Using behaviourally-informed reminders cuts missed hospital appointments by more than a third

Our approach – which resulted in public health and productivity benefits of almost $120,000 – can be used to optimise reminders in other customer service contexts.

While many government services use SMS texts to remind customers about their appointment times, this does not necessarily lead to more people showing up. That’s where behavioural insights can help. Behavioural insights can ensure reminders use effective, evidence-based principles to support changed behaviour.

In 2016, we reduced no-shows in Sydney's St Vincent's hospital by 19%, using timely reminders and a behaviourally-informed message about the cost of missed appointments.

In 2019, Central Coast Local Health District scaled this behavioural intervention in the Central Coast, NSW.

We found that similar reminders reduced no-shows at two hospitals by almost 34%, saving $119,000 in eight months at just four clinics. The reminders are now being implemented across 800 clinics.

The challenge

For patients who don’t need to be admitted to hospital, outpatient clinics will schedule appointments to assess, diagnose and treat patients who require specialised care. When patients don’t show up to these appointments, they miss out on healthcare.

These ‘no-shows’ also cause inefficiency and lost funding for the clinics – each missed appointment costs the hospital between $125 and $800.

What we did

In 2015, the UK’s Behavioural Insights Team found that SMS reminders which highlight the specific cost of a missed appointment was particularly effective in reducing no-shows, by 32%.

In 2016, we translated these findings into NSW, partnering with St Vincent’s Hospital in Sydney. We found that sending a SMS reminder with the specific cost of the missed appointment to the hospital was highly effective: ‘If you attend, the hospital will not lose the $125 we lose when a patient does not turn up.’

Our messages reduced no-shows by 19% and saved the hospital $200,000. Our results suggest that people care about the specific cost of their no show, especially when they know they are preventing a loss to the hospital and other patients. This is known as ‘loss aversion’ – in many contexts, people prefer to avoid losses, rather than focusing on potential gains. In this case, people care about who bears the cost of their no show, but are more motivated by being able to play a part in preventing the loss. Our trial was featured in the NSW Ministry of Health’s Outpatients Services Framework.

In 2019, we partnered with the Central Coast Local Health District (CCLHD) to scale (i.e. implement more widely) our behaviourally-informed reminders in Gosford and Wyong hospitals. We supported CCLHD to analyse their clinics’ data, select trial sites, co-design the reminder SMS, implement the messages, and evaluate their impact.

In these messages, we updated the average cost of a missed appointment at Gosford and Wyong Hospitals. Again, the message used loss aversion to highlight the loss that could be avoided, adjusted to the specific local hospital: “If you attend, the hospital will not lose the $215 we lose when a patient does not turn up.”

We co-designed the messaging with hospital staff, district staff and consumer panel representatives (patients). We also adapted the wording to local factors that could be influencing attendance. This included reminding patients to allow travel time, bring their test results, and highlighting the personal loss to be avoided (avoiding a waitlist).

What we found: 34% reduction in missed appointments

We ran a pre-post study for four months (i.e. we tested outcomes before and after we introduced our intervention). Reminders were sent seven days and 24 hours in advance of appointments for the Ear, Nose, Throat, and Orthopaedic outpatients at Gosford Hospital, and the Cardiac and Orthopaedic outpatients at Wyong Hospital. A total of 5,447 SMS reminders were sent. As is the case in all pre-post studies, it was possible that other initiatives could influence attendance during this time. To mitigate this, CCLHD chose clinics that were not undergoing any organisational or other changes during the study period. 

At the end of the study, we ran a logistic regression analysis on the proportion of missed appointments. We found that the proportion of missed appointments when the intervention was in place from March to June 2019 was 4.3 percentage points lower than March to June 2018 (p < .001). This was a 33.7% reduction in missed appointments.

Public health and productivity benefits of $119,606 

CCLHD’s accounts team calculated the productivity benefits of the BI reminders to be $119,606, across only four clinics and over only eight months in the district.

Since the study ended in June 2019, CCLHD has continued to use these SMS reminders at the four clinics. Between July 2019 to February 2020, CCLHD have experienced a 37.7% reduction in missed appointments at these clinics compared to July 2018 to February 2019.

There are many other benefits to reducing missed appointments with BI reminders.

• Patients are still free to choose if they attend, but their increased likelihood to attend provides them with timely healthcare
• Reduced appoints can potentially reduce the risk of other health issues arising
• CCLHD also reported that the study improved clinic efficiency. 

As a result of the initial and ongoing success of the intervention, and benefits to both hospitals, clinicians and patients, CCLHD are now committed to scaling up this intervention across the district’s 800 clinics.

How can you use this in your work?

• Send timely reminders: our behavioural insights can optimise SMS reminders for other health services, including GP appointments. Similarly, reminding customers what they lose by not showing up to appointments can be effective in other areas, such as service centres, parent-teacher interviews, license tests, and more. In fact, we’ve previously shown that SMS reminders can reduce the proportion of people not showing up to court for domestic violence attendance by 23% (see pages 14-17 (PDF 2.35MB)).
• Use loss frame messages: highlighting what customers stand to lose if they don’t turn up to appointments can improve customer retention across many government services and programs. Simply calculate the cost of the no-show appointment and tweak it to your local setting. For example, if you deliver community services, you could fill in gaps in bold text. “We are expecting you at your government service at XXX date and time. If you attend, the community will not lose the $XXX we lose when a customer does not turn up.”
• Encourage take-up of other opportunities (such as COVID testing): The Behavioural Insights Unit used behaviourally informed SMS to increase customers’ intentions to get another COVID-19 test. Timely reminders have proved effective in increasing take-up of the flu vaccine in the USA, by 11%.
• Consider and test whether insights on SMS reminders may, or may not, apply to QR check-ins, within app notifications and other technology: behavioural scientists are exploring whether reminders using other technologies might also have a positive impact on behaviours like turning up to hospital appointments. Testing is essential to prove impact.

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More information

For further information about how our reminder SMS study is being implemented, contact CCLHD directly. 

For further information about our study design and analysis, you can also contact the Behavioural Insights Unit.

Published: 6 April 2021