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Question Can social support strategies improve appointment keeping among patients with chronic illnesses?
Design
Randomised controlled trial with follow up at 3 months.
Setting
An ambulatory medical clinic in a large, inner city hospital in the US.
Patients
200 clinic patients (71% women, 95% black, 69% >50 y old) who were diagnosed with chronic asymptomatic illnesses (usually diabetes and/or hypertension), had ≥1 previous clinic appointment, were scheduled for follow up appointments within 3 months, and were able to identify a family member or significant other who could be reached by telephone. Most of the patients had an annual family income of <US$7000 (87%), ≤9 years of formal education (63%), and were widowed or divorced (55%).
Intervention
Patients were allocated to 1 of 3 intervention groups (each group n=50) or to the control group (n=50). All groups received an exit interview which involved completing a questionnaire. Patients in the control group (A) received only the exit interview. Patients in group B received a standard regimen of social support counselling in which they were encouraged to attend the follow up appointment with a significant other; those in group C received social support counselling and a reminder postcard sent 1 week before the follow up appointment; and those in group D received social support counselling, a reminder postcard, and a reminder telephone call to a designated significant other 3–5 days before the follow up appointment.
Main outcome measure
Percentage of appointments kept.
Main results
The percentage of appointments kept was higher for patients who received social support counselling alone (group B) (84%), social support counselling and a reminder postcard (group C) (88%), and social support counselling, a reminder postcard, and a reminder telephone call (group D) (88%) compared with control patients who received no social support intervention (group A) (60%) (p<0.001); but did not differ among the 3 intervention groups.
Analysis of women participants showed similar results (83%, 97%, and 93% appointments kept for the 3 intervention groups B, C, and D, respectively compared with 63% in the control group, p<0.001); and no differences among the 3 intervention groups. For men, no differences in appointment keeping were found for the 3 intervention groups combined (B, C, D) (87%, 67%, and 67%, respectively) compared with the control group (55%). Men who received an intervention of social support alone (group B) had higher appointment keeping than men in the control group (p<0.05).
Conclusions
An intervention of social support counselling alone; social support counselling and a reminder postcard; or social support, a reminder postcard, and a reminder telephone call improved appointment keeping among clinic patients with chronic illnesses. Women responded equally well to each of the 3 interventions, but men responded more favourably to an intervention of social support alone.
Commentary
The study by Tanner and Feldman examines the persistent problem of patient non-attendance at outpatient clinics. The results support previous studies which indicate that interventions such as the use of telephone and postal reminders successfully decrease the rates of missed appointments.1 McLean and McLorie found a 31% improvement in outpatient clinic attendance among pre-operative patients who were contacted on the telephone by a nurse who provided social support and advice.2
Tanner and Feldman explore the issue of improving clinic attendance by using various combinations of social support counselling and subsequent telephone and postcard reminders in a sample of patients with chronic illnesses who came from low income backgrounds. This strategy is more commonly used among patients from higher socioeconomic backgrounds.
Although the study sample included men and women, most of the participants were black women >50 years of age. The analysis clearly shows differences in the responses of men and women in terms of outpatient attendance. Women responded to all of the interventions, whereas men had lower attendance when postcard and telephone reminders were added to social support counselling.
Social support counselling appears to be a realistic, feasible, and inexpensive intervention which can increase outpatient clinic attendance in both men and women. A cost benefit analysis would be a useful adjunct to this study, as would a further exploration of sex differences in response to postcard and telephone reminders.
Patient non-attendance at outpatient clinics is clearly an inefficient use of healthcare resources. The results of this study emphasise the importance of exploring reasons for non-attendance at outpatient clinics and provides nursing staff with a possible intervention to improve patient compliance.
Footnotes
Source of funding: not stated.
For article reprint: Dr E K Tanner, College of Nursing, University of Alabama in Huntsville, Huntsville, AL 35899, USA. Fax +1 205 890 6026.