The effect of fines on nonattendance in public hospital outpatient clinics: study protocol for a randomized controlled trial

Policy-makers' conception of patient non-attendance fees in specialist healthcare: a qualitative document analysis

OBJECTIVES

Patients missing their scheduled appointments in specialist healthcare without giving notice can undermine efficient care delivery. To reduce patient non-attendance and possibly compensate healthcare providers, policy-makers have noted the viability of implementing patient non-attendance fees. However, these fees may be controversial and generate public resistance. Identifying the concepts attributed to non-attendance fees is important to better understand the controversies surrounding the introduction and use of these fees. Patient non-attendance fees in specialist healthcare have been extensively debated in Norway and Denmark, two countries that are fairly similar regarding political culture, population size and healthcare system. However, although Norway has implemented a patient non-attendance fee scheme, Denmark has not. This study aimed to identify and compare how policy-makers in Norway and Denmark have conceptualised patient non-attendance fees over three decades.

DESIGN

A qualitative document study with a multiple-case design.

METHODS

A theory-driven qualitative analysis of policy documents (n=55) was performed.

RESULTS

Although patient non-attendance fees were seen as a measure to reduce non-attendance rates in both countries, the specific conceptualisation of the fees differed. The fees were understood as a monetary disincentive in Norwegian policy documents. In the Danish documents, the fees were framed as an educative measure to foster a sense of social responsibility, as well as serving as a monetary disincentive. The data suggest, however, a recent change in the Danish debate emphasising fees as a disincentive. In both countries, fees were partly justified as a means of compensating providers for the loss of income.

CONCLUSIONS

The results demonstrate how, as a regulative policy tool, patient non-attendance fees have been conceptualised and framed differently, even in apparently similar contexts. This suggests that a more nuanced and complex understanding of why such fees are debated is needed.

Mapping out the arguments for and against patient non-attendance fees in healthcare: an analysis of public consultation documents

BACKGROUND

Patients not attending their appointments without giving notice burden healthcare services. To reduce non-attendance rates, patient non-attendance fees have been introduced in various settings. Although some argue in narrow economic terms that behavioural change as a result of financial incentives is a voluntary transaction, charging patients for non-attendance remains controversial. This paper aims to investigate the controversies of implementing patient non-attendance fees.

OBJECTIVE

The aim was to map out the arguments in the Norwegian public debate concerning the introduction and use of patient non-attendance fees at public outpatient clinics.

METHODS

Public consultation documents (2009-2021) were thematically analysed (n=84). We used a preconceived conceptual framework based on the works of Grant to guide the analysis.

RESULTS

A broad range of arguments for and against patient non-attendance fees were identified, here referring to the acceptability of the fees' purpose, the voluntariness of the responses, the effects on the individual character and institutional norms and the perceived fairness and comparative effectiveness of patient non-attendance fees. Whereas the aim of motivating patients to keep their appointments to avoid poor utilisation of resources and increased waiting times was widely supported, principled and practical arguments against patient non-attendance fees were raised.

CONCLUSION

A narrow economic understanding of incentives cannot capture the breadth of arguments for and against patient non-attendance fees. Policy makers may draw on this insight when implementing similar incentive schemes. The study may also contribute to the general debate on ethics and incentives.

To charge or not to charge: reducing patient no-show

BACKGROUND

In order to reduce patient no-show, the Israeli government is promoting legislation that will allow Health Plans to require a co-payment from patients when reserving an appointment. It is hoped that this will create an incentive for patients to cancel in advance rather than simply not show up. The goal of this policy is to improve patient access to medical care and ensure that healthcare resources are utilized effectively. We explore this phenomenon to support evidence-based decision making on this issue, and to determine whether the proposed legislation is aligned with the findings of previous studies.

MAIN BODY

No-show rates vary across countries and healthcare services, with several strategies in place to mitigate the phenomenon. There are three key stakeholders involved: (1) patients, (2) medical staff, and (3) insurers/managed care organizations, each of which is affected differently by no-shows and faces a different set of incentives. The decision whether to impose financial penalties for no-shows should take a number of considerations into account, such as the fine amount, service type, the establishment of an effective fine collection system, the patient's socioeconomic status, and the potential for exacerbating disparities in healthcare access. The limited research on the impact of fines on no-show rates has produced mixed results. Further investigation is necessary to understand the influence of fine amounts on no-show rates across various healthcare services. Additionally, it is important to evaluate the implications of this proposed legislation on patient behavior, access to healthcare, and potential disparities in access.

CONCLUSION

It is anticipated that the proposed legislation will have minimal impact on attendance rates. To achieve meaningful change, efforts should focus on enhancing medical service availability and improving the ease with which appointments can be cancelled or alternatively substantial fines should be imposed. Further research is imperative for determining the most effective way to address the issue of patient no-show and to enhance healthcare system efficiency.

Sociodemographic and Clinical Factors Associated with Nonattendance at the Hepatology Clinic

BACKGROUND

Absenteeism from clinic appointments reduces efficiency, wastes resources, and contributes to longer wait times. There are limited data regarding factors associated with nonattendance in hepatology clinics. Identifying factors related to appointment nonattendance may help in the design of interventions for reducing absenteeism.

METHODS

We aim to identify sociodemographic, clinical, and appointment-related factors associated with absenteeism following referral to a liver clinic in a tertiary academic center located in the US Midwest. We designed a case-control study using data from electronic medical records of patients scheduled for appointments between January 2016 and December 2021. Cases were defined as patients who canceled appointments on the same day or resulting in no-shows, and controls were those who completed the referral visit. Information about patients' sociodemographic characteristics, appointment details, and etiology of liver disease were recorded. Hierarchical logistic regression was used to analyze factors related to nonattendance.

RESULTS

Of 3404 scheduled appointments, 460 (13.5%) missed visits were recorded. In the multivariable logistic regression models, hepatitis C and alcohol-associated liver disease were associated with greater odds of nonattendance [odds ratio (OR) 4.0 (95% CI 3.2-4.9), OR 2.7 (1.7-4.2), respectively] compared to those with other liver disease. Sociodemographic characteristics associated with risk of nonattendance included being Black [OR 2.6, (1.8-3.7)], Medicaid insurance or no insurance [OR 2.3 (1.7-2.9), OR 2.5 (1.6-3.7), respectively], non-English speaking [OR 1.8 (1.1-3.1)], being unmarried [OR 1.8 (1.4-2.2)], and longer wait time (> 30 days) until appointments [OR 1.8 (1.5-2.2)].

CONCLUSION

Several sociodemographic and administrative characteristics, as well as hepatitis C and alcohol-associated liver disease were associated with appointment nonattendance. Targeted future interventions may help to decrease nonattendance.

Evaluation of an Automated Reminder System for Reducing Missed MRI Appointments

Background: The high frequency of missed appointments continues to be a burden on healthcare providers, leading to decreased productivity, quality of service, and quality of outcome. The purpose of this study is to evaluate the effectiveness of Televox's automated appointment reminder service in reducing the missed appointment rate for MRI (magnetic resonance imaging). The appointment reminders were sent 72 h in advance. The total and no-show numbers were tallied to calculate missed appointment rates. Comparison of the missed appointment rate with and without Televox implementation and different payment types was performed. Temporal comparisons were also made across the corresponding time periods in order to control for seasonal fluctuations. Results: An insignificant decline in missed appointment rates was found in locations implementing Televox (P = .495) overall, although a significant decrease in missed appointments was found among Medicaid patients (P = .0381). Conclusion: Implementation of Televox appointment reminder systems did not significantly affect appointment attendance overall, but could be more useful specifically for encouraging Medicaid patients to attend MRI appointments.

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.

Nonattendance rates of scheduled outpatient appointments in a university general hospital

OBJECTIVE

We aimed to estimate nonattendance to scheduled medical ambulatory appointments rates globally and by subgroups.

DESIGN AND PARTICIPANTS

We designed a retrospective cohort of all adult outpatients over 18 years old who requested at least one scheduled ambulatory medical appointment from 1 January 2015 to 31 December 2016.

SETTING

Hospital Italiano de Buenos Aires is a university general hospital in the Autonomous City of Buenos Aires, Argentina. It includes an integrated health care network that is formed by two high complexity hospitals and 22 primary care centers.

RESULTS

The age median was 60.4 years, and 31.33% of the appointments were scheduled by men; 2 526 549 appointments fulfilled selection criteria, belonging to 348 420 patients. The global nonattendance rate was 27.84% (95% CI, 27.79-27.9). The nonattendance rate to general practitioner appointments was 25.53% (95% CI, 25.42-25.63); to clinical specialties, 27.78% (95% CI, 27.68-27.87); and to surgical specialties, 29.31% (95% CI, 29.23-29.4).

CONCLUSIONS

Because of the consistent variability of nonattendance in different settings, it is strongly recommended that local estimates are used in the design of effective interventions to improve adherence with outpatient healthcare scheduled appointments.

Effectiveness and cost-effectiveness of fining non-attendance at public hospitals: a randomised controlled trial from Danish outpatient clinics

OBJECTIVES

Fines have been proposed as means for reducing non-attendance in healthcare. The empirical evidence of the effect of fines is however limited. The objective of this study is to investigate the effectiveness and cost-effectiveness of fining non-attendance at outpatient clinics.

DESIGN, PARTICIPANTS AND SETTING

1:1 randomised controlled trial of appointments for an outpatient clinic, posted to Danish addresses, between 1 May 2015 and 30 November 2015. Only first appointment for users was included. Healthcare professionals and investigators were masked.

INTERVENTION

A fine of DKK250 (€34) was issued for non-attendance. Users were informed about the fine in case of non-attendance by the appointment letter, and were able to reschedule or cancel until the appointment. A central administration office administered the fine system.

MAIN OUTCOME MEASURES

The main outcome measures were non-attendance of non-cancelled appointments, fine policy administration costs, net of productivity consequences and probability of fining non-attendance being cost-effective over no fining for a range of hypothetical values of reduced non-attendance.

RESULTS

All of the 6746 appointments included were analysed. Of the 3333 appointments randomised to the fine policy, 130 (5%) of non-cancelled appointments were unattended, and of the 3413 appointments randomised to no-fine policy, 131 (5%) were unattended. The cost per appointment of non-attendance was estimated at DKK 56 (SE 5) in the fine group and DKK47 (SE 4) in the no-fine group, leading to a non-statistically significant difference of DKK10 (95% CI -9 to 22) per appointment attributable to the fine policy. The probability of cost-effectiveness remained around 50%, irrespective of increased values of reduced non-attendance or various alternative assumptions used for sensitivity analyses.

CONCLUSIONS

At a baseline level of around 5%, fining non-attendance does not seem to further reduce non-attendance. Future studies should focus on other means for reduction of non-attendance such as nudging or negative reinforcement.

TRIAL REGISTRATION NUMBER

ISRCTN61925912.