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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 2  |  Page : 45-48

How to reduce no-show in pain clinic?


Department of Anesthesia, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Date of Submission08-May-2019
Date of Acceptance30-May-2019
Date of Web Publication30-Jul-2019

Correspondence Address:
Dr. Rabah Alharbi
Department of Anesthesia, Prince Sultan Military Medical City, PO Box 7897, Riyadh 11159
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijas.ijas_9_19

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  Abstract 


Background: Failure to attend scheduled appointments in the outpatient clinic represents a challenge to health care. Almost quarter billion dollar was lost in the United Kingdom in 2001; Saudi Arabia has 29.5% “no-show” rates, and these findings are encouraging to explore the reasons and to implement strategies to improve attendance. Moreover, we found 0.12% reduction in no-show, 1 month after using phone call reminder associated with the application of strategies to increase attendance rate used in similar work.
Context: To identify reasons of no-show and to use strategy to decrease the substantial no-show rates.
Aims: This study aimed to minimize significant loss of time and money and to decrease the dissatisfaction and worsening of patient's clinical outcome.
Settings and Design: The study was conducted in pain management clinic in King Abdulaziz Medical City National Guard Hospital, pain clinic, staffed by one consultant, one staff physician, one fellow and two nurses, and one patient service coordinator, responsible for answering phone calls and booking appointments; patient receives phone call 2 days prior to their scheduled appointment by obtaining their contact number from Bestcare® health information system. Data of all patients booked from the begging of August to the end of October 2017 were collected and analyzed, and no show rate was calculated by dividing the number of no show to the number of all booked appointments, showing that a mean average in 3 months of 100 visit per month, with a mean average of no show within 3 months of 0.34% no show rate.
Subjects and Methods: Contact information of all patients who had been booked in the month of November 2017 were collected; we applied strategy for all phone calls. First, we identified if the patient had answered or not and if he/she has answered a welcoming and orientation statement was used (i.e., who we are and why we are calling and where is exactly our clinic and the time of the appointment). Second we have to identify that the answering is either the patient or the caregiver to avoid breaching the confidentiality. Third we identified the appointment status if the patient is attending or not, and finally. Fourth we used verbal contract to inform the patient or the caregiver that in case of failure to show-up; patient might be discharged from the clinic to decrease the waiting list which can lead to further health deterioration of other patients.
Results: Total no-show has decreased from 0.34% to 0.22% within 1 month of implementation.
Conclusions: Significant strategies can be applied to enhance attendance rate implemented through telephone call which led to 0.12% reduction of no-show in 1 month compared to 3 months average no-show rate.

Keywords: Clinic nonattendance, no-show, outpatient clinic, pain clinic


How to cite this article:
Alharbi R. How to reduce no-show in pain clinic?. Imam J Appl Sci 2019;4:45-8

How to cite this URL:
Alharbi R. How to reduce no-show in pain clinic?. Imam J Appl Sci [serial online] 2019 [cited 2019 Dec 9];4:45-8. Available from: http://www.e-ijas.org/text.asp?2019/4/2/45/263667




  Background Top


No-show represents a significant loss in terms of time and financial cost. A survey carried out jointly by the Doctor–Patient Partnership and the Institute of Healthcare Management in the United Kingdom (UK) revealed that 17 million appointments were missed in 2000,[1] at an estimated cost of $240 million.[2]

In the USA, no-show represents loss of income;[3] Murray describes delays to access can lead to dissatisfaction for both patients and staff and may lead to worsening of clinical outcomes,[4] although timely access to primary health care is associated with improved health outcomes and contributes to cost control in Canada.[5],[6]

Having timely access to primary care has been shown to increase patient satisfaction as well as the quality of care delivered.[7]

Waiting for a primary health-care appointment can often impose a physical and emotional burden on an individual who is in pain or worried about a serious health condition, while increasing pressure from the health services to, see more patients and to see them more quickly, despite current shortages of doctors, nurses, and other health-care professionals.[8],[9],[10]

Understanding the nature of no-show and exploring ways to reduce it will help toward achieving these targets by improving the efficiency of the service provided.

Epidemiology

Two recent studies estimated the nonattendance rate in the UK to be 6.5%[11] and 7.7%.[12]

Nonattendance rates in the US primary care range from 5% to 55%, whereas studies from Saudi Arabia and Israel report rates of 29.5%[13] and 36%, respectively.[14]

Nonattendance rates in general practice are higher for return visits[15],[16] and for appointments made with those other than the patient's usual doctor (practice nurse,[17] GP registrar,[16] medical student, or 1st-year resident[18]). Patients who miss appointments tend to be young (aged 17–40 years), [11, 12, 16, 18-20] have more psychological problems,[16] come from a lower socioeconomic class,[11] and live in deprived areas,[12] but patients with chronic disease are better attenders.[20]

Reasons for no-show

Cosgrove followed up forty patients who failed to attend.[21]

The most common reasons were that they were not being well enough to attend (eight), resolution of symptoms (six), and forgotten appointments (seven), and most of the patients (eight) were too ill to attend.

Hamilton used a next-day postal questionnaire to 100 consecutive nonattenders from each of five local practices,[22] obtaining a 34.8% response from 500 patients.

Sixty patients (34%) said that they had forgotten about the appointment; 20 (12%) said that it was a practice error; 20 (12%) said that there was a mix up over the date/time of the appointment; and 16 (9%) gave other reasons such as traffic, oversleeping, and hospital admission.

Hamilton also tried to identify why they did not cancel the appointment.

From 158 of the patients, 50 (32%) had forgotten or not considered it, 18 (11%) had tried but the telephone lines were busy, and 34 (27%) gave other reasons.

Forgetfulness on behalf of the patient and communication errors (e.g., patients being told the wrong time for the appointment and appointments not being cancelled by reception staff) are issues that have also been identified in other studies.[19],[23] Neal found that 40% said they forgot the appointment and 25% said they try to cancel and it was at an inconvenient time, and 5% reported family commitment or being too ill.

How to improve attendance

Macharia et al., in a systematic review of interventions to improve attendance, identified that 23 studies were grouped into three main categories:

  • Reminders (letter and telephone)
  • Reducing perceived barriers (e.g., orientation statements)
  • Increasing motivation (e.g., patient information and contracts).


Prompts, either by letter or by telephone, were effective. Orientation statements provide information about the reasons for the appointment, what patients may expect, when they arrive, and how the clinic is organized. Contracting is a process where a formal agreement is made with patients to attend future appointments and to agree to treatment plans and may have a role in certain situations (e.g., chronic disease management) when compliance is poor.[24]

Posters displaying the number of missed appointments are used to influence patient behavior.[25]

Wilkinson[26] showed that reminding patients of the need to cancel appointments works in reducing nonattendance rates.

A dedicated cancellation line in the practice may provide the answer but has cost implications.

Patients would also need to be encouraged to cancel their appointments early enough so that they can be allocated to someone else.[27]

Molfenter used Strengthening Treatment Access and Retention program which used reminder calls, behavioral engagement strategy such as motivational interviewing and contingency management, and other practices which found to reduce no-show from 39% to 19.9%.[28]


  Subjects and Methods Top


We conducted this study in the Pain Management Clinic in King Abdulaziz Medical City National Guard Hospital, Pain Clinic, staffed by one consultant, one staff physician, one fellow and two nurses, and one patient service coordinator, responsible for answering phone calls and booking appointments; patient receives phone call 2 days prior to their scheduled appointments by obtaining their contact number from Bestcare® health information system.

Data of all patients booked from the begging of August to the end of October 2017 were collected and analyzed, (walkin) patients were excluded from the study, and noshow rate was calculated by dividing the number of noshow to the number of all booked appointments, showing that a mean average in 3 months of 100 visit per month, with a mean average of noshow within 3 months of 0.34% noshow rate.

Contact information of all patients who had been booked for the month of November 2017 were collected; we implemented strategy to be used for all phone calls used for every patient: we identified if the patient had answered or not, and if he/she has answered a welcoming and orientation statement (i.e., who we are and why we are calling and where is exactly our clinic and the time of the appointment), then we have to identify that the answering is either the patient or the caregiver not to breach the confidentiality, then we identified the appointment status if the patient is attending or not, and finally, we used verbal contract to inform the patient or the caregiver that in case of failure to show up; patient might be discharged from the clinic to decrease the waiting list which can lead to further health deterioration of other patients.


  Results Top


Total no-show rate has decreased from 0.34% to 0.22% within 1 month of implementation of this strategy.

However, 0.45% of “no-show” patients did not answer phone call reminder or they could not be reached.


  Discussion Top


This article demonstrated that telephone call led to 0.12% reduction of no-show in 1 month compared to 3 months' average no-show rate.

Prior studies have demonstrated superiority of phone call intervention in no-show; hospitals usually used a massaging system which is not as effective as a phone call which is evident in the outcome of this strategy, and it is recommended that all health facilities should have valid phone number for each patient checked and verified while opening file system for each patient.

Still some patients or caregiver can have an overwhelming circumstance that may prevent them from coming to attend their appointments, so to avoid such incident they have to have dedicated cancellation line which automatically can replace other patients' appointments.

Finally, hospitals have to establish a policy of no-show and to implement written contract that subjects “no-show appointment” to possible discharge from the clinic in case of frequent no-show status.


  Conclusion Top


Significant strategies can be applied to enhance attendance rate implemented through telephone call which led to 0.12% reduction of no-show in 1 month compared to 3 months average no-show rate.

Acknowledgment

The authors would like to thank pain management staff, in Riyadh National Guard Hospital, for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Griffiths J. Missed appointments rise by 60%. GP 2001. p. 7.  Back to cited text no. 1
    
2.
Beecham L. Missed GP appointments cost NHS money. Br Med J 1999;319:536.  Back to cited text no. 2
    
3.
Woodcock EW. Managing your appointment 'no-shows'. J Med Pract Manage 2000;15:284-8.  Back to cited text no. 3
    
4.
Murray M. Modernising the NHS. Patient care: Access. Br Med J 2000; 20:1594-6.  Back to cited text no. 4
    
5.
The College of Family Physicians of Canada. The Wait Starts Here. Available from: http://cfpc.ca/uploadedFiles/Resources/Resource_Items/ENGLISH20PCWTP20FINAL20-20DECEMBER202009.pdf. [Last accessed on 2015 Sep 15].  Back to cited text no. 5
    
6.
Comino EJ, Davies GP, Krastev Y, Haas M, Christl B, Furler J, et al. A systematic review of interventions to enhance access to best practice primary health care for chronic disease management, prevention and episodic care. BMC Health Serv Res 2012;12:415.  Back to cited text no. 6
    
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College of Family Physicians of Canada. Family Medicine in Canada: Vision for the Future. Available from: http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/FAMILY_MEDICINE_IN_CANADA_English.pdf. [Last accessed on 2015 Sep 15].  Back to cited text no. 7
    
8.
College of Family Physicians of Canada. Improving Access to Care for Patients in Canada. Available from: http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/CFPC20Position20Statement-20ENG20.pdf. [Last accessed on 2015 Sep15].  Back to cited text no. 8
    
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The Center for Spatial Economics. The Economic Cost of Wait Times in Canada. Available from: http://www.cimca.ca/i/m/TheCentreForSpatialEconomics-Jun06.pdf. [Last accessed on 2015 Jan 20].  Back to cited text no. 9
    
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Mathie AG. The Primary Care Workforce: An Update for the New Millennium. London: Royal College of General Practitioners; 2000.  Back to cited text no. 10
    
11.
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12.
Neal RD, Lawlor DA, Allgar V, Colledge M, Ali S, Hassey A, et al. Missed appointments in general practice: Retrospective data analysis from four practices. Br J Gen Pract 2001;51:830-2.  Back to cited text no. 12
    
13.
Al-Shammari SA. Failures to keep primary care appointments in Saudi Arabia. Fam Pract Res J 1992;12:171-6.  Back to cited text no. 13
    
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Hermoni D, Mankuta D, Reis S. Failure to keep appointments at a community health centre. Analysis of causes. Scand J Prim Health Care 1990;8:107-11.  Back to cited text no. 14
    
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Stevenson JS. Appointment systems in general practice. How patients use them. Br Med J 1967;2:827-9.  Back to cited text no. 15
    
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17.
Bean AG, Talaga J. Predicting appointment breaking. J Health Care Mark 1995;15:29-34.  Back to cited text no. 17
    
18.
Weingarten N, Meyer DL, Schneid JA. Failed appointments in residency practices: Who misses them and what providers are most affected? J Am Board Fam Pract 1997;10:407-11.  Back to cited text no. 18
    
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Smith CM, Yawn BP. Factors associated with appointment keeping in a family practice residency clinic. J Fam Pract 1994;38:25-9.  Back to cited text no. 19
    
20.
Vikander T, Parnicky K, Demers R, Frisof K, Demers P, Chase N. New-patient no-shows in an urban family practice center: Analysis and intervention. J Fam Pract 1986;22:263-8.  Back to cited text no. 20
    
21.
Cosgrove MP. Defaulters in general practice: Reasons for default and patterns of attendance. Br J Gen Pract 1990;40:50-2.  Back to cited text no. 21
    
22.
Hamilton W. General Practice Non-Attendance. A Questionnaire Survey (Pub ID: N0240056126). NHS National Research Register (4); 2001. Available from: http://www.update-software.com/nrr/CLIBINET.EXE?A=1&U=1001&P= 10001. [Last accessed on 2002 Feb19].  Back to cited text no. 22
    
23.
Neal RD, Hussain M, Ali S. Missed Appointments in General Practice: Findings from Two Parallel Studies [abstract]. Annual Meeting of the Association of University Departments of General Practice. Leeds; 11-13 July, 2001.  Back to cited text no. 23
    
24.
Macharia WM, Leon G, Rowe BH, Stephenson BJ, Haynes RB. An overview of interventions to improve compliance with appointment keeping for medical services. JAMA 1992;267:1813-7.  Back to cited text no. 24
    
25.
Doctor-Patient Partnership. Tips: Tackling DNAs. Doctor-Patient Partnership; 2001.  Back to cited text no. 25
    
26.
Wilkinson MJ. Effecting change in frequent non-attenders. Br J Gen Pract 1994;44:233.  Back to cited text no. 26
    
27.
Ross SK. Cancellation and default from appointments in primary care. Br J Gen Pract 1991;41:34.  Back to cited text no. 27
    
28.
Molfenter T. Reducing appointment no-shows: Going from theory to practice. Subst Use Misuse 2013;48:743-9.  Back to cited text no. 28
    




 

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