Behaviourally Informed Health Policy in Ireland

Below from Robert Murphy in the Irish Department of Health details the latest in a series of reports and publications on behaviourally-informed health policy in Ireland. Further details including links to papers are available on the following website. 

This paper reports the impact of a collaborative quality improvement project between the Department of Health, the National Treatment Purchase Fund (NTPF), and the Health Service Executive (HSE). It shows that using amended text (SMS) reminder content, informed by behavioural science, reduced DNA rates for outpatient hospital appointments by a substantial amount.

A “did not attend” (DNA) occurs when a patient unexpectedly does not attend an outpatient hospital appointment. This means that hospital staff expected the patient to attend but the patient did not attend and did not signal in advance that they would not attend. International research shows that DNAs for hospital outpatient appointments can lead to the inefficient use of staff time, worse care for patients, and increase waiting times for patients.

Sending a text (SMS) reminder to patients a few days in advance of appoints has been found to reduce DNA rates. International evidence suggests the effectiveness of these reminders at reducing DNA rates can be further enhanced by applying findings from behavioural science to enhance the content of SMS reminder messages. The quality improvement project sought to identify the best performing SMS reminder for Ireland.

We used a randomised control trial (RCT) to test the impact of four re-designed SMS appointment reminders (interventions) against an existing SMS reminder (control) on patient DNA rates in Naas General Hospital.

Previous international research shows that the most common reason reported by patients for not attending is that they forgot. All interventions aimed to help the patient remember better or to improve their recall.

 Intervention 1 (Recall I) included two design elements reported to increase engagement, namely personalisation and reciprocity. It also included the day of the appointment in words to help with recall.

All other interventions included these three design elements of Intervention 1 along with additional design features. Intervention 2 (Recall II) additionally included the name of the consultant and clinic name on the basis that this might help patients to remember their appointment.

Another commonly reported reason for not attending is that a patient felt the appointment appeared to have no benefit. Therefore, Intervention 3 additionally stated the importance of attendance for health (Recall II + Importance for health). Some previous international trials show an effect on DNAs of including the cost to hospitals of non-attendance, so Intervention 4 included text on the avoided loss if patients who cannot attend signal this in advance (Recall II + Avoided loss to patients and staff).

We found that the redesigned SMS of Intervention 2 (Recall II) is the best performing reminder. It reduced DNA rates by 12.7% compared to the control reminder. This small change to the content of the reminder resulted in one in eight non-attendees changing their behaviour. The intervention is highly cost effective. Applying the findings to 2022 national data suggests DNAs could be reduced by about 61,000 by using a better worded text reminder. 

Commenting on the publication, Minister for Health, Stephen Donnelly said:

“I welcome the findings of this impact evaluation. The paper identifies the best performing SMS reminder, which based on findings from behavioural science makes it easier to remember the appointment. Widespread adoption of the recommended SMS templates as part of national practice will substantially reduce non-attendance and improve hospital productivity.”

A special thank you to my co-authors Liam Delaney Deirdre A. Robertson Helen Ryan Alex Wood Alison Green Glenn Murphy and to my colleagues in the NTPF (especially Alison Green, Glenn Murphy, and Elva Powell) and the HSE (in particular Jenny O’Rourke) who made this project possible.