Prompts to encourage appointment attendance for people with serious mental illness

First appointments at a mental health clinic can be a daunting prospect. Failure to attend is common, wastes time, and can result in important delays in getting proper care. A gentle prompt, near to the time of appointment, would, if effective, seem a cost effective way of encouraging attendance. This review sought evidence for the effects of telephoning or sending a letter, in the days just before the appointment. Relevant studies were found, and although none were conclusive, all suggested that a simple prompt could indeed encourage attendance.

Authors' conclusions: 

There is evidence that a simple prompt to attend clinic, very close to the time of the appointment may encourage attendance, and a simple orientation-type letter may be more effective than a telephone prompt. This simple intervention could be a more cost effective means of encouraging compliance at first attendance, but supplementing these data with the results of large, well designed, conducted and reported randomised studies would be desirable.

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Background: 

Prompts to encourage attendance at clinics are often used in day-to-day practice by diligent carers of people with mental health problems. These may take the form of telephone prompting, financial incentives or issuing a copy of the referral letter to the appointee.

Objectives: 

To estimate the effects of simple prompting by professional carers to encourage attendance at clinics for those with suspected serious mental illness.

Search strategy: 

We searched the Cochrane Schizophrenia Group Trials Register (April 2009) and reference lists, as well as contacting authors of studies. We updated this search on 17 May 2012 and added the results to the awaiting classification section of the review.

Selection criteria: 

All relevant randomised (or quasi-randomised) studies comparing the addition of 'prompts' to standard care for those with serious mental illnesses such as schizophrenia. Prompts had the stated purpose of encouraging attendance or contact with mental health teams and could be text-based, (for example in the form of a letter), electronic, by telephone call, by personal visit, or could employ financial or other rewards.

Data collection and analysis: 

Studies and data were independently selected and extracted. For homogeneous dichotomous data the random effects relative risk (RR), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data the reviewers calculated weighted mean differences.

Main results: 

Only four relevant trials were identified (total n=789). It is not clear whether there is any real difference between attendance of those prompted by telephone one or two days before the appointment, and those given the standard appointment management system (2 RCTs, n=457, RR missed appointment 0.84 CI 0.7 to 1.1). Text-based prompts in the form of a letter, a few days before the appointment day, may increase clinic attendance when compared with no prompt (3 RCTs, n=326, RR missed appointment 0.76 CI 0.43 to 1.32). Only one small study (n=61) reported data on the combination of telephone and text-based prompts versus no prompt, no real difference between groups was apparent (RR missed appointment 0.7 CI 0.4 to 1.2). When telephone prompts were compared with text-based prompts (1 RCT, n=75), the latter, in the form of an 'orientation statement' (a short paragraph, taking about 30 seconds to read, explaining the programme of care, the fee system, and providing gentle encouragement) may be somewhat more effective than the telephone prompt (RR missed appointment 1.9 CI 0.98 to 3.8). One study (n=120) compared a standard letter prompt with a letter 'orientation statement'. Overall, results tended to favour the orientation statement approach rather than the simple letter prompting attendance but the results did not reach conventional levels of statistical significance (RR missed appointment 1.6 CI 0.9 to 2.9). When prompts were considered regardless of their type, the results were of greater significance and suggested an effect to increase the rate of attendance (RR missed appointments 0.80 CI 0.65 to 0.98). The inclusion of five new studies to the awaiting classification section may affect results when assessed.

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