Effect on hospital attendance rates of giving patients a copy of their referral letter: randomised controlled trial

Strengthening the referral Chain and providing one window diabetes eye care facility to people with Type-2 Diabetes: A six-year follow-up study from Pakistan

Objective:

To report the results of implementation of two-pronged system for strengthening of referral and receiving end of referral chain for people with Type-2 diabetes mellitus (T2DM) at a tertiary eye care hospital in Karachi.

Methods:

This observational, cross sectional study was conducted from the data collected in “Strengthening Pakistan’s response to Diabetic Retinopathy” project. Peripheral referral was improved through community awareness camps (n=48), refreshing knowledge of primary healthcare professionals (PHCP) and conducting retinopathy screening camps (n=85) in the community. T2DM patients with best corrected visual acuity (BCVA) <6/18 or had retinopathy sign on screening were referred to tertiary center. The receiving end of the referral was improved by establishing “one window facility” at tertiary eye care center. Facility consisted of eight stations starting from registration, visual assessment, fundus photographs, consultation with ophthalmologist, anthropometry measurement, consultation with diabetologist to finally meeting with diabetes educator. At every station, patient’s information was directly entered in HIMS software.

Results:

A total of 50,595 patients attended tertiary center over six years. Among all 34685 (68.5%) were new registration and 15910 (31.4%) were follow ups. During first year (2014-15) out of total registered individuals with DM, newly registered were 4414 (89.5%) and 518 (10.5%) were follow-ups. In the final year (2019-20) new cases registered reached to 62% (n= 7916) with 38% (n=4852) follow-ups. Patients referred by PHCP increased from 6.5% in 2014-15 to 43.7% in 2019-20. An increased uptake of all treatment modalities for retinopathy like laser (increased by 16.76%), intra-vitreal injections (by 14.72%) and vitrectomy (by 51.47%) were also observed.

Conclusion:

Implementation of two prong system resulted in improved service uptake, better referral system, enhanced follow-ups and increased intervention uptake.

Quantitative impact of the first COVID-19 lockdown on nuclear medicine in France: the CORALINE study

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic reshaped the usual risk: benefit equilibrium that became a trade-off between the infection exposure risk for the patient (and for staff) and the risk associated with delaying or cancelling the nuclear medicine examination. This study aimed at quantifying the impact of the first COVID-19 lockdown in France on nuclear medicine examination volume together with volume of examination cancellation and non-attendance.

METHODS

We retrospectively assessed the volume of planned examinations from 1 month before to 1 month after the first lockdown in French high-volume nuclear medicine departments (NMD) sharing the same information management system including both university hospitals, UH (n = 7), and cancer centres, CC (n = 2).

RESULTS

The study enrolled 31,628 consecutive patients referred for a nuclear medicine examination performed or not (NMEP or NMEnP). The total volume of NMEP significantly dropped by 43.4% between the 4 weeks before and after the starting of the lockdown. The comparison of the percentage of NMEP and NMEnP between UH and CC is significantly different (p < 0.001). The percentage of NMEP during the study was 67.9% in UH vs 84.7% in CC. Percentages of NMEnP in UH and CC were due respectively to cancellation by the patient (14.9 vs 7.4%), cancellation by the NMD (9.5 vs 3.4%), cancellation by the referring physician (5.1 vs 4.4%) and non-attender patients (2.7 vs 0.2%).

CONCLUSION

The study underlines the public health issue caused by COVID-19 above the pandemic itself and should be useful in preparing for potential resource utilisation and staffing requirements.

Using machine learning tools to investigate factors associated with trends in 'no-shows' in outpatient appointments

Missed appointments are estimated to cost the UK National Health Service (NHS) approximately £1 billion annually. Research that leads to a fuller understanding of the types of factors influencing spatial and temporal patterns of these so-called "Did-Not-Attends" (DNAs) is therefore timely. This research articulates the results of a study that uses machine learning approaches to investigate whether these factors are consistent across a range of medical specialities. A predictive model was used to determine the risk-increasing and risk-mitigating factors associated with missing appointments, which were then used to assign a risk score to patients on an appointment-by-appointment basis for each speciality. Results show that the best predictors of DNAs include the patient's age, appointment history, and the deprivation rank of their area of residence. Findings have been analysed at both a geographical and medical speciality level, and the factors associated with DNAs have been shown to differ in terms of both importance and association. This research has demonstrated how machine learning techniques have real value in informing future intervention policies related to DNAs that can help reduce the burden on the NHS and improve patient care and well-being.

Association between age and outpatient clinic arrival time: myth or reality?

BACKGROUND

Non-attendance and late arrivals diminish patient flow in outpatient clinics. On the other hand, patient earliness may also be undesirable. Physicians often experience that older patients are more punctual than younger patients, and often they come excessively early. The aim of this study was to determine whether an association between age and outpatient clinic arrival time could be established or not, i.e. to find out if it is a myth or a reality.

METHODS

Prospective descriptive study performed at a neurological outpatient clinic. Data were collected from all scheduled appointments during an eight-week period. Variables included were age, gender, appointment time, arrival time, no-shows, appointment type, need for assistance and if it was an early or late appointment. Outcomes were unpunctuality (early and late arrivals) and non-attendance.

RESULTS

Of 1353 appointments, non-attendance rate was 9.5 and 5.1% were late arrivals. Median age increased with increased patient earliness (p <  0.001). Younger age (p = 0.007) and new referrals (p = 0.025) were associated with non-attendance.

CONCLUSIONS

The intuition of an association between age and outpatient clinic arrival time was confirmed, thus it is a reality that older patients attend their appointments more frequently and have better punctuality than younger adults. This age effect in outpatient clinics should be considered when developing future simulation models and intervention studies.

A dynamic approach for outpatient scheduling

AIMS

Patient no-show is a recurrent problem in medical centers and, in conjunction with cancellation of appointments, often results in loss of productivity and excessive patient time to appointment. The purpose of this study was to develop a dynamic procedure for scheduling patients within an outpatient clinic where patients are expected to have multiple appointments, such as physical therapy, occupational therapy, primary care, and dentistry.

METHODS

This retrospective study involved the year 2014 de-identified patient records from an outpatient clinic affiliated with a large university hospital. A number of patient characteristics, appointment data, and historical attendance records were examined to determine whether they significantly impacted patients who missed scheduled appointments (no-shows). Patient attendance behaviors over multiple appointments were examined to determine whether their no-show and cancellation patterns differed from one appointment to the next. Decision tree analysis was applied to those predictors that significantly correlated with patient attendance behavior to assess the likelihood of a patient no-show. A sample dynamic appointment scheduling procedure that utilized different overbooking strategies for different appointment numbers was then developed. Computer simulation was used to assess the effectiveness of the dynamic procedure versus two other methods consisting of randomly assigned and uniformly assigned appointments.

RESULTS

The dynamic scheduling procedure resulted in increased scheduling efficiency through overbooking but with less than 5% risk of appointment conflicts (i.e. two patients showing at the same time), equating to approximately 0.16 conflicts per clinician per day. It also increased clinic utilization by about 6.7%. It consistently outperformed the other two methods with respect to the percentage of appointment conflicts.

LIMITATIONS

The study is limited with respect to potential clinician cost increase resulting from possible appointment conflicts. A second limitation is that patients experiencing appointment conflicts might not wait for treatment, resulting in potential loss of revenue. A third limitation is that the model does not take into account patient satisfaction, nor the ethics of overbooking patients.

CONCLUSIONS

A dynamic appointment scheduling procedure was developed using actual patient characteristics. The procedure resulted in creation of more efficient appointment schedules thereby increasing the clinic utilization.

Why children do not attend their appointments: is there a need for an interface between general practitioners and hospitals allowing for the exchange of patients' contact details?

OBJECTIVES

A service evaluation project on the reasons why children do not attend their outpatient appointments.

DESIGN

Analysis of paediatric clinic lists over two consecutive days. Parents of the non-attenders were identified and their reasons for not attending the appointment were elicited using a survey.

SETTING

The appointments were scheduled to take place in the Paediatric department at St. Mary's Hospital, London.

PARTICIPANTS

Of the 201 appointments scheduled, 49 patients did not attend their paediatric appointment. Telephone contact was successful with 35 parents.

MAIN OUTCOME MEASURES

Parents were asked to verify if their contact details were correct, if they were aware of the appointment and if they had received a reminder. The reasons for non-attendance were explored.

RESULTS

Of the 49 non-attenders, correct contact details were held on file for 24 of the patients (49.0%). Of the 35 parents contacted, 18 were aware (51.4%) of their child's appointment.

CONCLUSIONS

This project revealed that the principal reason for non-attendance is unawareness of the appointment due to incorrect contact details held by the hospital. Potential strategies for reducing non-attendance at this paediatric outpatient clinic include developing a confirmation or reminder system and improved communication with parents. The creation of a new interface between hospitals and GPs would allow hospitals to access patient contact details held by GPs. It would also ensure that hospitals hold up-to-date patient contact details and that appointment details are effectively communicated to parents. The interface would automatically feed through any updated patient details, keeping hospital records current.

Characteristics and outcomes of advanced cancer patients who miss outpatient supportive care consult appointments

BACKGROUND

Missed appointments (MA) are frequent, but there are no studies on the effects of the first MA at supportive care outpatient clinics on clinical outcomes.

METHODS

We determined the frequency of MA among all patients referred to our clinic from January-December 2011 and recorded the clinical and demographic data and outcomes of 218 MA patients and 217 consecutive patients who kept their first appointments (KA).

RESULTS

Of 1,352 advanced-cancer patients referred to our clinic, 218 (16 %) had an MA. The MA patients' median age was 57 years (interquartile range, 49-67). The mean time between referral and appointment was 7.4 days (range, 0-71) for KA patients vs. 9.1 days (range, 0-89) for MA patients (P = 0.006). Reasons for missing included admission to the hospital (17/218 [8 %]), death (4/218 [2 %]), appointments with primary oncologists (37/218 [18 %]), other appointments (19/218 [9 %]), visits to the emergency room (ER) (9/218 [9 %]), and unknown (111/218 [54 %]). MA patients visited the ER more at 2 weeks (16/214 [7 %] vs. 5/217 [2 %], P = 0.010) and 4 weeks (17/205 [8 %] vs. 8/217 [4 %], P = 0.060). Median-survival duration for MA patients was 177 days (range, 127-215) vs. 253 days (range, 192-347) for KA patients (P = 0.013). Multivariate analysis showed that MAs were associated with longer time between referral and scheduled appointment (odds ratio [OR], 1.026/day, P = 0.030), referral from targeted therapy services (OR, 2.177, P = 0.004), living in Texas/Louisiana regions (OR, 2.345, P = 0.002), having an advanced directive (OR, 0.154, P < 0.0001), and being referred for symptom control (OR, 0.024, P = 0.0003).

CONCLUSION

MA patients with advanced cancer have worse survival and increased ER utilization than KA patients. Patients at higher risk for MA should undergo more aggressive follow-up. More research is needed.

Parents and primary care physicians have different views about copying medical letters to parents after paediatric outpatient visits

AIM

We assessed how satisfied parents were when they received a copy of the letter sent to their primary care physician after their child attended a hospital outpatient clinic and compared their views with those of the primary care physician.

METHODS

Anonymised questionnaires were sent to parents, and their primary care physician, after their child had visited a paediatric nephrology unit.

RESULTS

We received responses from 112 parents (46%) and 69 primary care physicians (93%). Most parents (97%) were satisfied with the process, 94% thought that the letter was a true reflection of the outpatient consultation and easy to understand, and 55% read it to their child. However, 21% would have preferred a simpler letter. More than a third (37%) of the primary care physicians did not approve of the parents being sent the letter, and 30% felt that the letter was difficult for the parents to understand and should be replaced with a simpler letter.

CONCLUSION

Most parents (97%) appreciated receiving a copy of the letter following their child's outpatient clinic visit, and 95% understood its contents. More than half (55%) read the letter to their child. However, 37% of primary care physicians did not approve of the practice.

A multicenter randomized controlled trial of aftercare services for severe mental illness: study protocol

BACKGROUND

Severe mental illness is responsible for a significant proportion of burden of diseases in Iranian population. People with severe mental illnesses are more likely to have high rates of non-attendance at follow-up visits, and lack of an active follow-up system, particularly in the country's urban areas that has resulted in the revolving door phenomenon of rehospitalizations. Therefore, there is an increasing need for implementation of effective and cost-effective aftercare services.

METHOD/DESIGN

This is a randomized control trial with the primary hypothesis that aftercare services delivered to patients with severe mental illnesses in outpatient department and patient's home by a community care team would be more effective when compared to treatment as usual (TAU) in reducing length of hospital stay and any psychiatric hospitalization. Patients were recruited from three psychiatric hospitals in Iran. After obtaining informed written consent, they were randomly allocated into aftercare intervention and control (TAU) groups. Aftercare services included treatment follow-up (through either home care or telephone follow-up prompts for outpatient attendance), family psychoeducation, and patient social skills training that were provided by community mental health teams. Patients were followed for 12 months after discharge. The primary outcome measures were length of hospital stay and any hospitalization in the 12 month follow-up. Secondary outcome measures included patients' clinical global impression, global functioning, quality of life, and patient's satisfaction. The trial also allowed an assessment of direct cost-effectiveness of the aftercare services.

DISCUSSION

This paper presents a protocol for an RCT of aftercare services delivered to patients with severe mental illnesses within patients' home or outpatient department. The findings of this study can influence policy and program planning for people with severe mental illnesses in Iran.

TRIAL REGISTRATION

IRCT201009052557N2.

Failure of Fracture Patients to Attend Their Out Patient Appointments

The failure to attend outpatient clinics is a chronic problem throughout the NHS. Previous studies have compared individual specialties. Trauma has received little attention. The average NHS-wide figure for non-attendance in outpatient clinics nationally is often quoted at 12%.1 there is considerable variation in the rate of non-attendance and studies have reported this as ranging from 5% to 34%.

Defaulters among lung cancer patients in a suburban district in a developing country

INTRODUCTION

This study was carried out to determine the prevalence, patient's characteristic and reasons for defaulting follow-up and treatment among patients with lung cancer.

METHODS

Patients with histologically confirmed lung cancer were recruited. Patient's detailed demographic data, occupation, socioeconomic status, and educational level of both the patients and their children were recorded. Defaulters were classified as either intermittent or persistent defaulters. By using Chi-square test, defaulter status was compared with various demographic and disease characteristic factors. The reasons for default were determined.

RESULTS

Ninety five patients were recruited. Among them, 81.1% patients were males; 66.3% were Malays. The mean age (SD) was 60 ± 10.5 years. About 46.3% of the patients had Eastern Cooperation Oncology Group (ECOG) functional status 0/1 and 96.8% of the patients presented with advanced stage (Stage 3b or 4). Overall, 20 patients (21.1%) were defaulters (35.0% intermittent defaulters; 65.0% persistent defaulters). Among the intermittent defaulters, 8 patients defaulted once and one patient defaulted 3 times. Among the 20 defaulters, only 2 (10%) patients turned up for the second follow-up appointment after telephone reminder. Two main reasons for default were 'too ill to come' (38.5.5%) and logistic difficulties (23.1%). No correlation was found between patient education, children education, income, ECOG status, stage of the disease, race, and gender with the defaulter rate.

CONCLUSION

Defaulter rate among lung cancer patients was 21.1%. Children education level is the only significant factor associated with the defaulter rate.

Mobile telephone short message service reminders can reduce nonattendance in physical therapy outpatient clinics: a randomized controlled trial

OBJECTIVE

To investigate whether short message service (SMS) reminders reduce nonattendance in physical therapy outpatient clinics.

DESIGN

Prospective single-blinded randomized controlled trial.

SETTING

Two physical therapy outpatient departments in metropolitan acute public hospitals.

PARTICIPANTS

Participants with an appointment in a physical therapy outpatient clinic and who provided a contact mobile telephone number were included. Participants were excluded if their appointment was scheduled for the same day on which they made the appointment.

INTERVENTION

Participants allocated to the intervention group received an SMS reminder before their next appointment; participants allocated to the control group did not receive a reminder.

MAIN OUTCOME MEASURES

The primary outcome was rate of nonattendance without cancellation. Secondary outcomes were cancellation and attendance rates and exploration of other factors associated with nonattendance.

RESULTS

Patients (N=679) were allocated to receive either an SMS reminder (n=342) or no reminder (n=337). The nonattendance rate for patients who did not receive a reminder (16%) was more than nonattendance for patients receiving the SMS reminder (11%; odds ratio, 1.61; 95% confidence interval [CI], 1.03-2.51; number needed to treat, 19; 95% CI, 9-275). There were no differences in cancellation or attendance rates between groups. Exploration of other factors found that patients who were younger with a neck and trunk musculoskeletal or a neuromuscular disorder and who were scheduled to have an initial appointment or an appointment on a Monday or Friday were significantly predictive of increased nonattendance.

CONCLUSIONS

SMS reminders can reduce nonattendance in physical therapy outpatient clinics.

Reduction of missed appointments at an urban primary care clinic: a randomised controlled study

BACKGROUND

Missed appointments are known to interfere with appropriate care and to misspend medical and administrative resources. The aim of this study was to test the effectiveness of a sequential intervention reminding patients of their upcoming appointment and to identify the profile of patients missing their appointments.

METHODS

We conducted a randomised controlled study in an urban primary care clinic at the Geneva University Hospitals serving a majority of vulnerable patients. All patients booked in a primary care or HIV clinic at the Geneva University Hospitals were sent a reminder 48 hrs prior to their appointment according to the following sequential intervention: 1. Phone call (fixed or mobile) reminder; 2. If no phone response: a Short Message Service (SMS) reminder; 3. If no available mobile phone number: a postal reminder. The rate of missed appointment, the cost of the intervention, and the profile of patients missing their appointment were recorded.

RESULTS

2123 patients were included: 1052 in the intervention group, 1071 in the control group. Only 61.7% patients had a mobile phone recorded at the clinic. The sequential intervention significantly reduced the rate of missed appointments: 11.4% (n = 122) in the control group and 7.8% (n = 82) in the intervention group (p < 0.005), and allowed to reallocate 28% of cancelled appointments. It also proved to be cost effective in providing a total net benefit of 1846. - EUR/3 months. A satisfaction survey conducted with 241 patients showed that 93% of them were not bothered by the reminders and 78% considered them to be useful. By multivariate analysis, the following characteristics were significant predictors of missed appointments: younger age (OR per additional decade 0.82; CI 0.71-0.94), male gender (OR 1.72; CI 1.18-2.50), follow-up appointment >1 year (OR 2.2; CI: 1.15-4.2), substance abuse (2.09, CI 1.21-3.61), and being an asylum seeker (OR 2.73: CI 1.22-6.09).

CONCLUSION

A practical reminder system can significantly increase patient attendance at medical outpatient clinics. An intervention focused on specific patient characteristics could further increase the effectiveness of appointment reminders.

A survey of patient views on receiving vascular outpatient letters

AIM

To assess the attitude of patients to receiving a copy of vascular outpatient clinic letters.

METHOD

100 patients attending an outpatient vascular clinic at Christchurch Hospital were sent a copy of their outpatient letter along with a questionnaire. This gathered information on the content of the letter, their understanding of it, how useful they found it and whether they would want this practice to continue.

RESULTS

The response rate was 68%. Ninety four percent of the responders believed receiving a copy of the letter was a good reinforcement of the information they received at the consultation. Ninety three percent of responders also found being copied into correspondence helpful and 96% understood the contents of the letters. Ninety seven percent wished to receive more letters in the future.

CONCLUSION

These results suggest that vascular surgery patients both value and understand clinic letters, and that health professionals should consider adopting this practice into their vascular outpatient clinics.

Copying letters to patients with cystic fibrosis (CF): letter content and patient perceptions of benefit

BACKGROUND

Copying letters involves generating an extra copy of all correspondence between healthcare professionals about the patient, to the patient.

AIMS

To determine if the letter content was meaningful to the patient and to establish patient perceptions of copying letters from outpatient clinic visits.

METHODS

To assess letter content, a copy of all outpatient clinic letters were collected during a one month period and each copy was assessed for the use of plain English using the Drivel Defence software. To establish patient perceptions, patients completed a questionnaire relating to the potential advantages and disadvantages of copying letters.

RESULTS

Eighty letters were assessed for content. 77/80 (96.3%) of the letters had > or = 50% of sentences with <20 words. The mean (SD) sentence length was 15 (3) words. Abbreviations were minimal in most letters (71/80, 89%). Most letters explained the patient's clinical status in a meaningful way (76/80, 95%). Fifty patients completed a questionnaire. The large majority (46/50, 92%) "strongly agreed" or "agreed" that they felt more involved by receiving a copy. Most patients (48/50, 96%) would rather receive a copy with 40/50 (80%) reporting advantages.

CONCLUSION

Copying letters is well received amongst patients with CF, with numerous advantages and few disadvantages reported.

Does an encouraging letter encourage attendance at psychiatric out-patient clinics? The Leeds PROMPTS randomized study

BACKGROUND

The aim was to reduce non-attendance for first-time consultations at psychiatric out-patient clinics.

METHOD

The study was a pragmatic randomized controlled trial; the setting was seven inner-city UK out-patient clinics in Leeds. The participants were 764 subjects of working age with an appointment to attend a psychiatric out-patient clinic for the first time. The intervention was an 'orientation statement' letter delivered 24-48 h before the first appointment compared with standard care. The primary outcome measure was attendance at the first appointment; secondary outcomes included hospitalization, transfer of care, continuing attendance, discharge, presentation at accident and emergency and death by 1 year.

RESULTS

Follow-up was for 763 out of 764 subjects (>99%) for primary and for 755 out of 764 subjects (98.8%) of secondary outcome data. The orientation statement significantly reduced the numbers of people failing to attend [79 out of 388 v. 101 out of 376 subjects, relative risk 0.76, 95% confidence interval (CI) 0.59-0.98, number needed to treat 16, 95% CI 10-187].

CONCLUSIONS

Prompting people to go to psychiatric out-patient clinics for the first time encourages them to attend. Pragmatic trials within a busy working environment are possible and informative.

Does copying clinical or sharing correspondence to patients result in better care?

BACKGROUND

Communication between healthcare professionals and patients is suboptimal and the measures to improve patient satisfaction such as sharing correspondence have been reported in different settings.

METHODS

A review of published literature was undertaken to specifically examine patient satisfaction and the professional healthcare provider experience across a range of specialities and settings.

RESULTS

Patients generally report high rates of satisfaction when receiving copies of correspondence although both patient and professional experience within general psychiatry indicates that further consideration may be required before routinely adopting the practice of copying letters in this discipline.

CONCLUSIONS

Dictating letters in the presence of patients can improve patient satisfaction accuracy and modalities such as the use of audio or video recordings may be useful in more specialised settings.

Urology out-patient non-attenders: are we wasting our time?

BACKGROUND

Out-patient non-attendance leads to inefficiency and patient morbidity.

AIMS AND METHODS

A phone survey of urology out-patient non-attenders over 1-month was performed to determine reasons for non-attendance, to identify patients who could be discharged, and the manner in which patients want reminders.

RESULTS

Seventy-six non-attenders were contacted. Fourteen were GP referred new patients. The reason for non-attendance (n = 10) was due to patient issues. Of the patients due for review (n = 62), it was a first non-attendance in 56. Only 41 (66%) claimed to have received notification or appointment cards. Eight patients said they were written to and 13 (21%) denied either receiving a written notification or an appointment card. Only eight patients rang to confirm/change their appointment. Ninety-nine percent said that they would like a further appointment by text message (34%), phone (37%), letter (36%) or email (6%).

CONCLUSIONS

We now hope to implement a number of methods to further reduce non-attendance rates based on the findings in this study.

Understanding reasons for asthma outpatient (non)-attendance and exploring the role of telephone and e-consulting in facilitating access to care: exploratory qualitative study

OBJECTIVE

To understand factors influencing patients' decisions to attend for outpatient follow up consultations for asthma and to explore patients' attitudes to telephone and email consultations in facilitating access to asthma care.

DESIGN

Exploratory qualitative study using in depth interviews.

SETTING

Hospital outpatient clinic in West London.

PARTICIPANTS

Nineteen patients with moderate to severe asthma (12 "attenders" and 7 "non-attenders").

RESULTS

Patients' main reasons for attending were the wish to improve control over asthma symptoms and a concern not to jeopardise the valued relationship with their doctor. Memory lapses, poor health, and disillusionment with the structure of outpatient care were important factors implicated in non-attendance. The patients were generally sceptical about the suggestion that greater opportunity for telephone consulting might improve access to care. They expressed concerns about the difficulties in effectively communicating through non-face to face media and were worried that clinicians would not be in a position to perform an adequate physical examination over the telephone. Email and text messaging were viewed as potentially useful for sending appointment reminders and sharing clinical information but were not considered to be acceptable alternatives to the face to face clinic encounter.

CONCLUSIONS

Memory lapses, impaired mobility due to poor health, and frustration with outpatient clinic organisation resulting in long waiting times and discontinuity of care are factors that deter patients from attending for hospital asthma assessments. The idea of telephone review assessments was viewed with scepticism by most study subjects. Particular attention should be given to explaining to patients the benefits of telephone consultations, and to seeking their views as to whether they would like to try them out before replacing face to face consultations with them. Email and text messaging may have a role in issuing reminders about imminent appointments.

Time costs of waiting, doctor-shopping and private-public sector imbalance: microdata evidence from Hong Kong

OBJECTIVE

To quantify the disutility of waiting for a specialist consultation and to examine whether individuals' willingness-to-pay (WTP) to reduce waiting time is associated with doctor-shopping behavior in outpatient clinics of four large, public hospitals in Hong Kong.

METHODS

We performed a cross-sectional survey of 6495 outpatients on public sector waiting lists enrolled from July 2000 to October 2001. Main outcome measures were WTP to reduce queue time and odds ratios (ORs) for doctor-shopping according to WTP status.

RESULTS

The majority (74.5%) of respondents, excluding those registering "protest zeros", was willing to pay a median of 100HK Dollar (13US Dollar ) to reduce queue time by 2 weeks, which represents 14.6% of the total costs of care for a specialist outpatient visit. Respondents' WTP decreased as their expected waiting period increased. Multivariate regression modeling showed that those who were willing to pay more were also more likely to "doctor-shop" (ORs and 95% confidence intervals for doctor-shopping for the 1st through 4th quartile of WTP values respectively = 1.00; 0.88 (0.63, 1.23); 1.19 (0.57, 2.48); 1.52 (1.05, 2.20); p for linear trend = 0.009), in effect reducing waiting time to see a specialist by seeking and paying for care in the private sector.

CONCLUSIONS

Based on this preliminary evidence, we propose the further examination of a new policy of outsourcing some specialist care services to the private sector to improve allocative and technical efficiency.

Patient attitudes to receiving copies of outpatient clinic letters from the ocular oncologist to the referring ophthalmologist and GP

AIM

To investigate patients' views and understanding on receiving a copy of the outpatient clinic letter from the ocular oncologist to the referring ophthalmologist and GP.

METHODS

Face-to-face interviews were conducted with 52 patients attending outpatient ocular oncology follow-up clinics, in a semistructured format using a qualitative open-ended questionnaire. The clinics are held at Liverpool Ocular Oncology Centre, a tertiary specialist referral centre at St. Paul's Eye Unit in Royal Liverpool University Hospital.

RESULTS

Patients' views on receiving a copy of the outpatient letter, their understanding of the letter, and improvements suggested. A total of 58% of patients had received a letter and 97% of them said they were glad they had it. Of this group 77% had shown it to family/friend. Consistent comments included: 'help with accepting the news;' 'good to be informed and to know what to expect;' 'confirmed what was said in the consultation.' Of the patients who had not received a copy of the letter, 64% replied that they would have liked a copy. A total of 80% of patients reported that they fully understood the letter. In all, 17% wanted medical terms to be explained, when asked to suggest improvements.

CONCLUSIONS

Sending patients copies of the consultant outpatient letter seemed to be highly appreciated and a useful method of information giving regarding diagnosis and management.

The economics of non-attendance and the expected effect of charging a fine on non-attendees

Non-attendance is claimed to waste substantial health care resources. However, this is only vaguely supported by empirical evidence. The epidemiology of non-attendees is explored in a rather large number of studies along with a sizeable number of studies documenting the effectiveness of various interventions to reduce non-attendance rates. Very few studies include more than one intervention and very few report information on the cost of the intervention which enables only vague conclusions about the cost-effectiveness of the interventions. The effectiveness of charging a fine on non-attendees, which has recently been suggested in Denmark and United Kingdom, has been studied in very few studies. These studies reveal that a fine will as most economists expected reduce the non-attendance rate. The literature of non-attendance discloses an immense need for studies addressing the non-attendance problem applying economic theory and standards of analysis.

Predictors of failed attendances in a multi-specialty outpatient centre using electronic databases

Background

Failure to keep outpatient medical appointments results in inefficiencies and costs. The objective of this study is to show the factors in an existing electronic database that affect failed appointments and to develop a predictive probability model to increase the effectiveness of interventions.

Methods

A retrospective study was conducted on outpatient clinic attendances at Tan Tock Seng Hospital, Singapore from 2000 to 2004. 22864 patients were randomly sampled for analysis. The outcome measure was failed outpatient appointments according to each patient's latest appointment.

Results

Failures comprised of 21% of all appointments and 39% when using the patients' latest appointment. Using odds ratios from the mutliple logistic regression analysis, age group (0.75 to 0.84 for groups above 40 years compared to below 20 years), race (1.48 for Malays, 1.61 for Indians compared to Chinese), days from scheduling to appointment (2.38 for more than 21 days compared to less than 7 days), previous failed appointments (1.79 for more than 60% failures and 4.38 for no previous appointments, compared with less than 20% failures), provision of cell phone number (0.10 for providing numbers compared to otherwise) and distance from hospital (1.14 for more than 14 km compared to less than 6 km) were significantly associated with failed appointments. The predicted probability model's diagnostic accuracy to predict failures is more than 80%.

Conclusion

A few key variables have shown to adequately account for and predict failed appointments using existing electronic databases. These can be used to develop integrative technological solutions in the outpatient clinic.

Copying referral letters to patients: the views of patients, patient representatives and doctors

To discover the views of patients, patient representatives and doctors on copying referral letters to patients. A three-part study: an analysis of 50 GP referral letters against a standard template; 35 patient interviews using a semi-structured questionnaire in outpatient waiting rooms; 3 focus groups of patients, patient representatives and doctors. There was general agreement that copying referral letters to patients could improve information and decision sharing with patients. Copying referral letters could provide an opportunity for patients to correct mistakes, prepare for their appointments and have a personal record that they could keep and show to others. However, there were concerns about letter content, particularly medical terminology, character judgements and "sensitive" patient information. It was also recognised that providing more information to patients could increase patient anxiety. The style and content of some referral letters may need to change. This is particularly relevant where certain types of information included in referral letters could cause distress for patients or influence the time that patients have to wait for their outpatient appointments.

Email consultations in health care: 1--scope and effectiveness

Electronic communication promises to revolutionise the delivery of health care. In the first of two articles considering the potential for email consultations, Car and Sheikh summarise the evidence about their use for preventive health care, health education, and managing non-urgent conditions

Copying referral letters to patients: prepare for change

The National Health Service (NHS) Plan for England has directed that from April 2004 clinicians will offer patients the opportunity to receive copies of letters that are written about them. Patients like to have more information and patients who have received copies of letters have found them useful. It is hoped that copying letters will improve relationships between doctors and patients, encourage patients to be better informed, and improve the quality of information provided to patients. Relatively little empirical research has been performed in this area but what exists is generally supportive. Attention will need to be paid to issues of confidentiality, the language and content of letters, and individuals who may have difficulty obtaining information from letters. This initiative is one of many that the NHS has introduced to enhance openness, honesty and the quality of information provided to patients.

Waiting Time, Doctor Shopping, and Nonattendance at Specialist Outpatient Clinics

OBJECTIVE

Nonattendance is a major health services research and management issue that has received little attention or systematic study in Asia. We examined the independent associations between waiting time, doctor shopping, and nonattendance in specialist outpatient clinics of 4 large public hospitals in Hong Kong.

RESEARCH DESIGN

Case-control study.

SETTING AND PARTICIPANTS

A total of 6495 attenders and nonattenders enrolled from July 2000 through October 2001. PAIN OUTCOME MEASURES: Odds ratios (ORs) and associated 95% confidence intervals (CI) for nonattendance.

RESULTS

Longer waiting times (adjusted OR2nd quartile, 1.67; 95% CI, 1.38-2.03; adjusted OR3rd quartile, 1.90; 95% CI, 1.56-2.30; adjusted OR4th quartile, 2.30; 95% CI, 1.91-2.78) and doctor-shopping behavior (adjusted OR, 2.91; 95% CI, 2.51-3.38) were independent risk factors for nonattendance. These effects were robust after multivariate adjustment and testing for effect modification. They also appeared to persist uniformly across hospitals and specialties. There was no demonstrable relationship between waiting time and doctor shopping.

CONCLUSIONS

This is the largest study of nonattendance at outpatient clinics and the first such study carried out in Asia. Targeted strategies should be implemented and evaluated using these results to reduce waiting time, doctor shopping, and ultimately nonattendance.

A Triage Clinic in a Child and Adolescent Mental Health Service

AIMS

To determine whether non-urgent referrals can be adequately assessed in a triage clinic, to determine the service outcome of these referrals, and whether triage was acceptable to families, referrers and CAMHS clinicians.

METHOD

Families, CAMHS clinicians and GPs were surveyed to ascertain the acceptability of triage. Non-attendance and outcome of triage were recorded.

RESULTS

Ninety-two cases were included and the DNA rate fell by one-third.

CONCLUSIONS

Overall, clinicians and families reported high rates of satisfaction with triage (93.7% and 95.2%) and multidisciplinary working improved.

Domiciliary clinics II: a cost minimisation analysis

OBJECTIVES

We compare the cost of assessing new referrals to an old age psychiatry service at the patient's home or a hospital-based clinic.

METHOD

An old age psychiatry service in Liverpool where routine referrals were assessed at home (domiciliary clinic) was compared to an adjacent service which assessed people in an outpatient clinic. Activity levels for four years of the service were collected and analysed. A cost-minimization analysis was done using an algorithm which allowed all direct costs to the service to be taken into account. A sensitivity analysis changed key values of the algorithm allowing their relative contribution to be considered.

RESULT

The domiciliary clinic was marginally cheaper than outpatient assessment (48 pounds sterling compared to 50 pounds sterling per successful assessment). The most important variables in determining the cost effectiveness of the service were non-attendance rates, the grade of doctor seeing the patient and the time spent traveling for the home assessment.

CONCLUSIONS

Domiciliary initial assessments were comparable in cost to clinic assessments in this study but in other situations the cost will vary, depending on the key local variables.

Why do patients not keep their appointments? Prospective study in a gastroenterology outpatient clinic

Unkept outpatient appointments are a drain on resources. In a prospective study we asked non-attenders at a gastroenterology clinic why they had missed their appointment. 103 patients missed their appointment (14% of the total invited); 3 had died. The remaining 100 were asked to complete questionnaires, 68 by mail (43 returned) and 32 by telephone (30 successful); the response rate was thus 73%. 49 of the respondents were new patients, 6 of them with urgent referrals. The explanations for non-attendance by the 73 patients were: forgot to attend or to cancel (30%); no reason (26%); clerical errors (10%); felt better (8%), fearful of being seen by junior doctor (3%); inpatient in another hospital (3%); miscellaneous other (20%). 13 (27%) of the review patients had not kept one or more previous appointments. The non-attendance rates for different clinics ranged from 10% to 25% (average 14%). A substantial number of non-attenders claimed to have forgotten their appointment or to cancel it. If, as we surmise, this reflects apathy, no strategy to improve attendance is likely to have great impact. Since the non-attendance rate is reasonably constant, it can be taken into account when patients are booked.

Why do patients not keep their appointments? Prospective study in a gastroenterology outpatient clinic

Unkept outpatient appointments are a drain on resources. In a prospective study we asked non-attenders at a gastroenterology clinic why they had missed their appointment. 103 patients missed their appointment (14% of the total invited); 3 had died. The remaining 100 were asked to complete questionnaires, 68 by mail (43 returned) and 32 by telephone (30 successful); the response rate was thus 73%. 49 of the respondents were new patients, 6 of them with urgent referrals. The explanations for non-attendance by the 73 patients were: forgot to attend or to cancel (30%); no reason (26%); clerical errors (10%); felt better (8%), fearful of being seen by junior doctor (3%); inpatient in another hospital (3%); miscellaneous other (20%). 13 (27%) of the review patients had not kept one or more previous appointments. The non-attendance rates for different clinics ranged from 10% to 25% (average 14%). A substantial number of non-attenders claimed to have forgotten their appointment or to cancel it. If, as we surmise, this reflects apathy, no strategy to improve attendance is likely to have great impact. Since the non-attendance rate is reasonably constant, it can be taken into account when patients are booked.

Patient, hospital, and general practitioner characteristics associated with non-attendance: a cohort study

Studies examining characteristics of non-attendance at hospital outpatients have given inconsistent results. We examined a cohort of 1972 referrals from 26 general practitioners, with complete follow-up. Five factors were found to be significantly associated with non-attendance: male sex, younger age, longer interval between referral and appointment, higher Jarman score and patients of a high-referring general practitioner. Targeting of strategies to reduce non-attendance is possible using these results.

Use of referral reply letters for continuing medical education: a review

INTRODUCTION

Referrals between generalists and specialists are a central component of the health care system and necessitate effective communication between the involved providers. Despite the high prevalence of patient referrals and their crucial role in continuity and quality of care, the medical literature demonstrates that generalists may receive little or no information about the care their patients received and little information about the appropriateness of the referral or recommendations for follow-up care. General practitioners (GPs) prefer teaching that is directly related to their clinical work rather than traditional continuing education such as formal lectures. The purpose of this review is to assess the role of referral reply letters in the continuing education of GPs.

METHODS

A comprehensive literature search was conducted to November 2001 using MEDLINE, EMBASE, the Cochrane Library, and the Research and Development Resource Base developed by Continuing Education, Faculty of Medicine, University of Toronto, to identify studies that examined the use of referral letters for the transfer of information from specialists to referring physicians. Data on methodology, unit of analysis, main outcome measures, and results were extracted.

RESULTS

Of 1,250 articles retrieved, 9 met the eligibility criteria. Three of these analyzed the content of referral reply letters and 6 described the results of surveys of general and specialty physicians.

DISCUSSION

Little educational content is currently included in letters from specialists to referring GPs. GPs are receptive to the use of referral replies as sources of learning.

Prompts to encourage appointment attendance for people with serious mental illness

BACKGROUND

Prompts to encourage attendance at clinics are often used in day-to-day practice by diligent carers of people with mental health problems. These may take the form of telephone prompting, financial incentives or issuing a copy of the referral letter to the appointee.

OBJECTIVES

To estimate the effects of simple prompting by professional carers to encourage attendance at clinics for those with serious mental illness.

SEARCH STRATEGY

Methodical searches of Biological Abstracts (1985-2000), CINAHL (1982-2000), Cochrane Schizophrenia Group's Register (June 2000), Cochrane Library (Issue 2, 2000), EMBASE (1980-2000), MEDLINE (1966-2000) and PsycLIT (1887-2000) were undertaken. These were supplemented by searching of reference lists, personal contact and hand searching of high yield journals.

SELECTION CRITERIA

All relevant randomised (or quasi-randomised) studies comparing the addition of 'prompts' to standard care for those with serious mental illnesses such as schizophrenia. Prompts had the stated purpose of encouraging attendance or contact with mental health teams and could be text-based, electronic, by telephone call, by personal visit, or could employ financial or other rewards.

DATA COLLECTION AND ANALYSIS

Studies and data were independently selected and extracted. For homogeneous dichotomous data the random effects relative risk (RR), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data the reviewers calculated weighted mean differences.

MAIN RESULTS

Only three relevant trials were identified (total n=597). It is not clear whether there is any real difference between attendance of those prompted by telephone one or two days before the appointment, and those given the standard appointment management system (2 trials, n=457, RR missed appointment 0.84 CI 0.7 to 1.1). Text-based prompts, a few days before the appointment day, did increase clinic attendance when compared with no prompt (2 trials, n=200, RR missed appointment 0.6 CI 0.4 to 0.9, NNT 6 CI 2 to 14). Only one small study (n=61) reported data on the combination of telephone and text-based prompts versus no prompt (RR missed appointments 0.7 CI 0.4 to 1.2). When telephone prompts were compared with text-based prompts (1 trial, n=75), the latter, in the form of an 'orientation statement' (a short paragraph, taking about 30 seconds to read, explaining the programme of care, the fee system, and providing gentle encouragement) may be somewhat more effective than the telephone prompt (RR missed appointments 1.9 CI 0.98 to 3.8). One last study (n=120) compared a standard letter prompt with a letter 'orientation statement'. Overall, results tended to favour the orientation statement approach rather than the simple letter prompting attendance but the results did not reach conventional levels of statistical significance (RR missed appointments 1.6 CI 0.9 to 2.9).

REVIEWER'S CONCLUSIONS

There is evidence that a simple prompt to attend clinic, very close to the time of the appointment may encourage attendance, and a simple orientation-type letter, 24 hours before the clinic appointment, may be more effective than a telephone prompt. This simple intervention could be a more cost effective means of encouraging compliance at first attendance, but supplementing these data with the results of large, well designed, conducted and reported randomised studies would be desirable.

Use of an orientation clinic to reduce failed new patient appointments in primary care

Patients who fail to attend initial appointments reduce clinic efficiency. To maximize attendance by newly referred outpatients, we introduced a mandatory group orientation clinic for all new patients and determined its effects on no-show rates. Orientation clinic also provided health care screening and opportunities for patient feedback. The new patient no-show rate for initial provider visits decreased significantly from 45% before institution of orientation clinic to 18% afterwards (P<.0001). The total no-show (patients who failed to attend orientation clinic or an initial provider visit) rate of the postintervention group was 51% (P = .28, compared with before the intervention). This intervention improved the efficiency and minimized the wasted time of our clinicians.

A telephone call reminder to improve outpatient attendance in patients referred from the emergency department: a randomised controlled trial

BACKGROUND

Poor compliance with attendance at outpatient clinic appointments in patients referred from emergency departments (EDs) is a major problem in public hospitals.

AIMS

To determine whether the intervention of a telephone call within three days of ED attendance would improve: 1. the proportion of patients making recommended outpatient appointments; and 2. the proportion of patients attending scheduled appointments. To characterise reasons for non-attendance at appointments made by patients referred from the ED.

METHODS

A randomised controlled trial was undertaken of 400 patients recommended to make outpatient appointments during attendance at The Royal Melbourne Hospital ED in July-August 1999.

INTERVENTION

a telephone call one to three days after attendance to remind the patient about the appointment (and its importance for medical follow-up) if one had been made and to offer to make an appointment if one had not been made.

OUTCOME MEASURES

1. making the recommended appointment; 2. attendance at the scheduled appointment; and 3. reasons for non-attendance at scheduled appointments.

RESULTS

The telephone intervention improved attendance at scheduled appointments from 54.4% to 70.7% (p=0.002). The proportion of patients making appointments was not significantly affected. The commonest reasons given for non-attendance were: attended general practitioner (13%), attended private specialist (6.6%), inpatient in hospital at time of appointment (6.6%), too busy or inconvenient (5.3%), claimed to have attended (5.3%) and did not differ by intervention.

CONCLUSIONS

A significant improvement in the proportion of patients attending outpatients appointments can be made by a simple reminder telephone call one to three days after attendance at the ED.

Copying general practitioner referral letters to patients: a study of patients' views

Over the past decade there has been a significant shift towards greater involvement of patients in their health care and this has highlighted many areas relating to doctor-patient communication. One area of communication that has not been extensively researched is the referral letter between general practitioners (GPs) and their patients. This small study of patients' views suggests that patients value receiving a copy of their GP outpatient letter, appreciating greater understanding of, and involvement in, the referral process.