Have telephone reminders been a good way to reduce non-attendance rates for endoscopy during the COVID-19 pandemic?

Dear Editor,

Since its outbreak in January 2020, COVID-19 has affected health-care systems all over the world, constraining all activities and efforts to treatment in order to contain the spread of the disease.

During the first wave, all non-urgent outpatient endoscopic procedures were cancelled, causing longer waiting lists and increasing diagnostic delays [1], [2], [3]. During the later waves, it became necessary to find an alternative to closing endoscopy units’ activity, which would guarantee a safe access for patients and a safe work environment for healthcare providers. Solely requiring negative nasopharyngeal swabs for SARS-CoV2 to all outpatients was soon considered a non-viable option.

New scheduling strategies would require more efficient planning, able to reduce patients’ non-attendance [4], a well-known issue in virtually all fields of clinical practice, causing waste of resources and further lengthening waiting lists.

Focusing on the outpatient endoscopic setting during the pre-COVID era, several studies have documented an absenteeism rate ranging from 12% to 24% [5], [6], [7]. Procedure overbooking and telephone reminders have been proposed as possible solutions. In particular, the latter consists in calling or sending patients a text message a few days before the procedure in order to remind them about it and allow them to confirm their attendance. In case of cancellation, a patient is replaced with another from the waiting list. Both strategies have proved to be effective in reducing the rate of no-shows to 4%–10% [5]. As of today, there is no data either on the rate of absenteeism during the COVID-19 pandemic nor on any more effective planning strategies to should be adopted. It can be hypothesized that the no-show rate has increased as a result of both SARS-CoV2 infection or quarantines, as well as being the result of concerns regarding possible exposure to the virus and subsequent infection in the hospital setting. The aims of our study were, therefore, to evaluate the “no-show” rate in our outpatient endoscopic unit activity after the first wave of the COVID-19 pandemic, the reasons for “no-show” and the efficacy of telephone reminders as a strategy to optimize planning and reduce absenteeism. Overbooking was not considered as an appropriate approach in this particular setting due to recommendations to avoiding crowds during the pandemic [8].

Our endoscopy unit is located in a tertiary care university hospital in the centre of Milan. From November 1st, 2020 to October 31st, 2021, a telephone reminder was scheduled for all patients with a booked outpatient endoscopic procedure, 72 h before the due examination, with a maximum of two separate attempts. Patients’ phone numbers were retrieved from our hospital database. During the phone call, a standardized questionnaire was used (see Supplementary File). Firstly, patients were reminded of the appointment and known or suspected COVID-19 infection was searched for. In case of positivity or high-suspicion, the appointment was cancelled and rescheduled. In all other cases, patients were asked whether they would confirm the appointment. Empty slots resulting from the cancelled appointments were then assigned to patients retrieved from the waiting list.

Our results are summarized in Fig. 1 . We managed to contact 75% of the 3562 scheduled patients, a proportion similar to a previous report [5]. According to our results, absenteeism was in the lower range of pre-COVID-19 reports (10%) and similar for both contactable and uncontactable patients. The impact of COVID-19 on the cancellation of endoscopic procedures was minimal. Indeed, only 9 of the 184 patients who could be contacted and cancelled their endoscopy did it for COVID-19-related reasons (3 for COVID-19 positivity, 4 for quarantine following a positive contact and 2 for the presence of symptoms while waiting for the swab test results). Telephone reminders were useful, allowing for the cancellation and re-booking of 184 patients, halving the number of no-shows, i.e. from 347 to 163. This finding is in line with previously published data during the pre-COVID era [5], [6], [7], strongly suggesting the usefulness and cost/benefit advantages of performing telephone reminders also during the COVID-19 pandemic. Nevertheless, telephone reminders are unable to completely eliminate no-shows. In our series, both 8% of uncontactable patients and 4% of the contactable ones who confirmed the appointment at phone interview did not turn up, the latter being a known occurrence [5]. In order to understand the reasons for not showing up in this latter group, a telephone call was made after the missed endoscopy in the last two months of our study. Of the 9 patients who were in this group, 5 did not feel well after bowel preparation for colonoscopy, 3 changed their mind and cancelled the appointment, contacting the call-centre within 24 hrs of the appointment, and 1 did not answer the phone.

Fig. 1

Patients’ series divided according to telephone reminders results and attendance to endoscopy.

In conclusion, our study suggests that telephone reminders are a good strategy in order to optimize the scheduling and planning of outpatients’ endoscopic procedures during the COVID-19 pandemic. The rate of outpatients who have not attended a scheduled endoscopy has not increased compared to the past, COVID-19-related reasons for non-attendance being negligible.

Conflict of interest

None declared.