Targeting the Use of Reminders and Notifications for Uptake by Populations (TURNUP): a systematic review and evidence synthesis

Understanding the causes of missingness in primary care: a realist review

BACKGROUND

Although missed appointments in healthcare have been an area of concern for policy, practice and research, the primary focus has been on reducing single 'situational' missed appointments to the benefit of services. Little attention has been paid to the causes and consequences of more 'enduring' multiple missed appointments in primary care and the role this has in producing health inequalities.

METHODS

We conducted a realist review of the literature on multiple missed appointments to identify the causes of 'missingness.' We searched multiple databases, carried out iterative citation-tracking on key papers on the topic of missed appointments and identified papers through searches of grey literature. We synthesised evidence from 197 papers, drawing on the theoretical frameworks of candidacy and fundamental causation.

RESULTS

Missingness is caused by an overlapping set of complex factors, including patients not identifying a need for an appointment or feeling it is 'for them'; appointments as sites of poor communication, power imbalance and relational threat; patients being exposed to competing demands, priorities and urgencies; issues of travel and mobility; and an absence of choice or flexibility in when, where and with whom appointments take place.

CONCLUSIONS

Interventions to address missingness at policy and practice levels should be theoretically informed, tailored to patients experiencing missingness and their identified needs and barriers; be cognisant of causal domains at multiple levels and address as many as practical; and be designed to increase safety for those seeking care.

Improvements in nutrition knowledge among adults with physical disabilities: A program evaluation of the mindfulness, exercise, and nutrition to optimize resilience (MENTOR) program 2020-2021

BACKGROUND

The Centers for Disease Control and Prevention (CDC) funds a quality improvement (QI) health promotion telewellness program for adults with physical disabilities.

OBJECTIVE

The nutrition component of the parent program, Mindfulness, Exercise, and Nutrition to Optimize Resilience (MENTOR) program, from 2020 to 2021, was evaluated to assess changes in nutrition knowledge of people with physical disabilities.

METHODS

This was a quasi-experimental program evaluation by pre-post survey of participating adults with physical disabilities. Participants attended weekly nutrition classes for eight weeks with optional one-on-one counseling with a Registered Dietitian. Participants completed pre-post General Nutrition Knowledge Questionnaire Revised (GNKQ-R) that were analyzed using paired t-tests. Participants were grouped into quartiles by pre-program GNKQ-R scores for additional comparisons. Program attendance and post-program feedback were also evaluated.

RESULTS

A total of 286 participants completed the MENTOR program, and 31% (n = 89) completed pre-post questionnaires for data analysis. Mean pre-program GNKQ-R scores were 58.4 ± 15.1 and post scores were 64.4 ± 11.3, which demonstrated a statistically significant improvement in nutrition knowledge (p < .001). Ancillary analysis revealed that participants with the lowest quartile of pre-program nutrition knowledge had the greatest improvements in their post-GNKQ-R scores (Mean change 16.4 ± 13.9). Questionnaire data revealed participants' subjective knowledge changes and their feedback on the nutrition component of the program.

CONCLUSIONS

The eight-week MENTOR program effectively improved nutrition knowledge among people with physical disabilities. This demonstrates the impact the program can have on individual knowledge levels. Additionally, these results support the implementation of the program to the broader population of people with disabilities.

Missed Healthcare Visits During the COVID-19 Pandemic: A Longitudinal Study

INTRODUCTION

Missed visits have been estimated to cost the U.S. healthcare system $50 billion annually and have been linked to healthcare inefficiency, higher rates of emergency department visits, and worse outcomes. COVID-19 disrupted existing outpatient healthcare utilization patterns. In our study, we sought to examine the frequency of missed outpatient visits over the course of the COVID-19 pandemic and to examine patient-level characteristics associated with non-attendance.

METHODS

This study utilized data from a longitudinal cohort study (the Chicago COVID-19 Comorbidities (C3) study). C3 participants were enrollees in 1 of 4 active, "parent" studies; they were rapidly enrolled in C3 at the onset of the pandemic. Multiple waves of telephone-based interviews were conducted to collect experiences with the pandemic, as well as socio-demographic and health characteristics, health literacy, patient activation, and depressive and anxiety symptoms. For the current analysis, data from waves 3 to 8 (05/01/20-05/19/22) were analyzed. Participants included 845 English or Spanish-speaking adults with 1 or more chronic conditions.

RESULTS

The percentage of participants reporting missed visits due to COVID-19 across study waves ranged from 3.1 to 22.4%. Overall, there was a decline in missed visits over time. No participant sociodemographic or health characteristic was consistently associated with missed visits across the study waves. In bivariate and multivariate analysis, only patient-reported anxiety was significantly associated with missed visits across all study waves.

CONCLUSION

Findings reveal that anxiety was consistently associated with missed visits during the COVID-19 pandemic, but not sociodemographic or health characteristics. Results can inform future public health initiatives to reduce absenteeism by considering patients' emotional state during times of uncertainty.

Bridging gaps in health? A qualitative study about bridge-building and social inequity in Danish healthcare

Attendance to health appointments may pose challenges to patients, especially when living in socially disadvantaged situations, with a fragile network. Inequality in health is increasingly highlighted in Denmark. To enhance social equity in health, a non-governmental organization introduced bridge-building, where healthcare students volunteer to accompany persons in socially vulnerable situations to health appointments.The purpose of the study was to explore what bridge-building entails and which gaps bridge-building attempts to span, in a welfare state, based on equal rights to healthcare.The study is based on an ethnographic fieldwork among the stakeholders in bridge-building, using interviews and participant observation in the form of "walking fieldwork".Informants emphasized safe-making and wayfinding as important components in bridge-building, with bridge-builders acting as as-if-relatives. Bridge-building navigates in borderlands, the in-between spaces with fluid and contested borders, encompassing public, civic society, and family spheres. All informants emphasized that bridge-building covers a need in contemporary Danish healthcare.Bridge-building entails a double temporality, a here-and-now intervention where persons in vulnerable situations get social support to make it to health appointments, and a future investment in future health professionals' understanding of vulnerability in lives and barriers to health access; insights that may be valuable in their future job positions.

Role of communication in successful outpatient attendance in a New Zealand hospital: a qualitative study

BACKGROUND

There are significant implications for both patients and providers when patients do not attend outpatient specialist appointments. Nonattendance has an impact on the efficiency of health care, provider resources and patient health outcomes.

AIMS

In this qualitative study we aimed to gather insights on how Dunedin Hospital notifies patients about their appointments, the implications for the hospital and for patients and how the system could be improved.

METHODS

We interviewed 13 hospital staff members and nine patients who volunteered to participate because they had missed appointments as a result of communication problems. Interviews were transcribed and analysed thematically using NVivo software.

RESULTS

Dunedin Hospital relies heavily on posted letters to inform people about their appointments, with some also receiving reminder texts closer to the time of the appointment. Frustration with the current system was a common theme among both patients and staff. Almost all patients had missed an appointment because of a letter not arriving. While most patients found that the text reminders were helpful, most said they were sent too late and did not allow enough time for arrangements to be made for their appointments. Almost all patients experienced treatment delays, which caused distress. Most patients believed a self-booking system would improve the ability to attend their appointments, and most of them wanted to be notified of appointments via email.

CONCLUSIONS

We recommend that a patient-oriented approach to communication should be implemented, and alternative methods of communication should be explored.

Optimizing Forecasted Activity Notifications with Reinforcement Learning

In this paper, we propose the notification optimization method by providing multiple alternative times as a reminder for a forecasted activity with and without probabilistic considerations for the activity that needs to be completed and needs notification. It is important to consider various factors when sending notifications to people after obtaining the results of the forecasted activity. We should not send notifications only when we have forecasted results because future daily activities are unpredictable. Therefore, it is important to strike a balance between providing useful reminders and avoiding excessive interruptions, especially for low probabilities of forecasted activity. Our study investigates the impact of the low probability of forecasted activity and optimizes the notification time with reinforcement learning. We also show the gaps between forecasted activities that are useful for self-improvement by people for the balance of important tasks, such as tasks completed as planned and additional tasks to be completed. For evaluation, we utilize two datasets: the existing dataset and data we collected in the field with the technology we have developed. In the data collection, we have 23 activities from six participants. To evaluate the effectiveness of these approaches, we assess the percentage of positive responses, user response rate, and response duration as performance criteria. Our proposed method provides a more effective way to optimize notifications. By incorporating the probability level of activity that needs to be done and needs notification into the state, we achieve a better response rate than the baseline, with the advantage of reaching 27.15%, as well as than the other criteria, which are also improved by using probability.

Cost Comparison of Kirschner Wire Versus Intramedullary Screw Fixation of Metacarpal and Phalangeal Fractures

BACKGROUND

Intramedullary screw fixation is a relatively new technique for fixation of metacarpal and phalangeal fractures. The objective of this study was to compare health care-associated costs and outcomes for intramedullary screw versus Kirschner wire (K-wire) fixation of hand fractures.

METHODS

A retrospective review of patients undergoing intramedullary screw fixation of hand fractures at a single center during 2016-2019 inclusive was conducted. Health care-associated costs were compared with age-matched and fracture pattern-matched controls who underwent K-wire fixation.

RESULTS

Fifty patients met the study inclusion criteria, incorporating 62 fractures (29 K-wire, 33 intramedullary screw fixation). The median age was 34.6 years (18.0-90.1 years). There was no significant difference in primary operative costs (£1130.4 ± £162.7 for K-wire vs £1087.0 ± £104.2 for intramedullary screw), outpatient follow-up costs (£958.7 ± £149.4 for K-wire vs £782.4 ± £143.8 for intramedullary screw), or total health care-associated costs (£2089.1 ± £209.0 for K-wire vs £1869.4 ± £195.3 for intramedullary screw). However, follow-up costs were significantly lower for the uncomplicated intramedullary screw cohort (£847.1 ± £109.1 for K-wire vs £657.5 ± £130.8 for intramedullary screw, P = .05). Subgroup analysis also revealed that overall costs were significantly higher for buried K-wire techniques. Complication rates, time to return to active work, and Disabilities of the Arm, Shoulder, and Hand scores were similar.

CONCLUSIONS

This study identified significantly lower outpatient follow-up costs for uncomplicated intramedullary screw fixation of hand fractures compared with K-wires, along with a trend toward lower overall health care-associated costs. In addition, buried K-wire techniques were also found to carry a significantly higher financial burden. Higher powered prospective studies are required to determine indirect costs.

Social determinants of health: modeling and targeting patient propensity to attend pain clinic appointments

Aim: We sought to investigate the impact of social determinants of health on pain clinic attendance. Materials & methods: Retrospective data were collected from the Pain Center at Montefiore Medical Center from 2016 to 2020 and analyzed with multivariable logistic regression. Results: African-Americans were less likely to attend appointments compared with White patients (odds ratio [OR]: 0.73; 95% CI: 0.70-0.77; p < 0.001). Males had decreased attendance compared with females (OR: 0.89; 95% CI: 0.87-0.92; p < 0.001). Compared with Commercial, those with Medicaid (OR: 0.69; 95% CI: 0.66-0.72; p < 0.001) and Medicare (OR: 0.76; 95% CI: 0.73-0.80; p < 0.001) insurance had decreased attendance. Conclusion: Significant disparities exist in pain clinic attendance based upon social determinants of health including race, gender and insurance type.

Can uptake of childhood influenza immunisation through schools and GP practices be increased through behaviourally-informed invitation letters and reminders: two pragmatic randomized controlled trials

BACKGROUND

The UK is rolling out a national childhood influenza immunisation programme for children, delivered through primary care and schools. Behaviourally-informed letters and reminders have been successful at increasing uptake of other public health interventions. Therefore, we investigated the effects of a behaviourally-informed letter on uptake of the vaccine at GP practices, and of a letter and a reminder (SMS/ email) on uptake at schools.

METHODS AND RESULTS

Study 1 was a cluster-randomised parallel trial of 21,786 two- and three-year olds in 250 GP practices, conducted during flu season (September to January inclusive) 2016/7. The intervention was a centrally-sent behaviourally-informed invitation letter, control was usual care. The proportion of two- and three-year olds in each practice who received a vaccination by 31st January 2017 was 23.4% in the control group compared to 37.1% in the intervention group (OR = 1.93; 95% CI = 1.82, 2.05, p <  0.001). Study 2 was a 2 (behavioural letter vs standard letter) × 2 (reminder vs no reminder) factorial trial of 1108 primary schools which included 3010 school years 1-3. Letters were sent to parents from providers, and reminders sent to parents from the schools. In the standard-letter-no-reminder arm, an average of 61.6% of eligible children in each school year were vaccinated, compared to 61.9% in the behavioural-letter-no-reminder arm, 63.5% in the standard-letter-plus-reminder arm, and 62.9% in the behavioural-letter-plus reminder condition, F(3, 2990) = 2.68, p = 0.046. In a multi-level model, with demographic variables as fixed effects, the proportion of eligible students in the school year who were vaccinated increased with the reminder, β = 0.086 (0.041), p <  0.036, but there was no effect of the letter nor any interaction effect.

CONCLUSION

Sending a behaviourally informed invitation letter can increase uptake of childhood influenza vaccines at the GP surgery compared to usual practice. A reminder SMS or email can increase uptake of the influenza vaccine in schools, but the effect size was minimal.

TRIAL REGISTRATION

Study 1: Trial registration: ClinicalTrials.gov Identifier: NCT02921633. Study 2: Trial registration: ClinicalTrials.gov Identifier: NCT02883972.

Factors predicting first appointment attendance at a traumatic brain injury clinical neuropsychology outpatient clinic: a logistic regression analysis

BACKGROUND

The purpose of our study was to investigate factors which predicted first appointment attendance within a traumatic brain injury (TBI) neuropsychology outpatient department.

MATERIALS AND METHODS

A newly introduced telephone triaging system was implemented in a clinical neuropsychology service for individuals with a TBI. The effects of receiving a triage telephone call, amongst other variables, were analysed as predictors of attendance at the first face-to-face clinic appointment. The data from 161 individuals were analysed using routine patient information collected by the clinical neuropsychology service. Logistic regression analyses were performed to investigate predictors of first appointment clinic attendance.

RESULTS

Logistic regression analyses identified higher age, shorter waiting times, and answering the triage call as potential predictors of attendance, highlighting where the service might focus efforts to facilitate attendance.

CONCLUSIONS

Both patient and service factors were found to be significant predictors of patient attendance. Further service evaluation could explore patients' experiences of triage telephone calls, and investigate relationships between waiting times and neuropsychological outcomes.IMPLICATIONS FOR REHABILITATIONIdentifying predictors of appointment attendance can allow the service to focus on the needs of particular patient groups.Implementing a telephone triage initiative had positive effects, both on waiting times and efficient use of face-to-face clinic time.The analysis highlighted the need to think about better ways of reaching out to younger individuals and those who have waited longer to attend appointments, who are less likely to attend once invited.

Effects of a brief pre-admission telephone reminder on no-show and dropout rates in substance use disorder treatment: a quasi-experimental study

Background

Appointment no-show and early dropout from treatment represent major challenges in outpatient substance use disorder treatment, adversely affecting clinical outcomes and health care productivity. In this quasi-experimental study, we examined how a brief reminder intervention for new patients before their first appointment affected treatment participation and retention. No-shows (not attending any sessions) and dropouts (discontinuation of initiated treatment because of three consecutively missed appointments) were compared between a period with pre-admission telephone calls (intervention) and a period without such reminders (non-intervention).

Methods

Participants were all eligible patients (N = 262) admitted to a Norwegian specialist clinic for substance use disorder treatment. We used the Chi-square test for the no-show analysis. Of the eligible patients, 147 were included in a subsequent dropout analysis. We used the number of visits up to 10 appointments as a measure for time to event. Group differences were analyzed using a Kaplan–Meier plot and the log-rank test. To control for relevant sociodemographic variables, as well as substance use and mental distress severity, we used Cox regression.

Results

No-show rates did not differ between the two periods (12% for non-intervention vs. 14% for intervention; χ2 = 0.20, p = 0.653). Of those consenting to participate in the dropout analysis (n = 147), 28 (19%) discontinued treatment within the time frame of 10 appointments, with no differences between the two periods (log-rank test = 0.328, p = 0.567). Controlling for baseline characteristics did not alter this finding. In fact, of the registered covariates at baseline, only higher education level was associated with attrition, linked to a reduced risk for dropout (hazard ratio = 0.85, 95% CI = 0.74–0.98, p = 0.025).

Conclusion

These findings do not provide support for the systematic use of a brief pre-admission telephone reminder in the current treatment setting.

Trial registration

The study was retrospectively registered 13 Jan 2021 at ClinicalTrials.gov, NCT04707599.

The Impact of Mobile Phone Reminders on Perceived Self-Care Levels of Informal Caregivers

Informal caregivers play a fundamental role in caring for people that need assistance and provide an effective service in managing their loved ones’ health. Because of this, they have little time to attend to themselves and perform self-care practices. Some of these practices can improve mental health. By snowball sampling, we recruited 15 informal caregivers, 12 females and three males. Using the Wilcoxon signed-rank test, we analyzed the impact of the reminders on a self-care scale. We used the Mindful Self-Care Scale, comparing the same population without reminders and with reminders. Results indicated that total self-care scores with reminders increased statistically significantly, T = 13, Z = −2.481, p ≤ 0.013, with a large effect size (r = 0.64). This study shows a significant self-care increase in informal caregivers after using reminders. Future development of a reminders-based approach could focus on increasing self-care and the time caregivers take for themselves, empowering them to take a more active role in meeting their own needs.

Causes, impacts and possible mitigation of non-attendance of appointments within the National Health Service: a literature review

PURPOSE

Missed appointments within the National Health Service (NHS) are a drain on resources, associated with not only considerable time and cost implications, but also sub-optimal health outcomes. This literature review aims to explore non-attendance within the NHS in relation to causes, impacts and possible mitigation of negative effects of missed appointments.

DESIGN/METHODOLOGY/APPROACH

MEDLINE, CINAHL Plus and PubMed were searched with a date range of 2016-2021. Databases were searched for peer-reviewed articles published in English addressing non-attendance of adults within the NHS. Studies were excluded if they were theoretical papers, dissertations or research concerning patients aged under 18. A total of 21 articles met the inclusion criteria and were selected for analysis.

FINDINGS

The results indicate a significant association of non-attendance and poor health outcomes. Patients from a lower socioeconomic status, adults aged over 85 and those with multiple co-morbidities are more likely to miss appointments. The most commonly reported patient-centred reasons for failing to attend were forgetfulness, transportation difficulties, and family commitments. Practice-specific reasons were cited as inefficiencies of the appointment booking system, failure of traditional reminders and inconvenient timings. Interventions included text reminder services, the inclusion of costs within reminders and enhanced patient involvement with the booking process.

ORIGINALITY/VALUE

Non-attendance is complex, and to secure maximum attendance, targeted interventions are required by healthcare facilities to ensure patient needs are met. The adaption of scheduling systems and healthcare services can assist in reducing DNA rates.

Feasibility of decentralised, task-shifted hepatitis C testing and treatment services in urban Myanmar: implications for scale-up

OBJECTIVES

To assess the feasibility considerations for a decentralised, one-stop-shop model of care implemented in Yangon, Myanmar.

SETTING

Two primary care level clinics in urban Yangon, Myanmar.

DESIGN

This is a feasibility study of a highly effective care model. Using Intervention Complexity Framework by Gericke et al, we collated and analysed programmatic data and evaluation data to outline key project implementation requirements and experiences.

PARTICIPANTS

Programmatic data were collected from clinical records, GeneXpert device test and maintenance reports, national guidelines, product and device instructions and site monitoring visit reports. Healthcare providers involved in delivering care model contributed interview data.

RESULTS

The main feasibility considerations are appropriate storage for test kits and treatments (in response to temperature and humidity requirements), installation of a continuous stable electricity supply for the GeneXpert device, air-conditioning for the laboratory room hosting GeneXpert, access to a laboratory for pretreatment assessments and clear referral pathways for specialist consultation when required. Lessons from our project implementation experiences included the extensive time requirements for patient education, the importance of regular error monitoring and stock storage reviews and that flexible appointment scheduling and robust reminder system likely contributed to high retention in care.

CONCLUSIONS

Detailed documentation and dissemination of feasibility requirements and implementation considerations is vital to assist others to successfully implement a similar model of care elsewhere. We provide 10 recommendations for successful implementation.

TRIAL REGISTRATION NUMBER

The trial was registered at ClinicalTrials.gov NCT03939013 on May 6, 2019. This manuscript presents post-results data on feasibility.

Acceptability of mobile-phone reminders for routine childhood vaccination appointments in Nigeria - a systematic review and meta-analysis

BACKGROUND

Mobile-phone reminders have gained traction among policymakers as a way to improve childhood vaccination coverage and timeliness. However, there is limited evidence on the acceptability of mobile-phone reminders among patients and caregivers. This systematic review and meta-analysis aimed to evaluate the ownership of mobile-phone device and the willingness to receive mobile-phone reminders among mothers/caregivers utilizing routine childhood immunization services in Nigeria.

METHOD

MEDLINE, Scopus, CINAHL, CNKI, AJOL (African Journal Online), and Web of Science were systematically searched for studies on the acceptability of mobile-phone reminders for routine immunization appointments among mothers/caregivers in Nigeria. Studies were assessed for methodological quality using the Newcastle Ottawa Scale and JBI critical appraisal checklists. Meta-analysis was conducted using random-effects model to generate pooled estimates (proportion) of mothers who owned at least one mobile phone and proportion of mothers willing to receive mobile-phone reminders.

RESULTS

Sixteen studies (13 cross-sectional and three interventional) involving a total of 9923 mothers across 15 states and the Federal Capital Territory Abuja met inclusion criteria. Pooled estimates showed that the proportion of mothers who owned at least one mobile phone was 96.4% (95% CI = 94.1-98.2%; I2 = 96.3%) while the proportion of mothers willing to receive mobile-phone reminders was 86.0% (95% CI = 79.8-91.3%, I2 = 98.4%). Most mothers preferred to receive text message reminders at least 24 h before the routine immunization appointment day, and in the morning hours. Approximately 52.8% of the mothers preferred to receive reminders in English, the country's official language.

CONCLUSION

Current evidence suggests a high acceptability for mobile-phone reminder interventions to improve routine childhood immunization coverage and timeliness. Further studies, however, are needed to better understand unique regional preferences and assess the operational costs, long-term effects, and risks of this intervention.

SYSTEMATIC REVIEW PROTOCOL REGISTRATION

PROSPERO CRD42021234183.

Factors Associated With Adherence to Outpatient Follow-Up in Patients With Idiopathic Intracranial Hypertension (IIH)

Idiopathic intracranial hypertension (IIH) is a chronic condition characterized by raised intracranial pressure of undetectable origin, that causes morbidity due to debilitating headaches and vision loss. Continuity of outpatient care is important to monitor for permanent vision loss, manage symptoms and limit emergency care. The purpose of this retrospective study was to identify factors associated with neuro-ophthalmology follow-up appointment completion among patients with IIH at a US academic medical center in order to establish evidence-based interventions to improve adherence patterns. Included are 111 completed or no-show neuro-ophthalmology return outpatient appointments by 23 subjects with IIH. Generalized estimating equation models were used to assess association between appointment completion status and factors previously shown to be associated with appointment adherence. Appointments were more likely to be completed during the summer (p=0.08) and by subjects with headache symptoms (p=0.06), however none of the patient factors reached statistical significance. Completed and no-show appointments did not differ by subject demographic or insurance factors. Further studies are needed to identify risk factors for lack of appointment adherence by patients with IIH, particularly those amenable to intervention, in order to improve continuity of care for IIH.

The Effect of Direct Health Education on the Uptake of Screening by First Degree Relatives of Glaucoma Patients in Nigeria

PRCIS

First degree relatives (FDRs) of glaucoma patients are more likely to present for screening when they are directly contacted and educated by health workers on the phone compared with when they are only invited by their relative with glaucoma.

OBJECTIVE

The aim was to determine the effect of direct health education by phone calls on the uptake of glaucoma screening among FDRs of primary open angle glaucoma patients as a glaucoma blindness control strategy in an asymptomatic high-risk African population.

METHODS

This was a randomized clinical trial in which 102 primary open angle glaucoma patients (probands) were randomized into control and intervention groups. Both proband groups were educated about glaucoma and requested by the investigator to invite their adult FDR to attend a screening clinic within 1 month. In addition, the FDRs in the intervention group were directly contacted, educated, and invited for examination by phone calls. A total of 560 FDRs were enumerated by the probands. The main outcome measure was proportion of FDR that presented for screening.

RESULTS

A total of 218 (38.9%) FDRs took up glaucoma screening services. Eighty-nine (30.1%) of the 296 FDRs in the control group and 129 (48.9%) of the 264 FDRs in the intervention group presented for examination. After multivariate analysis, FDRs in the phone call group were 2.506 times [95% confidence interval (CI): 1.695-3.706] more likely to present than FDRs in the no phone call group. Young FDRs were more likely to present [odds ratio (OR)=3.593; 95% CI: 1.613-8.007] than the elderly FDRs, while FDRs living within 200 km of the hospital were also more likely to present (OR=5.200; 95% CI: 2.860-9.456) than those living far (>200 km) away. Probands with moderate to severe visual impairment were significantly more likely (OR=3.073; 95% CI: 1.845-4.352) to have their FDRs present than probands with mild or no visual impairment.

CONCLUSION

Direct contact and health education of FDRs through phone calls had a significant positive effect on the uptake of glaucoma screening by FDRs. We recommend direct contact and education of the FDRs of glaucoma patients.

Changes in headache characteristics with oral appliance treatment for obstructive sleep apnea

Changes in headache characteristics in obstructive sleep apnea (OSA) patients following oral appliance treatment was investigated for the first time. Thirteen OSA patients with headaches treated with a mandibular advancement device were investigated. Level I polysomnography and Migraine Disability Assessment Questionnaire were completed before and after treatment. Various headache characteristics and concomitant conditions were analyzed. The patient was considered a headache responder when ≥ 30% reduction in headache frequency following treatment. Differences in headache and polysomnographic parameters were compared between headache responder groups. Eight patients (62%) were headache responders. Eleven patients (85%) before and 7 (54%) after treatment reported morning headaches. Significantly more patients had bilateral headache in the responder group before treatment (P = 0.035). The severest headache intensity (P = 0.018) at baseline showed a significant decrease in the headache responder group after treatment. The time spent in N2 (r = - 0.663, P = 0.014), REM sleep (r = 0.704, P = 0.007) and mean oxygen saturation (r = 0.566, P = 0.044) showed a significant correlation with post-treatment average headache intensity. Pre-treatment lower PLM index (r = - 0.632, P = 0.027) and higher mean oxygen saturation levels (r = 0.592, P = 0.043) were significantly correlated with higher post-treatment severest headache intensity. Treatment with an oral appliance is beneficial for many OSA patients with headaches. It should be considered as an alternative treatment in headache patients with mild to moderate OSA.

The WELL diet score correlates with the alternative healthy eating index-2010

The quality of one's overall diet has proven to be of great importance to health and well-being. Unfortunately, diet quality is time-consuming to assess. The Stanford Wellness Living Laboratory (WELL) administered an online survey that included the WELL Diet Score (a novel diet quality assessment calculated from 12 diet-related items). Subsequently, WELL participants were asked to complete the 127-item Block Food Frequency Questionnaire (FFQ) online. The present study's primary objective was to compare the WELL Diet Score with the established FFQ-based Alternative Healthy Eating Index-2010 (AHEI-2010), in a subset of WELL participants (n = 248) who completed both dietary measures through WELL's online platform. The two scores were significantly correlated (r = .69; p < .0001). Regression analyses demonstrated that the WELL Diet Score was positively significantly associated with sociodemographic determinants of diet quality and protective health factors, including older age, higher education, lower BMI, and higher physical activity. In summary, the WELL Diet Score, derived from 12 small diet-related items that can be completed in 5 min, was significantly positively correlated with the AHEI-2010 derived from the lengthy 127-item FFQ, suggesting the potential utility of the WELL Diet Score in future large-scale studies, including future WELL studies.

Burden of eye conditions at a specialised eye hospital in KwaZulu-Natal, South Africa

Background: Comprehension of the burden of eye diseases in an area is essential for adequate budgeting and resource allocation.Aim: The aim of the study was to describe the epidemiology of the presenting eye conditions at a provincial eye hospital.Setting: A retrospective audit was conducted of first-time presenting patients at the McCord Provincial Eye Hospital over a 6-month period.Methods: This was an observational, analytic cross-sectional study. Patients’ basic demographic and diagnoses were captured. Categorical variables were summarised using frequencies and percentages. Age was summarised using the mean and standard deviation. Differences in the number of patients seen per month, week and day of the week were compared using analysis of variance.Results: A total of 2250 new patients were seen over the 6-month period. There were more females (n = 1253, 55.7%) than males (n = 997, 44.3%). There were 186 (8.3%) patients (≤ 14 years). The three most common presenting conditions among adults were cataract (n = 743, 36.0%), posterior segment disorders (n = 397, 19.2%) and glaucoma (n = 261, 12.6%). Regarding posterior segment disorders, diabetic retinopathy was the commonest condition (n = 284, 71%), followed by retinal detachment (n = 34, 8.5%). Among the paediatric patients, the most common condition was squint (n = 55, 29.6%), followed by orbital conditions (n = 29, 15.6%) and cataract (n = 25, 13.4%).Conclusion: Audits of the burden of eye conditions provide useful information for human resource management; appropriate allocation, as well as availability of ophthalmologic equipment and staff, can be guided by making use of such information. Further studies and surveillance of eye conditions are needed to plan for better eye health services for patient care.

Fine for non-attendance in public hospitals in Denmark: A survey of non-attenders' reasons and attitudes

OBJECTIVE

To investigate non-attending patients' reasons for non-attendance and their general and specific attitudes towards a non-attendance fine.

DATA SOURCES

Non-attenders at two hospital departments participating in a trial of fine for non-attendance from May 2015 to January 2017.

DESIGN

A quantitative questionnaire study was conducted among non-attenders.

DATA COLLECTION

Non-attending patients in the intervention group were invited to complete the questionnaire. The response rate was 39% and the total number of respondents was 71 individuals.

PRINCIPAL FINDINGS

The main reason for non-attendance was technical challenges with the digital appointment and with cancelation. The main part of the respondents was generally positive towards a fine for non-attendance. However, approximately the half had a negative attitude towards the actual fine issued.

CONCLUSIONS

Technical challenges with appointments and cancelation should get special attention when addressing non-attendance. Danish non-attending patients are primarily positive towards the general principle of issuing a fine for non-attendance. However, a significant proportion of the generally positive, reported a negative specific attitude to the specific fine issued to them. This, however, did not affect their general attitude.

Pre-notification and reminder SMS text messages with behaviourally informed invitation letters to improve uptake of NHS Health Checks: a factorial randomised controlled trial

BACKGROUND

The NHS Health Check (NHS HC) is a cardiovascular risk assessment to prevent cardiovascular disease. Public Health England (PHE) wants to increase uptake.

METHODS

We explored the impact of behaviourally informed invitation letters and pre-notification and reminder SMS on uptake of NHS HCs. Patients at 28 General Practices in the London Borough of Southwark who were eligible to receive an NHS HC between 1st November 2013 and 31st December 2014 were included. A double-blind randomised controlled trial with a mixed 2 (pre-notification SMS - yes or no) × 4 (letter - national template control, open-ended, time-limited, social norm) × 2 (reminder SMS - yes or no) factorial design was used. The open-ended letter used simplification, behavioural instruction and a personalised planning prompt for patients to record the date and time of their NHS HC. The time-limited letter was similar but stated the NHS HC was due in a named forthcoming month. The social norms letter was similar to the open-ended letter but included a descriptive social norms message and testimonials from local residents and no planning prompt. The outcome measure was attendance at an NHS HC.

RESULTS

Data for 12, 244 invites were analysed. Uptake increased in almost all letter and SMS combinations compared to the control letter without SMS (Uptake 18%), with increases of up to 12 percentage points for the time-limited letter with pre-notification and reminder (Uptake 30%; Adjusted Odds Ratio AOR 1.86; 95% CI 1.45-2.83; p < 0.00); 10 percentage points for the open-ended letter with reminder (Uptake 27%; AOR 1.68; 95% CI 1.31-2.17; p < 0.00) and a 9 percentage point increase using the time-limited letter with reminder (Uptake 27%; AOR 1.61; 95% CI 1.25-2.10; p < 0.00). The reminder SMS increased uptake for all intervention letters. The pre-notification did not add to this effect.

CONCLUSIONS

This large randomised controlled trial adds support to the evidence that small, low cost behaviourally informed changes to letter-based invitations can increase uptake of NHS HCs. It also provides novel evidence on the effect of SMS reminders and pre-notification on NHS HC attendance.

TRIAL REGISTRATION

Retrospectively Registered (24/01/2014) ISRCTN36027094 .

Effect of enhanced reminders on postnatal clinic attendance in Addis Ababa, Ethiopia: a cluster randomized controlled trial

Background: Failure to attend maternal health services is an intractable challenge for the health-care system in low- and middle-income countries. The use of technology for reminding patients about their appointments has been demonstrated to be an effective (future) tool toward increased health care services utilization in developing countries, such as Ethiopia. Objective: We aimed to investigate the effect of enhanced reminders on postnatal care attendance versus usual care (notification of an appointment at discharge). Methods: The study was a cluster randomized controlled trial: out of eligible 86 health centers, 16 health centers in Addis Ababa (AA) were randomized to either the intervention (8) or the control (8) groups; with a total of 350 mothers equally randomized into each arm. Mothers in the intervention group received the SMS (short message service) or a voice call reminder at 48 and 24 hours before the due postnatal appointment, whereas the control group received only the usual notification of appointments provided by health professionals at discharge from the ward following delivery. We recruited participants on wards after delivery at discharge and followed them up to 6 weeks. This study's primary outcome was postnatal visit compliance. Our assessment consisted of a two-level bivariate and a multivariate ordinal logistic regression analysis. Results: The majority (97.7%) of the participants completed the study; 173(98.9%) of women in the intervention group and 169 (96.5%) of women in the control group. There was a statistically significant difference in postnatal care (PNC) compliance among women who were in the intervention versus the control group (p-value = 0.005). Higher odds of postnatal compliance was observed among the intervention group (AOR:2.98, 95% CI 1.51-5.8). Conclusions: Mobile phone reminders were effective in terms of enhancing adherence to PNC appointments. This indicates integration of mobile phone reminders in postnatal care could improve postnatal appointment compliance.

Policy strategies to reduce waiting times for elective surgery: A scoping review and evidence synthesis

OBJECTIVES

The purpose of this evidence-based review is to identify and describe the interventions that have been implemented to reduce waiting times for major elective surgery.

METHODS

Scoping review and presentation of the results according to the SUPPORT tools. We searched MEDLINE/PubMed, Embase, Cochrane Library, SciELO, DARE-HTA, and Google Scholar. The inclusion criteria for research design were comprehensive.

RESULTS

We identified 5200 records. After eliminating duplicates and screening by title and abstract, 171 records remained for full-text assessment, of which 12 were ultimately included for this review because they reported specific interventions and 96 records were included for further reference. The included studies show significant variability regarding elective procedures, population, and type of provider, as well as in the characteristics of the interventions and the settings. All the studies had methodological limitations. We graded the certainty of the evidence as very low.

CONCLUSIONS

According to the evidence found for this review, interventions most likely should be multidimensional, with prioritization strategies on the waiting lists to incorporate equity criteria, together with quality management improvements of the surgical pathways and the use of operating rooms, as well as improvements in the planning of the surgical schedule.

Use of programme theory to understand the differential effects of interventions across socio-economic groups in systematic reviews-a systematic methodology review

BACKGROUND

Systematic review guidance recommends the use of programme theory to inform considerations of if and how healthcare interventions may work differently across socio-economic status (SES) groups. This study aimed to address the lack of detail on how reviewers operationalise this in practice.

METHODS

A methodological systematic review was undertaken to assess if, how and the extent to which systematic reviewers operationalise the guidance on the use of programme theory in considerations of socio-economic inequalities in health. Multiple databases were searched from January 2013 to May 2016. Studies were included if they were systematic reviews assessing the effectiveness of an intervention and included data on SES. Two reviewers independently screened all studies, undertook quality assessment and extracted data. A narrative approach to synthesis was adopted.

RESULTS

A total of 37 systematic reviews were included, 10 of which were explicit in the use of terminology for 'programme theory'. Twenty-nine studies used programme theory to inform both their a priori assumptions and explain their review findings. Of these, 22 incorporated considerations of both what and how interventions do/do not work in SES groups to both predict and explain their review findings. Thirteen studies acknowledged 24 unique theoretical references to support their assumptions of what or how interventions may have different effects in SES groups. Most reviewers used supplementary evidence to support their considerations of differential effectiveness. The majority of authors outlined a programme theory in the "Introduction" and "Discussion" sections of the review to inform their assumptions or provide explanations of what or how interventions may result in differential effects within or across SES groups. About a third of reviews used programme theory to inform the review analysis and/or synthesis. Few authors used programme theory to inform their inclusion criteria, data extraction or quality assessment. Twenty-one studies tested their a priori programme theory.

CONCLUSIONS

The use of programme theory to inform considerations of if, what and how interventions lead to differential effects on health in different SES groups in the systematic review process is not yet widely adopted, is used implicitly, is often fragmented and is not implemented in a systematic way.

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.

A dynamic approach for outpatient scheduling

AIMS

Patient no-show is a recurrent problem in medical centers and, in conjunction with cancellation of appointments, often results in loss of productivity and excessive patient time to appointment. The purpose of this study was to develop a dynamic procedure for scheduling patients within an outpatient clinic where patients are expected to have multiple appointments, such as physical therapy, occupational therapy, primary care, and dentistry.

METHODS

This retrospective study involved the year 2014 de-identified patient records from an outpatient clinic affiliated with a large university hospital. A number of patient characteristics, appointment data, and historical attendance records were examined to determine whether they significantly impacted patients who missed scheduled appointments (no-shows). Patient attendance behaviors over multiple appointments were examined to determine whether their no-show and cancellation patterns differed from one appointment to the next. Decision tree analysis was applied to those predictors that significantly correlated with patient attendance behavior to assess the likelihood of a patient no-show. A sample dynamic appointment scheduling procedure that utilized different overbooking strategies for different appointment numbers was then developed. Computer simulation was used to assess the effectiveness of the dynamic procedure versus two other methods consisting of randomly assigned and uniformly assigned appointments.

RESULTS

The dynamic scheduling procedure resulted in increased scheduling efficiency through overbooking but with less than 5% risk of appointment conflicts (i.e. two patients showing at the same time), equating to approximately 0.16 conflicts per clinician per day. It also increased clinic utilization by about 6.7%. It consistently outperformed the other two methods with respect to the percentage of appointment conflicts.

LIMITATIONS

The study is limited with respect to potential clinician cost increase resulting from possible appointment conflicts. A second limitation is that patients experiencing appointment conflicts might not wait for treatment, resulting in potential loss of revenue. A third limitation is that the model does not take into account patient satisfaction, nor the ethics of overbooking patients.

CONCLUSIONS

A dynamic appointment scheduling procedure was developed using actual patient characteristics. The procedure resulted in creation of more efficient appointment schedules thereby increasing the clinic utilization.

Targeted Reminder Phone Calls to Patients at High Risk of No-Show for Primary Care Appointment: A Randomized Trial

BACKGROUND

No-shows, or missed appointments, are a problem for many medical practices. They result in fragmented care and reduce access for all patients.

OBJECTIVE

To determine whether telephone reminder calls targeted to patients at high risk of no-show can reduce no-show rates.

DESIGN

Single-center randomized controlled trial.

PARTICIPANTS

A total of 2247 primary care patients in a hospital-based primary care clinic at high risk of no-show (>15 % risk) for their appointment in 7 days.

INTERVENTION

Seven days prior to their appointment, intervention arm patients were placed in a calling queue to receive a reminder phone call from a patient service coordinator. Coordinators were trained to engage patients in concrete planning. All patients received an automated phone call (usual care).

MAIN MEASURES

Primary outcome was no-show rate. Secondary outcomes included arrival rate, cancellation rate, reschedule rate, time to cancellation, and change in revenue.

KEY RESULTS

The no-show rate in the intervention arm (22.8 %) was significantly lower (absolute risk difference -6.4 %, p < 0.01, 95 % CI [-9.8 to -3.0 %]) than that in the control arm (29.2 %). Arrival, cancellation, and reschedule rates did not differ significantly. In the intervention arm, rescheduling and cancellations occurred further in advance of the appointment (mean difference, 0.35 days; 95 % CI [0.07-0.64]; p = 0.01). Reimbursement did not differ significantly.

CONCLUSIONS

A phone call 7 days prior to an appointment led to a significant reduction in no-shows and increased reimbursement among patients at high risk of no-show. The use of targeted interventions may be of interest to practices taking on increased accountability for population health.