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Published in final edited form as: Am J Ophthalmol. 2024 Feb 23;263:93–98. doi: 10.1016/j.ajo.2024.02.026

Effect of a patient portal reminder message after no-show on appointment reattendance in ophthalmology: a randomized clinical trial

Sarah Atta 1,2, Richard B Brown 1, Lauren M Wasser 1,3, Natasha Mayer 1, Julie Cassidy 1, Peggy J Liu 4, Andrew M Williams 1
PMCID: PMC11162931  NIHMSID: NIHMS1971674  PMID: 38403099

Abstract

Purpose:

To assess the efficacy of electronic health record (EHR) messaging for re-engaging patients with ophthalmology care after a missed appointment.

Design:

Prospective, randomized clinical trial.

Methods:

The study setting was an academic ophthalmology department. The patient population comprised return patients age 18 years or older with an appointment “no show,” or missed appointment. Over two phases of recruitment, 362 patients with an active patient portal in the EHR were selected consecutively each business day. Patients were randomized using a web-based tool to receive a reminder to reschedule via a standard mailed letter only (control) or the mailed letter plus an electronic message through the electronic record within one business day of the missed appointment (intervention). Reengagement with eye care was defined as attendance of a rescheduled appointment within 30 days of the no-show visit. Patient charts were reviewed for demographic and clinical data.

Results:

The average age of recruited patients was 59.9 years, just under half of the sample was male (42.5%, 154/362), and most patients were White (56.9%, 206/362) or Black (36.2%, 131/362). Patients were most commonly recruited from the retina service (39.2%, 142/362) followed by the glaucoma service (29.3%, 106/362). Many patients in this study had previous no-show appointments, with an average no-show rate of 18.8% out of all scheduled visits across our health system. In total, 22.2% (42/189) of patients in the intervention group attended a follow-up appointment within 30 days of their no-show visit compared to 11.6% (20/173) of the control group (OR, 2.186; 95% CI, 1.225-3.898; p=0.008). When including only the 74 patients in the intervention group who read the intervention message in the patient portal, 28.4% (21/74) attended a follow-up compared to 11.6% (20/173) of the control group (p=0.001).

Conclusions:

EHR-based reminder messages sent within a business day of a missed appointment may promote re-engagement in ophthalmology care after appointment no-show.

Table of Contents Statement

In this prospective, randomized trial, a reminder message was sent after a “no-show” visit to promote patient re-engagement with eye care. The reminder message was sent via electronic health record within one business day of no-show to prompt rescheduling. After 30 days, a greater proportion of patients from intervention group attended a rescheduled visit (22.2%, 42/189) compared to a control group (11.6%, 20/173), with an odds ratio (OR) of 2.186 (95% CI: 1.225-3.898, p=0.008).

Introduction

Missed appointments, or “no-shows,” are a pervasive issue in healthcare settings.1 Globally, nearly one-quarter of scheduled appointments are missed,2 leading to increased costs, inefficient use of clinic resources, diagnostic delays, and missed opportunities to avoid preventable illness.1-3 Patient engagement with medical care is crucial for disease prevention, appropriate screening, and management; and those not attending important screening or follow-up exams are at elevated risk for undesirable outcomes.3 In ophthalmology, routine appointments are necessary for the prevention and management of chronic eye diseases.4-6 Unfortunately, rates of patient attendance to these appointments are suboptimal,4,7 especially in glaucoma and retina clinics,8 and appointment no-show is predictive of loss to follow-up.9

Patient forgetfulness is an often-cited reason for missing scheduled appointments,10 and reminder messages can promote patient engagement.11 Compared to control groups, patients who receive a reminder message are 10-38% less likely to miss a scheduled visit.12,13 A variety of communication methods have been trialed for such reminders, including mail-based messages, phone calls, voice mails, text messages, and messages through the electronic health record (EHR).10,14-23 These reminder messages offer an effective method to improve patient accessibility and convenience, while improving patient follow-up and outcomes.10,13,18,21,24-34

Reminder messages sent through patient portals or the EHR have the advantage of increased security over text messages due to password and encryption protection,14 and EHR-based reminders have resulted in higher rates of scheduling and attending well-child visits as well as receiving the COVID-19 vaccine.23 Notably, studies investigating reminder messages have examined the effect of reminder messages sent prior to appointment occurrence, while few studies have examined these methods for re-engaging patients following a missed appointment. Further, none of these studies have specifically assessed the effectiveness of EHR messaging as a means for re-engagement with ophthalmology care after no-show.

Given the suboptimal rates of follow-up adherence in ophthalmology clinics and the importance of timely follow-up for chronic eye diseases, further assessment of effective patient communication methods to promote engagement with medical care is needed. The purpose of this randomized clinical trial is to assess whether EHR-based messaging promotes re-engagement with follow-up within 30 days after a no-show appointment among patients with chronic eye diseases.

Methods

This prospective, randomized clinical trial was approved by the Quality Review Committee at the University of Pittsburgh Medical Center (UPMC). This work adhered to the tenets of the Declaration of Helsinki and complied with the Health Insurance Portability and Accountability Act of 1996.

The study consisted of two phases: Phase 1 was an initial “pilot” phase (February 13 through March 28, 2023), and Phase 2 was a subsequent “expanded” phase aimed at increasing our study’s sample size (October 16, 2023 through November 16, 2023). The methods were nearly identical across the two phases, with only minor differences that are described subsequently.

All patients included in the study sample were adult patients (18 years or older) who were scheduled to return for follow-up at the UPMC Vision Institute after missing a scheduled appointment without cancellation or prior contact with the clinic (“no show”) over the study period. Phase 1 included patients with appointments with the retina or glaucoma services, and Phase 2 was expanded to include all services (retina, glaucoma, comprehensive, cornea, neuro-ophthalmology, oculoplastics, and strabismus). We excluded new patient visits as well as patients who did not have an active patient portal (termed “MyUPMC”) in our institution’s EHR (Epic Systems, Verona, WI).

For our power analysis, we assumed a baseline reattendance rate after no-show of 50% and a 75% reattendance rate with intervention, thus requiring a sample size of 58 patients in each arm (power = 80%, α = 5%).35 These baseline reattendance rates were based on a literature review of prior studies that have assessed appointment attendance after reminder messages.36-38 The Phase 1 study period continued until at least 58 patients were assigned to each group. The Phase 2 study period was continued for a one-month period (October 16-November 16, 2023). Patients who fit the inclusion criteria were identified at the end of each business day (Monday-Friday) and randomized into the control group or the intervention group. An online software tool was used for patient randomization.39

The control group received our institution’s present standard protocol following appointment no-show, which involves mailing a standard letter to the patient’s home address through the United States Postal Service within two weeks of the missed visit that recommends calling to reschedule. In addition to the standard protocol, the intervention group in our study also received a patient portal message through MyUPMC requesting that they reschedule their missed appointment. This electronic message was designed from prior literature and sent the following business day.36,37 In Phase 1, the message read: “UPMC Eye Center: Our records show that you recently missed an eye appointment. Routine eye exams are important for screening and monitoring chronic eye diseases. To reschedule your appointment, please call: (412) 647-2200.” The message was updated for Phase 2 to include our rebranded department name and to clarify that patients could reply to the message to reschedule: “UPMC Vision Institute: Our records show that you recently missed an eye appointment. Routine eye exams are important for screening and monitoring chronic eye diseases. To reschedule your appointment, please call: (412) 647-2200, or reply directly to this message.” Patients could call the listed number to reschedule, or they could reschedule by replying to the portal message directly.

One month after each appointment date, the EHR was reviewed to document whether the patient accomplished rescheduled follow-up within 30 days of the missed appointment (primary outcome). Additional documented factors included whether the patient “read” the EHR message and whether they rescheduled their appointment (secondary outcome). Each patient’s chart was also reviewed for data on the type of appointment missed (routine return, procedural, post-op), demographic information (age, race, gender), overall no-show rate within our health system, appointment burden within the prior 30 days, and medical comorbidities (diabetes, hypertension).

Statistical analysis was conducted to assess for adequacy of randomization to each group as well as effectiveness of the intervention in promoting follow-up as compared to the control group. Two-tailed chi-squared tests, t-tests, and binary logistic regression were calculated using IBM SPSS Statistics software (version 29.0.2.0 (20)).

Results

Baseline characteristics were similar across the two study phases (i.e., demographics, appointment type, no-show rate, appointment burden, and medical comorbidities were all similar between the two study phases; see Supplemental Table 1 and Supplemental Table 2). Therefore, patients from both phases were included together for final analysis, as summarized in Table 1. For completeness of reporting, the Supplemental Materials also contain baseline characteristics and results reported separately for the two study phases.

Table 1:

Baseline characteristics of control and intervention groups, showing adequate randomization with no significant differences between groups.

Alla
(n=362)		 Control Group
(n=173)		 Intervention Group
(n=189)		 p=value
Demographics
 Age (years, mean±SD) 59.9±16.5 59.1±17.0 60.7±15.9 p=0.356
 Gender (Male, %) 154 (42.5%) 71 (41.0%) 83 (43.9%) p=0.581
 Race p=0.349
  White 206 (56.9%) 91 (52.6%) 115 (60.8%)
  Black 131 (36.2%) 67 (38.7%) 64 (33.9%)
  Asian 18 (5.0%) 10 (5.8%) 8 (4.2%)
  Other 4 (1.1%) 3 (1.7%) 1 (0.5%)
Specialty Service p=0.143
 Retina 142 (39.2%) 61 (35.3%) 81 (42.9%)
 Glaucoma 106 (29.3%) 55 (31.8%) 51 (27.0%)
 Comprehensive 58 (16.0%) 28 (16.2%) 30 (15.9%)
 Cornea 33 (9.1%) 21 (12.1%) 12 (6.3%)
 Oculoplastics 13 (3.6%) 4 (2.3%) 9 (4.8%)
 Neuro-ophthalmology 8 (2.2%) 3 (1.7%) 5 (2.6%)
 Strabismus 2 (0.6%) 1 (0.6%) 1 (0.5%)
Appointment Type p=0.629
 Return 288 (79.6%) 140 (80.9%) 148 (78.3%)
 Procedure 37 (10.2%) 14 (8.1%) 23 (12.2%)
 Post-Operative 33 (9.1%) 17 (9.8%) 16 (8.5%)
 Testing only 4 (1.1%) 2 (1.2%) 2 (1.1%)
Baseline No-Show Rate (%) 18.8±12.7 19.7±12.4 18.1±13.0 p=0.225
Appointment Burden: appointments in prior 30 days (median, IQR) 1 (3) 2 (3) 1 (3)
Duration of Follow up with our Department before No-Show Visit (months) 80.8±146.8 82.5±131.3 79.3±160.1 p=0.835
Medical Comorbidities
 Diabetes 145 (40.1%) 74 (42.8%) 71 (37.6%) p=0.291
 Hypertension 194 (53.6%) 90 (52.0%) 104 (55.0%) p=0.607
Open in a new tab

SD: standard deviation; IQR: interquartile range

a

This table summarizes the pooled data across phases 1 and 2 (the Supplemental Material contains tables showing the similar baseline characteristics of control and intervention groups for phase 1 and phase 2 separately).

Across both study phases, 362 patients with an appointment no-show were included, with 173 patients randomized to the control group and 189 patients to the intervention group. The average age of recruited patients was 59.9 years, just under half of the sample was male (42.5%, 154/362), and most patients were White (56.9%, 206/362) or Black (36.2%, 131/362). Most patients had a long history of established care with our practice, with an average follow-up duration of 80.8 months before the no-show visit. Patients were most commonly recruited from the retina service (39.2%, 142/362) followed by the glaucoma service (29.3%, 106/362). The missed visit was most commonly a regular return clinic appointment (79.6%, 288/362), and less commonly a procedure visit (10.2%, 37/362) or a post-operative check (9.1%, 33/362). Many patients had diabetes (40.1%, 145/362) or hypertension (53.6%, 194/362) as medical comorbidities. Notably, many patients in this study had previous no-show appointments; our study population had an average no-show rate of 18.8% out of all scheduled visits across our health system (Table 1).

In total, 22.2% (42/189) of patients in the intervention group attended a follow-up appointment within 30 days of their no-show visit compared to 11.6% (20/173) of the control group (p=0.007) (Table 2). When including only the 74 patients in the intervention group who read the intervention message in the patient portal, 28.4% (21/74) attended a follow-up compared to 11.6% (20/173) of the control group (p=0.001) (Table 2), indicating that patients who received and read the portal message were more than twice as likely to re-establish follow up within 30 days than patients who did not receive the message.

Table 2:

Thirty-day follow-up outcomes after a patient portal message intervention for patients with appointment no-show compared to a control group.

Control Group
(n=173)		 Intervention Group
(n=189)		 p-valuea
Follow-up rescheduled within 30 days of no-show 39/173 (22.5%) 70/189 (37.0%) p=0.003
Including only those in the intervention group who read the message 37/74 (50.0%) p<0.001
Appointment attended within 30 days of no-show 20/173 (11.6%) 42/189 (22.2%) p=0.007
Including only those in the intervention group who read the message 21/74 (28.4%) p=0.001
Open in a new tab
a

Given similar methods and baseline characteristics across phases, this table summarizes the pooled results across phases 1 and 2.

Among those patients who re-established care within the 30-day window (i.e., re-scheduled and attended the re-scheduled visit), the average number of days until the return visit was 14 (SD=7), with a range from 1 to 28 days. There was no statistically significant difference in the number of days between no-show and attended appointment between the intervention and control groups (mean of 14 days for both, p=0.89); instead, our key finding is that the intervention led to a statistically significant increase in the likelihood that no-show patients did re-establish care (p=0.007).

A binary logistic regression showed that patients in the intervention group were twice as likely to reschedule follow-up within 30 days of the missed appointment (OR, 2.021; 95% CI, 1.272-3.211; p=0.003). Moreover, patients were twice as likely to attend the follow-up appointment within 30 days of the initial no-show visit when comparing the intervention group to the control group (OR, 2.186; 95% CI, 1.225-3.898; p=0.008).

Discussion

In this prospective, randomized clinical trial, we found that an EHR-based patient portal message within one business day after appointment no-show improved appointment reengagement by approximately two-fold compared to a standard mailed letter alone. Specifically, 22.2% (42/189) of patients in the reminder group re-established care within 30 days of their no-show visit compared to 11.6% (20/173) of the control group (p=0.007).

Our study is not the first to promote re-engagement with care among ophthalmic patients at risk of loss to follow-up. In 2021, Robbins et al. conducted a quality improvement initiative that contacted glaucoma patients who were lost to follow-up in the preceding six months by phone, and the phone intervention successfully scheduled 28% of reached patients with a future office appointment.9 Our intervention promotes re-engagement with care even earlier by contacting no-show patients within a business day of their missed appointment, and we measured the effect of our reminder intervention using a randomized controlled trial. By contacting patients soon after no-show and engaging them through the EHR patient portal, we were able to reduce the risk of loss to follow-up and to promote successful appointment reattendance within 30 days of the missed visit.

Not all patients in the intervention group who rescheduled their appointment within 30 days had their reminder message indicated as “read” by the system. It is possible that patients read the message preview without physically opening the page, so the system did not register the message as read, but it is also possible that not all patients with active patient portals utilize the messaging center. One possible approach to address the risk of messages being disregarded by patients is to employ interactive or two-way messaging that prompts recipients to respond,14 and offering the opportunity to reschedule an appointment by directly replying to the message may promote engagement with the intervention message.

Patient portal messages through the EHR add to the repertoire of types of reminder messages that can be used to decrease no-show visits, including phone, email, mail, and text reminders.36 Automated patient portal messages after appointment no-show have little cost compared to mailing letters or making telephone calls, and portal messages may serve as a valuable tool to contact patients much sooner after their missed visit than mailed letters or phone calls. Of note, we found that patients with no-show who use the patient portal were younger on average than patients with no-show who do not use the patient portal (59 years vs. 64 years, p=0.017; see Supplemental Material), which may relate to technological literacy and comfort using electronic methods for care management among younger patient populations.18 Thus, we do not suggest that EHR reminders should replace other types of reminder messages for all patients. However, for active patient portal users, automated messages may be an effective reminder with notable benefits, such as minimal cost, automated nature, and ability to be sent immediately after the missed visit.

Our study has some limitations, which we acknowledge and some of which also offer some opportunities for future research. We depended on patients having an active patient portal account in order to be eligible for inclusion in this study, and we were therefore unable to reach the approximately 40% of patients with no-show who did not have an active patient portal account (as detailed in Supplemental Material). The patient population without an active patient portal account may be fundamentally different than the population that engages with their health record online, and a potential difference in these populations may limit the generalizability of our findings to all patients with an ophthalmology appointment no-show. Notably, we chose the patient portal as our messaging platform for two reasons. First, our Institutional Review Board required that we utilize secure messaging to contact patients for this study. Second, EHR-based communication may facilitate ease of appointment rescheduling through direct interaction with the patient portal either by engaging with its scheduling software or by replying directly to the reminder message to reschedule. However, other reminder methods, such as text messages and reminder phone calls, may help to reach patients with no-show more broadly. Future research might examine taking additional steps, such as patient education and helping to set up online patient portals for patients at their appointments. Doing so may allow for an increase in rates of active patient portals, in order to allow for potentially reaching a wider patient population with secure reminder messages.

Another limitation of the study was that, due to sample size considerations associated with moderation analyses,40 we were unable to assess whether the reminder message intervention was differentially effective for addressing no-shows across different disease states and visit types. However, future research with even larger sample sizes (e.g., at least four times the sample size of the present study) might explore whether intervention effectiveness differs by type of chronic eye disease (glaucoma, diabetic retinopathy, age-related macular degeneration, etc.) or type of scheduled visit (routine clinic visit, injection-only visit, post-operative check, etc.). Finally, we did not explore the personalization of re-engagement messages, which might better connect with patients than our standard EHR reminder text about noticing that the patient missed an appointment and emphasizing the importance of follow up.

In conclusion, our randomized study offers contributions towards addressing the problematic issue of loss to follow-up in ophthalmology: a standard EHR-based reminder message sent via a patient portal within one business day after an appointment no-show doubled the likelihood of patient re-engagement with care within 30 days of missed appointment.

Supplementary Material

1

Acknowledgements:

Funding/Support: This work was supported by the Henry L. Hillman Foundation, NIH CORE Grant P30 EY08098, the Eye and Ear Foundation of Pittsburgh, and from an unrestricted grant from Research to Prevent Blindness to the Department of Ophthalmology at the University of Pittsburgh. The funding organizations had no role in the design or conduct of this research.

Footnotes

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Financial Disclosures: No financial disclosures.

Supplemental Material available at AJO.com.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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