Factors associated with non-attendance at outpatient endoscopy

Patient Navigation Plus Tailored Digital Video Disc Increases Colorectal Cancer Screening Among Low-Income and Minority Patients Who Did Not Attend a Scheduled Screening Colonoscopy: A Randomized Trial

BACKGROUND

Up to 50% of people scheduled for screening colonoscopy do not complete this test and no studies have focused on minority and low-income populations. Interventions are needed to improve colorectal cancer (CRC) screening knowledge, reduce barriers, and provide alternative screening options. Patient navigation (PN) and tailored interventions increase CRC screening uptake, however there is limited information comparing their effectiveness or the effect of combining them.

PURPOSE

Compare the effectiveness of two interventions to increase CRC screening among minority and low-income individuals who did not attend their screening colonoscopy appointment-a mailed tailored digital video disc (DVD) alone versus the mailed DVD plus telephone-based PN compared to usual care.

METHODS

Patients (n = 371) aged 45-75 years at average risk for CRC who did not attend a screening colonoscopy appointment were enrolled and were randomized to: (i) a mailed tailored DVD; (ii) the mailed DVD plus phone-based PN; or (iii) usual care. CRC screening outcomes were from electronic medical records at 12 months. Multivariable logistic regression analyses were used to study intervention effects.

RESULTS

Participants randomized to tailored DVD plus PN were four times more likely to complete CRC screening compared to usual care and almost two and a half times more likely than those who were sent the DVD alone.

CONCLUSIONS

Combining telephone-based PN with a mailed, tailored DVD increased CRC screening among low-income and minority patients who did not attend their screening colonoscopy appointments and has potential for wide dissemination.

Factors and Reasons Associated With Appointment Non-attendance in Hospitals: A Narrative Review

Non-attendance at hospital appointments is an extremely prevalent issue impacting healthcare systems on a daily basis. This phenomenon adversely affects patient health and healthcare providers, leading to delays in diagnosis and treatment, inefficient resource utilization, and increased healthcare expenses. The detrimental impact of non-attendance is not limited to patients who miss appointments, the knock-on effects of extended waiting times and reduced appointment availability are felt throughout healthcare systems. The purpose of this narrative review is to explore the factors underlying appointment non-attendance in hospital settings, to improve healthcare delivery and patient adherence. An extensive review of the existing global literature was conducted. Quantitative studies that explored the relationship between appointment non-attendance and patient characteristics, such as age, gender, marital status, education level, distance from the hospital, and source of referral, were included. Younger patients, males, individuals with lower levels of education, and those living farther from hospitals were more likely to miss appointments. Marital status was significant, with married patients showing better attendance, as was referral source, with general practitioner referrals associated with higher non-attendance. Qualitative studies identifying both patient-centered and hospital-specific reasons, such as forgetfulness, appointment time, protracted waiting times, patient-physician relationship, and patients' knowledge and perception of their health condition, were also included in the review. Lack of appointment reminders, difficulties in managing appointments, and inadequate patient-physician communication were significant hospital-specific reasons given for non-attendance. Patients' lack of awareness regarding the importance of attending appointments and limited understanding of their health conditions were also identified as patient-centered contributors. Non-attendance at hospital appointments is a multifaceted issue influenced by a range of socioeconomic, personal, and systemic factors. Addressing these factors requires a holistic approach that includes patient education, improved communication, and tailored healthcare delivery strategies, especially for vulnerable populations in rural areas. Enhanced reminder systems and streamlined appointment management could serve as pivotal interventions to reduce non-attendance rates, ultimately improving healthcare outcomes and resource utilization.

Comparison of Predictive Models for Prevention of Missed Endoscopy Appointments- failure of a Predictive Model to Outperform Overbooking Model

BACKGROUND

Patient late cancelation and nonattendance for endoscopy appointments is an ongoing problem affecting the productivity and wait times of endoscopy units. Previous research evaluated a model for predictive overbooking and had promising results.

STUDY

All endoscopy visits at an outpatient endoscopy unit during 4 nonconsecutive months were included in the data analysis. Patients who did not attend their appointment, or canceled with 48 hours of their appointment were considered nonattendees. Demographic, health, and prior visit behavior data was collected and the groups compared.

RESULTS

1780 patients attended 2331 visits in the study period. Comparing the attendee versus non-attendees, there were significant differences in mean age, prior absenteeism, prior cancelations, and total number of hospital visits. No significant differences were seen between groups in winter versus non-winter months, the day of the week, sex distribution, type of procedure booked, or whether the referral was from specialist clinic or direct to procedure. The visit cancelation proportion (calculated excluding current visit) was substantially higher in the absentee group ( P <0.0001). A predictive model was developed and compared to current booking as well as a straight overbooking of 7%. Both overbooking models performed better than the current practice, but the predictive overbooking model did not outperform straight overbooking.

CONCLUSIONS

Developing an endoscopy unit specific predictive model may not be more beneficial than straight overbooking as calculated by missed appointment percentage.

Open-Access Oesophagogastroduodenoscopy as an Effective and Safe Strategy for Patients With Non-alarming Symptoms

BACKGROUND

Open-access oesophagogastroduodenoscopy (OAO) is defined as the performance of oesophagogastroduodenoscopy (OGD) requested by referring physicians without a prior specialist consultation. With the increasing demand for specialist appointments, the use of OAO has helped to reduce healthcare utilization by decreasing prior clinic visits. This also allows endoscopies to be scheduled and performed earlier. This study aims to evaluate our experience in providing OAO services to patients with non-alarming dyspepsia symptoms under the age of 60.

METHODS

The records of patients scheduled for OAO from January 2019 to December 2022 at Singapore General Hospital (SGH) Department of Gastroenterology were analyzed.

RESULTS

Five hundred sixty-nine patients were scheduled for OAO, and 436 patients underwent the procedure. The mean age of patients was 45.7 (SD=10.9) years old. Thirty-six percent were males, and there were 80.8% Chinese, 5.3% Malay, 8.6% Indian, and 5.3% others. The median waiting time for endoscopy was 23 days (IQR 16-36), and no major adverse events were reported. Over half of the endoscopies were unremarkable (n=231, 53%). There were 25 (5.7%) patients with major findings; three had upper gastrointestinal adenocarcinoma (one oesophageal and two gastric), one had oesophageal varices, and 21 had peptic ulcer disease (10 gastric and 11 duodenal ulcers). A rapid urease test was conducted on 409 patients, and 55 (13.4%) were positive.

CONCLUSION

OAO is a safe and effective strategy for providing timely diagnostic OGD to normal-risk patients at our center. Primary care physicians are encouraged to refer non-alarming dyspepsia symptoms patients under 60 years for OAO over the conventional route.

Incidence and predictors of case cancellation within 24 h in patients scheduled for elective surgical procedures

OBJECTIVE

Avoidable case cancellations within 24 h reduce operating room (OR) efficiency, add unnecessary costs, and may have physical and emotional consequences for patients and their families. We developed and validated a prediction tool that can be used to guide same day case cancellation reduction initiatives.

DESIGN

Retrospective hospital registry study.

SETTING

University-affiliated hospitals network (NY, USA).

PATIENTS

246,612 (1/2016-6/2021) and 58,662 (7/2021-6/2022) scheduled elective procedures were included in the development and validation cohort.

MEASUREMENTS

Case cancellation within 24 h was defined as cancelling a surgical procedure within 24 h of the scheduled date and time. Our candidate predictors were defined a priori and included patient-, procedural-, and appointment-related factors. We created a prediction tool using backward stepwise logistic regression to predict case cancellation within 24 h. The model was subsequently recalibrated and validated in a cohort of patients who were recently scheduled for surgery.

MAIN RESULTS

8.6% and 8.7% scheduled procedures were cancelled within 24 h of the intended procedure in the development and validation cohort, respectively. The final weighted score contains 29 predictors. A cutoff value of 15 score points predicted a 10.3% case cancellation rate with a negative predictive value of 0.96, and a positive predictive value of 0.21. The prediction model showed good discrimination in the development and validation cohort with an area under the receiver operating characteristic curve (AUC) of 0.79 (95% confidence interval 0.79-0. 80) and an AUC of 0.73 (95% confidence interval 0.72-0.73), respectively.

CONCLUSIONS

We present a validated preoperative prediction tool for case cancellation within 24 h of surgery. We utilize the instrument in our institution to identify patients with high risk of case cancellation. We describe a process for recalibration such that other institutions can also use the score to guide same day case cancellation reduction initiatives.

Factors associated with non-attendance at appointments in the gastroenterology endoscopy unit: a retrospective cohort study

Background and Aims

Gastrointestinal (GI) endoscopy is a limited health resource because of a scarcity of qualified personnel and limited availability of equipment. Non-adherence to endoscopy appointments therefore wastes healthcare resources and may compromise the early detection and treatment of GI diseases. We aimed to identify factors affecting non-attendance at scheduled appointments for GI endoscopy and thus improve GI healthcare outcomes.

Methods

This was a single-center retrospective cohort study performed at a tertiary hospital gastroenterology endoscopy unit, 12 months before and 12 months after the start of the COVID-19 pandemic. We used multiple logistic regression analysis to identify variables associated with non-attendance at scheduled appointments.

Results

Overall, 5,938 appointments were analyzed, and the non-attendance rate was 18.3% (1,088). The non-attendance rate fell significantly during the pandemic (22.6% vs. 11.6%, p < 0.001). Multivariable regression analysis identified the absence of deep sedation (OR: 3.253, 95% CI [2.386-4.435]; p < 0.001), a referral from a physician other than a gastroenterologist (OR: 1.891, 95% CI [1.630-2.193]; p < 0.001), a longer lead time (OR: 1.006, 95% CI [1.004-1.008]; p < 0.001), and female gender (OR: 1.187, 95% CI [1.033-1.363]; p = 0.015) as associated with appointment non-attendance.

Conclusions

Female patients, those undergoing endoscopic procedures without deep sedation, those referred by physicians other than gastroenterologists, and with longer lead time were less likely to adhere to appointments. Precautions should be directed at patients with one or more of these risk factors, and for those scheduled for screening procedures during the COVID-19 pandemic.

Using Information Videos to Improve Patient Satisfaction in Endoscopy: A Prospective Service Improvement Project

Background: Endoscopy is a rapidly developing discipline with new techniques and procedures being introduced each year. The consenting process is central to patient perception; using information videos as additional tools to aid consent and improve the quality of care in endoscopy is not well established. Our aim was to develop, implement and validate the use of patient educational videos to improve patients’ satisfaction and experience in endoscopy.

Methods and analysis: This was a prospective service quality improvement study. Eligible patients were invited to watch the educational videos in addition to standard practice. We compared this group with a matched cohort of patients who were receiving standard care of postal information leaflets. Patient satisfaction was measured through the validated Gastrointestinal Endoscopy Satisfaction Questionnaire (GESQ).

Results: Patients in the intervention group scored four questions relating to pre-procedural information significantly higher than the control (p=0.038). The total mean GESQ score was also higher in the intervention group compared to the control, however this was not statistically significant (p=0.397). The intervention group had significantly lower cancellation rate (4%) compared to the control group (20%), p=0.023.

Conclusions: Patients who watched educational videos were more satisfied with pre-procedural information in the consenting period than those who did not. Further research is still needed to determine if they reduce patient anxiety. Meanwhile, it would be appropriate to implement these videos into routine practice as a cost-effective method of improving patient satisfaction.

Short Message Service reminders reduce outpatient colonoscopy nonattendance rate: A randomized controlled study

BACKGROUND AND AIM

Nonattendance of outpatient colonoscopy leads to inefficient use of health-care resources. We aimed to study the effectiveness of using Short Message Service (SMS) reminder prior in patients scheduled for outpatient colonoscopy on their nonattendance rate.

METHODS

Patients who scheduled for an outpatient colonoscopy and had access of SMS were recruited from three clinics in Hong Kong. Patients were randomized to SMS group and standard care (SC) group. All patients were given a written appointment slip on the booking date. In addition, patients in the SMS group received an SMS reminder 7-10 days before their colonoscopy appointment. Patients' demographics, attendance, colonoscopy completion, and bowel preparation quality were recorded. Logistic regression was performed to identify predictors of nonattendance.

RESULTS

From November 2013 to October 2019, a total of 2225 eligible patients were recruited. A total of 1079 patients were allocated to the SMS group and 1146 to the SC group. The nonattendance rate of patients in the SMS group was significantly lower than that in the SC group (8.9% vs 11.9%, P = 0.022). There were no significant differences in their baseline characteristics and colonoscopy completion rate and bowel preparation quality. A trend towards a higher rate of adequate bowel preparation was observed in the SMS group when compared with the SC group (69.9% vs 65.8%, P = 0.053). Independent predictors for nonattendance included younger age, underprivilege, and existing diabetes.

CONCLUSIONS

An SMS reminder for outpatient colonoscopy is effective in reducing the nonattendance rate and may potentially improve the bowel preparation quality.

Evaluation of an educational telephone intervention strategy to improve non-screening colonoscopy attendance: A randomized controlled trial

BACKGROUND

Colonoscopy attendance is a key quality parameter in colorectal cancer population screening programmes. Within these programmes, educative interventions with bidirectional contact carried out by trained personnel have been proved to be an important tool for colonoscopy attendance improvement, and because of its huge clinical and economic impact, they have been widely implemented. However, outside of this population programmes, educative measures to improve colonoscopy attendance have been poorly studied and no navigation interventions are usually performed.

AIM

To investigate the clinical and economic impacts of an educational telephone intervention on colonoscopy attendance outside colorectal cancer screening programmes.

METHODS

This randomized controlled trial included consecutive patients referred to colonoscopy from primary care centres from November 2017 to May 2018. The intervention group (IG) received a telephone intervention, while the control group (CG) did not. Patients assigned to the IG received an educational telephone call 7 d before the colonoscopy appointment. The intervention was carried out by two nurses with deep endoscopic knowledge who were previously trained for a telephone educational intervention for colonoscopy. The impact on patient compliance with preparedness protocols related to bowel cleansing, anti-thrombotic management, and sedation scheduling was also evaluated. A second call was conducted to assess patient satisfaction. Intention-to-treat (ITT) and per-protocol (PP) analyses were performed.

RESULTS

A total of 738 and 746 patients were finally included in the IG and CG respectively. Six hundred thirteen (83%) patients were contacted in the IG. The non-attendance rate was lower in the IG, both in the ITT analysis (IG 8.4% vs CG 14.3%, P < 0.001) and in the PP analysis (4.4% vs 14.3%, P < 0.001). In a multivariable analysis, belonging to the control group increased the risk of non-attendance in both, the ITT analysis (OR 1.81, 95%CI: 1.27 to 2.58, P = 0.001) and the PP analysis (OR 3.56, 95%CI: 2.25 to 5.64, P < 0.001). There was also a significant difference in compliance with preparedness protocols [bowel cleansing: IG 61.7% vs CG 52.6% (P = 0.001), antithrombotic management: IG 92.5% vs CG 62.8% (P = 0.001), and sedation scheduling: IG 78.8% vs CG 0% (P ≤ 0.001)]. We observed a net benefit of €55600/year after the intervention. The information given before the procedure was rated as excellent by 26% (CG) and 51% (IG) of patients, P ≤ 0.001.

CONCLUSION

Educational telephone nurse intervention improves attendance, protocol compliance and patient satisfaction in the non-screening colonoscopy setting and has a large economic impact, which supports its imple-mentation and maintenance over time.

Stop Blaming the Weatherman! A Retrospective Study of Endoscopy Show Rates at a Midwest Urban Safety-Net Hospital

BACKGROUND

Weather patterns are well-known to affect human health and behavior and are often arbitrarily blamed for high no-show rates (NSRs). The NSR for outpatient gastrointestinal procedures ranges from 4% to 41% depending on the population and procedure performed. Identifying potential causes will allow for the optimization of endoscopy resource utilization.

AIM

The aim of this study was to evaluate the effects of a day of the year and weather conditions have on NSRs for outpatient endoscopic procedures at a safety-net hospital in Cleveland, Ohio, United States.

METHODS

A 12-month, retrospective cohort study of the NSR for outpatient endoscopic procedures was performed using local weather data from January 1, 2017 to December 31, 2017. Data was assessed by analysis of variance/t test, and the χ test was used to analyze weather impact on NSR.

RESULTS

A total of 7935 patients had an average overall NSR of 11.8%. Average NSR for esophagogastroduodenoscopies (EGDs) were 9.9%, colonoscopies 12.3%, and advanced endoscopy procedures 11.1%. The NSR was highest in April (15.3%, P=0.01) and lowest in September (9.0%, P=0.04). There is a greater likelihood of procedural no-show for colonoscopies compared with EGDs when mean temperatures were at or below freezing (P=0.02) and with snowfall (P=0.03). NSR were also high for EGDs on federal holidays (25%, P=0.03) and colonoscopies on days following federal holidays (25.3%, P<0.01). Day of the week, wind speed, presence of precipitation, wind chill, the temperature change from the prior day, and temperature (high, low, and mean) had no significant impact on NSR.

CONCLUSIONS

Our study demonstrates that scheduling adjustments on federal holidays, days when temperatures are below freezing, and snowfall may improve department resource utilization. These data, along with other variables that affect NSR for endoscopic procedures, should be taken into consideration when attempting to optimize scheduling and available resources in a safety-net hospital.

Factors Associated with Missed and Cancelled Appointments in the Endoscopy Unit: Descriptive Study

Background and aim Canceled and missed appointments at the endoscopy unit affect the quality of the provided services and can negatively impact patient outcomes. Assessing the association between the various factors relating to nonattendance will show whether the defective aspects are organizational or personal, which is essential to improve the quality of the healthcare system. Moreover, this study will be of value in our region due to the current scarcity of studies in the Middle East. Methods A descriptive study was conducted at King Khaled University Hospital in Riyadh, Saudi Arabia. A database of participants was established from those who missed/canceled their outpatient endoscopy clinic appointment; purposive sampling was applied, excluding those who are under 14 years old. Demographic data and organizational factors (e.g., referred clinic and the lead time) were collected from the patients' files and a structured interview done by phone within 7-14 days of the missed/canceled appointment.  Results A total of 919 endoscopy procedures were scheduled in an eight-week period, and 179 procedures were missed/canceled (19.48%); 84% were missed, and 16% were canceled. The highest percentage of the population had a high-school diploma or less. The results showed that roughly half of the patients were unemployed. More than two-thirds of the patients had undergone an endoscopy within the past year or less. The majority stated that they underwent the procedure in a different facility, which might be due to various reasons, one of which could be justified as long lead time.  Conclusion An annual update of patients' files is suggested. Text messages can help serve as a reminder in addition to clear appointment instructions that will aid in minimizing the absence rates. Overbooking is recommended to decrease the lead time and increase clinic efficiency. Raising patients' awareness regarding the effect of missing appointments as well as upgrading the communication methods will assist in decreasing the rate of missed appointments.

Comparison of Referral Pathways in Otolaryngology at a Public Versus Private Academic Center

OBJECTIVE

Delayed medical care may be costly and dangerous. Examining referral pathways may provide insight into ways to reduce delays in care. We sought to compare time between initial referral and first clinic visit and referral and surgical intervention for index otolaryngologic procedures between a public safety net hospital (PSNH) and tertiary-care academic center (TAC).

METHODS

Retrospective cohort study of eligible adult patients undergoing one of several general otolaryngologic procedures at a PSNH (n = 216) and a TAC (n = 161) over a 2-year time period.

RESULTS

PSNH patients were younger, less likely to have comorbidities and more likely to be female, Hispanic or Asian, and to lack insurance. Time between referral and first clinic visit was shorter at the PSNH than the TAC (Mean 35.8 ± 47.7 vs 48.3 ± 60.3 days; P = .03). Time between referral and surgical intervention did not differ between groups (129 ± 90 for PSNH vs 141 ± 130 days for TAC, P = .30). On multivariate analysis, the TAC had more patient-related delays in care than the PSNH (OR: 3.75, P < .001). Time from referral to surgery at a PSNH was associated with age, source of referral, type of surgery, diagnostic workup and comorbidities, and at a TAC was associated with gender and type of surgery and comorbidities.

CONCLUSIONS

Sociodemographic differences between PSNH and TAC patients, as well as differences in referral pathways between the types of institutions, influence progression of surgical care in otolaryngology. These differences may be targets for interventions to streamline care.

LEVEL OF EVIDENCE

2c.

Establishing Clinical Utility for Diagnostic Tests Using a Randomized Controlled, Virtual Patient Trial Design

Demonstrating clinical utility for diagnostic tests and securing coverage and reimbursement requires high quality and, ideally, randomized controlled trial (RCT) data. Traditional RCTs are often too costly, slow, and cumbersome for diagnostic firms. Alternative data options are needed. We evaluated four RCTs using virtual patients to demonstrate clinical utility. Each study used a similar pre-post intervention, two round design to facilitate comparison. Representative samples of physicians were recruited and randomized into control and intervention arms. All physicians were asked to care for their virtual patients during two assessment rounds, separated by a multi-week time interval. Between rounds, intervention physicians reviewed educational materials on the diagnostic test. All physician responses were scored against evidence-based care criteria. RCTs using virtual patients can demonstrate clinical utility for a variety of diagnostic test types, including: (1) an advanced multi-biomarker blood test, (2) a chromosomal microarray, (3) a proteomic assay analysis, and (4) a multiplex immunofluorescence imaging platform. In two studies, utility was demonstrated for all targeted patient populations, while in the other two studies, utility was only demonstrated for a select sub-segment of the intended patient population. Of these four tests, two received positive coverage decisions from Palmetto, one utilized the study results to support commercial payer adjudications, and the fourth company went out of business. RCTs using virtual patients are a cost-effective approach to demonstrate the presence or absence of clinical utility.

Rate and predictors for non-attendance of patients undergoing hospital outpatient treatment for chronic diseases: a register-based cohort study

Background

Failure to keep medical appointments results in inefficiencies and, potentially, in poor outcomes for patients. The aim of this study is to describe non-attendance rate and to investigate predictors of non-attendance among patients receiving hospital outpatient treatment for chronic diseases.

Methods

We conducted a historic, register-based cohort study using data from a regional hospital and included patients aged 18 years or over who were registered in ongoing outpatient treatment courses for seven selected chronic diseases on July 1, 2013. A total of 5895 patients were included and information about their appointments was extracted from the period between July 1, 2013 and June 30, 2015. The outcome measure was occurrence of non-attendance. The associations between non-attendance and covariates (age, gender, marital status, education level, occupational status, specific chronic disease and number of outpatient treatment courses) were investigated using multivariate logistic regression models, including mixed effect.

Results

During the two-year period, 35% of all patients (2057 of 5895 patients) had one or more occurrences of non-attendance and 5% of all appointments (4393 of 82,989 appointments) resulted in non-attendance. Significant predictors for non-attendance were younger age (OR 4.17 for 18 ≤ 29 years as opposed to 80+ years), male gender (OR 1.35), unmarried status (OR 1.39), low educational level (OR 1.18) and receipt of long-term welfare payments (OR 1.48). Neither specific diseases nor number of treatment courses were associated with a higher non-attendance rate.

Conclusions

Patients undergoing hospital outpatient treatments for chronic diseases had a non-attendance rate of 5%. We found several predictors for non-attendance but undergoing treatment for several chronic diseases simultaneously was not a predictor. To reduce non-attendance, initiatives could target the groups at risk.

Trial registration

This study was approved by the Danish Data Protection Agency (Project ID 18/35695).

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4208-9) contains supplementary material, which is available to authorized users.

Primary care variability in patients at higher risk for colorectal cancer: evaluation of screening and preventive care practices

OBJECTIVE

Sub-optimal colorectal cancer (CRC) evaluations have been attributed to both physician and patient factors. The primary objective of this study was to evaluate physician practice variation in patients with a higher risk of CRC. We wanted to identify the physician characteristics and the types of patients that were associated with missed screening opportunities; we also explored whether screening for CRC served as a proxy for better preventive care practices.

METHODS

A total of 213 board-certified family and internal medicine physicians participated in the study, conducted between September and December 2016. We used Clinical Performance and Value (CPV^®) vignettes, simulated patients, to collect data on CRC screening. The CPV patients presented with a typical range of signs and symptoms of potential CRC. The care provided to the simulated patients was scored against explicit evidence-based criteria. The main outcome measure was rate a diagnostic CRC workup was ordered. This data quantified the clinical practice variability for CRC screening in high risk patients and other preventive and screening practices.

RESULTS

A total of 81% of participants ordered appropriate CRC workup in patients at risk for CRC, with a majority (71%) selecting diagnostic colonoscopy over FIT/FOBT. Only 6% of physicians ordering CRC workup, however, counseled patients on their higher risk for CRC. The most commonly recognized symptoms prompting testing were unexplained weight loss or inadequate screening history, while the least recognized symptoms of CRC risk were abdominal discomfort found on review of systems.

CONCLUSION

This study shows that primary care physician screening of CRC varies widely. Those physicians who successfully screened for CRC were more likely to complete other prevention and screening practices.

No-shows in appointment scheduling - a systematic literature review

No-show appointments significantly impact the functioning of healthcare institutions, and much research has been performed to uncover and analyze the factors that influence no-show behavior. In spite of the growing body of literature on this issue, no synthesis of the state-of-the-art is presently available and no systematic literature review (SLR) exists that encompasses all medical specialties. This paper provides a SLR of no-shows in appointment scheduling in which the characteristics of existing studies are analyzed, results regarding which factors have a higher impact on missed appointment rates are synthetized, and comparisons with previous findings are performed. A total of 727 articles and review papers were retrieved from the Scopus database (which includes MEDLINE), 105 of which were selected for identification and analysis. The results indicate that the average no-show rate is of the order of 23%, being highest in the African continent (43.0%) and lowest in Oceania (13.2%). Our analysis also identified patient characteristics that were more frequently associated with no-show behavior: adults of younger age; lower socioeconomic status; place of residence is distant from the clinic; no private insurance. Furthermore, the most commonly reported significant determinants of no-show were high lead time and prior no-show history.

Choosing and booking-and attending? Impact of an electronic booking system on outpatient referrals and non-attendances

Patient non-attendance can lead to worse health outcomes and longer waiting times. In the English National Health Service, around 7% of patients who are referred by their general practice for a hospital outpatient appointment fail to attend. An electronic booking system (Choose and Book-C&B) for general practices making hospital outpatient appointments was introduced in England in 2005 and by 2009 accounted for 50% of appointments. It was intended, inter alia, to reduce the rate of non-attendance. Using a 2004-2009 panel with 7,900 English general practices, allowing for the relaxation of constraints on patient of hospital, and for the potential endogeneity of use of C&B, we estimate that the introduction of C&B reduced non-attendance by referred patients in 2009 by 72,160 (8.7%).

Appointment Wait Time, Primary Care Provider Status, and Patient Demographics are Associated With Nonattendance at Outpatient Gastroenterology Clinic

GOALS

We intended to identify the factors associated with missed appointments at a gastroenterology (GI) clinic in an academic setting.

BACKGROUND

Missed clinic appointments reduce clinic efficiency, waste resources, and increase costs. Limited data exist on subspecialty clinic attendance.

STUDY

We performed a case-control study using data from the electronic health record of patients scheduled for an appointment at the adult GI clinic at the Banner University Medical Center between March and October of 2014. Patients who missed their appointment during the study period served as cases. Controls were randomly selected from patients who completed their appointment during the study period. Analysis included univariate and multivariate logistic regression analysis.

RESULTS

Of 2331 scheduled clinic appointments, 195 (8.4%) were missed appointments. Longer waiting time from referral to scheduled appointment was significantly associated with missed appointment (AOR=1.014; 95% CI, 1.01-1.02; P<0.001). Patients with primary care providers (PCPs) were less likely to miss their appointment than those without PCPs (AOR=0.35; 95% CI, 0.18-0.66; P=0.001). Among patient demographic characteristics, ethnicity and marital status were associated with missed appointment.

CONCLUSIONS

Wait time, ethnicity, marital status, and PCP status were associated with missed GI clinic appointments. Further investigations are needed to assess the effects of intervention strategies directed at reducing appointment wait time and increasing PCP-based care.

Appointment-keeping behaviors and procedure day are associated with colonoscopy attendance in a patient navigator population

BACKGROUND

Patient navigator programs (PNP) have been shown to improve colonoscopy completion with demonstrated cost-effectiveness. Despite additional resources available to these patients, many still do not attend their colonoscopies. The aim of this study was to determine factors associated with colonoscopy attendance amongst patients in whom logistical barriers to attendance have been minimized through enrollment in a PNP.

METHODS

Retrospective case-control study of patients enrolled in a PNP for colonoscopy performed at a tertiary endoscopy center from 2009 to 2014. Cases were defined as patients who did not attend their first scheduled colonoscopy after PNP enrollment. Age- and gender-matched controls completed their first scheduled colonoscopy after PNP enrollment.

RESULTS

514 subjects (257 cases, mean age 57.1years, 36.6% males) were included. Patients who attended their colonoscopy were less likely to be Spanish-speaking (64.6% vs 78.2%, p=0.0003) and uninsured (0.4% vs 3.9%, p=0.006). Attendance rates were significantly lower for screening colonoscopies compared to an indication of surveillance or diagnostic (45.5% vs 65.3%, p<0.0001). Fewer patients attended colonoscopies scheduled on Monday (39.2% vs 52.1%, p=0.04) and in December (10.7% vs 52.3%, p<0.0001). On multivariate analysis, poor appointment-keeping behaviors, including a prior missed colonoscopy (OR 0.20, 95% CI 0.10-0.39) or missed office visit (OR 0.44, 95% CI 0.26-0.73) and procedures scheduled on Mondays (OR 0.51, 95% CI 0.27-0.94) were negatively associated with attendance.

CONCLUSIONS

Appointment-keeping behaviors, in addition to insurance-status, language-barriers and medical comorbidities, influence colonoscopy attendance in a PNP population. Patients scheduled for colonoscopies on Mondays or in December may require more resources to ensure attendance.

Improving Adherence to Screening Colonoscopy Preparation and Appointments: A Multicomponent Quality Improvement Program

Colorectal screening for cancer by colonoscopy is recommended for adults 50 years and older. Scheduling patients for sedated endoscopic procedures involves balancing physician schedules, room availability and equipment, proper patient preparedness, and necessary personnel. Both nonattendance and poor preparations contribute to inefficiency, wasted resources, and increased costs. We noted nonattendance rates ranging from 21% to 29%. As a first step, we examined patient factors associated with nonattendance using a retrospective case control study. Younger patients (<60 years), screening appointment, and insurance type were associated with nonattendance. On the basis of these findings, initial efforts focused on additional nurse strategies of follow-up contact and education for screening colonoscopies. As we improved attendance rate, concomitantly we discovered cancellation rates increasing. Subsequently, an interdisciplinary and interdepartmental quality improvement program has been ongoing to target a number of system-, nurse-, and patient-specific factors contributing to nonattendance and cancellations due to poor preparations. Rates have improved but require ongoing monitoring and surveillance. We describe the ongoing efforts and challenges aimed at both nonattendance and cancellations.

The role of a nurse telephone call to prevent no-shows in endoscopy

BACKGROUND AND AIMS

Preventing missed appointments, or "no-shows," is an important target in improving efficient patient care and lowering costs in gastrointestinal endoscopy practices. We aimed to investigate whether a nurse telephone call would reduce no-show rates for endoscopic appointments, and to determine if hiring and maintaining a nurse dedicated to pre-endoscopy phone calls is economically advantageous. Our secondary aim was to identify predictors of no-shows to endoscopy appointments.

METHODS

We hired and trained a full-time licensed nurse to make a telephone call to patients 7 days before their scheduled upper endoscopy or colonoscopy. We compared this intervention with a previous reminder system involving mailed reminders. The effect of the intervention and impact of other predictors of no-shows were analyzed in 2 similar preintervention and postintervention patient cohorts. A mixed effects logistic regression model was used to estimate the association of the odds of being a no-show to the scheduled appointment and the characteristics of the patient and visit. An analysis of costs was performed that included the startup and maintenance costs of the intervention.

RESULTS

We found that a nurse phone call was associated with a 33% reduction in the odds of a no-show visit (odds ratio, 0.67; 95% confidence interval, 0.50-0.91), adjusting for gender, age, partnered status, insurer type, distance from the endoscopy center, and visit type. The recovered reimbursement during the study period was $48,765, with net savings of $16,190 when accounting for the maintenance costs of the intervention; this resulted in a net revenue per annum of $43,173.

CONCLUSIONS

We found that endoscopy practices may increase revenue, improve scheduling efficiency, and maximize resource utilization by hiring a nurse to reduce no-shows. Predictors of no-shows to endoscopy included unpartnered or single patients, commercial or managed care, being scheduled for colonoscopy as opposed to upper endoscopy, and being scheduled for a screening or surveillance colonoscopy.

Preventing Endoscopy Clinic No-Shows: Prospective Validation of a Predictive Overbooking Model

OBJECTIVES

Patient absenteeism for scheduled visits and procedures ("no-show") occurs frequently in healthcare systems worldwide, resulting in treatment delays and financial loss. To address this problem, we validated a predictive overbooking system that identifies patients at high risk for missing scheduled gastrointestinal endoscopy procedures ("no-shows" and cancellations), and offers their appointments to other patients on short notice.

METHODS

We prospectively tested a predictive overbooking system at a Veterans Administration outpatient endoscopy clinic over a 34-week period, alternating between traditional booking and predictive overbooking methods. For the latter, we assigned a no-show risk score to each scheduled patient, utilizing a previously developed logistic regression model built with electronic health record data. To compare booking methods, we measured service utilization-defined as the percentage of daily total clinic capacity occupied by patients-and length of clinic workday.

RESULTS

Compared to typical booking, predictive overbooking resulted in nearly all appointment slots being filled-2.5 slots available during control weeks vs. 0.35 slots during intervention weeks, t(161)=4.10, P=0.0001. Service utilization increased from 86% during control weeks to 100% during intervention weeks, allowing 111 additional patients to undergo procedures. Physician and staff overages were more common during intervention weeks, but less than anticipated (workday length of 7.84 h (control) vs. 8.31 h (intervention), t(161)=2.28, P=0.02).

CONCLUSIONS

Predictive overbooking may be used to maximize endoscopy scheduling. Future research should focus on adapting the model for use in primary care and specialty clinics.

Factors Associated With Missed and Cancelled Colonoscopy Appointments at Veterans Health Administration Facilities

BACKGROUND & AIMS

Cancelled and missed colonoscopy appointments waste resources, increase colonoscopy delays, and can adversely affect patient outcomes. We examined individual and organizational factors associated with missed and cancelled colonoscopy appointments in Veteran Health Administration facilities.

METHODS

From 69 facilities meeting inclusion criteria, we identified 27,994 patients with colonoscopy appointments scheduled for follow-up, on the basis of positive fecal occult blood test results, between August 16, 2009 and September 30, 2011. We identified factors associated with colonoscopy appointment status (completed, cancelled, or missed) by using hierarchical multinomial regression. Individual factors examined included age, race, sex, marital status, residence, drive time to nearest specialty care facility, limited life expectancy, comorbidities, colonoscopy in the past decade, referring facility type, referral month, and appointment lead time. Organizational factors included facility region, complexity, appointment reminders, scheduling, and prep education practices.

RESULTS

Missed appointments were associated with limited life expectancy (odds ratio [OR], 2.74; P = .0004), no personal history of polyps (OR, 2.74; P < .0001), high facility complexity (OR, 2.69; P = .007), dual diagnosis of psychiatric disorders and substance abuse (OR, 1.82; P < .0001), and opt-out scheduling (OR, 1.57; P = .02). Cancelled appointments were associated with age (OR, 1.61; P = .0005 for 85 years or older and OR, 1.44; P < .0001 for 65-84 years old), no history of polyps (OR, 1.51; P < .0001), and opt-out scheduling (OR, 1.26; P = .04). Additional predictors of both outcomes included race, marital status, and lead time.

CONCLUSIONS

Several factors within Veterans Health Administration clinic control can be targeted to reduce missed and cancelled colonoscopy appointments. Specifically, developing systems to minimize referrals for patients with limited life expectancy could reduce missed appointments, and use of opt-in scheduling and reductions in appointment lead time could improve both outcomes.

Prevalence and predictors of patient no-shows to outpatient endoscopic procedures scheduled with anesthesia

BACKGROUND

Demand for endoscopic procedures scheduled with anesthesia is increasing and no-show to appointments carries significant patient health and financial impact, yet little is known about predictors of no-show.

METHODS

We performed a 16-month retrospective observational cohort study of patients scheduled for outpatient endoscopy with anesthesia at a county hospital serving the safety-net healthcare system of San Francisco. Multivariate logistic regression analysis was performed to evaluate associations between attendance and predictors of no-show.

RESULTS

In total, 511 patients underwent endoscopy with anesthesia during the study period. Twenty-seven percent of patients failed to attend an appointment and were considered "no-show". In multivariate analysis, higher no-show rates were associated with patients with a prior history of no-show (odds ratio [OR] 6.4; 95% confidence interval [CI], 2.4- 17.5), those with active substance abuse within the past year (OR 2.2; 95% CI 1.4-3.6), those with heavy prescription opioids/benzodiazepines use (OR 1.6; 95% CI 1.0-2.6) and longer wait-times (OR 1.05; 95% CI 1.00-1.09). Inversely associated with patient no-show were active employment (OR 0.38; 95% CI 0.18-0.81), patients who attended a pre-operative appointment with an anesthesiologist (OR 0.52; CI 0.32-0.85), and those undergoing an advanced endoscopic procedure (OR 0.43; 95% CI 0.19-0.94).

CONCLUSION

In a safety-net healthcare population, behavioral and social determinants of health, including missed appointments, active substance abuse, homelessness, and unemployment are associated with no-shows to endoscopy with anesthesia.

Improving Nonattendance at Outpatient Pediatric Endoscopy Unit of a Tertiary Center

BACKGROUND AND OBJECTIVES

Failure to attend pediatric outpatient endoscopic procedures leads to inefficient use of resources, longer wait-list times, and delay in diagnoses. The causes for pediatric endoscopy nonattendance are not well studied. The aim of the study was to identify factors associated with failure to attend endoscopic procedures and to assess the value of quality improvement (QI) interventions implemented to improve pediatric endoscopy attendance.

METHODS

This was a continuous QI project. We collected nonattendance data from November 2011 to November 2013. Information collected included procedure type, age, sex, time on the waiting list, history of previous procedures, and reason for nonattendance. The following QI interventions were implemented sequentially: an appointment reminder letter, a telephone call 1 week before procedure, and creation of an electronic medical note dedicated to endoscopy appointment. Pareto charts and statistical process control charts were used for analysis.

RESULTS

From November 2011 to November 2013, we were able to decrease nonattendance from 17% to 11% (P = 0.005). No-show rate was reduced from 5% to 0.9% (P = 0.00001). There was no significant difference between attendees and nonattendees in relation to sex, age, or having a previous procedure. Longer waiting time (33 vs 26 days) was associated with increased risk for nonattendance (P = 0.0007). The most common causes for nonattendance were illness (31.5%), followed by caregiver/patients who no longer wanted the procedure (17.7%), and patients who improved (12.9%).

CONCLUSIONS

Applying QI methods and tools improved pediatric endoscopy attendance. Longer wait time for endoscopic procedures is associated with nonattendance. Given the increased pediatric endoscopy demand, strategies should be implemented to reduce wait time for pediatric endoscopy.

Predicting Non-Adherence with Outpatient Colonoscopy Using a Novel Electronic Tool that Measures Prior Non-Adherence

BACKGROUND

Accurately predicting the risk of no-show for a scheduled colonoscopy can help target interventions to improve compliance with colonoscopy, and thereby reduce the disease burden of colorectal cancer and enhance the utilization of resources within endoscopy units.

OBJECTIVES

We aimed to utilize information available in an electronic medical record (EMR) and endoscopy scheduling system to create a predictive model for no-show risk, and to simultaneously evaluate the role for natural language processing (NLP) in developing such a model.

DESIGN

This was a retrospective observational study using discovery and validation phases to design a colonoscopy non-adherence prediction model. An NLP-derived variable called the Non-Adherence Ratio ("NAR") was developed, validated, and included in the model.

PARTICIPANTS

Patients scheduled for outpatient colonoscopy at an Academic Medical Center (AMC) that is part of a multi-hospital health system, 2009 to 2011, were included in the study.

MAIN MEASURES

Odds ratios for non-adherence were calculated for all variables in the discovery cohort, and an Area Under the Receiver Operating Curve (AUC) was calculated for the final non-adherence prediction model.

KEY RESULTS

The non-adherence model included six variables: 1) gender; 2) history of psychiatric illness, 3) NAR; 4) wait time in months; 5) number of prior missed endoscopies; and 6) education level. The model achieved discrimination in the validation cohort (AUC= =70.2 %). At a threshold non-adherence score of 0.46, the model's sensitivity and specificity were 33 % and 92 %, respectively. Removing the NAR from the model significantly reduced its predictive power (AUC = 64.3 %, difference = 5.9 %, p < 0.001).

CONCLUSIONS

A six-variable model using readily available clinical and demographic information demonstrated accuracy for predicting colonoscopy non-adherence. The NAR, a novel variable developed using NLP technology, significantly strengthened this model's predictive power.

Estimating the cost of no-shows and evaluating the effects of mitigation strategies

OBJECTIVE

To measure the cost of nonattendance ("no-shows") and benefit of overbooking and interventions to reduce no-shows for an outpatient endoscopy suite.

METHODS

We used a discrete-event simulation model to determine improved overbooking scheduling policies and examine the effect of no-shows on procedure utilization and expected net gain, defined as the difference in expected revenue based on Centers for Medicare & Medicaid Services reimbursement rates and variable costs based on the sum of patient waiting time and provider and staff overtime. No-show rates were estimated from historical attendance (18% on average, with a sensitivity range of 12%-24%). We then evaluated the effectiveness of scheduling additional patients and the effect of no-show reduction interventions on the expected net gain.

RESULTS

The base schedule booked 24 patients per day. The daily expected net gain with perfect attendance is $4433.32. The daily loss attributed to the base case no-show rate of 18% is $725.42 (16.4% of net gain), ranging from $472.14 to $1019.29 (10.7%-23.0% of net gain). Implementing no-show interventions reduced net loss by $166.61 to $463.09 (3.8%-10.5% of net gain). The overbooking policy of 9 additional patients per day resulted in no loss in expected net gain when compared with the reference scenario.

CONCLUSIONS

No-shows can significantly decrease the expected net gain of outpatient procedure centers. Overbooking can help mitigate the impact of no-shows on a suite's expected net gain and has a lower expected cost of implementation to the provider than intervention strategies.

"Drop in" gastroscopy outpatient clinic--experience after 9 months

BACKGROUND

Logistics handling referrals for gastroscopy may be more time consuming than the examination itself. For the patient, "drop in" gastroscopy may reduce uncertainty, inadequate therapy and time off work.

METHODS

After an 8-9 month run-in period we asked patients, hospital staff and GPs to fill in a questionnaire to evaluate their experience with "drop in" gastroscopy and gastroscopy by appointment, respectively. The diagnostic gain was evaluated.

RESULTS

112 patients had "drop in" gastroscopy and 101 gastroscopy by appointment. The number of "drop in" patients varied between 3 and 12 per day (mean 6.5). Mean time from first GP consultation to gastroscopy was 3.6 weeks in the "drop in" group and 14 weeks in the appointment group. The half-yearly number of outpatient gastroscopies increased from 696 before introducing "drop in" to 1022 after (47% increase) and the proportion of examinations with pathological findings increased from 42% to 58%. Patients and GPs expressed great satisfaction with "drop in". Hospital staff also acclaimed although it caused more unpredictable working days with no additional staff.

CONCLUSIONS

"Drop in" gastroscopy was introduced without increase in staff. The observed increase in gastroscopies was paralleled by a similar increase in pathological findings without any apparent disadvantages for other groups of patients. This should legitimise "drop in" outpatient gastroscopies, but it requires meticulous observation of possible unwanted effects when implemented.

Hereditary angioedema: a clinical review for the otolaryngologist

Hereditary angioedema (HAE) is a relatively rare genetic disorder that is usually characterized by either low levels of C1 esterase inhibitor (C1-INH) or the presence of dysfunctional C1-INH. It can present with relatively mild and self-limiting symptoms, but it is also potentially fatal; the most common cause of death is asphyxiation secondary to edema of the upper airway. The diagnosis of HAE, especially in the emergency situation, is not straightforward. HAE must be distinguished from several other types of angioedema that require different management approaches. Management approaches include trigger avoidance and pharmacologic therapy; the latter has traditionally involved the administration of attenuated androgens and antifibrinolytics. Recently, a new class of agent-C1-INH-has been introduced in the United States. This article provides an update on the pathophysiology, clinical picture, diagnosis, prophylaxis, and acute treatment of HAE. We must keep HAE in mind as a possible diagnosis whenever we are faced with a case of unexplained angioedema if we are to take advantage of the effective and more specific therapies that are becoming available.

How to overbook procedures in the endoscopy unit

BACKGROUND

Because nonattendance of outpatients scheduled for GI endoscopy is unavoidable, a frequently recommended solution involves overbooking patient appointments.

OBJECTIVE

To provide a set of numerical guidelines of how to overbook patients scheduled for endoscopy.

DESIGN

Cost-benefit analysis using stochastic modeling to estimate the total number of endoscopy appointments (including overbooking) that maximize the expected benefit from endoscopy.

PATIENTS

Subjects scheduled for GI endoscopy.

MAIN OUTCOME MEASUREMENTS

The number of endoscopies that should be scheduled under various scenarios of patient attendance rates, the number of available endoscopy slots, and the cost impact of missed appointments.

RESULTS

Overbooking can increase the expected benefit but never quite reaches the benefit that would be achieved, if all patients were perfectly reliable in meeting their scheduled appointments. The expected benefit of overbooking always comes to lie between the low benefit without overbooking and the high benefit associated with perfectly reliable patients. The less reliable the patient population, the more overbooking needs to take place. Overbooking should also expand with a decreasing cost impact of overbooked endoscopies. Overbooking is most beneficial in large endoscopy units. This article provides a table with a large set of numerical examples for different scenarios of overbooking that cover endoscopy units of diverse sizes and patient attendance rates.

LIMITATIONS

The analysis does not take into account individual patient characteristics that may affect attendance rates.

CONCLUSION

This analysis yields a set of estimates for overbooking that can be readily applied to a large variety of endoscopic units.