Abstract
Introduction
No-show clinic appointments are defined as missed appointments without notification to the provider and represent a paradigm for the struggle between access to care for patients and practice management for physicians and administrators. With recent changes in the US health-care climate, access to care remains an increasingly pressing concern. A potential surrogate marker for lack of access to care is clinic no-show rate. The missed clinic appointments may not only have a direct detrimental impact on the health of the patient but also have an indirect impact on other patients as well as the provider practice—other patients suffer from the opportunity for more expedient new patient appointments, and practitioners suffer from lost clinical time and productivity.
Multiple factors, such as lack of transportation, impact of missed work, and financial barriers, have been noted to impact no-show rates. 1 Our group recently completed a study of nearly 23 000 patient visits examining and identifying factors associated with no-show visits in the academic otolaryngology setting. 2 The data in the academic otolaryngology setting found that satellite clinics, new patient visits, younger age of patients, and Medicaid insurance status were associated with reduced adherence to clinic visits. To the best of our knowledge, there are no data to published that examine no-show rates specifically in the hospital-employed otolaryngology practice model outside of the academic setting.
In “traditional” private practice, physicians have been able to tightly control the number of clinic appointments for different clinic visit types (ie, new patient, follow-up, postoperative), patient insurance distribution, practice scope, and other factors, if desired. A variety of factors, including economic pressures and administrative pressures, have resulted in a massive shift from “traditional” private practice to hospital-employed physicians over the past decade in the United States. With the shift from traditional private practice to the hospital-employee practice model, physicians may have less autonomy over their appointment schedules. The primary author (B.T.C.) was an employed physician at a regional hospital for approximately 2 years in a Midwestern state prior to taking his current academic position. In an attempt to improve clinic efficiency, he kept records on no-show rates.
In this data review, we sought to report the experience of an employed otolaryngologist in a nonacademic, regional hospital clinic setting. Outcomes included no-show clinic rates compared to clinic visit type and insurance status. Given that there is no literature discussing baseline no-show rates in employed otolaryngology practice, we report these data to fill in a knowledge gap, particularly for hospital administrators considering employing an otolaryngologist outside of the academic setting.
Patients and Methods
An institutional review board (IRB) exemption was obtained from the University of Kentucky (IRB Number 15-0432-X6B) for this study. A retrospective chart review of the electronic medical record (Cerner PowerChart; Cerner Corporation, Kansas City, Missouri) was performed by the primary author (B.T.C.) while in practice. All patients with a scheduled clinic appointment between October 2012 and July 2014 at a single-physician, hospital-employed, nonacademic general otolaryngology practice were included. This practice was located at a regional hospital in the Midwest, with a community catchment area of approximately 120 000 people. Data on clinic visit type, insurance type, and appointment adherence were collected. Clinic visit types were classified as new, follow-up, postoperative, or other. Insurance types were categorized into commercial, Medicare, Medicaid and self-pay. Data were compiled in Microsoft Excel 2013 (Redmond, Washington). Due to the initial intent of data collection—namely tracking no-show rates for clinic efficiency improvement—the primary author did not collect additional demographic data for statistical analysis and a career change prevented subsequent access to additional demographic data.
As standard protocol for the practice, all new patients were informed of the scheduled appointment by live clinic staff during the initial telephone scheduling conversation. Subsequently, an appointment reminder letter via US mail was sent to the patient. All follow-up patients had appointments scheduled either immediately at discharge from surgery or from the clinic. Follow-up patients were also called with a reminder of their clinic appointment or operative date 1 to 2 business days prior to their scheduled appointment. Repeat live telephone calls were made for those patients who could not initially be reached by telephone. Of note, the data obtained during this study period were originally collected in an effort to improve practice efficiency and not in the primary interest of traditional clinical research. As a result, patient-specific data such as demographics were not collected. Further retrospective access to the data was limited as the physician relocated to a new hospital system in a different state.
Results
During the period of review, there were a total of 5817 scheduled clinic visits, with 484 no-shows (8.3%). New patient, follow-up, and postoperative visits comprised approximately 35%, 57%, and 8% of the clinic visits, respectively. Table 1 summarizes no-show rates based on visit type and insurance type. Overall, new Medicaid, follow-up Medicaid, and follow-up commercial insurance patients were most likely to no-show, whereas postoperative Medicare and postoperative self-pay patients were least likely to no-show (Figure 1). Within each visit type, patients with Medicaid were most likely to no-show and self-pay patients were least likely (Figure 2).
Summary of No-Show Visits in the Employed Otolaryngology Practice Setting.
Abbreviation: N/A, not applicable.
Total no-shows (N = 484) by specific patient visit type.
No-shows as a function of insurance type.
Discussion
No-show appointments are disruptive to medical practices due to somewhat unquantifiable costs such as personnel overhead, utilities overhead, loss of potential patients due to extended clinic new patient wait lists, and lost productivity. The University of California, San Francisco estimated 67 000 no-show appointments annually at a cost of approximately US$7 million. One of the best predictors of no-show status has been shown to be insurance status. 3 -6 Other factors of increased no-show rates include long-lead time from appointment scheduling to the appointment, younger age of patients, and seeing a nonsurgical specialist. 6
Previous studies examining no-show rates have been performed within medicine and pediatric specialties. There are only a few studies within otolaryngology, specifically that examine clinic visit nonadherence, and most have been conducted at tertiary academic centers. A study from Canada examined no-show rates for an otolaryngology clinic in a universal health-care setting and found a 24.4% no-show rate. Factors associated with no-shows include part-time physician status, male sex, and younger age. 7 A study from Israel examined no-show rates and found an overall rate of 27.7%, with factors including female gender, younger age, and appointment wait time. 8 Miller et al examined no-show rates in an academic medical center setting in the United States and found that younger age, black race, lower income, and Medicaid insurance were found to correlate with higher no-show rates. 9 Our group recently completed a study of nearly 23 000 patient visits and found several factors related to no-show rates in the academic otolaryngology setting as listed above. 2 What factors to target to decrease no-show rates is clearly a very complex question. The present review of data was not designed to answer this question but rather to report baseline data in the hospital-employed, nonacademic physician practice.
Previous studies have looked at additional factors and interventions to improve no-show rates. 3,10,11 Among these remedies include capping the number of patients seen in certain insurance programs, overbooking patients, 12,13 text messaging, 14 automated or live telephone calls, 15,16 patient portal enrollment with e-mails, 17 and reducing appointment wait times. 18 Another study examined strategic scheduling that assigned patients to particular clinic slots according to their likelihood of no-showing an appointment. 19 General common themes that seem to arise from the aforementioned interventions, in terms of improving no-show rates, include repeated reminders to patients regarding appointments and reducing wait time from booking of appointments to seeing the patient.
Interestingly, we found a no-show rate of 8.4%, which is much lower than other reported no-show rates within academic otolaryngology practices. 1,2 This may be due to the patient population or geographical practice setting. However, this lower rate may be secondary to the preappointment reminders utilized in this practice. In this practice, phone calls were performed by a live staff member, not automated, and repeated attempts to contact patients were performed. Further study into the efficacy of live phone reminders including factors such as cost, time, and outcomes is indicated.
This data review has several limitations. The data were initially collected with the intent of self-improvement within the primary author’s own practice and not for typical clinical research purposes. The primary author did not collect additional demographic data for statistical analysis and a career change prevented subsequent access to additional demographic data. Therefore, a multivariate analysis to adjust for factors such as age, gender, race, or socioeconomic status, as has been done in other studies, was not performed; thus, statistical analysis is quite limited. While certain associations, such as socioeconomic status and insurance status, can be implied, this review can make no definitive association between these or other demographic factors based on available data. Examining these demographic factors and possible associations in the private or employed otolaryngology setting are certainly topics for future study. Additionally, these findings are from a regional hospital setting and extrapolation to other specialties or geographic regions may be limited. On the other hand, this review of data is able to provide a baseline for comparison for other practitioners within hospital-employed nonacademic otolaryngology, which has not been previously described to our knowledge. Further research into more specific patient demographic factors, travel distances, and patient motives and barriers affecting no-show rates has been performed by the primary author in an academic setting. 2 Ultimately, appointment adherence is a multifactorial issue. However, identifying appropriate focuses for decreasing no-show rates is an imperative first step to address both the patient-specific and provider-specific barriers to care.
The importance of this issue, as it relates to the learning curve for establishing employed otolaryngology practices, is that this study can provide an estimate of no-show rates specifically in the employed setting and thus help hospital systems establish reasonable benchmarks in terms of clinic volume and productivity. Given that there has been and continues to be a rapid rise in the number of hospital-employed practices, hospital administrators may be able to use these data to help with otolaryngology practice setup and staffing.
In conclusion, changing health-care economics and administrative considerations have resulted in an increase in the number of hospital-employed physicians relative to “classic” private practitioners. This study gives baseline data for no-show rates in the hospital-employed otolaryngologist regional hospital setting. Regional hospitals considering hiring an employed otolaryngologist may consider these data for economic benchmark purposes. Utilization of repeated, live person reminders for appointments warrants further investigation.
Footnotes
Authors’ Note
Declaration of Conflicting Interests
Funding
ORCID iD
