Dr. John Frey, MDClark DuMontier

Acknowledgments:Michael Seavecki, Clinic ManagerDr. Jon Temte, MD/PhDChuck Illingworth, DFM Data Base Admin.Wingra Faculty

• No-show (NS): Scheduled appointment missed without cancellation

• U.K.’s NHS incurred loss of 24 million pounds (39.4 million U.S. dollars) due to missed appointments in 2008

• Prevalent problem– No-show (NS) rates range from 5-55% (Bean and

Talaga, 1992; Rubin et al., 2003)

• Wingra Family Medical Center historical range of 14-17%– DFM Clinics 2009 Q1

avg: 4.4%

• 7,726 clinical hours (322 days) lost to missed appointments from May 1, 2002 to April 30, 2008

Effects of No-Shows

• Impair Access• Decrease Revenue

– Moore et al. (2001) estimated 3-14% of yearly revenue lost to NS

• Risk Health– Associated with adverse outcomes (Ciechanowski

et al. 2005; Griffin 1998)– Poor glycemic control and treatment adherence

(Jacobson et al. 1991; Karter et al. 2004)

1997 QI: Conclusions

• Small group of patients add to large amount of missed appointments – 12% of patients accounted for 35% of NS (Izard

2005)– Wingra: 1.6% accounted for 16% from Jan. 2008-

Sept. 2008• Institute transportation services and

mail/phone reminders• Perhaps rate cannot be improved considering

Wingra’s patient population

Prior Research

• DFM Warehouse data extraction• Frequent no-show cohort

– 141 individuals who missed 6 or more appointments within an 18-month period

• Chart audit• Open-ended survey

Survey• Semi-structured, open-

ended; asked “Why do you think people miss their appointments?” (Lacy et al. 2004)

• Results (62 interviewed)– Transportation: 62.9%– Disorganization: 41.9%– “S.E.C.U.”: 27.4%– Discontinuity, child care,

illness improved.

• Etiology of Missed Appointments– Located among a small group of patients– Recurrent behavior/disorganization

• Hypothesis– Multiple interventions must be implemented to

attend to the individual (behavioral) and systemic problems surrounding missed appointments

• Systemic: reduce time between demand and appt.

– Wingra: Modified double-booking, scripted discourse, and scheduling system change

– Tracked NS Rate for patient panel and NS Cohort before and after interventions

3 Interventions

1. Modified double booking (Oct. 1, 2008)2. Scripted discourse (Oct. 1, 2008)3. Advanced Access scheduling (Mar. 16, 2009)• Quasi-Experimental, time-series design.

Cohort and patient panel no-show rates measured in 9 months before Oct. 1, 2008 and 9 months after

– Chi-square used to evaluate distributions– T-test used to evaluate differences

Group Profile• Patient panel: Patients seen at Wingra in 2-

year span• NS Cohort: 141 patients with 6 or more no-

shows in 18-month span• Variables – extracted via data warehouse

– Gender, age, ethnicity, and payer – Chronic Physical Conditions: Hypertension;

Obesity; Asthma; COPD; GERD; Diabetes II– Chronic Psychosocial Conditions: Depression;

Panic/anxiety; PTSD; Bipolar/Schizo. – Substance Use/Abuse

Modified Double-Booking

• Izard, 2005• Separate schedule for “virtual provider”

– Placed habitual no-showers on this schedule upon demand for appointment. Primary care provider worked them into their schedules upon arrival for appointment

• Piloted with 3 providers• Purpose: Mitigate NS effects on clinic

Scripted Discourse

• Script distributed among receptionists and providers to be given to habitual no-showers– Delineated costs of missing appointments.

• Purpose: Modify individual behavior

Advanced Access

• Murray and Berwick, 2003. “Advanced Access: Reducing Waiting and Delays In Primary Care”– Differs from Traditional and Carve-Out models:

“Do today’s work today.” Idea is to more efficiently meet demand and prevent backlog.

• Purpose: Reduce time between demand for appointment and day of appointment, thus reducing probability of patient forgetting.

Demographic ProfileDemographics

No-Show Cohort (n=141)

Wingra Patient Panel (n=8974)

P-Value

Gender <0.001Female 114 (80.85%) 5079 (56.60%)

Male 27 (19.15%) 3894 (43.39%)

Ethnicity <0.001African American/Black 98 (69.50%) 1856 (20.68%)

Caucasian/White 22 (15.60%) 4275 (47.64%)Hispanic/Latino 17 (12.06%) 1792 (19.97%)

Other 4 (2.84%) 1051 (11.71%)

Age 0.0051_17 16 (11.35%) 1948 (21.71%)18_25 27 (19.15%) 1146 (12.77%)26_44 57 (40.43%) 3006 (33.50%)45_64 34 (24.11%) 2226 (24.80%)65+ 5 (3.55%) 561 (6.25%)

Payer <0.001Medicaid 60 (42.55%) 1057 (11.78%)Medicare 16 (11.35%) 777 (8.66%)

Self-pay/none 25 (17.73%) 1661 (18.51%)Private 38 (26.95%) 5327 (59.36%)Other* 2 (1.42%) 152 (1.69%)

*Excluded from Chi-square due to low expected value

DiagnosesNo-Show Cohort

(n=141)Wingra Patient Panel

(n=8974)P-Value

Chronic Physical Conditions (n) <0.0010 85 (60.28%) 7501 (83.59%)1 44 (31.21%) 1305 (14.54%)2* 12 (8.51%) 168 (1.87%)

Psychosocial Conditions (n) <0.0010 67 (47.52%) 7226 (80.52%)1 56 (39.72%) 1449 (16.15%)2* 15 (10.64%) 260 (2.90%)3* 3 (2.13%) 36 (0.40%)

Substance Use/AbuseTobacco 48 (34.04%) 1034 (11.52%) <0.001Alcohol 15 (10.64%) 376 (4.19%) <0.001Other* 14 (9.93%) 310 (3.45%) NAOpioid* 10 (7.09%) 119 (1.33%) NA

*Excluded from Chi-square due to low expected value

Health Profile

NS Rate vs. TimePatient PanelCohort

NS Rate vs. TimeInterventions 1 and 2

• NS Cohort predominantly African-American and female – (Majeroni et al. 1996; Neal et al. 2001)

• Results suggest hypothesis was correct– Multiple interventions significantly decreased cohort

NS rate (33.26% to 20.7%) and overall NS rate (12.84% to 8.72%)

• Advanced Access most effective intervention– Sustained rate between 5-7%

• Reducing NS cohort rate appeared to reduce overall NS rate– Apparent negative correlation between groups

Modified D.B. and Discourse

• Cost-effective solutions• Modified D.B.

– Protects clinic, but not habitual NS patient

• Scripted Discourse– NS Cohort individuals’ rate change

• Decreased: 66 (46.81%) • Increased: 28 (19.86%) • No Change: 17 (12.06%)• Lost to follow-up: 30 (21.28%)

Advanced Access• Wait time: span between demand and appt.• Continuity• Benefits come with costs

– Might negatively affect patients who need to schedule weeks in advance

• Appointment types such as follow-ups, physicals etc.• Employer notifications

– Small window of opportunity

• Extant literature of AA in academic clinics report conflicting conclusions

• Belardi et al., 2004: Controlled Trial– NS rate did not significantly change; higher continuity

• Steinbauer et al., 2006– NS rate did not change; 20% increase in monthly

visits; reduction in rescheduled appointments

• Bennett and Baxley, 2009– NS rate did not change

• Phan and Brown, 2009– Decreased continuity

• Scherger, 2009 (response to above articles)