, evaluation of incomplete outcome data, and lack of selective reporting. For the studies on the telephone reminders, only the evaluation of incomplete outcome data accounted for more than 50% of studies being at low risk of bias. The pooled odds ratio (OR) for the improvement of follow-up adherence in the SMS group compared with the control group was 1.76 (95% CI [1.37, 2.26]; P<0.01), and the pooled OR for the improvement of follow-up adherence in the telephone group compared with the control group was 2.09 (95% CI [1.85, 2.36]; P<0.01); both sets showed no evidence of publication bias.

CONCLUSIONS

SMS and telephone reminders could both significantly improve the FUR. Telephone reminders were more effective but had a higher risk of bias than SMS reminders.