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William M. Macharia, MMED; Gladys Leon, MD; Brian H. Rowe, MD; Barbara J. Stephenson, RN; R. Brian Haynes, MD, PhD

JAMA. 1992;267(13):1813-1817.

Abstract
Objective.
—To determine, by a quantitative meta-analysis of randomized trials, the effectiveness of strategies to improve patient compliance with screening, referral, and clinic appointments for health services that are provided at the time of the visit.

Data Sources.
—Computerized searches of MEDLINE (1966 through 1990) were done using two search strategies: (1) (Patient Compliance OR Adhere* OR Dropout*) AND (Appointment*) AND (Screen* OR Follow* OR Refer*); and (2) (Patient Compliance OR Adhere* OR Dropout*) AND (Attend* OR Screen*) OR (Appointment*). A computerized search of PSYCHLIT was done with the terms Compliance AND Appointment*. In addition, the reference list of each retrieved article was reviewed and relevant citations retrieved.

Study Selection.
—Only randomized trials with quantitative data concerning the effect of interventions to improve attendance at appointments for supervised administration of care were considered for detailed review. Studies of appointment keeping for self-administered treatments or tests were excluded. Two independent reviewers assessed each article for inclusion (, for agreement, 0.66 for MEDLINE; 0.95 for PSYCHLIT) and validity (, 0.62) using a priori criteria. Twenty-three (26%) of 88 relevant articles met all criteria.

Data Extraction.
—Data on study populations, interventions, and outcomes were extracted and analyzed using pooled odds ratios (ORs).

Data Synthesis.
—The average rate of compliance with appointments was 58%. Mailed reminders and telephone prompts were consistently useful in reducing broken appointments (OR, 2.2; 95% confidence interval [Cl], 1.7 to 2.9; and OR, 2.9, Cl, 1.9 to 4.3, respectively). An "orientation statement" (OR, 2.9; Cl, 1.5 to 5.6), "contracting" with patients (OR, 1.9; CI, 1.04 to 3.5), and prompts from physicians (OR, 1.6; Cl, 1.4 to 2.0) showed positive effects as well.

Conclusions.
—In clinic settings where kept appointments can be an accurate measure of patient compliance with health care interventions, broken appointments can be reduced by mail, telephone, or physician reminders; orienting patients to the clinic; or contracting with patients.

(JAMA. 1992;267:1813-1817)

Author Affiliations
From the Design, Measurement, and Evaluation Program, McMaster University Faculty of Health Sciences, Hamilton, Ontario. Dr Macharia is now with the Department of Pediatrics, Faculty of Medicine, University of Nairobi, Kenya; Dr Leon is now with the Department of Dermatology, Faculty of Medicine, National Autonomous University of Mexico, Mexico, DF; Dr Rowe is now with the Department of Family Practice, North Eastern Family Medicine Program, University of Ottawa. Ontario: and Ms Stephenson is now with the District Health Council in Hamilton, Ontario.

Footnotes
Reprint requests to McMaster University Medical Center, Room 3H7,1200 Main St W, Hamilton, Ontario, Canada L8N 3Z5 (Dr Haynes).

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