By Author
  By Title
  By Keywords

July 2019, Volume 69, Issue 7

Research Article

Efficacy of Mobile Phone SMS Reminder for Increasing the Patient Follow-Up Consultation Visits in OPD Clinics

Ayesha Sabah  ( Department of Health and Hospital Management, Institute of Business Management,Karachi, Pakistan )
Asif Khaliq  ( Department of Paediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan )
Ebad ur Rehman Ghouri  ( Department of Physical Therapy, Ziauddin University, Karachi, Pakistan )

Abstract

Objective: To measure the effect of mobile phone Short Message Service reminder on the followup rate among patients visiting outpatient clinics.
Methods: The quasi-experimental study was conducted from September to November 2016 in three outpatient clinics of Saima
General Hospital, Karachi. The intervention used was consultation  follow upreminderuing Short Message Service. SPSS 1 9 was used for data analysis .
Results: Of the 606 subjects, 291(48%) visited the clinics in the pre intervention phase, and 315(52%) in the post-intervention
phase. Of the former, 200(70%) patients adhered to the follow-up, while post-intervention adherence went up to 256(81%) (p<0.05).
Conclusion: Using Short Message Service for reminders increased the follow-up rate.
Keywords: Mobile phone, SMS, Profitability, Clinics, Patient compliance. (JPMA 69: 964; 2019)

Introduction

The healthcare sector is constantly facing numerous issues and the situation is getting alarming throughout the world.1 Poor practices, lack of communication and inadequate e-health application in the delivery of healthcare services are some of the emerging issues confronted by a healthcare institute. 2 Simulation is needed to manage current and future healthcare issues which can lead towards successful healthcare delivery. 3 The key responsibility of health managers is to bridge the relationship with patient and his family by discussing disease nature and treatment options by providing cost effective care and by advising self-care and follow-up consultation visits. 4 The success of any treatment is largely based on patient compliance. Poor treatment compliance is a major treatment failure constraint. 5 The treatment adherence for chronic disease is around 40-50%, while those of acute diseases is around 70-80%.6 Likewise, loss of follow up  consultation is a leading source of healthcare delivery ineffectiveness. The loss to follow-up occurs because of patient forgetfulness that causes delayed diagnosis and thereby compromise treatment efficacy. 7 In the modern era, intensified use of internet and cell phones has opened novel avenues for delivering healthcare services. 8,9The integration of cell phone technology into the healthcare delivery system is now used as a tool to boost behavioural change. 10Cell phone has been suggested as a method to improve healthcare service delivery. 11 Distinctive communication reminders methods, i.e., Shor t Message Service (SMS) and Multimedia Message Service (MMS), act as an important delivery standard for health care appointment reminders. 12 Moreover, the effective use of cell phone SMS has enhanced treatment adherence among patients requiring chronic disease management . 13 The current study was planned to assess the proportion of loss to consultation follow-up and to measure the effectiveness of SMS-reminder services for improving consultation follow-up among patients visiting a private health facility in an urban centre.

Patients and Methods

The quasi-experimental study was conducted from September to November 2016 in three outpatient clinics of Saima General Hospital, Karachi. After approval was obtained from Management Research Cell (MRC) of the Department of Health and Hospital Management,  Institute of Business Management, Karachi, the study was conducted in pre-intervention, intervention and post-intervention phases. In the first phase, multiple operational activities were designed, like content, language, timing and the designated person for sending SMSs. It was decided that 3 SMSs would be sent to each patient for follow-up consultation reminder. The first SMS was a 'Thank You' message for availing the service. However, the other 2 SMSs were solely reminders and were sent a day before and on the day of consultation. Again, the 'Thank You' message was to be sent to all patients who adhered to the follow-up. The same cycle continued for next appointment. The SMS language was kept Roman English, i.e. the text was in English but the language content was Urdu. In order to execute the study, all new and follow-up patients who visited the outpatient department (OPD) for physical therapy, antenatal consultation or chronic diseases, like diabetes, hypertension and osteoporosis etc., were contacted. The patients were approached using consecutive sampling technique after physician / physical therapist consultation and they were informed verbally briefed about the study. Before taking any information from the patients or their caregivers, a pledge to keep their information confidential was specified and they were also informed regarding their right to withdraw from the study. After the briefing, all patients who needed consultation followup were asked to provide their cell phone numbers. Those who did not have a cell phone or were not able to read Roman English were excluded. Also, patients with acute medical conditions, i.e., fever, cold, cough, flu, diarrhoea, etc. or those who were referred to any other healthcare facility or any other doctor were excluded. All the patients or their caregivers approached knew their contact numbers and affirmed that they were able to read the SMS in Roman English, which is Urdu written with English alphabets? Patients were approached and data was collected over a month. During this period, data regarding the number of new patients, number of follow-up patients, and their medical condition was also collected. Moreover, information regarding need for follow-up consultation visit and follow-up consultation date were also noted. Data was initially noted in a logregister, and was then transferred onto an Excel sheet. After planning and organising all the tasks and activities, the interventional phase was initiated. In this phase, 'Thank You' SMS was sent to all the subjects after their consultation visit, and 2 'Reminder SMS' were also sent to all of them a day before their consultation and on the day of their consultation. This activity was carried out for a month as well. During this phase, all the new as well as follow-up patients were approached in similar fashion as they were approached during the pre-intervention phase. All the information gathered during this phase was also collected in log-registers and Excel sheets. During the post-intervention phase, the feasibility, affordability and efficacy of sending SMS-reminder was assessed. The post-intervention phase was almost simultaneous with the intervention phase, because in this phase all the data received daily was entered into SPSS 19 by another researcher so that the inconsistencies in data entry could be minimised. Moreover, in the post-intervention phase, statistical analysis of all the pre-intervention and intervention phase data was also performed. Data was presented descriptively in terms of frequencies and percentages. Inferential analysis of the data was carried out by using non-parametric Wilcoxon test.

Result

Of the 606 subjects, 291(48%) visited the clinics in the pre-intervention phase, and 315(52%) in the postintervention phase (Figure).



In the pre-intervention phase, 285(98%) needed follow-up consultation, while the corresponding number in the post-intervention phase was 312(99%). From among the former, 200(70%) patients attended follow-up consultation, but postintervention the number increased to 256(81.2%) (p<0.001).  During the pre-intervention phase, 56, 149 and 86 patients visited in ANC, Physiotherapy and chronic illness OPD respectively. Out of which 56, 143 and 83 patients of respective clinics were advised for follow-up visit but 48 (85.7%), 97(65.1%) and 52 (60.4%) patients of ANC, Physiotherapy and chronic disease OPD adhered to follow-up. However, during the intervention phase, 315 patients visited of which 36 patients were of ANC, 75 patients were of physiotherapy and rest of the patients were of chronic illness. Among the ANC patients, all the patients were asked for follow-up consultation, and all have adhered to the follow-up consultation as well. While among the physiotherapy and chronic illness patients, 56 (74.6%) and 160 (80.8%) adhered to follow-up consultation respectively. Thus, a significant difference in the follow-up visit rate was observed in physiotherapy and chronic illness OPD clinics after SMS reminder intervention. i.e., p<0.001, while no difference was observed in the ANC clinic follow-up before and after intervention. The mean rank at pre-intervention phase was 1.31±0.46 and the mean rank during post-intervention phase was 1.17±0.39.

Discussion

The setting selected for the current study was actually suffering from loss to follow-up consultation as the adherence rate at baseline was 70%. A study conducted in 2011 also showed similar mismatch. 14 Healthcare organisations are continuously testing and implementing various strategies that can possibly reduce loss to follow-up. 15 In this study, mobile phone SMS reminder was used as an intervention for reducing nonattendance of patients in OPD consulting clinics in line with the success reported in this regard by numerous studies. 16,17 The consultation follow-up rates in the current study were high among the women visiting antenatal clinics. Likewise, a qualitative study conducted in different African countries indicated that antenatal follow-up was a source of motivation for pregnant women. 18 Implementation of mobile phone SMS reminder increased overall follow-up consultation visits from 70% to 81% in the current study (p<0.001) which depicts that SMS reminder is an effective tool for enhancing patient influx. Another study on the mobile intervention for smoking cessation showed benefits of the intervention on longterm outcome. 19 The results of the current study has provided very promising evidence that mobile phone SMS reminders is an effective tool for improving follow-up consultation in private-sector OPD clinics. Despite having positive findings, there are many issues that were not considered during this study and these were of time constraints, patient literacy, mobile phone network issues, cell phone charging, snatching and reporting to healthcare centres and sudden change of patient’s number. Many socio-cultural factors like physician relation, cost of consultation, treatment outcome, etc. were not considered. Moreover, no sample size was calculated and the data was collected by primary researcher because of lack of financial and human resources. Similar studies on a large scale in routine clinic operations are recommended.

Conclusion

Mobile phone SMS reminder service were found to be an effective intervention tool as it significantly improved adherence rate of patients in all the clinics targeted.

Acknowledgement: We would like to thank Dr. Asima Faisal (Head of the Department, MBA-Health and Hospital program), all members of Institute of Business Management, Management Research Cell and also to Ms. Mehak Qamar Somoro and her parents for granting us permission in their hospital for data collection and through facilitation.
Disclaimer: The study was part of an MBA dissertation.
Conflicts of Interest: None.
Source of Funding: None.

References

1. Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH. Improving the quality of health care for chronic conditions. Qual Saf Health Care 2004; 13: 299-305.
2. Thomson F, Milne H, Hayward J. Understanding the impact of information technology on interactions between patients and healthcare professionals: the INTERACT-IT study. Health Serv J. 2012(Suppl):P46. [not found]
3. Sanchez SM, Ferrin DM, Ogazon T, Sepúlveda JA, Ward TJ. Emerging issues in healthcare simulation. In: Proceedings of the
32nd conference on Winter simulation 2000 (pp. 1999-2003). Society for Computer Simulation International.
4. Wagner EH. The role of patient care teams in chronic disease management. BMJ 2000; 320: 569-72.
5. Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther 2001; 26: 331-42.
6. Jin J, Sklar GE, Oh VM, Li SC. Factors affecting therapeutic compliance: A review from the patient's perspective. Ther Clin Risk Manag 2008; 4: 269-86.
7. Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R, Car J.Mobile phone messaging reminders for attendance at scheduled healthcare appointments. Cochrane Database Syst Rev 2013; (12): CD007458.
8. Luxton DD, McCann RA, Bush NE, Mishkind MC, Reger GM. mHealth for mental health: Integrating smartphone technology in behavioral healthcare. Professional Psychology: Res Pract 2011; 42: 505-12.
9. Ybarra ML, Bull SS. Current trends in Internet-and cell phone-based HIV prevention and intervention programs. Curr HIV/AIDS Rep 2007; 4: 201-7.
10. Gurman TA, Rubin SE, Roess AA. Effectiveness of mHealth behavior change communication interventions in developing countries: a systematic review of the literature. J Health Commun 2012; 17: 82- 104.
11. Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, et. al., Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet 2010; 376: 1838-45.
12. Car J, Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R. Mobile phone messaging reminders for attendance at scheduled healthcare appointments. Cochrane Database Syst Rev 2013; (12): CD007458
13. Mukund Bahadur KC, Murray PJ. Cell phone short messaging service (SMS) for HIV/AIDS in South Africa: a literature review. Stud Health Technol Inform 2010; 160: 530-4.
14. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood) 2001; 20: 64-78.
15. Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, et al. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet 2010; 376: 1838-45.
16. Koshy E, Car J, Majeed A. Effectiveness of mobile-phone short message service (SMS) reminders for ophthalmology outpatient appointments: observational study. BMC Ophthalmol 2008; 8: 9.
17. Pop-Eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, De Walque D, et al. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011; 25: 825-34
18. Pell C, Meñaca A, Were F, Afrah NA, Chatio S, Manda-Taylor L, et al. Factors affecting antenatal care attendance: results from qualitative studies in Ghana, Kenya and Malawi. PloS one 2013; 8: e53747.
19. Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile phone?based interventions for smoking cessation. Cochrane Database Syst Rev 2016; 4: CD006611.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: