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Reducing non-attendance at outpatient clinics

Authors:
Chris Stone at Exeter Medical
Chris Stone
  • Exeter Medical
John H Palmer
John H Palmer
John H Palmer
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Peter John Saxby at Royal Devon and Exeter NHS Foundation Trust
Peter John Saxby
Vikram Devaraj at University of Exeter
Vikram Devaraj
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Abstract and Figures

Outpatient non-attendance is a common source of inefficiency in a health service, wasting time and resources and potentially lengthening waiting lists. A prospective audit of plastic surgery outpatient clinics was conducted during the six months from January to June 1997, to determine the clinical and demographic profile of non-attenders. Of 6095 appointments 16% were not kept. Using the demographic information, we changed our follow-up guidelines to reflect risk factors for multiple non-attendances, and a self-referral clinic was introduced to replace routine follow-up for high risk non-attenders. After these changes, a second audit in the same six months of 1998 revealed a non-attendance rate of 11%—i.e. 30% lower than before. Many follow-up appointments are sent inappropriately to patients who do not want further attention. This study, indicating how risk factor analysis can identify a group of patients who are unlikely to attend again after one missed appointment, may be a useful model for the reduction of outpatient non-attendance in other specialties.
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JOURNAL
OF
THE
ROYAL
SOCIETY
OF
MEDICINE
Volume
92
March
1
999
Reducing
non-attendance
at
outpatient
clinics
Christopher
A
Stone
MSc
FRCS
John
H
Palmer
FRCS(Plast)
Peter
J
Saxby
ChM
FRCS(Plast)
Vikram
S
Devaraj
FRCS(Plast)
J
R
Soc
Med
1999;92:114-118
Outpatient
non-attendance
is
a
common
source
of
inefficiency
in
a
health
service,
wasting
time
and
resources
and
potentially
lengthening
waiting
lists.
A
prospective
audit
of
plastic
surgery
outpatient
clinics
was
conducted
during
the
six
months
from
January
to
June
1997,
to
determine
the
clinical
and
demographic
profile
of
non-attenders.
Of
6095
appointments
16%
were
not
kept.
Using
the
demographic
information,
we
changed
our
follow-up
guidelines
to
reflect
risk
factors
for
multiple
non-attendances,
and
a
self-referral
clinic
was
introduced
to
replace
routine
follow-up
for
high
risk
non-attenders.
After
these
changes,
a
second
audit
in
the
same
six
months
of
1998
revealed
a
non-attendance
rate
of
11%
-i.e.
30%
lower
than
before.
Many
follow-up
appointments
are
sent
inappropriately
to
patients
who
do
not
want
further
attention.
This
study,
indicating
how
risk
factor
analysis
can
identify
a
group
of
patients
who
are
unlikely
to
attend
again
after
one
missed
appointment,
may
be
a
useful
model
for
the
reduction
of
outpatient
non-attendance
in
other
specialties.
INTRODUCTION
In
1984
it
was
estimated
that
of
35.5
million
National
Health
Service
(NHS)
outpatient
appointments
booked,
5
million
were
broken1
at
a
cost
of
up
to
£266
million.
More
recent
Department
of
Health
figures
indicate that
as
much
as
£360
million
is
now
wasted
each
year2.
6
million
appointments,
at
an
average
cost
of
£61
each,
were
missed
in
1996-1997,
accounting
for
12%
of
all
appointments
made.
In
addition
156000
patients
(4.6%)
did
not
turn
up
for
scheduled
operations.
Non-attendance
at
outpatient
clinics
is
thus
not
only
wasteful
of
resources
but
may
also
increase
patient
morbidity
and
lengthen
waiting
lists,
extending
the
waiting
time
for
an
outpatient
appointment
from
between
one
week
to
up
to
six
months3.
The
main
reasons
for
patient
non-
attendance
are
often
specialty
non-specific,
and
include
simply
forgetting,
illness,
work
commitments
and
transport
difficulties-1
8.
The
time
interval
from
referral
to
the
appointment
date
also
seems
to
influence
attendance,
with
those
patients
receiving
appointments
beyond
two
months19
or
within
one
week6
of
referral
least
likely
to
attend.
Despite
attempts
to
reduce
non-attendance
rates
by
raising
public
awareness
(Figure
1)
and
by
specifically
addressing
these
various
causal
factors,
non-attendance
remains
persistently
troublesome
throughout
the
NHS.
Telephone
and
postal
reminders
can
help13'20
but
may
not
be
cost-effective
if
up
to
60%
of
unkept
appointments
remain
unkept8.
More
convincing
successes
have
been
gained
by
restoring
the
responsibility
for
making
new
appointments
Figure
1
Public
awareness
campaign
launched
by
the
Exeter
and
District
Community
Health
Service
Trust,
autumn
1998
(Reproduced
with
permission)
Nobody
likes
a
missed
appointment
ijC
k
'
..
Please
keep
your
iA
hospital
appointment
I
Exete&istrict
I
.Z@
|V
I
a-d-
6
g
Department
of
Plastic
and
Reconstructive
Surgery,
Royal
Devon
and
Exeter
Hospital,
Barrack
Road,
Exeter
EX2
5DW
Correspondence
to:
Mr
CA
Stone
JOURNAL
OF
THE
ROYAL
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Volume
92
March
1
999
to
the
patients
themselves.
When
provided
with
a
freephone
telephone
number
by
one
hospital,
88%
of
new
gynaecology
referral
patients
arranged
their
own
appointments,
of
which
only
2.5%
were
missed21.
Another
promising
strategy
has
been
recently
piloted
whereby
patients
are
provided
with
a
copy
of
their
referral
letter22.
In
one
general
practice
this
reduced
the
non-attendance
rate
for
referrals
from
6%
to
zero.
It
seems,
therefore,
that
compensating
for
non-
attendances
by
overbooking,
rather
than
by
trying
to
reduce
non-attendance
rates,
can
no
longer
be
considered
conducive
to
the
efficient
running
of
an
outpatient
service.
Here
we
report
a
study
of
the
factors
relevant
to
attendance
and
non-
attendance
by
plastic
surgery
outpatients.
PATIENTS
AND
METHOD
176
outpatient
clinics
were
audited
during
the
study
period
from
1
January
1997
to
30
June
1997.
Most
of
these
were
at
the
Royal
Devon
and
Exeter
Hospital,
although
peripheral
clinics
were
also
held
at
Axminster,
Barnstaple,
Taunton,
and
Torbay
hospitals.
Only
one
clinic
per
week
was
regularly
conducted
by
a
registrar
alone,
while
all
others
were
attended
by
one
of
three
consultants.
At
the
completion
of
each
clinic,
the
notes
for
those
patients
who
did
not
attend
were
examined
by
the
registrar
or
the
consultant,
and
an
audit
questionnaire
was
completed
in
each
case.
For
new
patients,
this
questionnaire
recorded
the
source
of
the
referral
(general
practitioner
[GP],
another
consultant,
accident
and
emergency
department),
the
provisional
diagnosis
and
the
triage
category
(urgent,
soon,
routine).
For
follow-up
patients,
treatment
already
received
(if
any)
and
the
time
since
operation
were
noted.
For
all
patients,
the
number
of
consecutive
non-attenders
(N-As),
the
decision
to
send
a
further
appointment
or
to
discharge,
and
whether
or
not
the
patient's
GP
was
informed
of
their
non-attendance,
were
recorded.
An
anonymous
questionnaire
was
also
sent
to
the
patient,
along
with
an
explanatory
letter
and
freepost
return
envelope.
This
questionnaire
requested
the
age,
sex
and
occupation
of
the
patient
and,
by
listing
several
possible
reasons
for
missing
appointments,
asked
patients
to
account
for
their
non-attendance.
Reasons
not
covered
by
our
list
could
be
specified
in
the
'other'
category.
Lastly,
patients
were
asked
to
describe
briefly
what
treatment
they
had
already
received,
whether
they
were
happy
with
their
care
overall,
whether
they
felt
their
problem
to
have
resolved,
and
whether
or
not
they
were
back
at
work.
RESULTS-PART
I
Doctor
questionnaire
Of
the
6095
appointments
booked
into
the
176
clinics
held
during
the
six
month
period,
892
were
missed
by
731
patients,
an
overall
N-A
rate
of
15%,
equivalent
to
about
5
appointments
per
clinic.
New
referrals
had
a
slightly
lower
N-A
rate
(1
3%)
than
follow-up
appointments
(15%).
The
highest
number
of
N-As,
197,
was
recorded
during
the
first
month
of
the
study,
while
the
average
monthly
figure
was
149.
Of
the
new
referrals
(24%),
who
comprised
a
quarter
of
the
trial,
85%
of
N-As
were
referred
by
their
GP,
the
remainder
being
consultant
and
casualty
referrals.
61%
of
new
referrals
were
triaged
as
'routine'
while
19%
were
deemed
'urgent'
and
20%
needed
to
be
seen
'soon'.
According
to
the
British
Association
of
Plastic
Surgeons
system,
the
main
group
of
missed
appointments
were
hand
trauma
(23%),
followed
by
excision
of
benign
skin
lesions
(14%),
basal
cell
or
squamous
cell
carcinomas
(10%)
and
melanomas
(5%)
(Figure
2).
62%
of
the
appointments
were
missed
in
the
year
after
surgery.
A
first
N-A
was
recorded
536
times,
a
second
consecutive
N-A
219
times,
a
third
105
times,
a
fourth
18
times
and
a
fifth
8
times
(for
6
patients
the
data
were
unavailable).
Hence
some
patients
missed
appointments
more
than
once
within
the
study
period.
596
patients
failed
to
attend
once
during
the
study
period,
1
10
patients
missed
two
consecutive
appointments,
and
24
patients
missed
three
consecutive
appointments.
Only
one
patient
missed
four
consecutive
appointments
during
the
audit.
a)
V
0
enOO
E
a._
0
2
3
4
6
7
1I
13
74
15
16
17
21
22
23
26
27
30
31
32
33
34
35
40
41
42
50
57
o
200
300
Number
of
missed
appointments
Figure
2
Distribution
of
unkept
appointments
according
to
British
Association
of
Plastic
Surgeons
primary
coding
miscellaneous
other
(18)
leg
ulcer
(5)
pressure
sore
(6)
facial
palsy
(1)
*
breast
reconstruction
(12)
scar
revision
(58)
tattoo
removal
(2)
*
congenital
ear
(1
1)
congenital
clefts
(2)
craniofacial
(4)
congenital
limb
(7)
genito-urinary
(1
3)
congenital
skin
(15)
facial
trauma
(29)
hand
trauma
lower
limb
trauma
(19)
(203)
bum
debndement
(19)
bum
scar
(3)
neoplasia
other
(1)
benign
skin
(127)
benign
subcutaneous
(59)
BCC
/
SCC
(88)
malignant
melanoma
(45)
head
&
neck
oncology
(1
)
hand
surgery
other
(48)
Dupuytren's
(1
1)
rheumatoid
hand
(14)
aesthetic
other
(35)
aesthetic
breast
(36)
115
I-
*100
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95
0
E
0
0
-
0
80-
60
40-
20
-
0-
94
64
25
2
3
4
Number
of
missed
appointments
E:
further
follow-up
arranged
patient
discharged
letter
sent
to
GP
Figure
3
Percentage
of
patients
receiving
a
further
follow-up
appointment
or
discharged
following
a
given
missed
appointment
The
decision
to
send
a
further
appointment
after
non-
attendance
broadly
reflected
the
number
of
consecutive
appointments
missed
(Figure
3).
After
one
missed
appoint-
ment,
95%
of
patients
were
sent
another
appointment.
After
two
consecutive
N-As
this
fell
to
64%
and
after
three,
21%.
Only
6%
of
patients
were
sent
for
again
after
four
consecutive
N-As;
after
five,
all
patients
were
discharged.
Correspondence
with
patients'
GPs
largely
correlated
with
discharge
rates.
Patient
questionnaire
731
patients
received
a
questionnaire
during
the
course
of
the
study
and
250
of
these
were
returned,
a
response
rate
of
34%
(male:
female
ratio
I
1
.04).
65%
of
patients
were
among
the
working
population
but
27%
were
retired.
The
reasons
for
non-attendance
could
be
broadly
divided
into
those
attributable
to
hospital
factors
(41%)
and
those
determined
by
the
patient
(59%)
(Figure
4).
Of
the
latter,
35%
simply
forgot,
14%
had
work-related
reasons,
10%
were
ill,
and
10%
could
not
get
transport
to
the
hospital.
However,
a
substantial
proportion
of
patients,
16%,
gave
reasons
about
which
the
hospital
could
have
done
nothing,
such
as
poor
weather
making
the
journey
difficult.
Hospital
factors
were
blamed
by
41%
of
respondents
for
their
non-attendance,
including
a
failure
of
the
hospital
to
inform
them
of
their
appointment
(40%)
and
the
appointment
having
been
formally
cancelled
in
advance
by
either
the
patient
(33%)
or
the
hospital
(10%).
At
the
time
of
completing
the
questionnaire,
94%
of
respondents
were
happy
with
their
care
overall,
61%
felt
that
their
problem
was
already
resolved
and
75%
had
returned
to
work.
Statistical
analysis
The
aim
of
the
first
audit
was
to
identify
factors
which
might
influence
a
patient's
likelihood
of
not
attending.
Several
trends
may
be
observed
in
the
above
results,
but
two
factors
only
were
found
significant.
By
means
of
x2
analysis,
comparison
of
appointments
missed
for
a
first
time
with
serially
missed
appointments
(multiple
N-As)
identified
predictors
of
multiple
non-attendance
as
(1)
coding
for
hand
trauma
(relative
risk
1.4,
P
<0.01)
and
(2)
after
one
missed
appointment,
time
since
surgery
greater
than
three
months
(relative
risk
1.9,
P<0.01).
After
one
'hand
trauma'
N-A,
the
chance
of
a
subsequent
appointment
being
missed
was
50%.
Similarly,
after
one
N-A,
the
risk
of
a
further
N-A
within
three
months
of
surgery
was
calculated
at
26%,
rising
to
49%
after
three
months.
INTERVENTION
As
a
result
of
this
audit,
areas
of
inefficiency
became
apparent.
Our
follow-up
guidelines
were
amended
to
ensure
that
wherever
there
may
be
an
element
of
concern
(such
as
treatment
for
skin
cancers,
congenital
malforma-
tions,
or
complex
hand
trauma),
patients
were
sent
a
Co
C)
.0
cd
C%
.I.
a)
Co
0
a.
0
0
_
..
f l
.forgot
(61
)
patient
unaware
of
appointment
(49)
cancelled
by
patient
(40)
_~
cancelled
by
hospital
(12)
*
seen
in
another
cinic
(6)
*
no
parking
available
(3)
|
clinic
running
late
(2)
_~
other
(9)
II
20
40
60
80
Number
of
missed
appointments
Figure
4
Factors
contributing
to
non-attendance
according
to
the
patient
questionnaire
_illness
(I17)
work
commitment
(15)
no
transport
(12)
couldn't
afford
time
off
work
(9)
i
inconvenient
time
of
day
(9)
previous
engagement
(7)
looking
after
a
dependent
relative
(7)
couldn't
afford
transport
(6)
inconvenient
day
of
week
(5)
g_
_
other
(28)
I
a
V
olIu
me
9
2
Ma
r
ch
1
99
9
1
JOURNAL
OF
THE
ROYAL
SOCIETY
OF
MEDICINE
Volume
92
March
1
999
further
appointment,
perhaps
even
after
several
N-As.
Otherwise
all
patients
were
discharged
after
two
non-
attendances.
However,
on
the
basis
of
the
risk
factor
analysis
for
multiple
N-As,
those
patients
non-attending
for
the
first
time,
if
beyond
3
months
from
a
minor
procedure
(such
as
excision
of
a
benign
skin
lesion)
or
if
originally
treated
for
a
minor
hand
injury,
were
either
discharged
or
sent
details
of
a
new
'self-referral'
clinic
essentially
the
existing
registrar
clinic
to
which
patients
could
directly
gain
access.
This
empowered
patients
to
telephone
for
a
further
appointment
if
they
so
desired,
thereby
returning
responsibility
for
care,
where
appropriate,
to
the
patient.
Second
audit
Changes
to
our
follow-up
guidelines,
and
the
new
self-
referral
clinic,
were
introduced
in
October
1997.
Three
months
later,
a
second
audit
was
begun
to
assess
the
impact
of
these
changes
during
an
equivalent
time
period
from
January
to
June
1998.
During
this
period,
however,
only
clinics
at
the
Royal
Devon
and
Exeter
Hospital
were
audited
(120
in
total).
Information
regarding
the
number
of
patients
who
did
not
keep
appointments,
the
number
to
whom
self-
referral
advice
letters
were
sent,
and
the
number
requesting
self-referral
clinic
appointments
was
collected
prospec-
tively.
RESULTS-PART
2
During
the
second
audit,
7135
appointments
were
booked
of
which
787
were
missed.
This
N-A
rate,
at
11%,
was
30%
lower
than
that
in
the
main
hospital
for
the
equivalent
period
of
1997
(16%).
107
self-referral
clinic
advice
letters
were
sent
to
patients
who
did
not
attend
outpatients
for
a
first
time
who
met
the
criteria
established
by
our
unit
follow-up
guidelines
(1.1
per
clinic
on
average).
Only
2
of
these
107
patients
asked
to
be
seen
again.
DISCUSSION
NHS
Executive
data
for
1996-1997
identified
94
000
missed
appointments
in
plastic
surgery
clinics
in
England
alone,
with
a
mean
national
N-A
rate
within
the
specialty
of
around
16%
(Table
1)23.
The
N-A
rate
for
the
Royal
Devon
and
Exeter
Healthcare
NHS
Trust
during
the
1997
audit
was
also
16%,
while
our
overall
N-A
rate,
including
peripheral
clinics,
was
15%.
This
compares
favourably
with
non-
attendance
rates
recorded
by
other
specialties10-'4'17'2425.
A
sizeable
increase
in
the
number
of
appointments
booked
at
the
main
hospital
in
the
second
year
raises
a
question
whether
like
is
being
compared
with
like.
Part
of
the
explanation
may
be
an
increase
in
the
activity
of
the
self-
referral
clinic.
There
was
no
obvious
change
in
the
nature
of
the
population
attending
outpatient
clinics
in
the
second
year.
The
main
reasons
for
non-attendance-namely,
forget-
ting,
illness,
work
commitments,
transport
and
adminis-
trative
problems
on
the
part
of
the
hospital-were
similar
to
those
reported
previously"'4.
Of
the
administrative
failures,
common
errors
were
failure
of
notification
and
cancellation.
The
large
number
of
missed
appointments
relating
to
hand
trauma
and
excision
of
benign
skin
lesions
during
the
six
month
period
was
in
proportion
to
the
overall
case
mix
in
the
unit.
Nevertheless,
unnecessarily
booked
appoint-
ments
are
often
missed
because
the
patient
believes
the
problem
to
have
resolved.
Additionally,
some
follow-up
patients
may
be
long-term
attenders,
with
chronic
disorders
changing
little
from
one
appointment
to
another.
They
may
account
for
high
N-A
rates
among
certain
other
patient
groups,
such
as
melanoma
review
patients.
The
number
of
N-As
prevented
by
changes
to
our
follow-
up
guidelines
may
be
estimated
by
comparison
of
rates
before
and
after
intervention.
On
this
basis,
we
would
have
expected
1141
patients
not
to
keep
appointments
during
the
second
audit,
whereas
only
787
did
so;
thus
354
potentially
wasted
appointments
were
avoided.
Furthermore,
the
near-
zero
uptake
of
self-referral
clinic
appointments
validates
exclusion
of
this
targeted
patient
group
(n
=
107)
from
further
follow-up
in
main
outpatient
clinics.
Clearly
there
is
a
massive
financial
incentive
to
reducing
high
numbers
of
missed
appointments.
In
our
study,
the
cost
of
354
missed
appointments
(if
each
one
is
valued
at
£612)
equates
to
over
£20
000.
At
a
national
level,
there
Table
1
KHO9
data
relating
to
plastic
surgery
outpatient
attendance
1992-1997
First
seen
First
N-A
F/u
seen
Flu
N-A
Overall
N-A
%
1996-1997
168000
23000
414000
71
000
16.15
1995-1996
162
000
23
000
394
000
66
000
16.01
1994-1995
142
000
19
500
349 000
58
000
15.78
1993-1994
89
000
12
000
222
000
37
000
15.76
1992-1993
117
000
17
500 357 000
59
000
16.12
F/u
=
follow-up;
N-A
=
non-attendance
JOURNAL
OF
THE
ROYAL
SOCIETY
OF
MEDICINE
Volume
92
March
1
999
were
94000
plastic
surgery
non-attendances
recorded
for
the
year
1996-1997
(Table
1):
reducing
this
by
30%
(28
000)
implies
a
cost
saving
of
around
£1E.7
million.
Acknowledgments
We
thank
Dr
Rod
Taylor,
Depart-
ment
of
Research
and
Development,
Royal
Devon
and
Exeter
Hospital,
for
help
with
the
statistical
analysis
and
Sarah
Lawrence
for
her
assistance
in
the
collection
of
data.
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... A study of nonattendance at surgical control after trauma hospitalization showed, for example, that 37% of nonattendances were solely owing to the lack of communication about the appointment between the surgeon and nurse or between the medical team and the patient, which resulted in miscommunication [39] and not because the patients simply forgot the appointments, as other studies have claimed [40]. Another study claims that 41% of nonattendances are caused by errors on the part of the hospital [41]. ...
... The nonattendance rates can also differ significantly among different hospitals and among different units at the same hospital. The nonattendance rate in medical outpatient clinics in Denmark is 12% to 13% compared with 16% to 20% in England [41], and some specialties (eg, orthopedic surgery and type 2 diabetes) are systematically overrepresented among the high nonattendance rates, whereas others most often have low nonattendance rates (eg, in cancer treatment). Although it can be difficult to compare the nonattendance rates across units, both because the percentage can be estimated differently (per patient or per course of treatment and ≥1 nonattendances/course of treatment) and because there is a significant difference in the severity of illness (for instance, being a patient with cancer; being a patient with a chronic illness such as diabetes; or having a disease burden owing to, for example, multimorbidity) [26,42], we see that in chronical specialties, patients with low attendance compliance weigh heavily, whereas very few patients are represented in repeated rehospitalizations [41]. ...
... The nonattendance rate in medical outpatient clinics in Denmark is 12% to 13% compared with 16% to 20% in England [41], and some specialties (eg, orthopedic surgery and type 2 diabetes) are systematically overrepresented among the high nonattendance rates, whereas others most often have low nonattendance rates (eg, in cancer treatment). Although it can be difficult to compare the nonattendance rates across units, both because the percentage can be estimated differently (per patient or per course of treatment and ≥1 nonattendances/course of treatment) and because there is a significant difference in the severity of illness (for instance, being a patient with cancer; being a patient with a chronic illness such as diabetes; or having a disease burden owing to, for example, multimorbidity) [26,42], we see that in chronical specialties, patients with low attendance compliance weigh heavily, whereas very few patients are represented in repeated rehospitalizations [41]. ...
Protocol Causes of Patient Nonattendance at Medical Appointments: Protocol for a Mixed Methods Study
Article
Full-text available
  • Jan 2024
  • J MED INTERNET RES
Background: Approximately one-third of patient appointments in Danish health care result in failures, leading to patient risk and sizable resource waste. Existing interventions to alleviate no-shows often target the patients. The underlying reason behind these interventions is a view that attendance or nonattendance is solely the patient's problem. However, these interventions often prove to be ineffective and can perpetuate social biases and health inequalities, leaving behind patients who are more vulnerable or disadvantaged (in terms of social, economical, and linguistic factors, etc). A more holistic understanding of no-shows is needed to optimize processes, reduce waste, and support patients who are vulnerable.
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... In summary, whilst there are differences in findings between studies, partly arising from variations in the nature of the methodological approach adopted, the majority have drawn attention to the importance of factors such as the age and socioeconomic status of patients as characteristics associated with missed appointments (Campbell et al., 1991;Catz et al., 1999;Kruse et al., 2002;Lehmann et al., 2007). History of illness, presenting complaint, severity of illness and comorbidities have also all been shown to affect patient attendance (Carpenter et al., 1981;Catz et al., 1999;Chen, 1991;Frankel et al., 1989;Nel, 2014;Nicholson, 1994;Sparr et al., 1993;Stone et al., 1999). However, there is less agreement regarding the importance of factors such as educational level, race, or the distance from the patient's home to the clinic. ...
... One study, for example, found that all the missed appointments in their sample were caused by only 19.4% of patients (Sparr et al., 1993). A history of missed appointments for the patient is a factor in future non-attendance (Campbell et al., 1991;Stone et al., 1999). A more recent study found that "less than 10% of patients who failed to attend twice, turned up for the third appointment" (Mohamed et al., 2016, p.3). Deprivation may also be a factor with some suggestions that nonattendance at NHS outpatient clinics is more common in deprived populations (Sharp and Hamilton, 2001). ...
... In Cwm Taf Morgannwg University Health Board, this rate rises to 1.54, suggesting a larger repeat non-attendance problem whereas Powys Teaching LHB had the lowest rate of 1.28. This finding concurs with the work of others that suggests that missed appointments lead to more missed appointments (Campbell et al., 1991;Stone et al., 1999). ...
Using machine learning tools to investigate factors associated with trends in ‘no-shows’ in outpatient appointments
Article
  • Jan 2021
  • HEALTH PLACE
Missed appointments are estimated to cost the UK National Health Service (NHS) approximately £1 billion annually. Research that leads to a fuller understanding of the types of factors influencing spatial and temporal patterns of these so-called “Did-Not-Attends” (DNAs) is therefore timely. This research articulates the results of a study that uses machine learning approaches to investigate whether these factors are consistent across a range of medical specialities. A predictive model was used to determine the risk-increasing and risk-mitigating factors associated with missing appointments, which were then used to assign a risk score to patients on an appointment-by-appointment basis for each speciality. Results show that the best predictors of DNAs include the patient's age, appointment history, and the deprivation rank of their area of residence. Findings have been analysed at both a geographical and medical speciality level, and the factors associated with DNAs have been shown to differ in terms of both importance and association. This research has demonstrated how machine learning techniques have real value in informing future intervention policies related to DNAs that can help reduce the burden on the NHS and improve patient care and well-being.
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... The non-attendance rate in medical outpatient clinics in Denmark is 12-13%, compared with 16-20% in England (13). Although it can be difficult to compare the non-attendance rates across units, because the percentage can be estimated differently (per patient or per course of treatments, and one or more non-attendances per course of treatments), some specialities (e.g. ...
... The interesting thing is that interventions that target the specific causes for non-attendance at hospital appointments do work and can significantly reduce the number of non-attendances. We know of five well-documented, simple interventions which can reduce non-attendances at hospitals and ensure equality (13,(33)(34)(35) therefore be reluctant to use the system (38). ...
2023 non-attendant JMIR preprint-46227-submitted
Preprint
Full-text available
  • Feb 2023
Background Approximately one-third of patient appointments in Danish health care result in failures, leading to patient risk and sizable resource waste. Existing interventions to alleviate no-shows often target the patients. The underlying reason behind these interventions is a view that attendance or nonattendance is solely the patient’s problem. However, these interventions often prove to be ineffective and can perpetuate social biases and health inequalities, leaving behind patients who are more vulnerable or disadvantaged (in terms of social, economical, and linguistic factors, etc). A more holistic understanding of no-shows is needed to optimize processes, reduce waste, and support patients who are vulnerable. Objective This study aims to gain a deep and more comprehensive understanding of the causes, mechanisms, and recurring patterns and elements contributing to nonattendance at Danish hospitals in the Region of Southern Denmark. It emphasizes the patient perspective and analyzes the relational and organizational processes surrounding no-shows in health care. In addition, the study aims to identify effective communicative strategies and organizational processes that can support the development and implementation of successful interventions. Methods The study uses mixed quantitative-qualitative methods, encompassing 4 analytical projects focusing on nonattendance patterns, patient knowledge and behavior, the management of hospital appointments, and in situ communication. To address the complexity of no-shows in health care, the study incorporates various data sources. The quantitative data sources include the electronic patient records, Danish central registries, Danish National Patient Registry, and Register of Medicinal Product Statistics. Baseline characteristics of patients at different levels are compared using chi-square tests and Kruskal-Wallis tests. The qualitative studies involve observational data, individual semistructured interviews with patients and practitioners, and video recordings of patient consultations. Results This paper presents the protocol of the study, which was funded by the Novo Nordisk Foundation in July 2022. Recruitment started in February 2023. It is anticipated that the quantitative data analysis will be completed by the end of September 2023, with the qualitative investigation starting in October 2023. The first study findings are anticipated to be available by the end of 2024. Conclusions The existing studies of nonattendance in Danish health care are inadequate in addressing relational and organizational factors leading to hospital no-shows. Interventions have had limited effect, highlighting the Danish health care system’s failure to accommodate patients who are vulnerable. Effective interventions require a qualitative approach and robust ethnographic data to supplement the description and categorization of no-shows at hospitals. Obtaining comprehensive knowledge about the causes of missed patient appointments will yield practical benefits, enhancing the safety, coherence, and quality of treatment in health care. International Registered Report Identifier (IRRID) PRR1-10.2196/46227
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... The financial and public health impacts of unkept appointments are therefore vast. It is wasteful of resources and may also increase patient morbidity and lengthen waiting lists from 1 week to up to 6 months [5,6]. A nationwide study in Scotland reported that those who missed more than 2 appointments had a 3-fold increase in hazards of mortality compared to those who did not miss Episode Statistics (HES) Outpatients. ...
... Other proactive interventions such as appointment reminders by phone call, letter, or text message have been implemented to try to reduce the number of unkept appointments. Other strategies have included giving patients the responsibility of booking their appointment, either through Freephone service or online [5]. Interventions may fail as they are often targeted using a blanket approach, without knowing which cohort of patients or clinical factors are most effective to target. ...
Characterising the nationwide burden and predictors of unkept outpatient appointments in the National Health Service in England: A cohort study using a machine learning approach
Article
Full-text available
Background: Unkept outpatient hospital appointments cost the National Health Service £1 billion each year. Given the associated costs and morbidity of unkept appointments, this is an issue requiring urgent attention. We aimed to determine rates of unkept outpatient clinic appointments across hospital trusts in the England. In addition, we aimed to examine the predictors of unkept outpatient clinic appointments across specialties at Imperial College Healthcare NHS Trust (ICHT). Our final aim was to train machine learning models to determine the effectiveness of a potential intervention in reducing unkept appointments. Methods and findings: UK Hospital Episode Statistics outpatient data from 2016 to 2018 were used for this study. Machine learning models were trained to determine predictors of unkept appointments and their relative importance. These models were gradient boosting machines. In 2017-2018 there were approximately 85 million outpatient appointments, with an unkept appointment rate of 5.7%. Within ICHT, there were almost 1 million appointments, with an unkept appointment rate of 11.2%. Hepatology had the highest rate of unkept appointments (17%), and medical oncology had the lowest (6%). The most important predictors of unkept appointments included the recency (25%) and frequency (13%) of previous unkept appointments and age at appointment (10%). A sensitivity of 0.287 was calculated overall for specialties with at least 10,000 appointments in 2016-2017 (after data cleaning). This suggests that 28.7% of patients who do miss their appointment would be successfully targeted if the top 10% least likely to attend received an intervention. As a result, an intervention targeting the top 10% of likely non-attenders, in the full population of patients, would be able to capture 28.7% of unkept appointments if successful. Study limitations include that some unkept appointments may have been missed from the analysis because recording of unkept appointments is not mandatory in England. Furthermore, results here are based on a single trust in England, hence may not be generalisable to other locations. Conclusions: Unkept appointments remain an ongoing concern for healthcare systems internationally. Using machine learning, we can identify those most likely to miss their appointment and implement more targeted interventions to reduce unkept appointment rates.
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... Few studies focused on other types of interventions in reducing non-compliance includes a study in 1999 [71] in which providers changed their outpatient follow-up guidelines, replaced routine Submit your Manuscript | www.austinpublishinggroup.com follow-up with a self-referral clinic, which led to a 30% reduction in non-attendance [71]. An RCT (Randomized Controlled Trial) by Hamilton et al. [72] assessed the effect of giving a copy of referral letter to patients on hospital outpatient attendance rate evaluation and they found out no significant difference between the copy and control groups for the attendance rate. ...
... Few studies focused on other types of interventions in reducing non-compliance includes a study in 1999 [71] in which providers changed their outpatient follow-up guidelines, replaced routine Submit your Manuscript | www.austinpublishinggroup.com follow-up with a self-referral clinic, which led to a 30% reduction in non-attendance [71]. An RCT (Randomized Controlled Trial) by Hamilton et al. [72] assessed the effect of giving a copy of referral letter to patients on hospital outpatient attendance rate evaluation and they found out no significant difference between the copy and control groups for the attendance rate. ...
Factors Associated with Scheduled Endoscopy Non-Compliance – A Literature Review
Article
Full-text available
  • Jun 2021
Non-Compliance with endoscopy appointments places a major burden on the healthcare system and can lead to delay in the diagnosis and treatment of potentially life-threatening conditions. Although several studies have investigated causes, trends, and interventions to improve compliance with endoscopy appointments, we present a comprehensive, high-quality, and focused literature review on this important topic. A search of the PubMed database revealed 72 papers that were screened for eligibility according to their title and text; among these 72, a total of 42 papers are focused on non-compliance with endoscopy, and 12 investigated ways to improve compliance. The average non-compliance rate for endoscopy was found 22.25%. Patients’ age (younger than 60-year-old), low socioeconomic status, history of healthcare visits non-adherence, medical history, and season/month of the appointment all contribute to non-compliance with endoscopy appointments. On the other hand, decreasing scheduling lead time and some specific modes of appointment confirmations could improve appointment-keeping behavior.
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... Similarly, longer distances of patients' residences from the hospital independently predicted follow-up non-attendance. This is intuitive in that travelling long distances to the hospital often translates to a higher cost and transport difficulty [34]. It may also mean patients did not return because they have sought follow-up care somewhere more proximal than where their surgery was done. ...
Follow-up non-attendance after long-bone fractures in a low-resource setting: a prospective study of predictors and interventions to increase attendance rates
Article
Full-text available
  • Dec 2023
  • BMC HEALTH SERV RES
Background While the majority of traumatic injuries occur in low- and middle-income countries, the published literature comes chiefly from high-income countries due to poor follow-up. Clinical and radiographic post-surgical trauma follow-up is essential to high-quality research and objective monitoring for healing and/or complications. This study aimed to identify the predictors of follow-up non-attendance in a low-resource setting and investigate the extent to which interventional efforts based on mobile phone technology (MPT) and home visits improved the follow-up rates for fractures treated with SIGN nails. Methods This was a prospective study of 594 patients with long-bone fractures. Socio-demographic (e.g. age, gender, marital status, education level, etc.) and clinical (e.g. fracture type, concomitant injuries, comorbidity, etc.) data were collected on each patient. Before discharge, the importance of follow-up was explained to patients and their relations. They were encouraged to attend even if they felt well. Their residential addresses and telephone numbers were validated and securely stored. Patients who missed their appointments were contacted by phone. Those who failed to honour 2 or 3 rescheduled appointments were visited in their home. The patients were divided into those who returned for the primarily scheduled follow-up without prompting (volition group) and those who did not come (non-attenders). Univariate analyses and binary logistic regression were conducted to determine the significant predictors of non-attendance. Results The proportion of patients in the volition group reduced from 96.1% at 6 weeks to 53.0% at 12 weeks and 39.2% at 6 months. However, interventional efforts increased these values to 98.5%, 92.5%, and 72.4% respectively. Walking unaided before the primarily scheduled 12-week appointment was the major reason for not attending the follow-up. Education, occupation, post-operative length of hospital stay (PLOS) and infection were significantly associated with non-attendance but younger age, long distances from the hospital, being separated or divorced, difficulty paying the in-patient care bill, closed fracture, having no (or a non-limb) concomitant injury, achieving painless weight bearing ≤ 6 weeks post-operatively and needing no additional surgery were independent predictors of non-attendance. Conclusions Our study sheds light on the predictors of follow-up non-attendance and demonstrates how interventional efforts improved attendance rates in a low-resource setting. In addition, efforts that better the socio-economic status of people such as more-encompassing health insurance coverage and greater work flexibility can improve the follow-up attendance rates.
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... Reasons given for this included forgetting the appointments, being busy, unclear appointment details, non-satisfaction with caregivers approach, and feeling of wellness [16]. Others include the state of being too ill to attend, work commitments, difficulty with transportation, wide interval between time of booking and the next appointment [9,[17][18]. In low-income countries such as Nigeria, structural barriers, including poverty, poor infrastructure and the absence of formal social welfare services and trained staff, limit the applicability of adherence strategies used in high-income countries [15]. ...
Missed appointment at specialist outpatient clinics: The Federal Medical Centre Bida, Northern Nigeria experience
Article
Full-text available
  • May 2021
Background/Objective: Thousands of patients miss their appointments every year in all kind of practices including specialists’ cares. Timely access at scheduled clinic appointment is important for achieving good medical outcomes to smoothen workflow, reduce crowding and waiting period, and often determines patient’s satisfaction. However, the after effect of missed appointment include; disruption of daily work planning of both physicians and administrative staff, interfered with adequate medical care, time lost and decreased efficiency on the part of physicians and as well as prolonged waiting time at the clinic. This study aims to determine the rate of missed appointments, reasons for missing appointments, the predisposing factors and aftereffect of missed appointments at specialist outpatient clinics of the hospital. Methods/Design: This was a cross-sectional study carried out at the consultative outpatient clinics of FMC Bida. Out of 38,837 patients’ population, a total of 380 patients were systematically co-opted into the study using a stratified sampling technique. A semi structured questionnaire was used to collect data. The questionnaires comprised of questions that assessed the participant’s demographic characteristics, rate, reasons and predisposing factors of missed appointment. Results: out of 380 participants co-opted into the study, 315 responses were obtained. The result showed that the majority of the participants was within the age range of 25-34 (105, 33.3%), mostly female (220, 69.8%) and predominately Nupe dialect. A total of 139(44.1%) participants claimed to have ever missed their appointment. The reasons for the missed are; forgetfulness, lack of money for treatment, lack of money for transport and work commitment respectively. The majority who missed their appointment attend gyne infertility, orthopedic and psychiatric clinics. They are uneducated, artisans and from villages outside Bida town. Conclusion: since the reasons of missed appointment and predisposing factors have been identified, healthcare professionals and hospital management will need to pay serious attention with regards to the following; reduce waiting time at the clinic, restructure appointment scheduling system, educate patients on appointment, subsidize the cost of treatment for
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Loss to Follow-Up and Unplanned Readmission After Emergent Surgery for Acute Subdural Hematoma
Article
  • Jun 2022
Background: Loss to follow-up (LTF) and unplanned readmission are barriers to recovery after acute subdural hematoma evacuation. The variables associated with these postdischarge events are not fully understood. Objective: To determine factors associated with LTF and unplanned readmission, emphasizing socioeconomic status (SES). Methods: A retrospective analysis was conducted of surgical patients with acute subdural hematoma managed operatively from 2009 to 2019 at a level 1 regional trauma center. Area Deprivation Index (ADI), which is a neighborhood-level composite socioeconomic score, was used to measure SES. Higher ADI corresponds to lower SES. To decrease the number of covariates in the model, principal components (PCs) analysis was used. Multivariable logistic regression analyses of PCs were performed for LTF and unplanned readmission. Results: A total of 172 patients were included in this study. Thirty-six patients (21%) were LTF, and 49 (28%) patients were readmitted; 11 (6%) patients were both LTF and readmitted (P = .9). The median time to readmission was 10 days (Q1: 4.5, Q3: 35). In multivariable logistic regression analyses for LTF, increased ADI and distance to hospital through PC2 (odds ratio [OR] 1.49; P = .009) and uninsured/Medicaid status and increased length of stay through PC4 (OR 1.73; P = .015) significantly contributed to the risk of LTF. Unfavorable discharge functional status and nonhome disposition through PC3 were associated with decreased odds of unplanned readmission (OR = 0.69; P = .028). Conclusion: Patients at high risk for LTF and unplanned readmissions, as identified in this study, may benefit from targeted resources individualized to their needs to address barrier to follow-up and to ensure continuity of care.
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Patient factors associated with dermatology outpatient non-attendance: An analysis of racial and ethnic diversity
Article
  • Aug 2021
Non-attendance to dermatology outpatient appointments has been shown to be a risk factor for poorer patient outcomes. The culturally and linguistically diverse (CALD) communities in Australia have been identified as at risk of poorer health outcomes, but there is paucity of data assessing patient factors that may increase outpatient non-attendance. To investigate this, we performed a retrospective cross-sectional study of dermatology appointments from patients attending a tertiary, referral public hospital located in one of Australian’s most racially and ethnically diverse communities. Patients within the 18-45 years age bracket were 61% more likely to not attend compared to older age groups. Those born in Oceania, Middle East Asia and surprisingly Australia were more likely to miss an appointment, whilst those born in East and Southeast Asia were more likely to attend. Those who spoke Arabic at home were more likely to not attend, whilst those who spoke Vietnamese at home were more likely to attend. This study sheds further light on health disparities in non-attendance and emphasizes the importance of not collectively amalgamating all groups of the CALD community.
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Non-attendance or non-invitation? A case-control study of failed outpatient appointments
Article
Full-text available
  • Jun 1989
To determine the causes of non-attendance at new outpatient appointments. Case-control study of non-attenders and attenders. Outpatient department of a general hospital. All non-attenders (n = 277) for first outpatient appointments in six specialties during a three month period were included. Controls (n = 135) were the attenders who followed every second non-attender; thus they attended the same consultant on the same day that the non-attenders were expected. None. Information on the clinical problem, difficulties in attending the hospital, and reasons for non-attendance from the questionnaire were coded and classified. Non-attenders had received shorter notice of their appointment than attenders (14% v 1% had received three days' notice or less). There were small differences in the seriousness of patients' clinical condition. Client factors are less important than aspects of the service in explaining non-attendance at outpatient appointments.
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Referrals to hospital by general practitioners: A study of compliance and communication
Article
Full-text available
  • Dec 1988
To determine the extent of non-attendance at first hospital appointments 269 hospital referrals made in one practice over 14 weeks were analysed retrospectively. Non-attendance was more likely among patients referred to outpatient departments than to casualty or for admission. Fifteen per cent (41/269) of all patients and 20% (33/167) of outpatients failed to keep their initial appointments. Prolonged waiting times from referral to appointment were significantly related to non-attendance. Twenty weeks after the last referral had been made no communication had been received by the practice for 24% (61/252) of all referral letters received by the hospital. Minimum delays to appointments and improved communication between hospitals and general practitioners would help general practitioners to make appropriate referrals and improve compliance.
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Dictating clinic letters in front of the patient
Article
  • May 1997
Editor—B W Lloyd shows that patients approve of a consultant's dictating clinic letters in front of them, but Mike Pringle asks for more evidence to support the idea.1 Our study, funded by Devon Family Health Services Authority, may give this evidence. During 1994, consecutive referrals from two general practitioners were randomised to (a) dictation in their presence or immediately after they left the room and (b) whether they were sent a copy of their referral letter. Terminations of pregnancy were excluded. All patients were sent a questionnaire. We monitored attendances at hospital. Altogether 171 patients entered the study. The randomisation was to a Latin square design. Thus, of the 137 (80%) patients who responded to the questionnaire, 65 had had dictation in their presence and 72 had not; and 70 had received a copy of the letter and 67 had not. Forty patients received both dictation and a copy of the letter. Fifty three patients rated dictation in their presence very helpful, nine moderately helpful, and two not very helpful; one patient made no answer. Fifty three patients rated receipt of a copy letter very helpful, 12 moderately helpful, and five not very helpful. Eighty one respondents stated that the referral process had increased their understanding of their condition. This was unrelated to dictation in their presence or receipt of a copy letter. Table 1 shows the effect of dictating the letter in their presence on its accuracy, as judged by the patient. All 89 patients who received a copy letter attended their outpatient appointment, but five of the 82 without a copy letter did not attend. Table 1 Accuracy of referral letter, depending on whether dictation was done in patient's presence, for patients who received copy of their referral letter. Figures are numbers (percentages)
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A survey of the non-attendance rate at the ENT clinic of a District General Hospital
Article
  • Feb 1986
  • Clin Otolaryngol Allied Sci
A survey of the non-attendance rate at the ENT clinic of a district general hospital A survey of the number of patients who failed to keep outpatient appointments at the ENT clinic of a rurally situated district general hospital (Bangour General Hospital, West Lothian) was carried out. The results were compared with non-attendance rates of the general medical clinic of the same hospital and of the ENT clinic of a nearby urban hospital (the Royal Infirmary in Edinburgh). A particularly high non-attendance rate was demonstrated for the ENT clinic of the district general hospital. The reasons for this are discussed in the light of currently available literature on the ‘no show’ patient and possible means of improving the situation are suggested.
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Non-attendance at out-patient clinics: A case study
Article
  • May 1992
  • J ADV NURS
Non-attendance at out-patient dimes is a persistent, worldwide problem In contrast with previous research, a qualitative approach was used in this study to examine reasons for non-attendance at out-patient clinics in one Belfast hospital, by exploring perspectives of general practitioners (GPs), hospital staff and defaulters Findings revealed conflicts of opinion between GPs and hospital staff on appropriate management of certain medical and postnatal patients Patients’ reasons for defaulting were wide-ranging, however, 32% of those interviewed did not attend, or were recorded as non-attenders, for reasons relating to inefficient hospital administration. It is concluded that the causes of non-attendance were multifactorial, and non-attenders could not be stereotyped as irresponsible Suggested measures to alleviate the problem include discussion between groups of professionals on responsibility for care of medical and postnatal patients, increased negotiation between patients and physicians in order to develop agreed programmes of care, and, where possible, a shifting of the onus of responsibility for making and cancelling appointments onto patients
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Why 100 Patients Failed to Keep an Outpatient Appointment — Audit in a Dermatology Department
Article
  • Jun 1992
Failure to keep outpatient appointments is common at all clinics and various explanations may be offered. One hundred attending patients who had failed to keep their previous dermatology clinic appointment were asked the reason for their non-attendance. Many and varied reasons were given but illness (28%), and problems related to appointments (33%) were prominent. They were also asked how. they had obtained a further appointment. Stricter follow-up of non-attenders by the hospital including informingthe GP, and subsequent GP action if necessary, may improve attendance figures.
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Consultation time, workload, and problems for audit in outpatient clinics
Article
  • Mar 1992
  • Arch Dis Child
Fifty four of 74 paediatricians in the West Midlands (43 general medical, 11 subspecialist) replied to a postal questionnaire about their outpatient practice: 37 timed each consultation in one clinic. On average, subspecialty consultations lasted 37 minutes for new patients and 29 minutes for review. In general clinics new patient consultations took 23 minutes, review 12. Mean 'single handed' general clinic size was 18, clinics with assistants 24; subspecialist clinics nine and 15. Four to five new patients and nine to 19 review patients were booked per clinic on average; 17/51 clinics used block booking, 34 provided individual appointment times. Mean referral delay was 4.9 weeks, mean clinic wait 22 minutes, and non-attendance averages 16-29%. Solutions are suggested to four main problems: non-attendance, referral delay, unpunctuality and disorganisation, with audit levels for paediatric outpatient activity.
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Can Outpatient Non-Attendance Be Predicted from the Referral Letter? An Audit of Default at Neurology Clinics
Article
  • Dec 1991
Data obtained from new patient referral letters to regional and peripheral neurology clinics were studied prospectively over a 6-month period in an attempt to determine factors predicting non-attendance. Attendance at peripheral clinics was significantly better, confirming their value. At regional clinics, factors associated with non-attendance were male sex, patient age less than 50 years, urban home address, referral from Accident and Emergency Departments, symptom duration less than 12 months, and wait for appointment more than 2 months. Of these, referral source and waiting time were identified as factors which could be modified, confirming that this analysis of referral letters was a useful exercise.
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Are patient attitudes the cause of long waiting lists?
Article
  • Feb 1991
  • Br J Clin Pract
This paper studies the rate of non‐attendance for both out‐patient clinics and in‐patient care. It relates this to the waiting times for both services. If all patients who did not attend clinics had informed us beforehand, thus enabling us to give their appointments to other patients, the out‐patient waiting time could have been reduced from six months to one week. If a similar approach was taken with the in‐patient waiting list, the waiting time could have been reduced from 15 months to nine months.
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Understanding non-attendance in outpatient clinics
Article
  • Mar 1990
  • Arch Dis Child
Outpatient clinic appointments are often not kept. There has been little study of the reasons for this, but failure to attend may affect future health. Our study was based on the children's outpatient department of a large inner city district general hospital. The parents of 34 children who had failed to keep appointments and of 12 who did attend were interviewed in depth and the appointment systems of the hospital and of a nearby regional referral centre for children were reviewed. At the district general hospital 23% of first appointments and 35% of subsequent appointments were not kept. We found that parents usually made a conscious decision about attending, balancing the perceived advantages and disadvantages of doing so. Their assessment of the severity of the child's illness was crucial in this. Twenty one of the 34 children who had not attended were assessed at the time of interview as still needing to attend. Of these, 16 subsequently kept an appointment and 11 underwent further investigation or treatment. We conclude that children who are not brought for outpatient appointments may be at risk of avoidable ill health and that ways of either ensuring attendance at outpatient clinics or providing alternative means of health supervision are needed.
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