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Non-Attendance in Primary Care: The Views of Patients and Practices on Its Causes, Impact and Solutions
Abstract
More than 12 million appointments in primary care are not attended each year: this is about 6.5% of the appointments made. Missing appointments is widely perceived as a waste of resources and a potential barrier to the achievement of the 48-hour access target.
To explore and compare the views of primary care team members and patients in relation to the causes, impacts and potential solutions to the issue of non-attendance.
A qualitative study using semi-structured interviews with a purposive sample of 24 patients over the age of 18 years, 7 GPs, a GP Registrar, a Nurse Practitioner and 5 receptionists carried out in one health centre in urban South Essex with additional interviews in a practice in rural Essex and a practice in inner city London.
The major themes were: competing priorities for patients; the efficiency of appointment booking systems; the significance of relationships on non-attendance; differing attitudes towards non-attendance between different groups; and interventions. Poor patient-staff relationships was given as a reason for non-attendance, while missing appointments was seen as making relationships worse. Inefficiencies in the appointment booking systems were perceived as key in this 'relationship' context.
Some non-attendance is inevitable with pre-booked appointments, as GP appointments must compete with patients' other priorities and the complexities of their day. Utilising modern communication technologies, such as SMS text messaging, may make cancellation simpler. A structured approach to matching supply and demand of appointments might reduce problems arising from non-attendance.
... Relational dynamics are refracted through wider life experiences and circumstances, and some may be particularly at risk of problematic relational or power dynamics and their impacts. Some patients may have experienced judgemental, punitive or stigmatising interactions with services, whether because of missed appointments or other aspects of their lives or identities [11,31,40,68,69,96,101,103,105,111,[113][114][115]. Stigma is part of fundamental causation because it increases exposure to identity-threatening encounters while reducing interpersonal power, making people less likely to be acknowledged or heard within them [116]. ...
... Registration and appointment systems in general have been described as a "threat" ( [78], p.6) to some patients and a contributor to health inequalities [71,101,117]. By not attending in the past, patients are positioned as deviant or troublesome in the eyes of staff, creating "friction" ( [115], p.642) and many of the relational challenges above [19,35,36,40,68,69,96,115,118,137,151]. Appointment-making requirements might be narrow and hard for patients to fulfil-calling at certain times, with telephone-only systems, to monolingual staff-and the personal resources (knowledge, skills, confidence, language) needed to fulfil these expectations or to negotiate and persist in pursuit of the right appointment are unequally distributed or depleted by negative experiences with services [18,32,47,58,69,96,105,117,137]. ...
... Registration and appointment systems in general have been described as a "threat" ( [78], p.6) to some patients and a contributor to health inequalities [71,101,117]. By not attending in the past, patients are positioned as deviant or troublesome in the eyes of staff, creating "friction" ( [115], p.642) and many of the relational challenges above [19,35,36,40,68,69,96,115,118,137,151]. Appointment-making requirements might be narrow and hard for patients to fulfil-calling at certain times, with telephone-only systems, to monolingual staff-and the personal resources (knowledge, skills, confidence, language) needed to fulfil these expectations or to negotiate and persist in pursuit of the right appointment are unequally distributed or depleted by negative experiences with services [18,32,47,58,69,96,105,117,137]. ...
Background This protocol describes a realist review exploring the problem of “missingness” in healthcare, defined as the repeated tendency not to take up offers of care that has a negative impact on the person and their life chances. More specifically, the review looks at the phenomenon of patients missing multiple appointments in primary care in the UK – at the causal factors that influence how patients come to be “missing” in this way, and what interventions might support uptake and “presence” in healthcare. Background research informing this project suggests that a high rate of missed appointments predicted high premature death rates, and patients were more likely to have multiple long-term health conditions and experience significant socioeconomic disadvantage. Most research in this field focuses on population- or service-level characteristics of patients who miss appointments, often making no distinction between causes of single missed appointments and of multiple missed appointments. There have therefore been no interventions for ‘missingness’, accounting for the complex life circumstances or common mechanisms that cause people to repeatedly miss appointments. Methods We use a realist review approach to explore what causes missingness - and what might prevent or address it - for whom, and in what circumstances. The review uses an iterative approach of database searching, citation-tracking and sourcing grey literature, with selected articles providing insight into the causal dynamics underpinning missed appointments and the interventions designed to address them. Discussion The findings of this review will be combined with the findings of a qualitative empirical study and the contributions of a Stakeholder Advisory Group (STAG) to inform the development of a programme theory that seeks to explain how missingness occurs, whom it affects and under what circumstances. This will be used to develop a complex intervention to address multiple missed appointments in primary care. PROSPERO registration CRD42022346006
... Relational dynamics are refracted through wider life experiences and circumstances, and some may be particularly at risk of problematic relational or power dynamics and their impacts. Some patients may have experienced judgemental, punitive or stigmatising interactions with services, whether because of missed appointments or other aspects of their lives or identities [11,31,40,68,69,96,101,103,105,111,[113][114][115]. Stigma is part of fundamental causation because it increases exposure to identity-threatening encounters while reducing interpersonal power, making people less likely to be acknowledged or heard within them [116]. ...
... Registration and appointment systems in general have been described as a "threat" ( [78], p.6) to some patients and a contributor to health inequalities [71,101,117]. By not attending in the past, patients are positioned as deviant or troublesome in the eyes of staff, creating "friction" ( [115], p.642) and many of the relational challenges above [19,35,36,40,68,69,96,115,118,137,151]. Appointment-making requirements might be narrow and hard for patients to fulfil-calling at certain times, with telephone-only systems, to monolingual staff-and the personal resources (knowledge, skills, confidence, language) needed to fulfil these expectations or to negotiate and persist in pursuit of the right appointment are unequally distributed or depleted by negative experiences with services [18,32,47,58,69,96,105,117,137]. ...
... Registration and appointment systems in general have been described as a "threat" ( [78], p.6) to some patients and a contributor to health inequalities [71,101,117]. By not attending in the past, patients are positioned as deviant or troublesome in the eyes of staff, creating "friction" ( [115], p.642) and many of the relational challenges above [19,35,36,40,68,69,96,115,118,137,151]. Appointment-making requirements might be narrow and hard for patients to fulfil-calling at certain times, with telephone-only systems, to monolingual staff-and the personal resources (knowledge, skills, confidence, language) needed to fulfil these expectations or to negotiate and persist in pursuit of the right appointment are unequally distributed or depleted by negative experiences with services [18,32,47,58,69,96,105,117,137]. ...
Background
Although missed appointments in healthcare have been an area of concern for policy, practice and research, the primary focus has been on reducing single ‘situational’ missed appointments to the benefit of services. Little attention has been paid to the causes and consequences of more ‘enduring’ multiple missed appointments in primary care and the role this has in producing health inequalities.
Methods
We conducted a realist review of the literature on multiple missed appointments to identify the causes of ‘missingness.’ We searched multiple databases, carried out iterative citation-tracking on key papers on the topic of missed appointments and identified papers through searches of grey literature. We synthesised evidence from 197 papers, drawing on the theoretical frameworks of candidacy and fundamental causation.
Results
Missingness is caused by an overlapping set of complex factors, including patients not identifying a need for an appointment or feeling it is ‘for them’; appointments as sites of poor communication, power imbalance and relational threat; patients being exposed to competing demands, priorities and urgencies; issues of travel and mobility; and an absence of choice or flexibility in when, where and with whom appointments take place.
Conclusions
Interventions to address missingness at policy and practice levels should be theoretically informed, tailored to patients experiencing missingness and their identified needs and barriers; be cognisant of causal domains at multiple levels and address as many as practical; and be designed to increase safety for those seeking care.
... Likewise, 1 qualitative study from the U.K. identified issues such as competing priorities for patients, patient/staff relationships, and appointment booking systems. 15 Previous research has not focused specifically on the role of social and economic factors, particularly poverty and access to healthcare in a rural environment. For example, Martin et al 15 do not explicitly examine the experience of rural patients. ...
... 15 Previous research has not focused specifically on the role of social and economic factors, particularly poverty and access to healthcare in a rural environment. For example, Martin et al 15 do not explicitly examine the experience of rural patients. Further, while some studies on the patient perspective described their clinics as predominately serving low-income patients, 11,14 they lack detail on the context in which patients live and make decisions. ...
... Our theme of competing demands is similar, yet to not identical, to another qualitative study that found competing priorities, such as family or employment and increased forgetfulness about appointments. 15 Specifically, our findings illustrate the insufficiencies of both scheduling and transportation systems to meet patients' needs. Martin et al 15 had similar findings in relation to scheduling systems; appointment booking systems were a barrier to attendance. ...
Introduction
While evidence has been established on the impact of medical appointment non-attendance on the healthcare system and patient health, previous research has not focused on how poverty and rurality may influence patient experiences with non-attendance. This paper explores patient perceptions of non-attendance among those experiencing poverty in a rural U.S county to better inform providers to the context in which their patients make attendance-related decisions.
Methods
Using a grounded theory approach, we conducted semi-structured interviews with 32 U.S. low-income adults in the rural Western U.S. who recurrently missed primary care appointments. We also used a questionnaire to assess individual characteristics related to health, resiliency, personal mastery, medical mistrust, life chaos, and adverse childhood experiences.
Results
Participants identified 3 barriers to attending appointments: appointment disinterest, competing demands, and insufficient systems. Appointment disinterest stemmed from physical and mental health issues, misalignment between needs and treatment, and comfort with the provider. Competing demands included family responsibilities, employment, and relationships. Finally, participants reported that current scheduling and transportation systems were helpful but insufficient. To provide further context, participants also reported low overall health, moderate levels of medical mistrust, life chaos, and mastery, moderate to low resilience, and very a high number of adverse childhood experiences.
Conclusions
Results point to the need for modified structures that allow low-income patients more control over their personal health and highlight opportunities for clinics to address patients’ lack of interest and fear in the medical encounter.
... When a client does not attend his/her scheduled appointments, it is called a 'no show'. The consequences of non-attendance include increased appointment waiting times (Gucciardi, 2008), increased costs of care delivery (Murdock, Rodgers, Lindsay & Tham, 2002;Weinger, Lin, McMurrich & Rodriguez, 2005), under-utilisation of equipment and personnel (Murdock et al., 2002) reduced appointment availability (Martin, Perfect & Mantle, 2005;Weinger et al., 2005), reduced client satisfaction (Taylor, Ellis, & Gallagher,2002;Lloyd, Dillon & Hariharan, 2003), and negative relationships between clients and staff (Martin et al., 2005;Gucciardi, 2008). Although data on non-attendance varies, studies from around the world consistently report non-attendance rates between 15% and 30% in outpatient health clinics (Ulmer & Troxler, 2006;Taylor, Bottrell, Lawler & Benjamin, 2012). ...
... When a client does not attend his/her scheduled appointments, it is called a 'no show'. The consequences of non-attendance include increased appointment waiting times (Gucciardi, 2008), increased costs of care delivery (Murdock, Rodgers, Lindsay & Tham, 2002;Weinger, Lin, McMurrich & Rodriguez, 2005), under-utilisation of equipment and personnel (Murdock et al., 2002) reduced appointment availability (Martin, Perfect & Mantle, 2005;Weinger et al., 2005), reduced client satisfaction (Taylor, Ellis, & Gallagher,2002;Lloyd, Dillon & Hariharan, 2003), and negative relationships between clients and staff (Martin et al., 2005;Gucciardi, 2008). Although data on non-attendance varies, studies from around the world consistently report non-attendance rates between 15% and 30% in outpatient health clinics (Ulmer & Troxler, 2006;Taylor, Bottrell, Lawler & Benjamin, 2012). ...
... Multiple studies that have investigated the reasons for non-attendance reported forgetfulness, competing work or family-related commitments, poor health, poor client-provider relationships, adverse clinical experiences, practice error, and client confusion over dates and times, as the most frequent causes of non-attendance (Martin et al., 2005;Neal, Hussain-Gambles, Allgar, Lawlor & Dempsey, 2005;Crosby et al., 2009). Some of these causes could potentially be averted -particularly practice error and client confusion over dates and times if a reminder service were implemented. ...
... A variety of factors were found effective on patient's attendance in paediatric urology unit (Bush et al., 2014), pulmonary rehabilitation (Hayton et al., 2013;Sabit et al., 2008), psychiatric (Killaspy et al., 2000;Mitchell & Selmes, 2007a, 2007b and HIV (Catz et al., 1999), primary care (Giunta et al., 2013), inpatient and outpatient in the hospital (Shahriar Tavakoli-Tabasi, 2015) through analysing multiple correlation from hospital administrative database. A few studies also used survey and interviews to explore and compare the views of patient and health professionals on the reasons for nonattendance (Harte et al., 2018;Husain-Gambles et al., 2004;Lawson et al., 2005;Martin et al., 2005). The factors relate to inaccessibility, including physical location (Lasser et al., 2005), opening hours and days (Chariatte et al., 2007), and barriers such as language, stigma and cultural differences (Burns et al., 2007;Franks et al., 2007) may all be important. ...
... The factors relate to inaccessibility, including physical location (Lasser et al., 2005), opening hours and days (Chariatte et al., 2007), and barriers such as language, stigma and cultural differences (Burns et al., 2007;Franks et al., 2007) may all be important. However, the interplay between the accessibility of a service and the perceived worthiness of the attendee, or "candidacy", competing priorities (Harte et al., 2018;Mackenzie et al., 2013;Martin et al., 2005;Woods et al., 2005) (both self-perceived and as perceived by the service provider) can also lead to differences in how likely particular groups are to "get into, through and on" with services (Rosengard et al., 2007). ...
... The non-attendance in primary care (Giunta et al., 2013), hospital inpatient and outpatient from all specialities (Shahriar Tavakoli-Tabasi, 2015) are studied focusing on single missed appointment. Factors are reported to be associated with age, sex, transport logistics, and clinic or practitioner factors such as booking efficiency and the rapport between staff and patients (Lawson et al., 2005;Martin et al., 2005;Murdock et al., 2002;Neal et al., 2005;Nielsen et al., 2008;Waller & Hodgkin, 2000). Williamson et al. (Williamson et al., 2017) and Ellis et al. (Ellis et al., 2017) focused on the patient demographics and practice factors that predict serial missed appointments in general practice. ...
The hospital outpatient non-attendance imposes a substantial financial burden on hospitals and roots in multiple diverse reasons. This research aims to build an advanced predictive model for predicting non-attendance regarding the whole spectrum of probable contributing factors to non-attendance that could be collated from heterogeneous sources including electronic patients records and external non-hospital data. We proposed a new non-attendance prediction model based on deep neural networks and machine learning models. The proposed approach works upon sparse stacked denoising autoencoders (SDAEs) to learn the underlying manifold of data and thereby compacting information and providing a better representation that can be utilised afterwards by other learning models as well. The proposed approach is evaluated over real hospital data and compared with several well-known and scalable machine learning models. The evaluation results reveal the proposed approach with softmax layer and logistic regression outperforms other methods in practice.
... 6 Reception teams feel the impact of DNAs on capacity most acutely, as they try to fit patients in to scarce appointments. 7 Many GPs, however, might challenge the assertion that all DNAs represent 'waste' -the time is filled with other work, particularly when the DNA occurs late in a surgery session. 7 In addition, DNAs can be an indicator of patient risk -for example, they could serve as a pointer to possible neglect of a child repeatedly not brought to appointments. ...
... 7 Many GPs, however, might challenge the assertion that all DNAs represent 'waste' -the time is filled with other work, particularly when the DNA occurs late in a surgery session. 7 In addition, DNAs can be an indicator of patient risk -for example, they could serve as a pointer to possible neglect of a child repeatedly not brought to appointments. There are also vulnerable patients, for whom a missed appointment may trigger a proactive check on welfare. 1 Patients report competing demands that influence their attendance at the surgery: fitting appointments around work and family commitments, difficulty getting an appointment, and long wait times are reported as factors influencing nonattendance. ...
... There are also vulnerable patients, for whom a missed appointment may trigger a proactive check on welfare. 1 Patients report competing demands that influence their attendance at the surgery: fitting appointments around work and family commitments, difficulty getting an appointment, and long wait times are reported as factors influencing nonattendance. 7,8 Further, busy telephone lines have been reported to act as a barrier to cancelling appointments. 7,8 Viewed from a systems perspective, the percentage of DNAs is a useful indicator of the 'health' of an appointment system. ...
Background
Missed appointments are common in primary care, contributing to reduced clinical capacity. NHS England has estimated that there are 7.2 million missed general practice appointments annually, at a cost of £216 million. Reducing these numbers is important for an efficient primary care sector.
Aim
To evaluate the impact of a system-wide quality improvement (QI) programme on the rates of missed GP appointments, and to identify effective practice interventions.
Design and setting
Practices within a clinical commissioning group (CCG) in East London, with an ethnically diverse and socially deprived population.
Method
Study practices engaged in a generic QI programme, which included sharing data on appointment systems and Did Not Attend (DNA) rates. Fourteen out of 25 practices implemented DNA reduction projects, supported by practice-based coaching. Appointment data were collected from practice electronic health records. Evaluation included comparisons of DNA rates pre- and post-intervention using interrupted times series analysis.
Results
In total, 25 out of 32 practices engaged with the programme. The mean DNA rate at baseline was 7% (range 2–12%); 2 years later the generic intervention DNA rates were 5.2%. This equates to a reduction of 4030 missed appointments. The most effective practice intervention was to reduce the forward booking time to 1 day. The practice that made this change reduced its mean DNA rate from 7.8% to 3.9%.
Conclusion
Forward booking time in days is the best predictor of practice DNA rates. Sharing appointment data produced a significant reduction in missed appointments, and behaviour change interventions with patients had a modest additional impact; in contrast, introducing structural change to the appointment system effectively reduced DNA rates. To reduce non-attendance, it appears that the appointment system needs to change, not the patient.
... 5 Segundo a literatura, os principais motivos apresentados para a falta a uma consulta são o esquecimento, 2,5-7,10 a incompatibilidade de horários e a incompatibilidade laboral. [5][6][7]10 O perfil do utente que falta tende a ser mais jovem, 1-2,7-8,10 desempregado 2,10 e de classes socioeconómicas mais baixas. 2,7 Quanto ao sexo não existe concordância entre estudos. ...
... 7 Estudos sugeriram o pagamento de uma penalização pela falta; contudo, verificou-se que o número de faltas em países como os Estados Unidos, onde a maioria das consultas envolve custos financeiros para o utente, é idêntico. 6 Nem todos as faltas são por esquecimento, existindo razões que de facto impossibilitam o doente de se deslocar à unidade de saúde. 2 É importante o reforço da educação para a saúde dos utentes, utilizando informação de fácil compreensão, promovendo conhecimento e evolução de situações autolimitadas e de situações que não constituam motivos que necessitem de agendamento. É ainda importante relembrar as pessoas que existem diferentes tipos de consulta com diferentes regras de agendamento, permitindo uma melhor utilização das diversas tipologias, um correto acompanhamento médico e, consequentemente, um benefício na sua saúde. ...
Introdução:
A informação sobre faltas às consultas de medicina geral e familiar (MGF) é escassa em Portugal.
Objetivos:
Estudar os motivos de falta a consultas de MGF em três Unidades de Saúde Familiar no centro de Portugal, em 2022, segundo as variáveis de contexto sexo, grupo etário, índice de Graffar, tempo decorrido desde a marcação e slot horário da consulta.
Métodos:
Estudo observacional transversal no centro de Portugal, realizado após parecer positivo da Comissão de Ética, com recolha, em anonimato, dos dados de utentes com consulta agendada e não realizada de maio a julho de 2022, através de entrevista telefónica efetuada por um médico interno de MGF de cada unidade, no mês de agosto. Após introdução, garantido o anonimato, era questionado há quanto tempo tinha realizado o agendamento e o motivo da falta à consulta.
Resultados:
Foram contactados 617 utentes que faltaram nos meses de maio a julho de 2022, tendo-se obtido 455 (73,7%) respostas. Os motivos mais frequentes foram esquecimento (27,6%), dificuldades de transporte e problema já solucionado (8,9% para cada) e “julgar o motivo já não merecer consulta” (8,1%). Em função das variáveis de contexto verificou-se diferença significativa para “há quanto tempo tinha marcado a consulta” (p<0,001) e não significativa para sexo (p=0,721), grupo etário (p=0,765), índice de Graffar (p=0,084) e slot horário (p=0,084). O grupo “outros motivos” teve prevalência de 42,8%, revelando diferença não significativa para as variáveis consideradas.
Discussão:
A compreensão das razões para a falta à consulta agendada implica a verificação das razões pelo utente, permitindo ao prestador adotar atitudes pró-ativas para a resolução do acesso.
Conclusão:
O esquecimento, as dificuldades de transporte e o problema já ter sido solucionado foram os motivos de falta a consultas mais frequentes na população em estudo.
... Human tuberculosis (TB), although an ancient disease, has re-emerged with devastating consequences on global public health and is currently one of the most widespread infectious diseases. In addition, it is the leading cause of death due to a single infectious agent among human adults in the world [20]. Tuberculosis is caused by members of the Mycobacterium tuberculosis complex (MTC), which includes Mycobacterium tuberculosis, Mycobacterium bovis, Mycobacterium africanum, Mycobacterium caprae, Mycobacterium microti, Mycobacterium pinnipedii and Mycobacterium canettii [20]. ...
... In addition, it is the leading cause of death due to a single infectious agent among human adults in the world [20]. Tuberculosis is caused by members of the Mycobacterium tuberculosis complex (MTC), which includes Mycobacterium tuberculosis, Mycobacterium bovis, Mycobacterium africanum, Mycobacterium caprae, Mycobacterium microti, Mycobacterium pinnipedii and Mycobacterium canettii [20]. Approximately one third of the world's population is infected with bacteria belonging to the MTC complex, with Sub-Saharan Africa having the highest annual incidence since the advent of HIV and AIDS [21]. ...
Tuberculosis (TB) is a disease that reappears after they have been on a significant decline occurring worldwide and a source of multi-billion- dollar loss and human fatality yearly. The situation is worse in developing countries like Somalia, where lower knowledge, attitude, and practice (KAP) of the people is impending. A cross sectional survey was conducted between January 2022 and June 2022 to assess the knowledge, attitude and practices towards tuberculosis among 171 household heads in Wadajir district Mogadishu, Somalia. A structured questionnaire was designed, pretested and self-administered to household heads. Human TB was recognized by 157(91.8 %) of household heads, while only 34(19.9%) had heard of animal TB. In the present study, 121(70.8%) of household heads had not considered bovine Tb as zoonosis. Majorities of respondents indicated that they have acquired the awareness about TB from Family/neighbors that accounts for about 80(46.8%), and only 38(22.2%) of them got information from radio/TV. Knowledge on the infectious cause of human and animal TB was known by 4.7%. However, misperceptions such as weather and toxins were also implicated as causes of human TB. In the present study, a significant proportion (48.5%) of the study population used to consume raw milk that was studied as the sources of infection to TB. Herein, the majority of household heads have indicated inhalation (57.3%) and contacts (23.4%) as means of transmission of human tuberculosis and only (15.7%) of respondents mentioned consuming raw animal products. In conclusion, as the bovine tuberculosis is less aware as well as misperception about cause, ways of transmission and prevention towards human tuberculosis on household heads. Thus, it is highly necessary to convey public health education to assemble public awareness about the transmission, etiology, predisposing factors of infection and its prevention and control in the study area.
... Patients in the KGH reported that nurse patient relationships have encouraged their continued attendance to the hospital. Patient and health care workers' relationship is paramount in encouraging patients to attend their scheduled appointments [17] as patients look forward to having a fulfilling interaction with healthcare service providers. However, some patients would not come to the KGH because they have not had a good relationship with the nurse as they contend that the nurses shout at them or the nurses were disrespectful or did not attend to them promptly when they needed their services. ...
... Patients' perceptions of the received care have been found to contribute to the quality of care [18]. Due to fear of being embarrassed by nurses, patients opt out to attend hospitals for health services [17,19]. The general disregard to human dignity irrespective of the circumstance can adversely affect the resulting behaviour of the person even when sick. ...
Background
The relationship of nurses and patients in healthcare settings has been central in ensuring good and efficient healthcare delivery. The total hospital attendance in the Kwahu Government Hospital have reduced in recent years. The study explored patients’ perceptions of the nurse-patient relationship and its influence on hospital attendance at the Kwahu Government Hospital.
Methods
A phenomenological qualitative study design, with a purposive sampling technique, was used to interview ten participants from the various wards in the hospital on their perceptions of the nurse patient relationship and its influence on hospital attendance. The data were transcribed and analysed using a thematic content analysis approach that embraces three interrelated stages, namely data reduction, data display, and data conclusion drawing.
Results
Many of the participants had positive perceptions regarding the attitude of nurses, and that influenced hospital attendance while others opined that nurses’ attitudes towards them made them attend a private facility. Almost all the participants suggested that patients should exhibit an equally good attitude and behaviour towards nurses, and better communication between patients and nurses as vital ways of improving the nurse-patient relationship. Nurses in the Kwahu Government Hospital are described as friendly, respectful and attend promptly to patient health care needs adequately. The range of perceived respect differed from patient to patient and include the nurse called patient by name, respond promptly to patient needs, helped “helpless patients” to feed and also assisted them change diapers, listen to patient concerns, linked patient to other professionals, work within the cultural context of hierarchy and that the nurse is sociable and interacted with patient positively.
Conclusion
Hospital management should conduct regular evaluations of patients' experiences as well as nurses’ experiences to address deficiencies in communication and nurse-patient interactions.
... Providing services in the afternoon can be a solution to this problem. This was one of the reasons why people turned to the private sector, which was in line with Martin's study [30]. ...
... For instance, these people expect to be examined privately and receive the necessary information about their illness and manner of their own treatment. In other studies, the reasons for not visiting a specialist were different on the part of people of different age groups and different level of education [27,30]. The job variable was also signi cantly related to the reasons for not visiting specialists. ...
Background
Utilizing electronic referral (eReferral) system while enhancing the efficiency and quality of medical services may improve the access level to specialized services and reduce patients' wait times; however, some patients do not follow the the eReferral system guidelines. The present study aims at figuring out why outpatients referred by family physicians to specialists do not visit specialists.
Methods
The present cross-sectional study was conducted in the hospitals wherein eReferral system was implemented as a pilot plan in the calendar year started on 21 March 2019. The sampling was done in two phases: 1) proportionate stratified sampling method, and 2) systematic random sampling. The first, 429 patients were selected. These patients were referred by a rural family physician (FP) to a specialist in the district hospital, but despite appointment made for them by the relevant FP, they had not visited specialists. Then, data was collected using a self-made questionnaire whose validity and reliability were confirmed (α = 0.90). Descriptive statistical methods were used to describe the data and analytical methods, i.e. Spearman, Mann-Whitney and Croscal Wallis correlation tests were also conducted. Data analysis was performed using SPSS 16 at a significant level of 0.05.
Findings
: Most of the participants (54.7%) were female, 43.4% were in the age group of 30–60, 81.6% were married, 26.4% had high school diploma, 47.2% were housewives, 81.6% were rural residents. Among the dimensions of the reasons why patients did not visit specialists, the clinic conditions (3.26 ± 0.74), side expenditures (2.51 ± 0.74), admission and queuing system (2.45 ± 0.70) accounted for the highest average score, respectively. There was significant relationship between age groups, marital status, level of education, occupation, place of residence and type of insurance (p < 0.05), but no significant relationship was observed between them and gender (p > 0.05).
Conclusion
Reducing patient wait times in the clinic, providing patients with appropriate guidance, enhancing patients’ freedom to determine the time to visit specialists, training physicians to communicate with patients properly, reassuring and reducing costs were of great importance to encourage receiving outpatient services within the framework of eReferral system.
... According to the Kenya Demographic and Health Survey (KDHS) report of 2014 [4], only 51% of the 39% of women who delivered at home sought postnatal care services at the health facility within 48 hours post-delivery and data from the Kenya District Health Information System (DHIS), 2015, showed that nationally, postnatal care coverage was only 53% and 55% for Nairobi County. Low uptake of PNC services has also been experienced in other countries like Pakistan where about 23% of women seek the services post-delivery [4][5]. There is no recent documentation in Kenya on the proportion of women who attend postnatal care clinics at twoweeks and four to six-weeks postpartum. ...
... Documentation from various studies conducted in other countries have shown that patients cite reasons like forgetting date, time and place/location of the clinic as a reason for failing-to-attend their scheduled clinics [5][6][7][8][9]. Some strategies developed to mitigate the challenges include use of innovative technologies such as short message service (SMS), telephone calls, e-mail reminders, fax services or sending letters. ...
Introduction: Globally about 830 women die daily due to complications of pregnancy and child birth out of which 550 occur in Sub-Saharan Africa, with about 8,000 maternal deaths occurring annually in Kenya. 66% of maternal deaths occur within the first week and 85% of maternal deaths occur within two weeks post-delivery. Attendance of postnatal services during this time could significantly reduce morbidity and mortality. We determined effectiveness of short text message (SMS) in reducing failure-to-attend rates (FTA) of postnatal clinic at the largest maternity hospital in Nairobi, Kenya. Methods: We conducted a hospital-based randomised controlled trial. Women who delivered between March and May 2016 at Pumwani Maternity Hospital were recruited, enrolled and randomised into SMS (intervention) or no SMS (control) arms. Women were masked to which arm they belonged during randomisation but were unmasked during the appointments as the intervention had been sent. The investigators were not masked. Reminders were sent three days prior to and on the morning of the appointment. Relative Risk (RR) at 95% Confidence Interval were calculated to estimate the effectiveness of intervention at two and six-weeks. Results: We enrolled 754 women, with 377 randomly assigned into each arm. There were no differences in socio-demographic characteristics between the study arms at baseline. After two-weeks, women in the intervention arm had an 80% reduction in FTA risk (RR=0.2, 95% CI 0.1-0.3). After six weeks, women in the intervention arm had a 60% reduction in FTA risk (RR=0.4, 95% CI 0.2-0.6). Among participants, 80 (42.1%) women at two-weeks and 30 (41.7%) women at six-weeks cited forgetting appointment as the most common reason for failing to attend postnatal clinic. Conclusion: SMS reminders were effective in reducing failure-to-attend clinic appointments. We recommend the use of SMS reminder strategy for postnatal care.
... According to the Kenya Demographic and Health Survey (KDHS) report of 2014 [4], only 51% of the 39% of women who delivered at home sought postnatal care services at the health facility within 48 hours post-delivery and data from the Kenya District Health Information System (DHIS), 2015, showed that nationally, postnatal care coverage was only 53% and 55% for Nairobi County. Low uptake of PNC services has also been experienced in other countries like Pakistan where about 23% of women seek the services post-delivery [4][5]. There is no recent documentation in Kenya on the proportion of women who attend postnatal care clinics at twoweeks and four to six-weeks postpartum. ...
... Documentation from various studies conducted in other countries have shown that patients cite reasons like forgetting date, time and place/location of the clinic as a reason for failing-to-attend their scheduled clinics [5][6][7][8][9]. Some strategies developed to mitigate the challenges include use of innovative technologies such as short message service (SMS), telephone calls, e-mail reminders, fax services or sending letters. ...
Introduction: Globally about 830 women die daily due to complications of pregnancy and child birth out of which 550 occur in Sub-Saharan Africa, with about 8,000 maternal deaths occurring annually in Kenya. 66% of maternal deaths occur within the first week and 85% of maternal deaths occur within two weeks post-delivery. Attendance of postnatal services during this time could significantly reduce morbidity and mortality. We determined effectiveness of short text message (SMS) in reducing failure-to-attend rates (FTA) of postnatal clinic at the largest maternity hospital in Nairobi, Kenya. Methods: We conducted a hospital-based randomised controlled trial. Women who delivered between March and May 2016 at Pumwani Maternity Hospital were recruited, enrolled and randomised into SMS (intervention) or no SMS (control) arms. Women were masked to which arm they belonged during randomisation but were unmasked during the appointments as the intervention had been sent. The investigators were not masked. Reminders were sent three days prior to and on the morning of the appointment. Relative Risk (RR) at 95% Confidence Interval were calculated to estimate the effectiveness of intervention at two and six-weeks. Results: We enrolled 754 women, with 377 randomly assigned into each arm. There were no differences in socio-demographic characteristics between the study arms at baseline. After two-weeks, women in the intervention arm had an 80% reduction in FTA risk (RR=0.2, 95% CI 0.1-0.3). After six weeks, women in the intervention arm had a 60% reduction in FTA risk (RR=0.4, 95% CI 0.2-0.6). Among participants, 80 (42.1%) women at two-weeks and 30 (41.7%) women at six-weeks cited forgetting appointment as the most common reason for failing to attend postnatal clinic. Conclusion: SMS reminders were effective in reducing failure-to-attend clinic appointments. We recommend the use of SMS reminder strategy for postnatal care.
... In their survey study, Martin, Perfect and Mantle reported that healthcare personnel feel that patients do not show up due to personal reasons like other commitments [7]. On the patients' side, some reasons cited include a long wait to see their preferred doctor and difficulty in telephone communication with clinics [7]. ...
... In their survey study, Martin, Perfect and Mantle reported that healthcare personnel feel that patients do not show up due to personal reasons like other commitments [7]. On the patients' side, some reasons cited include a long wait to see their preferred doctor and difficulty in telephone communication with clinics [7]. In order to alleviate the effects of patient no-show, overbooking patients is a common adopted algorithm in many clinics' booking systems. ...
In this paper, we predict patient no-show using a random forest model. To mitigate the effects of patient no-show, we propose a predictive overbooking algorithm as a strategy. The overbooking algorithm was simulated using a single server queue model in which patient appointments for a specific timeslot were scheduled in advanced, based on the probability of no-shows for that day. The focus of this paper was to evaluate our proposed overbooking algorithm compared to the reference scenario of no overbooking, as well as blind overbooking, commonly applied today.
The criteria used for evaluation of the three methods was clinic efficiency and clinic profitability. Our findings conclude that predictive overbooking brings about significant improvements in several aspects of clinic efficiency as compared to both no overbooking and blind overbooking. We also observed a significant increase in clinic profits in the simulation of predictive overbooking compared to no overbooking and blind overbooking.
... Health care scheduling is an issue that is too often overlooked and can impede program success if it is not patient-friendly. 6,7 Respondents highly valued having low-barrier access to care with seamless appointment booking procedures and convenient appointment times. A survey conducted to assess employee willingness for pharmacist-led practice Brief preventive health services supported appointment lengths ranging from 15 to 45 minutes, depending on employeespecific needs. ...
... The relationships with the administrative staff along with the practitioner have been cited as perceived barriers for patients gaining access to primary care services. 7 Following the check-in process with the receptionist, all respondents agreed their wait time was reasonable, which is an important factor, as existing data have solidified that long wait times to see a primary care practitioner act as a barrier to accessing appropriate care. 10 Modern pharmacist practice requires a patient-centred approach and patient partnerships. ...
... 4 Algumas das razões encontradas para a não utilização dos cuidados de saúde primários são: a mudança de morada; a consulta médica disponibilizada pelo local de trabalho; o medo de ser diagnosticado algum problema grave; a pouca confiança nos rastreios populacionais; terem melhor sensação de saúde; o reconhecimento por parte dos utentes que não têm hábitos saudáveis e não quererem mudá-los; as crenças e medos pessoais; a procura de aconselhamento com um farmacêutico; a preferência em consultar um especialista numa área específica em vez de um médico de medicina geral e familiar; uma relação médico-doente insatisfatória. 3,[10][11][14][15] Além do prejuízo para a própria saúde, pela interrupção na continuidade dos cuidados que lhe são pres-tados, a população de hipoutilizadores, pela não comparência às consultas, é responsável por tempos de consulta perdidos, prejudicando o acesso de outros utentes aos cuidados de saúde primários e implicando gastos em saúde. 12,[16][17][18][19] Os autores da presente investigação pretendem caracterizar o perfil sociodemográfico e clínico, bem como os motivos da não utilização da consulta médica presencial numa Unidade de Saúde Familiar na cidade do Porto -a Unidade de Saúde Familiar Arca D'Água (USF AA). ...
Introdução: A não utilização dos cuidados de saúde primários é problemática, especialmente pela ausência de vigilância do hipoutilizador. Reduzida frequência em consultas com o médico de família impede realização de rastreios, deteção precoce/prevenção de patologias e controlo adequado de doenças crónicas. Objetivos: Caracterizar o perfil sociodemográfico e clínico e os motivos da população hipoutilizadora da consulta médica numa unidade de saúde familiar. Métodos: Selecionaram-se todos os utentes com 18 ou mais anos que não utilizaram a consulta nos últimos três anos. A recolha de dados foi realizada primeiramente via questionário telefónico para traçar o perfil sociodemográfico e clínico. Posteriormente, via e-mail, foi aplicado um segundo questionário relativo aos motivos. Resultados: Dos 1.182 indivíduos foram estudados 413 quanto ao perfil sociodemográfico e clínico. Os hipoutilizadores possuíam uma idade média de 47 anos. A maioria pertencia ao sexo masculino (60,8%), tinha curso superior (59,8%), emprego ativo (71,2%) e era saudável (62,7%). A patologia mais prevalente era a hipertensão arterial (10,4%). Os indivíduos com doença crónica eram mais velhos (p<0,001 e p=0,004, respetivamente). Verificou-se que uma maior proporção de mulheres tinha diabetes mellitus (p=0,009), dislipidemia (p=0,048) e ansiedade generalizada (p=0,016). Apenas 119 responderam ao segundo questionário. Referiram sentir-se saudáveis 74%, 49% admitiram acompanhamento noutra especialidade no setor público/privado e 28% confessaram uma insuficiente relação com o médico de família. Conclusão: O hipoutilizador típico pertence ao género masculino, quinta década de vida, com curso superior, profissionalmente ativo, saudável. A hipoutilização da consulta médica pode dever-se a uma menor noção de risco pessoal de doença ou maior noção de literacia em saúde entre estes utentes, ou a uma maior oportunidade/acesso a consulta no setor privado. Verificou-se a necessidade de investir em medidas para aumentar a adesão destes utentes, como formações em comunicação para a equipa médica.
... In contrast to studies conducted before, which found sociodemographic characteristics like health literacy, race, or socioeconomic status to be predictive of visit non-attendance, our study highlighted the role played by psychological factors, such as increased anxiety and depressive symptoms. 3,21 After controlling for relevant covariates, we found that only greater anxiety symptoms were consistently associated with canceling or missing medical appointments due to COVID-19 across nearly all surveys. ...
Introduction
Missed visits have been estimated to cost the U.S. healthcare system $50 billion annually and have been linked to healthcare inefficiency, higher rates of emergency department visits, and worse outcomes. COVID-19 disrupted existing outpatient healthcare utilization patterns. In our study, we sought to examine the frequency of missed outpatient visits over the course of the COVID-19 pandemic and to examine patient-level characteristics associated with non-attendance.
Methods
This study utilized data from a longitudinal cohort study (the Chicago COVID-19 Comorbidities (C3) study). C3 participants were enrollees in 1 of 4 active, “parent” studies; they were rapidly enrolled in C3 at the onset of the pandemic. Multiple waves of telephone-based interviews were conducted to collect experiences with the pandemic, as well as socio-demographic and health characteristics, health literacy, patient activation, and depressive and anxiety symptoms. For the current analysis, data from waves 3 to 8 (05/01/20-05/19/22) were analyzed. Participants included 845 English or Spanish-speaking adults with 1 or more chronic conditions.
Results
The percentage of participants reporting missed visits due to COVID-19 across study waves ranged from 3.1 to 22.4%. Overall, there was a decline in missed visits over time. No participant sociodemographic or health characteristic was consistently associated with missed visits across the study waves. In bivariate and multivariate analysis, only patient-reported anxiety was significantly associated with missed visits across all study waves.
Conclusion
Findings reveal that anxiety was consistently associated with missed visits during the COVID-19 pandemic, but not sociodemographic or health characteristics. Results can inform future public health initiatives to reduce absenteeism by considering patients’ emotional state during times of uncertainty.
... It has been found that the non-attended appointments in health care facilities create a disruption in the planned schedule and wastes resources, resulting in inefficiencies and a loss of clinical productivity. 1 This problem is not only a concern in private practices but more so at educational institutions as students rely on patient attendance to fulfil curriculum requirements and academic competency. Patients miss their appointments for various reasons and will either cancel their appointment ahead of time, or by not attending their appointment on the day. ...
Aims
To investigate the non-attendance of patients at orthodontic appointments and to determine related reasons.
Methods
Appointment data were collected from the Faculty of Dentistry, University of Otago between August and October in 2013 (paper-appointment system using post letters) and 2019 (digital-appointment system using automatically generated short message service (SMS) texts before the Covid-19 pandemic). The demographic and time characteristics of patients who attended and failed their appointments were collected for statistical analysis.
Results
The total number of appointments was 5810, including 2761 by 1901 patients in 2013 and 3049 by 2009 patients in 2019. The overall fail to attend (FTA) rates were 16.1% in 2013 and 12.9% in 2019. Morning appointments showed a higher failure rate (16.0% in 2013 and 14.2% in 2019) than the afternoon appointments (12.1% in 2013 and 11.1% in 2019) ( p < 0.05). Bonding appointments had a significantly lower failure rate (6.2%) compared with other treatment procedures with an attendance rate of 93.8% ( p < 0.05). People living between the 901 and 950 (higher socioeconomic status, SES) suburb index were 1.5 times less likely to fail compared with people living in other categories ( p < 0.05).
Conclusion
The fail to attend (FTA) of orthodontic appointments was approximately 15% in the Otago University Orthodontic Clinic, New Zealand. Patients from lower SES, Māori and Pasifika peoples, and morning appointments had higher FTA rates. Bonding appointments had the lowest FTA rate. FTA significantly decreased after the introduction of a SMS text reminder system. An effort is still required to improve the orthodontic attendance rate, and future studies could consider investigating the digital reminder systems, such as smart phone apps, to enhance clinical attendance in the electronic age.
... The problem of non-attendance can be attributed to numerous reasons including physical barriers to access (e.g., lack of affordable transportation [6], absence of childcare [7]), opportunity cost (e.g., the time required to seek care), and patient forgetfulness [8]. Moreover, behavioural science indicates that often patients do not behave in the way we would expect, and that behavioural factors such as limited attention, cognitive overload, and avoidance can impede timely care seeking and influence motivation to honour appointments. ...
Background
Appointment non-attendance – often referred to as “missed appointments”, “patient no-show”, or “did not attend (DNA)” – causes volatility in health systems around the world. Of the different approaches that can be adopted to reduce patient non-attendance, behavioural economics-oriented mechanisms (i.e., psychological, cognitive, emotional, and social factors that may impact individual decisions) are reasoned to be better suited in such contexts – where the need is to persuade, nudge, and/ or incentivize patients to honour their scheduled appointment. The aim of this systematic literature review is to identify and summarize the published evidence on the use and effectiveness of behavioural economic interventions to reduce no-shows for health care appointments.
Methods
We systematically searched four databases (PubMed/Medline, Embase, Scopus, and Web of Science) for published and grey literature on behavioural economic strategies to reduce no-shows for health care appointments. Eligible studies met four criteria for inclusion; they were (1) available in English, Spanish, or French, (2) assessed behavioural economics interventions, (3) objectively measured a behavioural outcome (as opposed to attitudes or preferences), and (4) used a randomized and controlled or quasi-experimental study design.
Results
Our initial search of the five databases identified 1,225 articles. After screening studies for inclusion criteria and assessing risk of bias, 61 studies were included in our final analysis. Data was extracted using a predefined 19-item extraction matrix. All studies assessed ambulatory or outpatient care services, although a variety of hospital departments or appointment types. The most common behaviour change intervention assessed was the use of reminders (n = 56). Results were mixed regarding the most effective methods of delivering reminders. There is significant evidence supporting the effectiveness of reminders (either by SMS, telephone, or mail) across various settings. However, there is a lack of evidence regarding alternative interventions and efforts to address other heuristics, leaving a majority of behavioural economic approaches unused and unassessed.
Conclusion
The studies in our review reflect a lack of diversity in intervention approaches but point to the effectiveness of reminder systems in reducing no-show rates across a variety of medical departments. We recommend future studies to test alternative behavioural economic interventions that have not been used, tested, and/or published before.
... Caregivers placed responsibility on services for encouraging engagement and access, in contrast to research on service perspectives, where engagement difficulties are often framed within an individual's choices and perceptions of services (Martin et al., 2005;Starke, 2011). Having a trusting therapeutic relationship with professionals was highlighted as important caregivers in the current study. ...
Autistic individuals with intellectual disability are at greater risk of experiencing anxiety than their non-autistic peers without intellectual disability. Anxiety in this group may present as behaviour that challenges, often leading families to reach out to healthcare or support services. However, many families experience difficulties accessing services and, due to the lack of research into evidence-based anxiety interventions for people with intellectual disability, may not receive individualised support once in a service. This study explored caregivers’ experiences of accessing services for autistic individuals with intellectual disability, and their considerations when developing new interventions for this population. Interviews and focus groups were completed with 16 caregivers of autistic people with intellectual disability. Reflexive thematic analysis was used to develop five themes about service access experiences, and three themes about caregiver considerations for anxiety interventions. Caregivers reported that their experiences of accessing services did not meet their expectations, and considerations for future anxiety interventions were often reflective of this. Interventions being flexible to family circumstances to aid accessibility, the embedding of peer support in services, and skills that can be generalised across the lifespan could be applied when aiming to improve outcomes and develop interventions for this under-served population.
Lay Abstract
Many autistic individuals with intellectual disability experience anxiety, and for those who use few or no words, anxiety may present as behaviour that challenges, such as self-injury and avoiding anxiety-provoking situations. Families report difficulty accessing support from services for autistic individuals experiencing anxiety. Moreover, once receiving support, effective interventions for autistic people with intellectual disability are limited. We completed individual and group discussions with 16 caregivers of autistic people with intellectual disability, to (a) explore their experiences of accessing services for anxiety and/or behaviour that challenges for their child; and (b) understand what matters to caregivers when developing interventions that have been designed for them and the autistic individual with intellectual disability that they support. Caregivers reported that services, in their experience, did not deliver the support that they expected, and that they often needed to ‘fight’ for support. Caregivers considered services and families working together, the inclusion of peer support, and families being offered interventions that are flexible to individual circumstances to be important. These considerations are valuable for clinicians and researchers developing interventions and aiming to improve outcomes for autistic people with intellectual disability and their families.
... However, in this case, the HCPs registered the patient as 'invited but did not attend. The inefficiency of appointment booking systems was highlighted in another study that explored the views of patients and practices on non-attendance causes in NHS primary care (Martin et al., 2005). Furthermore, there is strong evidence that reminder systems effectively reduce non-attendance at appointments across diverse service contexts and patient populations (McLean et al., 2016). ...
Background:
Lumbar disc disease is a leading cause of low back pain. Lumbar discectomy (LD) may be indicated if symptoms are not managed conservatively. Rehabilitation has traditionally been delivered postoperatively; however, there is increasing delivery preoperatively. There are few data concerning perceptions and experiences of preoperative rehabilitation. Exploring experiences of preoperative rehabilitation may help in the development and delivery of effective care for patients.
Objectives:
To develop an understanding of patient and healthcare provider (HCP) experiences, perspectives and preferences of preoperative LD rehabilitation, including why patients do not attend.
Design:
A qualitative interpretive approach using focus groups and individual interviews.
Methods:
Data were collected from; a) patients listed for surgery and attended the preoperative rehabilitation (October 2019 to March 2020), b) patients listed for surgery but did not attend rehabilitation, and c) HCPs involved in the delivery of rehabilitation. Data were transcribed verbatim and analysed using thematic analysis.
Results/findings:
Twenty participants were included, twelve patients and eight HCPs. The preoperative class was a valuable service for both patients and HCPs. It provided a solution to staffing and time pressures. It provided the required education and exercise content helping the patients along their surgery pathway. Travel distance, transportation links, parking difficulty and cost, lack of knowledge about the class aims, and previous negative experiences were barriers to patient attendance.
Conclusions:
For most patients and HCPs, the preoperative class was valuable. Addressing the challenges and barriers could improve attendance. Future research should focus on management of patient expectations and preferences preoperatively.
... First order No-Show behaviour studies Cervical cancer screening studies 5 Work Commitments (Alanazy et al., 2019;Alderson et al., 2021;Britton & Robinson, 2016;Cameron et al., 2014;Chamberlin et al., 2021;Cibulka et al., 2012;Copeland et al., 2017;Eades & Alexander, 2019;Feitsma et al., 2012;French et al., 2017;Klatte et al., 2019;Lam et al., 2016;Ofei-Dodoo et al., 2019;Saleh et al., 2021;Sinclair & Alexander, 2012;Touch & Berg, 2016;Wolf et al., 2020;Zanardelli & Robinson, 2019) (Christie- de Jong & Reilly, 2020;Matenge & Mash, 2018;Vasudevan et al., 2020) Barriers Service delivery 6 Bad experiences with service delivery (Ballantyne et al., 2019;Cameron et al., 2014;Campbell et al., 2015;Dahl et al., 2018;Heaman et al., 2015;Lacy et al., 2004) ( Borrull-Guardeño et al., 2021;Christie-de Jong & Reilly, 2020;Gu et al., 2018;Hasahya et al., 2016;Mkhonta & Shirinde, 2021;Roux et al., 2021;Sadler et al., 2013;Schoenberg et al., 2013;Vasudevan et al., 2020) 7 Bad experiences with home visit Inductive category* Inductive category* 8 Communication (Alderson et al., 2021;Ballantyne et al., 2019;Cibulka et al., 2012;Dilgul et al., 2018;DuMontier et al., 2013;Fägerstad et al., 2019;Freed et al., 2013;Gashu et al., 2021;Hussain-Gambles et al., 2004;Jefferson et al., 2019;Llovet et al., 2018;Lou et al., 2016;D. Marshall et al., 2016;Martin et al., 2005;Morris et al., 2009;Saleh et al., 2021;Sheppard et al., 2013;Sinclair & Alexander, 2012;Zanardelli & Robinson, 2019) (Gu et al., 2018;Roux et al., 2021;Schoenberg et al., 2013;Vasudevan et al., 2020) 9 Dismissive staff (Alanazy et al., 2019;Ballantyne et al., 2019;Campbell et al., 2015;DuMontier et al., 2013;Heaman et al., 2015;M. Yang et al., 2020) - Munthali et al., 2015;Ogunsiji et al., 2013;Rasul et al., 2016;Raymond et al., 2014;Roux et al., 2021;Sadler et al., 2013;Schoenberg et al., 2013;Vahabi & Lofters, 2016;L. ...
This thesis studies no-show behaviour for medical appointments. It comprises four research papers, each of which addresses a different aspect of the problem. The case study is an outreach program designed to overcome access barriers affecting low-income patients in Bogotá, Colombia. The research uses a range of approaches, both qualitative and quantitative, and represents a scientific contribution in terms of the novel methodology developed to tackle some of these problems. However its key feature is its relevance to real world decision making through a longstanding collaboration with the Secretaria Distrital de Salud in Bogotá, who have supported the research throughout.
First, in Chapter 2, we assess the effectiveness of three machine learning models to predict individual attendance probabilities using routinely collected administrative data. Although all three models allow us to identify those patients at higher risk of no-show, due to the limitations of the data it is not possible to understand the reasons behind patients’ health-seeking behaviour. Therefore, in Chapter 3 we show the benefits of combining these machine learning models with an in-depth qualitative methodology. Particularly, we aim at understanding patients’ experience with the cervical cancer screening program in Bogotá. This paper uses a mixed methods approach, in which qualitative data are used to explain quantitative results. Sixty semi-structured interviews were conducted, and the Health Belief Model (HBM) used as a conceptual framework to build
second order categories. The Framework method was used to analyse the qualitative data. Then, in Chapter 4, we validate the use of the HBM to explain and predict no-show behaviour for cervical cancer screening appointments among low-income hard-to-reach women in Bogotá. A randomly selected sample of 1699 women was surveyed using a 37-item instrument. We quantify the relationship between each construct of the HBM and the attendance probabilities for cervical cancer screening. Additionally, we propose a sequential approach to improve the accuracy of the no-show prediction, using the survey results. Finally, in Chapter 5 we develop a model to select which patients will receive a given behavioural intervention to increase attendance, in situations where funding is limited. Our aim is to classify patients into three groups, based on their attendance probabilities: one group at high risk of no-show who will receive a more costly personalized intervention; a medium-risk group who will receive a cheaper mass intervention; and a low-risk group who will not receive any intervention at all. To do this in a fair way, i.e. one that does not disadvantage specific subgroups, we develop a novel optimization-based post processing approach aimed at addressing machine learning bias in the algorithmic classification problem.
... No-show patients represent 9.3% of total polyclinic appointments in the United Kingdom, leading to reported annual financial losses of 225 million sterling (3). Forgetfulness, poor health, confusion of examination times and dates, inadequate follow-up on the part of individuals concerned with health care, and family-and workrelated conditions all prevent individuals attending polyclinic examinations (2,5). Mobile phone use permits direct, instant, and ubiquitous communications (1). ...
Giriş ve Amaç: Poliklinik randevusuna katılmayan hastalar sağlık kaynaklarının etkin kullanımını engellemektedir. Bu durumun etkisini azaltmak için kısa mesaj servisi (SMS) ile poliklinik randevu hatırlatıcı bilgi gönderilmesi uygulaması oldukça yaygınlaşmıştır. Türkiye'de ilk kez üçüncü basamak bir hastanenin pilot uygulaması olarak, Merkezi Hekim Randevu Sistemi vasıtası ile Çocuk Sağlığı ve Hastalıkları poliklinik randevusu alan hastalara SMS ile randevu hatırlatıcı bilgi gönderildi. Bu çalışmada SMS ile randevu hatırlatıcı bilgi gönderilen döneme ait verilerin retrospektif değerlendirilmesi amaçlandı. Gereç ve Yöntem: Pediatri poliklinikleri için 01.04.2017-31.12.2017 tarihleri arasında MHRS vasıtası ile poliklinik randevusu alan ve SMS ile randevu hatırlatıcı bilgi gönderilen hastalar Çalışma Grubu olarak, 01.04.2016-31.12.2016 tarihleri arasında MHRS ile poliklinik randevusu alan ancak SMS ile poliklinik randevu hatırlatıcı bilgi gönderilmeyen hastalar Kontrol Grubu olarak çalışmaya dahil edildi. İki grup karşılaştırıldı. Bulgular: Çalışma grubunda ve kontrol grubunda muayene olan hastaların sayısı sırası ile 75279 ve 49531 idi. Çalışma grubunda 27416 hastanın, Kontrol Grubunda ise 11909 hastanın MHRS vasıtası ile randevu aldığı belirlendi. Çalışma grubunda 2120, Kontrol Grubunda 2151 hastanın poliklinik randevusuna katılmadığı belirlendi (p<0.01). SMS ile bilgilendirme yapılması sonucunda randevusuna katılan hastaların randevu alan hasta sayısına oranı % 81.9'dan % 92.2'ye arttığı tespit edildi. Sonuç: SMS ile poliklinik randevu hatırlatıcı bilgi gönderilmesi poliklinik randevusuna katılımı arttırıyor. ABSTRACT Objective and Aim: Patients who fail to attend outpatient clinic appointments hinder the efficient use of health resources. Sending outpatient clinic appointment reminder information by the short mail service (SMS) in order to reduce the impact of no-shows is now widespread. Appointment reminder messages were sent by SMS via the Central Physician Appointment System (CPAS) to patients with Pediatric Outpatient Clinic appointments as a first pilot measure in a tertiary hospital in Turkey. The purpose of this retrospective study was to examine data for the period in which reminder information was sent by SMS. Materials and Methods: Patients making pediatric outpatient clinic appointments via the CPAS between 01.04.2017 and 31.12.2017 and sent appointment reminder information by SMS were included as the study group (SG). Patients making pediatric outpatient clinic appointments via the CPAS between 01.04.2016 and 31.12.2016 but not sent appointment reminder information by SMS were enrolled as the control group (CG). The two groups were then compared. Results: The numbers of patients in the SG and CG were 75,279 and 49,531, respectively. We determined that 27,416 patients in SG and 11,909 in CG made appointments via the CPAS, and that there were 2120 no-shows in SG and 2151 in CG (p<0.01). Sending information via SMS increased the level of patients making appointments and attending them from 81.9% to 92.2%. Discussion: Sending appointment reminder information by SMS increases outpatient clinic appointment attendance.
... It has been highlighted elsewhere that medication compliance is influenced by a myriad of factors, including patients' trust in their prescriber, knowledge of health, and healthcare accessibility [79]. Similarly, studies have highlighted that a lack of empathy from physicians and communication barriers result in poor engagement [80]. These process measures improve with LIC engagement, highlighted within themes 1, 2 and 3. Improving these process measures may result in positive health outcome measures. ...
Background:
Longitudinal Integrated Clerkships (LIC) are a relatively novel type of clinical placement model within medical education, particularly within the UK. The research on LICs primarily focuses on the impact of the model on students, tutors, communities, and organisations. The impact of LICs on patients has not yet been adequately synthesised. This systematic review aims to fill this gap by examining empirical evidence regarding the impact of LICs on patient care using quality-of-care measures, namely, health process measures and outcome measures.
Methods:
A systematic search was conducted in MEDLINE, PsycINFO, Academic Search Premier, Education Research Complete, CINAHL Complete, ERIC, Web of Science, and Scopus. Two reviewers independently conducted the screening process for study selection. Results across studies were analysed and summarised by thematic analysis.
Results:
The reviewers screened 1632 records. Seven studies met the inclusion criteria following a full-text review, from which four themes were created. Three themes describe health process measures, including: 1) Advocacy within healthcare system, 2) Provision of supplementary and personalised care, and 3) Providing companionship with care. One theme described a health outcome measure: Therapeutic Alliance.
Conclusion:
Current evidence demonstrates an overall beneficial impact of LICs on patient health processes and outcome measures. However, the available evidence is weak and limited. Further research is required to illuminate the true impact of LICs on patient health.
... Kaplan-Lewis and Percac-Lima (2013) found that the two most common reasons for no-show were forgetting the appointment and miscommunication of the appointment time; no statistically significant differences were found between races in regard to the reason for no-show. Campbell et al. (2000), Martin et al. (2005), Neal et al. (2005), and Corfield et al. (2008) confirmed these results by finding that patients often attempted to cancel but were unable to reach the clinic. Lacy et al. (2004) identified that some patients fail to show up because they perceived the appointment to be uncomfortable, because the clinic did not respect them, or because they did not perceive their no-show as disruptive for the clinic. ...
Problem definition: Machine learning is often employed in appointment scheduling to identify the patients with the greatest no-show risk, so as to schedule them into or right after overbooked slots. That scheduling decision maximizes the clinic performance, as measured by a weighted sum of all patients’ waiting time and the provider’s overtime and idle time. However, if a racial group is characterized by a higher no-show risk, then the patients belonging to that racial group will be scheduled into or right after overbooked slots disproportionately to the general population. Academic/Practical Relevance: That scheduling decision is problematic because patients scheduled in those slots tend to have a worse service experience than the other patients, as measured by the time they spend in the waiting room. Thus, the challenge becomes minimizing the schedule cost while avoiding racial disparities. Methodology: Motivated by the real-world case of a large specialty clinic whose black patients have a higher no-show probability than non-black patients, we analytically study racial disparity in this context. Then, we propose new objective functions that minimize both schedule cost and racial disparity and that can be readily adopted by researchers and practitioners. We develop a race-aware objective, which instead of minimizing the waiting times of all patients, minimizes the waiting times of the racial group expected to wait the longest. We also develop race-unaware methodologies that do not consider race explicitly. We validate our findings both on simulated and real-world data. Results: We demonstrate that state-of-the-art scheduling systems cause the black patients in our data set to wait about 30% longer than nonblack patients. Our race-aware methodology achieves both goals of eliminating racial disparity and obtaining a similar schedule cost as that obtained by the state-of-the-art scheduling method, whereas the race-unaware methodologies fail to obtain both efficiency and fairness. Managerial implications: Our work uncovers that the traditional objective of minimizing schedule cost may lead to unintended racial disparities. Both efficiency and fairness can be achieved by adopting a race-aware objective.
History: This paper has been accepted for the Manufacturing & Service Operations Management Special Section on Responsible Research in Operations Management.
Funding: M. Samorani’s work was partly funded by the 2020 Leavey Research Grant.
Supplemental Material: The online supplement is available at https://doi.org/10.1287/msom.2021.0999 .
... Non-adherence to TB treatment has been reported as a major challenge in Ethiopia [12][13][14][15][16][17]. Forgetfulness [12,16,18,19]; poor provider-patient relationship as well as communication [19][20][21], poor knowledge towards TB treatment, distance to the health facility, adverse clinical experiences and alcohol intake [14,18,19,[22][23][24][25] were most commonly reported reasons for non-adherence to TB treatment. All the previous studies, however, pooled level of adherence from both intensive and continuation phase, where the treatment approach for intensive and continuation phases were quite different. ...
Background
Patients’ failure to adhere to TB treatment was a major challenge that leads to poor treatment outcomes. In Ethiopia, TB treatment success was low as compared with the global threshold. Despite various studies done in TB treatment adherence, little was known specifically in continuation phase where TB treatment is mainly patient-centered. This study aimed to determine adherence to TB treatment and its determinants among adult patients during continuation phase.
Methods
We deployed a facility-based cross-sectional study design supplemented with qualitative data to explore perspectives of focal healthcare providers. The study population was all adult (≥18 years) TB patients enrolled in the continuation phase and focal healthcare workers in TB clinics. The study included 307 TB patients from 22 health facilities and nine TB focal healthcare providers purposively selected as key-informant. A short (11 questions) version Adherence to Refill and Medication Scale (ARMS) was used for measuring adherence. Data was collected using an interviewer-administered questionnaire and in-depth interview for qualitative data. Binary logistic regression was applied to identify factors associated with patient adherence. We followed a thematic analysis for the qualitative data. The audio data was transcribed, coded and categorized into themes using OpenCode software.
Results
Among 307 participants, 64.2% (95% CI (58.6–69.4%) were adherent to TB treatment during continuation phase. A multi-variable analysis shown that secondary education (AOR = 4.138, 95% CI; 1.594–10.74); good provider-patient relationship (AOR = 1.863, 95% CI; 1.014–3.423); good knowledge on TB treatment (AOR = 1.845, 95% CI; 1.012–3.362) and middle family wealth (AOR = 2.646, 95% CI; 1.360–5.148) were significantly associated with adherence to TB treatment. The majority (58%) of patients mentioned forgetfulness, and followed by 17.3% of them traveling away from home without pills as major reasons for non-adherence to TB treatment.
Conclusions
The study indicated that patients’ adherence to TB treatment remains low during continuation phase. The patient’s education level, knowledge, family wealth, and provider-patient relationship were found positively associated with patient adherence. Forgetfulness, traveling away, and feeling sick were major reasons for non-adherence to TB treatment. Interventional studies are needed on those factors to improve patient adherence to TB treatment during continuation phase.
... Kheirkhah et al. (2016) found that in 2008, the marginal cost of no-shows at 10 clinics run by the U.S. Veterans Health Administration medical centres in Houston was estimated to be 14.58 USD million, while the lowest and highest marginal costs were 10.48 USD million in 1997 and 16.65 USD million in 2005. For medical providers, Martin et al. (2005) conducted a qualitative study in one health centre in urban South Essex, England, using semi-structured interviews with a purposive sample of 24 patients over the age of 18, 7 general practitioners (GPs), a GP Registrar, a nurse practitioner and 5 receptionists. There were additional interviews in a practice in rural Essex and a practice in inner city London. ...
It has been established that high no-show rates of publicly supported health systems in economically depressed areas are largely due to a lack of inexpensive, reliable transportation. The purpose of this paper is to determine the financial feasibility of offering transportation and investigate the net cost savings by reducing no-show rates. The approach starts with a data analysis on 636 patients at the Family Health Center (FHC) in San Antonio, Texas, followed by logistic regression to determine the impact of various transportation factors on cancellations/no-shows and late arrivals. We then investigate the costs savings that could be realised by reducing the no-show rate from 24.3% by up to 60%. Finally, we analyse the expenses that would be incurred should the FHC provide transportation. The full analysis indicates a cost reduction of more than $15,000 per month can be achieved when the no-show rate is reduced by 25% down to 18.2%.
... Symptoms that inadvertently occur or are exacerbated subsequent to the actions or comments made by HCPs are the definition of an iatrogenic condition [45]. As such, discordant clinical conversations may iatrogenically create a negative feedback loop in CMP, as other undesirable patient responses include higher rates of patient non-attendance [46] and inefficient pain management [47]. This is a significant issue, as improving outcomes in CMP management is imperative, given the $600 billion spent annually in the United States [48]. ...
Objective
Chronic musculoskeletal pain (CMP) outcomes are affected by numerous variables including the clinical conversation. When good therapeutic/working alliances are formed, congruent clinical conversations can lead to improved CMP outcomes. Identifying patient/provider attitudes, beliefs, and biases in CMP that can influence the clinical conversation, and thus clinical management decisions, is foundationally important.
Design
The aims of this systematic review were to 1) summarize the evidence of the attitudes and beliefs of patients and healthcare providers (HCPs) involved in the clinical conversation of CMP; 2) examine if/how these perceptions impacted the process of care.
Methods
A systematic search of CINAHL, PubMed, Scopus, Sociology Database in ProQuest, and Web of Science used PRISMA guidelines. Included studies: vulnerable adult populations with chronic pain. Study bias was examined using the Downs and Black tool.
Results
Seven retrospective studies were included. HCPs demonstrated negative implicit biases toward minorities and women when making pharmaceutical management decisions. HCPs demonstrated negative implicit biases toward lower educated women when making referrals to multidisciplinary care. Unmet patient expectations resulted in higher drop-out rates at multidisciplinary pain management programs. Patients’ trust was influenced by healthcare setting and patients often had limited options secondary to health insurance type/status.
Conclusion
These findings suggest that patients with CMP may experience a marginalized process of care due to HCPs’ negative implicit biases, unmet patient expectations, and healthcare setting. Results suggest several factors may contribute to inequitable care and the recalcitrant nature of CMP, particularly in vulnerable populations with limited healthcare choices.
... Studies investigating the effectiveness of exercise programs for neck or low back pain reported low to moderate participant adherence to the exercise program (Anar, 2016;Sihawong et al., 2014;Viljanen et al., 2003). Low adherence to exercise recommendations has been reported to negatively affect treatment duration, waiting times, and cost of care (Martin et al., 2005;Weinger et al., 2005). ...
Background
Much attention has been paid to the evaluation of the efficacy of exercise therapy or increasing physical activity with the aim to prevent or alleviate neck and low back pain. However, exercise adherence is necessary for the effective management of neck and low back pain.
Objective
We aimed to systematically review randomized controlled trials and cohort studies to gain insights into the factors associated with adherence to exercise or physical activity programs to prevent or treat neck pain and low back pain.
Method
Publications were systematically searched from 1980 - December 2019 in several databases. The following key words were used: neck pain or low back pain paired with exercise or physical activity and adherence or compliance. Relevant studies were retrieved and assessed for methodological quality by two independent reviewers. Quality of evidence was assessed and rated according to GRADE guidelines.
Results
Nine randomized controlled trials and eight cohort studies were included in this review. Randomized controlled trials indicated moderate-quality evidence for the association between exercise adherence and self-efficacy. Cohort studies showed moderate-quality evidence for the association between exercise adherence and education level.
Conclusions
Literature investigating factors associated with exercise adherence to prevent or treat neck and low back pain was heterogeneous. Few factors were found to be associated with exercise adherence. More studies are needed before any firm conclusions can be reached.
... indicated that forgetfulness [13][14][15][16]; poor provider-patient relationship as well as communication [15,17,18], poor knowledge towards TB treatment, distance to the health facility, and adverse clinical experiences [9,13,15,[19][20][21][22] were most commonly reported reasons for non-adherence to Anti-TB treatment. ...
Background: Adherence to Tuberculosis (TB) treatment remained a challenge for TB treatment programs. However, paucity of evidences specifically during continuation phase where the treatment is mainly patient-centered. This study aimed to determine the level and determinants of adherence to TB treatment among adult patients during continuation phase.
Methods: We deployed a facility-based cross-sectional study design supplemented with lived experiences and perspectives of focal care providers. The study population included all adult (≥18 years) TB patients enrolled in the continuation treatment phase and TB focal care providers (for key-informant interviews). The study included 307 participants from 22 health facilities. Nine TB focal care providers were purposively selected for key-informant interviews. A shorter form, 11-item ARMS (adherence to refill and medication scale) was used for measuring adherence. Binary logistic regression was applied to identify factors associated with patient adherence. The audio data was transcribed, coded and categorized into themes using OpenCode software. The interpretation and analysis were conducted using thematic analysis.
Results: Among 307 participants, 197 (64.2%) [95% CI (58.6% - 69.4%)] were adhere to TB treatment. A multi-variable analysis shown that secondary education (AOR = 4.138, 95% CI; 1.594-10.74); good provider-patient relationship (AOR=1.863, 95% CI; 1.014-3.423); good knowledge on TB treatment (AOR=1.845, 95% CI; 1.012-3.362) and middle family wealth (AOR= 2.646, 95% CI; 1.360-5.148) have shown significant association with adherence. Many patients mentioned that forgetfulness, traveling away from home without pills, and feeling sick were major reasons for non-adherence to TB treatment.
Conclusions: The study indicated that patients’ adherence to TB treatment remains low during continuation phase. The patient’s education level, knowledge, family wealth, and provider-patient relationship were found positively associated with patient adherence. Forgetfulness, traveling away, and feeling sick were major reasons for non-adherence to TB treatment. Interventional studies are needed on those factors to improve patient adherence to TB treatment during continuation phase.
... Whereas, nonadherence to TB treatment has remained a major challenge in Ethiopia [7][8][9][10][11][12]. Studies in Ethiopia indicated that forgetfulness [13][14][15][16]; poor provider-patient relationship as well as communication [15,17,18], poor knowledge towards TB treatment, distance to the health facility, and adverse clinical experiences [9,13,15,[19][20][21][22] were most commonly reported reasons for non-adherence to Anti-TB treatment. ...
Background: Adherence to Tuberculosis (TB) treatment remained a challenge for TB treatment programs. However, paucity of evidences specifically during continuation phase where the treatment is mainly patient-centered. This study aimed to determine the level and determinants of adherence to TB treatment among adult patients during continuation phase.
Methods: We deployed a facility-based cross-sectional study design supplemented with lived experiences and perspectives of focal care providers. The study population included all adult (≥18 years) TB patients enrolled in the continuation treatment phase and TB focal care providers (for key-informant interviews). The study included 307 participants from 22 health facilities. Nine TB focal care providers were purposively selected for key-informant interviews. A shorter form, 11-item ARMS (adherence to refill and medication scale) was used for measuring adherence. Binary logistic regression was applied to identify factors associated with patient adherence. The audio data was transcribed, coded and categorized into themes using OpenCode software. The interpretation and analysis were conducted using thematic analysis.
Results: Among 307 participants, 197 (64.2%) [95% CI (58.6% - 69.4%)] were adhere to TB treatment. A multi-variable analysis shown that secondary education (AOR = 4.138, 95% CI; 1.594-10.74); good provider-patient relationship (AOR=1.863, 95% CI; 1.014-3.423); good knowledge on TB treatment (AOR=1.845, 95% CI; 1.012-3.362) and middle family wealth (AOR= 2.646, 95% CI; 1.360-5.148) have shown significant association with adherence. Many patients mentioned that forgetfulness, traveling away from home without pills, and feeling sick were major reasons for non-adherence to TB treatment.
Conclusions: The study indicated that patients’ adherence to TB treatment remains low during continuation phase. The patient’s education level, knowledge, family wealth, and provider-patient relationship were found positively associated with patient adherence. Forgetfulness, traveling away, and feeling sick were major reasons for non-adherence to TB treatment. Interventional studies are needed on those factors to improve patient adherence to TB treatment during continuation phase.
... However, there is a wide discrepancy in findings across studies, and even across clinics within a single health system [7]. When patients have been asked about reasons for non-attendance at clinical appointments, studies have identified a variety of reasons including transportation problems [9][10][11], financial difficulties [11], being unable to take time from work [9,12,13], childcare and family commitments [9,14], long clinic wait times [9,11], being hospitalized or too ill to attend [9][10][11], prioritizing other health problems [12], and forgetting [10][11][12]14]. ...
Non-attendance of healthcare appointments impact individual health outcomes and the capacity and financial stability of clinics. While non-attendance of appointments has been associated with a variety of factors, interventions to increase attendance have had mixed success. The most widely used intervention, reminder systems like phone calls or text messages, generally improves attendance rates but is insufficient for many clinics as a sole intervention. This study of underresourced patients who did not attend appointments at two clinics for uninsured individuals describes the multifactorial, individualized, and interacting reasons for non-attendance among these methods: Forty-three patients were interviewed by phone within 3 weeks of missing a clinic appointment using a scripted interview based on the literature. Responses were coded and analyzed. For 57% of respondents, a competing priority such as work or caregiving was a reason for missing an appointment. Forgetting about the appointment was a barrier for 38% of participants despite reminder systems being in place. Contributions to non-attendance were identified through thematic analysis: emotional and physical exhaustion, prioritization of work over healthcare, unreliable transportation, financial stress, and being unaware of an appointment. These findings demonstrate the need to test multiple patient-centered interventions, particularly in the context of underresourced communities.
... Simple straightforward reminders implicitly assume that one key reason a patient does not attend their appointment is due to forgetfulness. Yet, there is vast evidence suggesting that other reasons for non-attendance without notification are more prominent and that a more holistic approach to this issue is needed [17][18][19][20]. ...
Failure to attend hospital appointments has a detrimental impact on care quality. Documented efforts to address this challenge have only modestly decreased no-show rates. Behavioral economics theory has suggested that more effective messages may lead to increased responsiveness. In complex, real-world settings, it has proven difficult to predict the optimal message composition. In this study, we aimed to systematically compare the effects of several pre-appointment message formats on no-show rates. We randomly assigned members from Clalit Health Services (CHS), the largest payer-provider healthcare organization in Israel, who had scheduled outpatient clinic appointments in 14 CHS hospitals, to one of nine groups. Each individual received a pre-appointment SMS text reminder five days before the appointment, which differed by group. No-show and advanced cancellation rates were compared between the eight alternative messages, with the previously used generic message serving as the control. There were 161,587 CHS members who received pre-appointment reminder messages who were included in this study. Five message frames significantly differed from the control group. Members who received a reminder designed to evoke emotional guilt had a no-show rates of 14.2%, compared with 21.1% in the control group (odds ratio [OR]: 0.69, 95% confidence interval [CI]: 0.67, 0.76), and an advanced cancellation rate of 26.3% compared with 17.2% in the control group (OR: 1.2, 95% CI: 1.19, 1.21). Four additional reminder formats demonstrated significantly improved impact on no-show rates, compared to the control, though not as effective as the best performing message format. Carefully selecting the narrative of pre-appointment SMS reminders can lead to a marked decrease in no-show rates. The process of a/b testing, selecting, and adopting optimal messages is a practical example of implementing the learning healthcare system paradigm, which could prevent up to one-third of the 352,000 annually unattended appointments in Israel.
... No-shows also have an economic impact on health facilities limiting future staff recruitment and the improvement of the center's infrastructure. As an example, considering only the primary care centers in the United Kingdom, the number of missed appointments exceeds 12 million [1]. Moore et al. [2] reported that the percentage of no-shows and cancellations represented 32.2% of the scheduled time in a family planning residence clinic. ...
Nowadays, across the most important problems faced by health centers are those caused by the existence of patients who do not attend their appointments. Among others, these patients cause loss of revenue to the health centers and increase the patients’ waiting list. In order to tackle these problems, several scheduling systems have been developed. Many of them require predicting whether a patient will show up for an appointment. However, obtaining these estimates accurately is currently a challenging problem. In this work, a systematic review of the literature on predicting patient no-shows is conducted aiming at establishing the current state-of-the-art. Based on a systematic review following the PRISMA methodology, 50 articles were found and analyzed. Of these articles, 82% were published in the last 10 years and the most used technique was logistic regression. In addition, there is significant growth in the size of the databases used to build the classifiers. An important finding is that only two studies achieved an accuracy higher than the show rate. Moreover, a single study attained an area under the curve greater than the 0.9 value. These facts indicate the difficulty of this problem and the need for further research.
... 1,2 Non-attendance at scheduled appointments, or no-shows, is one of the factors that can potentially reduce access to care by increasing wait times. 3,4 A no-show is usually defined as a missed appointment not canceled [5][6][7][8][9][10][11][12] or canceled belatedly up to a few days before. 13 No-shows affect clinic efficiency, reducing appointment availability for other patients and increasing the economic burden associated with health care costs. ...
Objective:
To determine the prevalence of no-show patients in 4 family medicine teaching units (FMTUs) and to investigate the reasons given by patients for past missed appointments in order to identify factors that could be acted on to improve access to care.
Design:
Retrospective data collection through electronic medical records and a self-administered survey.
Setting:
Four FMTUs at the University of Montreal in Quebec.
Participants:
Patients older than 18 years of age (or younger patients' guardians) who were able to read French and had visited the clinic at least once.
Main outcomes measures:
No-show prevalence among patients scheduled to see different types of health care professionals, and patients' reasons for past missed appointments and for not notifying the clinic before missing an appointment.
Results:
The overall prevalence of no-show patients was 7.8% (2700 missed appointments of 34 619 scheduled appointments), ranging from 6.3% to 9.0% among the 4 FMTUs. The survey participation rate was 91.0% (1757 completed surveys of 1930 distributed surveys). A total of 19.1% of respondents acknowledged previous no-show behaviour. Resolved issues (22.9%) and work obligations (19.4%) were the most frequent personal reasons for missing an appointment, whereas inconvenient timing of the appointment (17.0%), delay before the appointment (14.6%), and lack of confirmation (13.7%) were the most frequent organizational reasons. The most frequent reason for not notifying the clinic of the absence was forgetting to call (55.2%).
Conclusion:
The no-show phenomenon, although not very prevalent in our clinics, is present and can potentially affect access to care. Reasons for missing an appointment without notifying the clinic are varied and point toward different potential solutions to reduce no-shows. Educating patients about the importance of informing the clinic when they cannot come, offering a wider range of appointment dates and times, systematically confirming appointments, improving telephone service, and offering different methods to communicate with the clinic could all be solutions to improve access to care.
... Two early studies showed that reminder text messages could be used to enhance clinic attendance and vaccination rates. [11][12][13] Textmessaging interventions have also been used to enhance tobacco cessation, sunscreen use, and weight loss. [14][15][16] A recent meta-analysis was conducted on mobile telephone text messaging for medication adherence in chronic, noncancer disease. ...
PURPOSE
Nonadherence to aromatase inhibitors (AIs) for breast cancer is common and increases the risk of recurrence. Text messaging increases adherence to medications for chronic conditions.
METHODS
We conducted a randomized clinical trial of text messaging (TM) versus no text messaging (No-TM) at 40 sites in the United States. Eligible patients were postmenopausal women with early-stage breast cancer taking an AI for > 30 days with a planned duration of ≥ 36 months. Test messages were sent twice a week over 36 months. Content themes focused on overcoming barriers to medication adherence and included cues to action, statements related to medication efficacy, and reinforcements of the recommendation to take AIs. Both groups were assessed every 3 months. The primary outcome was time to adherence failure (AF), where AF was defined as urine AI metabolite assay results satisfying one of the following: < 10 ng/mL, undetectable, or no submitted specimen. A stratified log-rank test was conducted. Multiple sensitivity analyses were performed.
RESULTS
In total, 724 patients were registered between May 2012 and September 2013, among whom,702 patients (348 in the text-messaging arm and 354 in the no–text-messaging arm) were eligible at baseline. Observed adherence at 36 months was 55.5% for TM and 55.4% for No-TM. The primary analysis showed no difference in time to AF by arm (3-year AF: 81.9% TM v 85.6% No-TM; HR, 0.89 [95% CI, 0.76 to 1.05]; P = .18). Multiple time to AF sensitivity analyses showed similar nonsignificant results. Three-year self-reported time to AF (10.4% v 10.3%; HR, 1.16 [95% CI, 0.69 to 1.98]; P = .57) and site-reported time to AF (21.9% v 18.9%; HR, 1.31 [95% CI, 0.86 to 2.01]; P = .21) also did not differ by arm.
CONCLUSION
To our knowledge, this was the first large, long-term, randomized trial of an intervention directed at improving AI adherence. We found high rates of AI AF. Twice-weekly text reminders did not improve adherence to AIs. Improving long-term adherence will likely require personalized and sustained behavioral interventions.
... One untreated infectious tuberculosis patient is likely to infect 10 to 15 persons annually [16]. The consequences of poor adherence to long-term therapies are poor health outcomes and increased health care costs interventions aimed at improving adherence would provide a signi cant positive return on investment through primary prevention and secondary prevention of adverse health outcomes [17][18][19][20][21][22]. ...
Background: Compliance to anti-TB treatment is crucial in achieving cure and avoiding the emergence of drug resistance. Electronic health (eHealth) interventions are included in the strategy to end the global Tuberculosis (TB) epidemic by 2035. Evidences showed that mobile messaging systems could improve patient adherence to clinic appointment for diagnosis and treatment. This review aimed to assess the effect of mobile-phone messaging on anti-TB treatment success.
Methods: All randomized controlled trial (RCT) and quasi-experimental studies done prior to August 26, 2019 were included in the review. Studies were retrieved from PubMed, EMBASE, Cochrane and ScienceDirect databases. In addition, gray literatures and non-indexed articles were searched on Google and Google scholar. Searching strategies was based on PICO criteria and using Medical Subject Headings (MeSH), Boolean search operators, truncation symbols to robust the searching scheme. Articles were independently screened and appraised by two authors. PRISMA flow diagrams were used to summarize article selection process, see Additional file 1.
Results: A total of 1237 articles were identified, with 14 meeting the eligibility criteria for qualitative synthesis. Nine studies with a total of 6030 TB patients (2893 in intervention and 3137 in control groups) were included in meta-analysis. The pooled effect of mobile-phone messaging revealed a small increase in treatment success compared to standard of care (RR 1.04, 95% CI 1.02 to 1.06), with low heterogeneity (I 2 =25%, p<0.0001). In the review, performance, detection and attrition biases were reported as major risk of biases.
Conclusions: Mobile-phone messaging showed a modest effect in improving anti-TB treatment success; however, the quality of evidence was low. Further controlled studies are needed to increase the evidence-base on the role of mHealth interventions to improve TB care. Protocol registration number: CRD420170744339 http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017074439 Key Words: Mobile phone, Treatment success, Text messaging, Tuberculosis
... One untreated infectious tuberculosis patient is likely to infect 10 to 15 persons annually [16]. The consequences of poor adherence to long-term therapies are poor health outcomes and increased health care costs interventions aimed at improving adherence would provide a signi cant positive return on investment through primary prevention and secondary prevention of adverse health outcomes [17][18][19][20][21][22]. ...
Background: Compliance to anti-TB treatment is crucial in achieving cure and avoiding the emergence of drug resistance. Electronic health (eHealth) interventions are included in the strategy to end the global Tuberculosis (TB) epidemic by 2035. Evidences showed that mobile messaging systems could improve patient adherence to clinic appointment for diagnosis and treatment. This review aimed to assess the effect of mobile-phone messaging on anti-TB treatment success. Methods: All randomized controlled trial (RCT) and quasi-experimental studies done prior to August 26, 2019 were included in the review. Studies were retrieved from PubMed, EMBASE, Cochrane and ScienceDirect databases including, grey and non-indexed literatures from Google and Google scholar. Quality of studies were independently assessed using Cochrane Risk of Bias Assessment Tool. A qualitative synthesis and quantitative pooled estimation were used to measure the effect of phone messaging on TB treatment success rate. PRISMA flow diagrams were used to summarize article selection process, see Additional file 1. Results: A total of 1237 articles were identified, with 14 meeting the eligibility criteria for qualitative synthesis. Eight studies with a total of 5680 TB patients (2733 in intervention and 2947 in control groups) were included in meta-analysis. The pooled effect of mobile-phone messaging revealed a small increase in treatment success compared to standard of care (RR 1.04, 95% CI 1.02 to 1.06), with low heterogeneity (I 2 =7%, p
... One untreated infectious tuberculosis patient is likely to infect 10 to 15 persons annually [16]. The consequences of poor adherence to long-term therapies are poor health outcomes and increased health care costs interventions aimed at improving adherence would provide a signi cant positive return on investment through primary prevention and secondary prevention of adverse health outcomes [17][18][19][20][21][22]. ...
Background: Compliance to anti-TB treatment is crucial in achieving cure and avoiding the emergence of drug resistance. Electronic health (eHealth) interventions are included in the strategy to end the global Tuberculosis (TB) epidemic by 2035. Evidences showed that mobile messaging systems could improve patient adherence to clinic appointment for diagnosis and treatment. This review aimed to assess the effect of mobile-phone messaging on anti-TB treatment success.
Methods: All randomized controlled trial (RCT) and quasi-experimental studies done prior to August 26, 2019 were included in the review. Studies were retrieved from PubMed, EMBASE, Cochrane and ScienceDirect databases including, grey and non-indexed literatures from Google and Google scholar. Quality of studies were independently assessed using Cochrane Risk of Bias Assessment Tool. A qualitative synthesis and quantitative pooled estimation were used to measure the effect of phone messaging on TB treatment success rate. PRISMA flow diagrams were used to summarize article selection process, see Additional file 1.
Results: A total of 1237 articles were identified, with 14 meeting the eligibility criteria for qualitative synthesis. Eight studies with a total of 5680 TB patients (2733 in intervention and 2947 in control groups) were included in meta-analysis. The pooled effect of mobile-phone messaging revealed a small increase in treatment success compared to standard of care (RR 1.04, 95% CI 1.02 to 1.06), with low heterogeneity (I2=7%, p<0.0002). In the review, performance, detection and attrition biases were reported as major risk of biases.
Conclusions: Mobile-phone messaging showed a modest effect in improving anti-TB treatment success; however, the quality of evidence was low. Further controlled studies are needed to increase the evidence-base on the role of mHealth interventions to improve TB care.
Protocol registration number: CRD420170744339 http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017074439
Key Words: Mobile phone, Treatment success, Text messaging, Tuberculosis
... 8 9 Conversely, nonadherence may be a missed opportunity for therapeutic benefit and may negatively affect treatment duration, the therapeutic relationship, waiting times, cost of care and may be responsible for non-significant research outcomes. [10][11][12][13] Systematic reviews consistently show the beneficial effects of different types of exercise on key clinical outcomes, such as pain, physical function and quality of life, [14][15][16] leading to clinical guidelines that advocate the use of exercise programmes to manage MSDs. 17 18 Despite its importance, adherence to clinic-based exercise protocols is approximately 50% 19 20 and is often lower for unsupervised home exercise programmes. ...
Objectives
The objective was to the undertake nominal group technique (NGT) to evaluate current exercise adherence measures and isolated domains to develop stakeholder consensus on the domains to include in the measurement of therapeutic exercise adherence for patients with musculoskeletal disorders.
Design
A 1-day NGT workshop was convened. Six exercise adherence measures were presented to the group that were identified in our recent systematic review. Discussions considered these measures and isolated domains of exercise adherence. Following discussions, consensus voting identified stakeholder agreement on the suitability of the six offered adherence measures and the inclusion of isolated domains of exercise adherence in future measurement.
Setting
One stakeholder NGT workshop held in Sheffield, UK.
Participants
Key stakeholders from the UK were invited to participate from four identified populations. 14 participants represented patients, clinicians, researchers and service managers.
Results
All six exercise adherence measures were deemed not appropriate for use in clinical research or routine practice with no measure reaching 70% group agreement for suitability, relevance, acceptability or appropriateness. Three measures were deemed feasible to use in clinical practice. 25 constructs of exercise adherence did reach consensus threshold and were supported to be included as domains in the future measurement of exercise adherence.
Conclusion
A mixed UK-based stakeholder group felt these six measures of exercise adherence were unacceptable. Differences in opinion within the stakeholder group highlighted the lack of consensus as to what should be measured, the type of assessment that is required and whose perspective should be sought when assessing exercise adherence. Previously unused domains may be needed alongside current ones, from both a clinician's and patient’s perspective, to gain understanding and to inform future measurement development. Further conceptualisation of exercise adherence is required from similar mixed stakeholder groups in various socioeconomic and cultural populations.
... One untreated infectious tuberculosis patient is likely to infect 10 to 15 persons annually [16]. The consequences of poor adherence to long-term therapies are poor health outcomes and increased health care costs interventions aimed at improving adherence would provide a significant positive return on investment through primary prevention and secondary prevention of adverse health outcomes [17][18][19][20][21][22]. ...
Background
Compliance to anti-TB treatment is crucial in achieving cure and avoiding the emergence of drug resistance. Electronic health (eHealth) interventions are included in the strategy to end the global Tuberculosis (TB) epidemic by 2035. Evidences showed that mobile messaging systems could improve patient adherence to clinic appointment for diagnosis and treatment. This review aimed to assess the effect of mobile-phone messaging on anti-TB treatment success.
Methods
All randomized controlled trial (RCT) and quasi-experimental studies done prior to August 26, 2019 were included in the review. Studies were retrieved from PubMed, EMBASE, Cochrane and ScienceDirect databases including, grey and non-indexed literatures from Google and Google scholar. Quality of studies were independently assessed using Cochrane Risk of Bias Assessment Tool. A qualitative synthesis and quantitative pooled estimation were used to measure the effect of phone messaging on TB treatment success rate. PRISMA flow diagrams were used to summarize article selection process.
Results
A total of 1237 articles were identified, with 14 meeting the eligibility criteria for qualitative synthesis. Eight studies with a total of 5680 TB patients (2733 in intervention and 2947 in control groups) were included in meta-analysis. The pooled effect of mobile-phone messaging revealed a small increase in treatment success compared to standard of care (RR 1.04, 95% CI 1.02 to 1.06), with low heterogeneity (I² = 7%, p < 0.0002). In the review, performance, detection and attrition biases were reported as major risk of biases.
Conclusions
Mobile-phone messaging showed a modest effect in improving anti-TB treatment success; however, the quality of evidence was low. Further controlled studies are needed to increase the evidence-base on the role of mHealth interventions to improve TB care.
Protocol registration number
CRD420170744339. http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017074439
Background
Previous research suggests that medico-legal complaints often arise from various factors influencing patient dissatisfaction, including medical errors, physician-patient relationships, communication, trust, informed consent, perceived quality of care, and continuity of care. However, these findings are not typically derived from actual patients’ cases. This study aims to identify factors impacting the interpersonal dynamics between physicians and patients using real patient cases to understand how patients perceive doctor-patient relational problems that can lead to dissatisfaction and subsequent medico-legal complaints.
Methods
We conducted a retrospective study using data from closed medical regulatory authority complaint cases from the Canadian Medical Protective Association (CMPA) between January 1, 2015, and December 31, 2020. The study population included patients who experienced sepsis and survived, with complaints written by the patients themselves. A multi-stage standardized thematic analysis using Braun and Clarke’s approach was employed. Two researchers independently coded the files to ensure the reliability of the identified codes and themes.
Results
Thematic analysis of 50 patient cases revealed four broad themes: (1) Ethics in physician’s work, (2) Quality of care, (3) Communication, and (4) Healthcare system/policy impacting patient satisfaction. Key sub-themes included confidentiality, honesty, patient involvement, perceived negligence, perceived lack of concern, active engagement and empathy, transparency and clarity, informed consent, respect and demeanor, lack of resources, long wait times, and insufficient time with physicians.
Conclusions
This study identifies and categorizes various factors impacting relational issues between physicians and patients, aiming to increase patient satisfaction and reduce medico-legal cases. Improving physicians’ skills in areas such as communication, ethical practices, and patient involvement, as well as addressing systemic problems like long wait times, can enhance the quality of care and reduce medico-legal complaints. Additional training in communication and other skills may help promote stronger relationships between physicians and patients.
Healthcare providers have long grappled with patients not showing up for their scheduled medical appointments; such no-shows lead to wasted resources and longer wait times for other patients. However, new operations research offers a promising solution to this problem. The study finds that using text message reminders that include an additional line of text indicating a potentially long wait for the next available appointment can significantly reduce no-shows by a factor of 28.6%. The intervention, called waits framing, was found to be more effective among patients who were more sensitive to wait times and when the information in the message was novel and credible. The study also uncovered the mechanism underlying the intervention. Specifically, the waits framing messages increased the perceived cost of missing an appointment, leading to a reduction in queue abandonment. This study provides insights into how behavioral science can improve service operations and help tackle challenges in healthcare delivery.
Background
Patients not attending their appointments without giving notice burden healthcare services. To reduce non-attendance rates, patient non-attendance fees have been introduced in various settings. Although some argue in narrow economic terms that behavioural change as a result of financial incentives is a voluntary transaction, charging patients for non-attendance remains controversial. This paper aims to investigate the controversies of implementing patient non-attendance fees.
Objective
The aim was to map out the arguments in the Norwegian public debate concerning the introduction and use of patient non-attendance fees at public outpatient clinics.
Methods
Public consultation documents (2009–2021) were thematically analysed (n=84). We used a preconceived conceptual framework based on the works of Grant to guide the analysis.
Results
A broad range of arguments for and against patient non-attendance fees were identified, here referring to the acceptability of the fees’ purpose, the voluntariness of the responses, the effects on the individual character and institutional norms and the perceived fairness and comparative effectiveness of patient non-attendance fees. Whereas the aim of motivating patients to keep their appointments to avoid poor utilisation of resources and increased waiting times was widely supported, principled and practical arguments against patient non-attendance fees were raised.
Conclusion
A narrow economic understanding of incentives cannot capture the breadth of arguments for and against patient non-attendance fees. Policy makers may draw on this insight when implementing similar incentive schemes. The study may also contribute to the general debate on ethics and incentives.
Purpose:
To investigate the rate of missed appointments in a Canadian academic hospital-based pediatric ophthalmology and adult strabismus practice and the demographic and clinical factors associated with missed appointments.
Methods:
This cross-sectional study included all consecutive patients seen from June 1, 2018, to May 31, 2019. Multivariable logistic regression model assessed associations between clinical and demographic variables with no-show status. A literature review on evidence-based interventions to reduce no-show appointments in ophthalmology was performed.
Results:
Of 3,922 visits, 718 (18.3%) were no-shows. Characteristics associated with no-shows included new patient (OR = 1.4; 95% CI, 1.1-1.7 [P = 0.001]), age 4-12 years (OR = 1.6; 95% CI, 1.1-2.3 [P = 0.011]) or age 13-18 years (OR = 1.8; 95% CI, 1.2-2.7 [P = 0.007]) compared with age 19+ years, history of previous no-shows (OR = 2.2; 95% CI, 1.8-2.7 [P = 0.001]), referrals from nurse practitioners (OR = 1.8; 95% CI, 1.0-3.2 [P = 0.037]), nonsurgical diagnoses such as retinopathy of prematurity (OR = 3.2; 95% CI, 1.8-5.6 [P < 0.001]), and winter season (OR = 1.4; 95% CI, 1.2-1.7 [P < 0.001]).
Conclusions:
Missed appointments in our pediatric ophthalmology and strabismus academic center are more likely new patient referrals, prior no-shows, referrals from nurse practitioners, and nonsurgical diagnoses. These findings may facilitate targeted strategies to help improve utilization of healthcare resources.
Our research aims to develop intelligent collaborative agents that are human-aware : They can model, learn, and reason about their human partner’s physiological, cognitive, and affective states. In this article, we study how adaptive coaching interactions can be designed to help people develop sustainable healthy behaviors. We leverage the common model of cognition (CMC) [31] as a framework for unifying several behavior change theories that are known to be useful in human–human coaching. We motivate a set of interactive system desiderata based on the CMC-based view of behavior change. Then, we propose PARCoach, an interactive system that addresses the desiderata. PARCoach helps a trainee pick a relevant health goal, set an implementation intention, and track their behavior. During this process, the trainee identifies a specific goal-directed behavior as well as the situational context in which they will perform it. PARCCoach uses this information to send notifications to the trainee, reminding them of their chosen behavior and the context. We report the results from a 4-week deployment with 60 participants. Our results support the CMC-based view of behavior change and demonstrate that the desiderata for proposed interactive system design is useful in producing behavior change.
Purpose:
Missed appointments within the National Health Service (NHS) are a drain on resources, associated with not only considerable time and cost implications, but also sub-optimal health outcomes. This literature review aims to explore non-attendance within the NHS in relation to causes, impacts and possible mitigation of negative effects of missed appointments.
Design/methodology/approach:
MEDLINE, CINAHL Plus and PubMed were searched with a date range of 2016-2021. Databases were searched for peer-reviewed articles published in English addressing non-attendance of adults within the NHS. Studies were excluded if they were theoretical papers, dissertations or research concerning patients aged under 18. A total of 21 articles met the inclusion criteria and were selected for analysis.
Findings:
The results indicate a significant association of non-attendance and poor health outcomes. Patients from a lower socioeconomic status, adults aged over 85 and those with multiple co-morbidities are more likely to miss appointments. The most commonly reported patient-centred reasons for failing to attend were forgetfulness, transportation difficulties, and family commitments. Practice-specific reasons were cited as inefficiencies of the appointment booking system, failure of traditional reminders and inconvenient timings. Interventions included text reminder services, the inclusion of costs within reminders and enhanced patient involvement with the booking process.
Originality/value:
Non-attendance is complex, and to secure maximum attendance, targeted interventions are required by healthcare facilities to ensure patient needs are met. The adaption of scheduling systems and healthcare services can assist in reducing DNA rates.
Background
Scalable, positive, behaviourally informed interventions may help people remember to attend their primary care appointment or cancel in good time, but have not yet been implemented long term.
Aim
To examine effects of social norms and making active commitments on missed and cancelled appointments in primary care over 12 months and explore implementation factors.
Design and setting
A mixed-methods design evaluation and implementation study led by a Patient Participation Group (PPG) member in a large GP practice in the West Midlands.
Methods
Following a 6-month baseline, waiting room notices were redesigned to emphasise positive social norms for desired behaviours. When booking appointments, receptionists were trained to invite patients to (i) verbally actively commit to cancelling if needed; (ii) write down their own appointment details. Monthly missed appointments (MAs) and cancellations were statistically compared with baseline averages and seasonally equivalent months. To explore implementation, reception staff completed a knowledge, attitude, and behaviour questionnaire at 9 months, analysed descriptively. Study team field notes were thematically analysed.
Results
Across 12 intervention months there was a mean of 37.67 fewer MAs per month (20% reduction) and 102.66 more cancellations (21.07% increase) compared with 6-month baseline means [MAs t(11) = −6.15, P < 0.001; cancellations t(11) = 3.637, P = 0.004] with statistically significant differences in seasonally equivalent months [MAs t(5) = −4.65, P = 0.006; cancellations t(5) = 3.263, P = 0.022]. Receptionists (n = 12) reported implementing the strategies except when facing pressures; knowledge and attitudes varied.
Conclusions
Behaviourally informed interventions reduced primary care MAs longer term; PPGs and practice teams can work together on quality improvement projects with support from leaders to prioritise and embed new practices.
Background:
Missed GP appointments have considerable time and cost implications for healthcare services.
Aim:
This systematic review aims to explore the rate of missed primary care appointments, what the reported reasons are for appointments being missed, and which patients are more likely to miss appointments.
Design:
This study reports the findings of a systematic review.
Setting:
Included studies report the rate or reasons of missed appointments in a primary care setting.
Method:
Databases were searched using a pre-defined search strategy. Eligible studies were selected for inclusion based on detailed inclusion criteria through title, abstract and full text screening. Quality was assessed on all included studies, and findings were synthesised to answer the research questions.
Results:
A total of 26 studies met the inclusion criteria for inclusion in the review. Of these, 19 reported a rate of missed appointments, with a mean rate of 15.2% and a median of 12.9% appointments being missed. Twelve studies reported a reason appointments were missed, with work or family commitments, forgetting the appointment and transportation difficulties were most commonly reported. 20 studies reported characteristics of people likely to miss appointments. Patients who were likely to miss appointments were those from minority ethnicity, low socio-demographic status and younger patients.
Conclusions:
Findings from this review have potential implications for targeted interventions to address missed appointments in primary care. This is the first step for clinicians being able to target interventions to reduce the rate of missed appointments.
The International Conference on primary health care was held in Alma-Ata, USSR on the twelfth day of
September in the year Nineteen Hundred and Seventy-eight. Primary health care is the first level of
contact of individuals, the family and the community with the national health system. Primary health care
addresses the main health problems in the community, providing education concerning prevailing health
problems and the methods of preventing and controlling them, promotion of food supply and proper
nutrition, adequate provision of safe water and basic sanitation. Other services provided include
maternal and child health including family planning, immunization against the major infectious diseases,
prevention and control of locally endemic diseases, appropriate treatment of common diseases and
injuries and provision of essential drugs. The four types of health facility that provides primary health
care services in Nigeria are health post, basic health clinic, primary health centre and comprehensive
health centre. The main objective of the study was to determine utilization and factors influencing access
to primary health care services in model primary health centre, Ajiolo-Abokoche, Dekina LGA, Kogi
Sate, Nigeria. It is a descriptive cross sectional study, conducted between 24th August 2015 and 25th
September 2015. Ethical approval for the study was obtained from the Dekina Local Government
Authorities, while informed consent was taken from all attendees at the Centre. Instruments of data
collection were semi-structured interviewer administered questionnaires, focus group discussion and
medical records at the Model PHC Ajiolo-Abokoche. Pre-testing of the data collection instruments was
done at the Primary healthcare centre Makutu Isanlu, Yagba East Local government Area, Kogi State.
Four hundred questionnaires were administered using a Multistage sampling technique. Data entry,
validation and analysis were carried out using the statistical package for social science (SPSS) version
21. Frequency distribution tables were generated, cross tabulations carried out and Chi-squared test of
significance to compare rates, ratios and proportions was carried out. The P value was set at < 0.05 and a
95% confidence interval was used for the study. The mean age of respondents was 31.81 ± 12.87 years
with a male to female ratio of 1:1.1. Utilization of model PHC Ajiolo-Abokoche was 127(31.7%)
Determinants of utilization of model PHC Ajiolo-Abokoche were appropriateness of infrastructure
310(77.5%), personnel availability 244(61.0%), staff high competency 200(50.0%), good attitude of
staff 200(50.0%), availability of essential drugs 202(50.5%), appropriate PHC Location 204(51.0%) and
clinic schedule 216(54.0%). Other factors include availability and adequacy of equipment 122(30.5%),
appropriate cost of health care services 124(31.0%), client awareness 120(30.0%), financial status
124(31.0%), patient satisfaction 54(13.5%), health seeking behavior 42(10.5%) and community
participation 44(11.0%). P = 0.00
To compare the demographic characteristics of patients who miss appointments with those who do not and to identify subgroups who would benefit from specific interventions for improving attendance.
Retrospective cohort study of an 18-month period.
An urban primary care practice.
A random sample (N = 477) of patients who were seen at least twice during the study period.
Number of missed visits and kept visits, insurer, age, sex, race, ZIP code, and diagnoses.
Of the established patients, 48% missed 1 or more visits. Patients in managed care programs, private and Medicaid, were likely to have missed more visits during the study period than those not in managed care programs (P < .001). Medicaid managed care patients had also scheduled more visits. Significantly higher rates of missed appointments were found in patients aged 19 to 35 years (P = .02), blacks (P < .001), patients in Medicaid managed care programs (P < .001), and patients who scheduled more visits (P < .001). After adjusting for age, race, and sex, Medicaid managed care insurance remained a significant (P < .01) predictor of rate of missed appointments.
Patients in managed care programs missed more appointments. Patients in Medicaid managed care programs scheduled more appointments and had higher rates of missed appointments than their counterparts in other insurance groups.
The issue of missed appointments in primary care is important for patients and staff. Little is known about how missed appointments, and the people who miss them, are managed in primary care, or about effective strategies for managing missed appointments.
To understand the perceptions of primary care staff as to why patients miss appointments, to determine how these perceptions influence their management, and to explore the merit of different management strategies. Design of study: A postal questionnaire survey and focus group interviews.
General practices in Yorkshire.
Missed appointments were regarded as an important problem. Patient factors rather than practice factors were perceived as most important in causing missed appointments. Intervention strategies appeared to be driven by perceptions of why patients miss appointments. Negative attitudes, embodied in terms such as "offenders" to refer to those who missed appointments were prevalent, and favoured intervention strategies included punishing the patient in some way. Receptionists believed that general practitioners should address the issue of the missed appointment with the patient. General practitioners felt guarded about addressing missed appointments with their patients in case it affected the doctor-patient relationship.
People who miss appointments were viewed negatively by primary care staff, and most of the reasons for missed appointments were focused on patients. These beliefs underpinned intervention strategies aimed mainly at punishment. Since there is no evidence base concerning interventions that are effective in reducing missed appointments, these negative attitudes may not be beneficial to staff or their patients.
This is the fifth of seven articles Delays for access to care plague our healthcare systems. These delays cause patient dissatisfaction, contribute to staff dissatisfaction, and may lead to worsening clinical outcomes. They are also expensive: patients often consume scarce resources while waiting, there is a cost in maintaining any waiting list; the longer the wait the higher the “fail to show” rate, which represents unused capacity; and, finally, there is the risk that patients waiting will arrive with a more costly clinical condition. Access to care can be improved. Improving access involves looking at system flexibility or capacity. There are three fundamental methods of gaining capacity in a system of care. Summary points Delays plague all healthcare systems, causing discontent, consuming resources, and worsening clinical outcomes Most waiting systems rely on distinguishing between urgent and routine cases and so maintain two queues Real improvements in access come about when there is only one queue and it is short enough to ensure prompt treatment for urgent cases Improving access involves determining the demand and applying resources to match it or reduce it
Missed appointments can affect patient health, disrupt schedules, and result in poor utilization of resources, increased workload for staff and physicians, and lost learning opportunities for residents in training programs.
The setting was an established community-hospital-based family practice residency practice averaging 25,000 outpatient visits per year in a small northern New England town. Data from a computer-scheduling system and hospital mainframe, as well as demographic and other information contained in billing records and patient schedules, were abstracted for patients who scheduled 3962 appointments on 36 sampled days during 1995.
The missed appointment rate during the study period was 6.7 percent. Characteristics associated with missed appointments were younger patient age (17 to 30 years), Medicaid coverage or lack of health insurance, and appointments scheduled with first-year residents or medical students.
Attention should be given to those patients most likely to miss appointments and, in training programs, to patients seeing first-year residents and medical students. It is possible that our relatively low missed appointment rate overall resulted from the nature of the practice and its environment.
The study of patients in primary care settings who default on their appointment has been based largely on short-term surveys in individual health centres.
As part of a wider research project into the potential of practice computer appointment systems as a data source, we wanted to explore the aggregate pattern of default.
Comprehensive computer appointment data from nine general practices for 1 or 2 years were analysed to explore the pattern of defaulted appointments for doctors and practice nurses.
Around 6.5% of all appointments ended in a default. Default rates were found to be highest amongst young adults and, at a practice level, to be highly correlated with deprivation level. About two-thirds of those who defaulted only did it once during the year. A small core of patients defaulted frequently, but only a quarter of these repeated their behaviour in the following year.
The discussion suggests that strategies based on educating or punishing defaulters in order to change their behaviour may be of limited effectiveness.
Little is known about which patients miss appointments or why they do so. Using routinely collected data from four practices, we aimed to determine whether patients who missed appointments differed in terms of their age, sex, and deprivation scores from those who did not, and to examine differences between the practices with respect to missed appointments. The likelihood of someone missing at least one appointment was independently associated with being female, living in a deprived area, and being a young adult. Living in a deprived area was associated with a threefold increase in the likelihood of missing an appointment, and the extent of this association was the same across all four practices. Interventions aimed at reducing missed appointments need to be based upon these findings.
Non-attendance in general practice has received increasing attention over the past few years. Its relationship with access to health care has been recognized and is of particular relevance in light of the access targets set out in the NHS Plan.
The literature was searched for articles relating to non-attendance. Titles and abstracts were examined, and relevant articles obtained. Bibliographies were examined for further references. Articles that described interventions for reducing non-attendance that were comparative studies and that examined general appointments, as opposed to appointments for screening purposes for example, were of particular interest.
The epidemiology of non-attendance has been well described, but there is little work on the reasons for non-attendance. Evidence for effective interventions to improve attendance in primary care is lacking, and this may prove to be an area of research interest in the future. As well as specific interventions to reduce non-attendance, new approaches to health care access are required in order to tackle this issue.
Advanced Access in Primary Care. National Primary Care Development Team
- J Oldham
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Care Development Team; 2001.