"Nudge" and the epidemic of missed appointments

Understanding the causes of missingness in primary care: a realist review

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.

Identifying barriers to outpatient appointment attendance in patient groups at risk of inequity: a mixed methods study in a London NHS trust

BACKGROUND

There is significant health inequity in the United Kingdom (U.K.), with different populations facing challenges accessing health services, which can impact health outcomes. At one London National Health Service (NHS) Trust, data showed that patients from deprived areas and minority ethnic groups had a higher likelihood of missing their first outpatient appointment. This study's objectives were to understand barriers to specific patient populations attending first outpatient appointments, explore systemic factors and assess appointment awareness.

METHODS

Five high-volume specialties identified as having inequitable access based on ethnicity and deprivation were selected as the study setting. Mixed methods were employed to understand barriers to outpatient attendance, including qualitative semi-structured interviews with patients and staff, observations of staff workflows and interrogation of quantitative data on appointment communication. To identify barriers, semi-structured interviews were conducted with patients who missed their appointment and were from a minority ethnic group or deprived area. Staff interviews and observations were carried out to further understand attendance barriers. Patient interview data were analysed using inductive thematic analysis to create a thematic framework and triangulated with staff data. Subthemes were mapped onto a behavioural science framework highlighting behaviours that could be targeted. Quantitative data from patient interviews were analysed to assess appointment awareness and communication.

RESULTS

Twenty-six patients and 11 staff were interviewed, with four staff observed. Seven themes were identified as barriers - communication factors, communication methods, healthcare system, system errors, transport, appointment, and personal factors. Knowledge about appointments was an important identified behaviour, supported by eight out of 26 patients answering that they were unaware of their missed appointment. Environmental context and resources were other strongly represented behavioural factors, highlighting systemic barriers that prevent attendance.

CONCLUSION

This study showed the barriers preventing patients from minority ethnic groups or living in deprived areas from attending their outpatient appointment. These barriers included communication factors, communication methods, healthcare the system, system errors, transport, appointment, and personal factors. Healthcare services should acknowledge this and work with public members from these communities to co-design solutions supporting attendance. Our work provides a basis for future intervention design, informed by behavioural science and community involvement.

Factors influencing non-attendance at sexual healthcare appointments in the UK: a qualitative study

BACKGROUND

Missed sexual healthcare appointments lead to inefficiencies and wasted resources, longer waiting times and poorer outcomes. The aim of this research was to identify factors influencing non-attendance at sexual healthcare appointments and to make recommendations for interventions.

METHODS

Semi-structured interviews were carried out with UK-based sexual health service-users with experience of booking and missing appointments and sexual health professionals (n =28). Interviews were analysed using a thematic framework approach.

RESULTS

Perceptual, practical, and organisational factors were found to influence missed appointments. Perceptual factors included beliefs about the outcomes of attending; sense of responsibility to attend; and concerns about privacy and security. Practical factors included competing demands and disruption to daily life; ability to attend; and forgetting. Organisational factors included mode of appointment delivery and availability of appointments.

CONCLUSIONS

Interventions should combine strategies shown to be effective for overcoming practical barriers to attendance (e.g. reminder systems) with novel strategies communicating the benefits of attending and risks of missed appointments (e.g. behaviourally informed messaging). Text reminders containing behaviourally informed messages may be an efficient intervention for targeting perceptual and practical factors associated with missed appointments. Offering appointment modalities to suit individual preference and enabling service-users to remotely cancel/reschedule appointments maight further support a reduction in missed appointments.

Understanding the psychological therapy treatment outcomes for young adults who are not in education, employment, or training (NEET), moderators of outcomes, and what might be done to improve them

BACKGROUND

To determine: whether young adults (aged 18-24) not in education, employment or training (NEET) have different psychological treatment outcomes to other young adults; any socio-demographic or treatment-related moderators of differential outcomes; and whether service-level changes are associated with better outcomes for those who are NEET.

METHODS

A cohort was formed of 20 293 young adults treated with psychological therapies in eight Improving Access to Psychological Therapies services. Pre-treatment characteristics, outcomes, and moderators of differential outcomes were compared for those who were and were not NEET. Associations between outcomes and the following were assessed for those that were NEET: missing fewer sessions, attending more sessions, having a recorded diagnosis, and waiting fewer days between referral and starting treatment.

RESULTS

Those who were NEET had worse outcomes: odds ratio (OR) [95% confidence interval (CI)] for reliable recovery = 0.68 (0.63-0.74), for deterioration = 1.41 (1.25-1.60), and for attrition = 1.31 (1.19-1.43). Ethnic minority participants that were NEET had better outcomes than those that were White and NEET. Living in deprived areas was associated with worse outcomes. The intensity of treatment (high or low) did not moderate outcomes, but having more sessions was associated with improved outcomes for those that were NEET: odds (per one-session increase) of reliable recovery = 1.10 (1.08-1.12), deterioration = 0.94 (0.91-0.98), and attrition = 0.68 (0.66-0.71).

CONCLUSIONS

Earlier treatment, supporting those that are NEET to attend sessions, and in particular, offering them more sessions before ending treatment might be effective in improving clinical outcomes. Additional support when working with White young adults that are NEET and those in more deprived areas may also be important.

Causes, impacts and possible mitigation of non-attendance of appointments within the National Health Service: a literature review

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.

Characterising the nationwide burden and predictors of unkept outpatient appointments in the National Health Service in England: A cohort study using a machine learning approach

BACKGROUND

Unkept outpatient hospital appointments cost the National Health Service £1 billion each year. Given the associated costs and morbidity of unkept appointments, this is an issue requiring urgent attention. We aimed to determine rates of unkept outpatient clinic appointments across hospital trusts in the England. In addition, we aimed to examine the predictors of unkept outpatient clinic appointments across specialties at Imperial College Healthcare NHS Trust (ICHT). Our final aim was to train machine learning models to determine the effectiveness of a potential intervention in reducing unkept appointments.

METHODS AND FINDINGS

UK Hospital Episode Statistics outpatient data from 2016 to 2018 were used for this study. Machine learning models were trained to determine predictors of unkept appointments and their relative importance. These models were gradient boosting machines. In 2017-2018 there were approximately 85 million outpatient appointments, with an unkept appointment rate of 5.7%. Within ICHT, there were almost 1 million appointments, with an unkept appointment rate of 11.2%. Hepatology had the highest rate of unkept appointments (17%), and medical oncology had the lowest (6%). The most important predictors of unkept appointments included the recency (25%) and frequency (13%) of previous unkept appointments and age at appointment (10%). A sensitivity of 0.287 was calculated overall for specialties with at least 10,000 appointments in 2016-2017 (after data cleaning). This suggests that 28.7% of patients who do miss their appointment would be successfully targeted if the top 10% least likely to attend received an intervention. As a result, an intervention targeting the top 10% of likely non-attenders, in the full population of patients, would be able to capture 28.7% of unkept appointments if successful. Study limitations include that some unkept appointments may have been missed from the analysis because recording of unkept appointments is not mandatory in England. Furthermore, results here are based on a single trust in England, hence may not be generalisable to other locations.

CONCLUSIONS

Unkept appointments remain an ongoing concern for healthcare systems internationally. Using machine learning, we can identify those most likely to miss their appointment and implement more targeted interventions to reduce unkept appointment rates.

After COVID-19: Improving the Patient's Outpatient Appointment Experience

As the COVID-19 pandemic diminishes, it is expected that patients will seek more outpatient appointments resulting in adverse patient and clinic experiences if there is a corresponding increase in missed appointments. This study's purpose was to determine if there was an association between advanced access scheduling, also known as open access or same day scheduling, and missed appointment rates for patients scheduled with preferred primary care physicians vis-a-vis nonpreferred primary care physicians. Patients prescheduled with primary care providers and over the age of 18 years were included in the study, which totaled 4815 visits. Study results demonstrated a statistically significant mean proportion difference between the national no-show rate and the study's no-show rate as well as a significant association between physician type and visit status. The results suggested the potential for improving the patient experience with advanced access scheduling if patients are scheduled with their preferred primary care physician. This study may promote positive patient experiences by providing patients and clinicians with an understanding of the significance surrounding advanced access scheduling thus decreasing missed appointments.

A text mining study of topics and trends in health care management journals: 1998-2018

BACKGROUND

Advances in natural language processing and text mining provide a powerful approach to understanding trending themes in the health care management literature.

PURPOSE

The aim of this study was to introduce machine learning, particularly text mining and natural language processing, as a viable approach to summarizing a subset of health care management research. The secondary aim of the study was to display the major foci of health care management research and to summarize the literature's evolution trends over a 20-year period.

METHODOLOGY/APPROACH

Article abstracts (N = 2,813), from six health care management journals published from 1998 through 2018 were evaluated through latent semantic analysis, topic analysis, and multiple correspondence analysis.

RESULTS

Using latent semantic analysis and topic analysis on 2,813 abstracts revealed eight distinct topics. Of the eight, three leadership and transformation, workforce well-being, and delivery of care issues were up-trending, whereas organizational performance, patient-centeredness, technology and innovation, and managerial issues and gender concerns exhibited downward trending. Finance exhibited peaks and troughs throughout the study period. Four journals, Frontiers of Health Services Management, Journal of Healthcare Management, Health Care Management Review, and Advances in Health Care Management, exhibited strong associations with finance, organizational performance, technology and innovation, managerial issues and gender concerns, and workforce well-being. The Journal of Health Management and the Journal of Health Organization and Management were more distant from the other journals and topics, except for delivery of care, and leadership and transformation.

CONCLUSION

There was a close association of journals and research topics, and research topics evolved with changes in the health care environment.

PRACTICE IMPLICATIONS

As scholars develop research agendas, focus should be on topics important to health care management practitioners for better informed decision-making.

A telephone assessment and advice service within an ED physiotherapy clinic: a single-site quality improvement cohort study

BACKGROUND

In response to issues with timely access and high non-attendance rates for Emergency Department (ED) physiotherapy, a telephone assessment and advice service was evaluated as part of a quality improvement project. This telehealth option requires minimal resources, with the added benefit of allowing the healthcare professional streamline care. A primary aim was to investigate whether this service model can reduce wait times and non-attendance rates, compared to usual care. A secondary aim was to evaluate service user acceptability.

METHODS

This was a single-site quality improvement cohort study that compares data on wait time to first physiotherapy contact, non-attendance rates and participant satisfaction between patients that opted for a service based on initial telephone assessment and advice, versus routine face-to-face appointments. 116 patients were referred for ED physiotherapy over the 3-month pilot at the ED and out-patient physiotherapy department, XMercy University Hospital, Cork, Ireland. 91 patients (78%) opted for the telephone assessment and advice service, with 40% (n=36) contacting the service. 25 patients (22%) opted for the face-to-face service. Data on wait time and non-attendance rates was gathered using the hospital data reporting system. Satisfaction data was collected on discharge using a satisfaction survey adapted from the General Practice Assessment Questionnaire. Independent-samples t-test or Mann Whitney U Test was utilised depending on the distribution of the data. For categorical data, Chi-Square tests were performed. A level of significance of p ≤ 0.05 was set for this study.

RESULTS

Those that contacted the telephone assessment and advice service had a significantly reduced wait time (median 6 days; 3-8 days) compared to those that opted for usual care (median 35 days; 19-39 days) (p ≤ 0.05). There was no significant between-group differences for non-attendance rates or satisfaction.

CONCLUSION

A telephone assessment and advice service may be useful in minimising delays for advice for those referred to ED Physiotherapy for musculoskeleltal problems. This telehealth option appears to be broadly acceptable and since it can be introduced rapidly, it may be helpful in triaging referrals and minimising face-to-face consultations, in line with COVID-19 recommendations. However, a large scale randomised controlled trial is warranted to confirm these findings.

Fine for non-attendance in public hospitals in Denmark: A survey of non-attenders' reasons and attitudes

OBJECTIVE

To investigate non-attending patients' reasons for non-attendance and their general and specific attitudes towards a non-attendance fine.

DATA SOURCES

Non-attenders at two hospital departments participating in a trial of fine for non-attendance from May 2015 to January 2017.

DESIGN

A quantitative questionnaire study was conducted among non-attenders.

DATA COLLECTION

Non-attending patients in the intervention group were invited to complete the questionnaire. The response rate was 39% and the total number of respondents was 71 individuals.

PRINCIPAL FINDINGS

The main reason for non-attendance was technical challenges with the digital appointment and with cancelation. The main part of the respondents was generally positive towards a fine for non-attendance. However, approximately the half had a negative attitude towards the actual fine issued.

CONCLUSIONS

Technical challenges with appointments and cancelation should get special attention when addressing non-attendance. Danish non-attending patients are primarily positive towards the general principle of issuing a fine for non-attendance. However, a significant proportion of the generally positive, reported a negative specific attitude to the specific fine issued to them. This, however, did not affect their general attitude.

Decreasing the number of arthroscopies in knee osteoarthritis - a service evaluation of a de-implementation strategy

BACKGROUND

The Personalised Knee Improvement Programme (P-KIP) was developed based on previously published work, with the hypothesis that surgeons would refer patients to a well-structured conservative management intervention instead of for arthroscopy (de-implementation of arthroscopy by substitution with P-KIP). This meets NICE guidelines and international recommendations but such programmes are not widely used in the UK. Our aim was to determine whether P-KIP would reduce the number of arthroscopies performed for knee osteoarthritis.

METHODS

P-KIP is a conservative care pathway including a group education session followed by individually tailored one-to-one dietician and physiotherapy sessions. Virtual clinic follow-up is conducted three to 6 months after completion of the programme. The service began in July 2015. The number of arthroscopies saved, measured from hospital level coding data, is the primary outcome measure. Interrupted time series analysis of coding data was conducted. As a quality assurance process, patient reported outcome measures (Oxford Knee Score; Euroqol 5D) were collected at baseline and at follow up.

RESULTS

Time series analysis demonstrates that the programme saved 15.4 arthroscopies a month (95% confidence interval 9-21; p < 0.001), equating to 184 arthroscopies a year in a single hospital. The PROMs data demonstrated improvements in patient reported outcome scores consistent with previous published reports of conservative interventions in similar patient populations.

CONCLUSIONS

Results suggest that P-KIP reduces the number of arthroscopies performed, and patients who took part in P-KIP had an improvement in their knee and general health outcomes. P-KIP has the potential to deliver efficiency savings and relive pressure on operative lists, however replication in other sites is required.

Outcomes of a randomized controlled trial assessing a smartphone Application to reduce unmet needs among people diagnosed with CancEr (ACE)

BACKGROUND

Smartphone technology represents an opportunity to deliver practical solutions for people affected by cancer at a scale that was previously unimaginable, such as information, appointment monitoring, and improved access to cancer support services. This study aimed to determine whether a smartphone application (app) reduced the unmet needs among people newly diagnosed with cancer.

METHODS

A single blind, multisite randomized controlled trial to determine the impact of an app-based, 4-month intervention. Newly diagnosed cancer patients were approached at three health service treatment clinics.

RESULTS

Eighty-two people were randomized (intervention; n = 43 and control; n = 39), average age was 59.5 years (SD: 12.9); 71% female; 67% married or in a de facto relationship. At baseline, there were no differences in participants' characteristics between the groups. No significant effects, in reducing unmet needs, were demonstrated at the end of intervention (4-month) or 12-month follow-up. Overall, 94% used the app in weeks 1-4, which decreased to 41% in weeks 13-16. Mean app use time per participant: Cancer Information, 6.9 (SD: 18.9) minutes; Appointment Schedule, 5.1 (SD: 9.6) minutes; Cancer Services 1.5 minutes (SD: 6.8); Hospital Navigation, 1.4 (SD: 2.8) minutes.

CONCLUSIONS

Despite consumer involvement in the design of this smartphone technology, the app did not reduce unmet needs. This may have been due to the study being underpowered. To contribute to a meaningful understanding and improved implementation of smartphone technology to support people affected by cancer, practical considerations, such as recruitment issues and access to, and confidence with, apps, need to be considered. Australian New Zealand Clinical Trials Registration (ACTRN) Trial Registration: 12616001251415; WEF 7/9/2016.

Does pain take holidays? Non-attendance rates at a hospital-based pain clinic are elevated during the Jewish high-holidays

Background

Patient non-attendance is an expensive and persistent problem worldwide with rates between 5–39% reported in the literature. The objective of the study was to assess whether there is a higher incidence of non-attendance in a hospital-based pain clinic during the period of the Jewish High Holidays (Rosh-Hashanah to Sukkot) and whether this is further compounded by other factors, such as demographic characteristics and previous visits to the clinic.

Methods

Records were taken from the Lowenstein Rehabilitation Hospital appointment scheduling system. Data was gathered from two time-periods: High-Holidays and Control for each year, over a total of 6 years 2008–2013. Non-attendance was analyzed by period, by age, by gender and by previous visits to the clinic.

Results

In the entire population studied (666 distinct records), the non-attendance rate was higher during the High-Holidays as compared to the Control period (32 vs. 24.1%; p = 0.030). Non-attendance rates were significantly higher during the Holidays among repeating patients (28.6 vs. 14.8%; p = 0.002) and among women (34.6 vs. 20.7%; p = 0.004).

Discussion

Our data suggest that non-attendance is elevated during the High-Holidays in specific groups of patients, namely, repeating patients and women. Despite no direct inquiry into the reasons for non-attendance, we speculate that the elevated well-being and familial support during the holidays contribute to the patients’ ability to cope with persistent pain and possibly directly reduce the amount of pain, leading to patients missing their pain clinic appointments.

Conclusion

Our results, provided they can be corroborated by larger-scale studies, can assist in scheduling policy adjustments such as avoidance of appointments during the High-holidays for specific patient populations and more rigorous reminder efforts during these times of the year that may lead to reduction in overall non-attendance rates in the pain clinic. Further, our data provide an impetus for further studies of non-attendance patterns among pain clinic patients, in order to acquire a better understanding of the reasons for non-attendance and develop strategies to reduce it and thus contribute to the continuous improvement of the Israeli health systems as well as others worldwide.

Electronic supplementary material

The online version of this article (doi:10.1186/s13584-017-0132-9) contains supplementary material, which is available to authorized users.