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BioMed Central
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BMC Ophthalmology
Open Access
Research article
Effectiveness of mobile-phone short message service (SMS)
reminders for ophthalmology outpatient appointments:
Observational study
Elizabeth Koshy*, Josip Car and Azeem Majeed
Address: Department of Primary Care and Social Medicine, Imperial College London, London, UK
Email: Elizabeth Koshy* - e.koshy@imperial.ac.uk; Josip Car - j.car@imperial.ac.uk; Azeem Majeed - a.majeed@imperial.ac.uk
* Corresponding author
Abstract
Background: Non-attendance for hospital outpatient appointments is a significant problem in
many countries. It causes suboptimal use of clinical and administrative staff and financial losses, as
well as longer waiting times. The use of Short Message Service (SMS) appointment reminders
potentially offers a cost-effective and time-efficient strategy to decrease non-attendance and so
improve the efficiency of outpatient healthcare delivery.
Methods: An SMS text message was sent to patients with scheduled appointments between April
and September 2006 in a hospital ophthalmology department in London, reminding them of their
appointments. This group acted as the intervention group. Controls were patients with scheduled
ophthalmology appointments who did not receive an SMS or any alternative reminder.
Results: During the period of the study, 11.2% (50/447) of patients who received an SMS
appointment reminder were non-attenders, compared to 18.1% (1720/9512) who did not receive
an SMS reminder. Non-attendance rates were 38% lower in patients who received an SMS
reminder than in patients who did not receive a reminder (RR of non-attendance = 0.62; 95% CI =
0.48 – 0.80).
Conclusion: The use of SMS reminders for ophthalmology outpatient appointments was
associated with a reduction of 38% in the likelihood of patients not attending their appointments,
compared to no appointment reminder. The use of SMS reminders may also be more cost-effective
than traditional appointment reminders and require less labour. These findings should be confirmed
with a more rigorous study design before a wider roll-out.
Background
Non-attendance for hospital outpatient appointments is a
major burden on healthcare systems and costs the
National Health Service (NHS) in the UK an estimated
£790 million per year [1]. It reduces the efficiency and
effectiveness of the delivery of outpatient healthcare and
causes substantial financial losses for healthcare systems
[2]. It also results in suboptimal use of clinical and admin-
istrative staff and results in increased waiting times for
other patients [3]. The increased waiting time can result in
delay in presentation of patients' symptoms and also
decreased monitoring of long-term chronic conditions;
which can, in turn, lead to increased patient morbidity
Published: 31 May 2008
BMC Ophthalmology 2008, 8:9 doi:10.1186/1471-2415-8-9
Received: 29 February 2008
Accepted: 31 May 2008
This article is available from: http://www.biomedcentral.com/1471-2415/8/9
© 2008 Koshy et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
BMC Ophthalmology 2008, 8:9 http://www.biomedcentral.com/1471-2415/8/9
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[4]. Additionally, there are worse outcomes for non-
attenders and a loss of continuity of care [5].
Some of the main reasons for patients not attending their
outpatient appointments are forgetting their appoint-
ments [6] and confusion over the date, time and location
of the appointment [6,7] There are many methods of
delivering appointment reminders which have been stud-
ied to date, including personalised and automated tele-
phone reminders [6,8-12], posted letters [13,9] and
awareness campaigns [14]. Most of the studies have
shown a reduction in non-attendance rates, irrespective of
the method of reminder used. However, there is a paucity
of research in relation to the use of mobile phone SMS
(Short Message Service)/text message reminders for out-
patient hospital appointments [3].
As mobile phone ownership continues to increase rapidly
in many countries worldwide, there is potential to utilise
SMS reminders to increase the effectiveness and efficiency
of health care delivery. A recent survey showed that over
85% of adults in the UK used a mobile phone [15] SMS
facilities on mobile phones were introduced in the early
1990s and now represents one of the most widely used
methods of communication, with about 41.8 billion texts
sent in the UK in 2006 [16]. SMS messages have a number
of characteristics that make them very appropriate for use
in a healthcare setting including: direct patient communi-
cation, privacy, confidentiality, swift delivery of messages
and receipt of responses, convenience for health providers
and patients. SMS messaging technology also allows the
dispatching of substantial numbers of messages simulta-
neously, so reducing labour expenditure.
Non-attendance at hospital outpatient clinics is a com-
mon problem which every specialty faces. It is particularly
important for specialties such as ophthalmology which
are predominantly outpatient-based [17] An audit in an
ophthalmology clinic in a Birmingham hospital in the
UK, reported a non-attendance rate of 12.6% [18]. A New
Zealand study found non-attendance rates at a public eye
clinic of 17.2% [17]. This highlights that it is essential to
maximise patient attendance to optimise the efficiency of
the service delivered. We could not identify any studies
relating to the use of SMS-based reminders for hospital
appointments for ophthalmology appointments within
the Medline, Embase, Cochrane, and PsycInfo databases.
This pilot study primarily focused on patients attending
ophthalmology clinics as these outpatient clinics had one
of the highest non-attendance rates. Our study assessed
the effectiveness of the use of SMS-based reminders for
hospital outpatient appointments as a method of reduc-
ing the non-attendance rates in an inner-city London
teaching hospital. The null hypothesis was that (non-
)attendance rates for those receiving an SMS reminder did
not differ from the (non-)attendance rates for those who
did not receive an SMS reminder.
Methods
This is an observational study and analysis is based on
data collected from the ophthalmology department at
Barts and the London Hospitals NHS Trust, UK between
April and September 2006. Ethics committee approval
was obtained from Barts and The London NHS Trust for
SMS reminders to be sent to patients. We analysed data
that did not contain any patient identifiable information.
All patients, where a mobile number was obtainable from
the Patient Administration System and who were due to
attend their first (new) ophthalmology consultation dur-
ing the study period, were sent an automated SMS
reminder. The SMS reminders were sent one day before
the appointment if it was booked within seven days of the
appointment. If an appointment had been booked more
than seven days in advance of an appointment, the patient
received an SMS four days beforehand. A four day interval
was chosen to minimise the time delay for patients to still
forget their appointments, but also to allow time to
reschedule appointments, if patients subsequently can-
celled their appointment. Information required for the
SMS reminders was obtained from the Patient Adminis-
tration System hospital database. This included the
patients' mobile numbers, appointment dates and times.
Patients who received an SMS formed the intervention
group. A control group were all patients who had a sched-
uled first (new) appointment during this same study
period, who may or may not have had a mobile phone,
but whose mobile number was not available and did not
receive any other form of appointment reminder.
The text message read: "This is a reminder of your appoint-
ment at Barts and the London Hospital at <time> <date>.
Please call xxxxx or reply to text to cancel."
The automated SMS reminders transmitted were timed so
that they did not reach the recipients at inappropriate
times, such as night-time. The attendance/non-attendance
status for patients who received and did not receive an
SMS appointment reminder were recorded using the IT
software installed. Data on cancellations by patients for
the SMS and control groups was also collected.
Statistical analysis was performed using Stata 9. The
attendance rates in the SMS reminder group were com-
pared with those in the control group. A chi-squared test
was conducted to compare the proportions of patients not
attending appointments and also the proportions of can-
cellations by patients between the SMS and the control
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groups. Relative risks of non-attendance are presented
with 95% confidence intervals (CI).
Results
Of the 9959 ophthalmology hospital outpatient appoint-
ments between April and September 2006, 447 patients
(4.5%) received an SMS appointment reminder (Table 1).
The control group (patients who did not receive an SMS
reminder) consisted of 9512 patients and had a non-
attendance rate of 18.1% (1720/9512). Amongst the
patients who received an SMS reminder (447 patients),
the non-attendance rate was 11.2% (50/447) (Table 1, Fig
1). The absolute reduction in non-attendance rates for
those who received an SMS reminder was 6.9%. This rep-
resents about 31 more (of the 447 ophthalmology outpa-
tient appointments) being kept over a 6 month period
that would have otherwise been lost through patients not
keeping their scheduled appointments. The cancellation
rates of appointments by patients who received an SMS
and those who did not receive an SMS were 13.4% and
11.2%, respectively (Table 1).
Patients who received a text reminder were 38% less likely
to be non-attenders for their appointment (relative risk of
non-attendance = 0.62; 95% CI 0.48 – 0.80, p = 0.0002).
Patients in the SMS group were also 26% more likely to
cancel their appointments, but this was not statistically
significant (relative risk of cancellation 1.26, 95% confi-
dence interval 0.98 – 1.61, P = 0.068). There was a total of
340,700 scheduled outpatient appointments (for all spe-
cialities) between April-September 2006. Of the 340,146
who did not receive an SMS appointment reminder the
non-attendance rate was 12.1%.
The cost of sending an automated SMS reminder was 7.2
pence. Therefore, extrapolating the six month data to one
year for the ophthalmology clinics, sending 894 SMS
reminders (447 × 2) would have cost £64.37. The cost of
approximately 62 (31 × 2) extra appointments being
attended as a consequence of the SMS reminders, is £4030
(with a cost of a hospital appointment in England being
approximately £65.00). Therefore, the net saving would
have been £3965.63, just for the ophthalmology depart-
ment. The 'number needed to text' (NNT) in this study to
prevent one appointment non-attendance is 14 (95%
confidence interval: 10 to 31).
Discussion
Patients who had received an SMS reminder were signifi-
cantly more likely to attend their ophthalmology hospital
appointments compared to those who had not received
an SMS. This study showed that sending SMS reminders
led to a 6.9% absolute reduction and 38% relative reduc-
tion in non-attendance rates for ophthalmology outpa-
tient appointments. Non-attendance rates in the SMS
group and the control group were 11.2% and 18.1%,
respectively. The cancellation of appointments in the SMS
group compared to the control group was slightly higher
Percentage of non-attenders by SMS reminder statusFigure 1
Percentage of non-attenders by SMS reminder sta-
tus.
0
2
4
6
8
10
12
14
16
18
20
sms reminder no sms reminder
sms reminder status
percentage
Table 1: Non-attendance rates for patients sent a SMS reminder and those not sent a SMS reminder
SMS appointment reminders No SMS appointment reminders Non-attendance
rate reduction
(%) with SMS
reminders
TOTAL
outpatient
appointments
Non-attendance
appointment
numbers (%)
Cancellations by
patients (%)
TOTAL
outpatient
appointments
Non-attendance
appointment
numbers (%)
Cancellations by
patients (%)
447 50 (11.2) 60 (13.4) 9512 1720 (18.1) 1016 (10.7) 6.9
N = 9959
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(13.4% vs 11.2%). Cancellation rates were not statistically
significantly different between the two groups but there
was a trend towards a higher cancellation rate in the SMS
group (relative risk of cancellation 1.26; 95% CI 0.98–
1.61).
The non-attendance rate for ophthalmology appoint-
ments (18.1%) in our control group was higher than the
mean non-attendance rate for all the different hospital
specialty outpatient appointments (12.1%). This con-
firmed that non-attendance was a greater problem for the
ophthalmology department compared to many other spe-
cialties within the same hospital. It is difficult to speculate
why this might be, but there could have been administra-
tion problems, for example, due to staff shortages; or per-
haps, though this may be unlikely, the demographic
characteristics or behaviours of the patients in this geo-
graphical area who attend the ophthalmology clinics may
differ from that of other specialties. The 18.1% non-
attendance rate in the control group in our study is higher
than that quoted in other studies [19,18,17]. For example,
the Birmingham ophthalmology department audit, over a
year, was 12.6% [18]. However, our study was only con-
ducted over a 6 month period and ideally, information
relating to a year, taking into account seasonal variations,
would be valuable. Also, this Birmingham study was in
1990–1, so non-attendance rates may have changed over
this time period. A New Zealand audit showed a non-
attendance rate of 17.2% [17].
The non-attendance rate of the SMS group in our study
was 38% lower than that of the control group (RR = 0.62)
and there was strong evidence (P = 0.0002) to reject the
null hypothesis of no difference between these two
groups. A multi-centred, randomised controlled trial in
China also found an increase in the likelihood of attend-
ance (OR = 1.59, P = 0.005) [20]. This study had 993 par-
ticipants who were divided into 3 study arms; and
compared SMS reminders and mobile telephone conver-
sations reminders with a control group of no intervention.
There was no statistically significant difference in non-
attendance observed between their SMS group and mobile
phone-call reminders. This study was conducted in a pri-
mary care setting, which may have represented a systemat-
ically different group of patients in terms of non-
attendance characteristics to those attending secondary
care appointments, so direct comparisons cannot be
made. Additionally, Family Practice-based factors such as
mistakes or misunderstandings surrounding appointment
details, relayed over the telephone, from the health pro-
vider are possible reasons for non-attendance in this
healthcare setting [21].
The percentage reduction in non-attendance rates with
SMS reminders of 6.9% in our study is lower than that
reported for a recent study in an Irish ENT outpatient
department [2], where there was a 11.6% reduction (from
33.6% to 22%). This study, however, used data from a
much larger sample size (3981 patients) and covered a 3
year period. Studies of other methods of appointment
reminders such as posted letters and telephone calls
found reductions of non-attendance rates between 6%
and 19% [6,8,12,10]. The reduction in non-attendance
found in our study is within the range of these other stud-
ies. Therefore, SMS reminders are at least as effective as
alternative methods. The SMS reminders also have the
advantage of being more cost-effective and requiring less
labour than the other methods.
Limitations of this study
Although there seems to be an association between the
use of SMS reminders and a decrease in non-attendance
rates, this is not necessarily causal and there could be con-
founding factors and biases which may partially or fully
explain this association. This study suggests that the use of
SMS reminders could help to reduce ophthalmology non-
attendance rates. However, the design in this paper is sub-
optimal, and a rigorous randomised controlled trial, strat-
ified by socio-demographic characteristics and clinical
conditions, is required to determine if the potential bene-
fits observed in this study can be replicated. Knowledge of
the patients' clinical presentation in the intervention and
control groups is also important as it could affect the
'value' placed on it by patients and potentially affect the
likelihood of an appointment being kept.
We do not know what proportion of the control group
owned mobile phones, but whose mobile number was
not available for this service. We are also unaware of the
number of patients who were unfamiliar with using text-
messaging and so unable to read the reminder. There
could also have been participation bias, as the SMS group
patients (who provided a mobile phone number) may
have been a more motivated group of patients; and these
patients may have been more likely to attend their
appointments irrespective of receiving an SMS reminder.
This could have potentially led to an over-estimate of the
association between SMS reminders and non-attendance
rates. Data was only available for a 6 month period, and
so did not take account of seasonal and monthly varia-
tions in non-attendance. However, using the same time-
frame for the controls helped to reduce the chance of
monthly and seasonal variations contributing to the
observed differences. We did not have demographic infor-
mation relating to those patients who owned a mobile
phone or for those who received an SMS reminder who
subsequently attended and did not attend their scheduled
appointments. Data relating to potential confounding fac-
tors (such as age, sex, ethnicity and socio-economic sta-
tus) was not collected, so we were not able to adjust for
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these in the statistical analysis. We did not have demo-
graphic information available relating to age in either
groups and recognise this is a weakness and could
account, in part or fully, for the observed difference. How-
ever, as younger patients are more likely to own mobile
phones and also have higher non-attendance rates, the
fact that the non-attendance rate decreased in the SMS
group (who are more likely to be younger), suggests that
use of SMS reminders may be beneficial to target younger
patients. Finally, patients who received SMS reminders
were for a first consultation and it has been suggested that
follow-up appointments have higher non-attendance
rates [22]. This was the first stage of the study; the next
stage will be focusing on follow-up appointments.
What this study adds
SMS appointment reminders seem to be an effective and
efficient method of improving ophthalmology outpatient
attendance, which is less labour intensive than the more
traditional reminder systems that have been used in the
past. The facility for patients to reply or call in response to
an SMS reminder to cancel their appointment can help to
reduce the non-attendance rates and free up appoint-
ments for other patients, which otherwise may be lost. We
cannot extrapolate our findings to other specialties or hos-
pitals; so future research should include suitably powered
randomised controlled trials for assessing SMS appoint-
ment reminders for ophthalmology and other specialties
to assess the cost-effectiveness within the NHS. The use of
SMS technology is expanding and has already been used
to help in the management of some health problems and
diseases; for example, asthma [23] and diabetes [24,25]
management and smoking cessation [26]. Hence, the
potential scope for the further utilisation of this technol-
ogy is tremendous. SMS reminders could offer a cost-effec-
tive method for reducing non-attendance rates for retinal
screening appointment follow-ups for diabetic patients.
Strengths and weaknesses of SMS technology
In addition to the advantages already described, SMS
reminders require minimal investment in IT infrastruc-
ture, as this is already in existence; as the IT software for
sending automated SMS integrates with existing electronic
patient health records and hospital administrative data-
base systems. Once the system is in place, the cost of run-
ning the service increases very little as the number of SMS
reminders increases. As they are automated messages, it
does not require staff training so this offers a time, labour
and cost-efficient system.
There are a number of potential weaknesses. Patients may
not receive the SMS reminders due to incorrect data entry.
However, this problem can occur with other methods of
appointment reminders such as letters and telephone calls
(with change of address) [12]. The uses of different tech-
nologies are very fluid and dynamic and so it is not known
how the use of mobile phones and the use of SMS tech-
nology will evolve over time. However, it is anticipated
that there will be an increase in mobile phone ownership
and use of SMS messaging facilities in the immediate few
years. Elderly people have lower ownership rates of
mobile phones and may not be able to use SMS facilities
[27]. The Office for National Statistics (UK) [27] found
mobile ownership in 2003 varied by age, with nearly 90%
of 15–24 year olds owning one and less than a quarter of
those aged 75 years and over owning one in 2003. How-
ever, between 2001 and 2003, the largest increases in
ownership were amongst those aged 75 and over, with the
proportions almost doubling [27]. However, it has tradi-
tionally been younger patients who have missed their out-
patient appointments more than older patients, so the use
of SMS reminders could be targeted towards patients
under 60 years old.
Cost-effectiveness analysis
There is always some wastage in any system and the real
cost of a missed appointment is difficult to quantify. It
may be, in some cases, that the appointment may not
have really been needed, although this is difficult to
prove. For example, patients' agenda may influence pres-
entation and attendance [28]. Based on the 'number
needed to text' analysis, approximately fourteen people
would need to be sent an SMS reminder to prevent one
non-attendance. As the cost of outpatient appointments is
considerable, this could potentially be worthwhile, but
needs to be tested through a more rigorous economic
analysis. A well-designed randomised controlled trial
would give a more accurate representation of the NNT to
prevent one non-attendance. Only around 5% of the
patients with scheduled ophthalmology appointments
were sent SMS reminders in this study; so, if the reminders
were sent on a much larger scale to patients with first and
follow-up appointments and for all the departments in
the hospital, the savings to the NHS could be large. A pre-
vious cost-effectiveness analysis has estimated that the
annual direct cost of missed hospital appointments in
England is estimated to be close to £575 million [1] and
that the use of SMS-based reminders could lead to a
potential saving of £55.6 to £83.5 million a year [1], so
the potential scope for this technology is considerable.
Conclusion
The use of SMS reminders for ophthalmology outpatient
appointments was associated with a reduction of 38% in
the likelihood of patients not attending their appoint-
ments, compared to no appointment reminder. Addition-
ally, the use of SMS reminders appears more cost-effective
than traditional appointment reminders and requires less
labour. These findings suggest that SMS text reminders
have great potential value in reducing non-attendance
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rates in outpatient departments but that the potential ben-
efits should be confirmed with a more rigorous study
design before a wider roll-out.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
EK and JC conceived the idea for this paper. EK wrote the
manuscript. EK and AM performed the statistical analysis
and data interpretation. JC and AM were involved in inter-
pretation of findings and revised the paper critically for
intellectual content. All authors read and approved the
final manuscript. EK and JC are the guarantors for this
study.
Acknowledgements
We would like to acknowledge Barts and the London Hospitals NHS Trust
who were responsible for initiating this intervention study. We would also
like to thank Tobias Alpsten, the Managing Director of iPLATO. iPLATO is
the telecommunications company, who integrated the patient information
systems and were responsible for organising all the automated SMS
appointment reminders to patients at Barts and The London Hospitals NHS
Trust.
We would also like to thank the Department of Health (UK) National Insti-
tute for Health Research who funded a research fellowship for Dr Elizabeth
Koshy. The Department of Primary Care & Social Medicine at Imperial Col-
lege receives support from the NIHR Biomedical Research Centre Funding
Scheme.
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Pre-publication history
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