Reducing Appointment No-Shows: Understanding Determinants and Solutions

The key goal of this study is to investigate social and health system level determinants of appointment no-shows at a community health centre (Access Alliance). The end goal of this project is to identify evidence-informed institutional solutions and best practices for reducing appointment no-shows.

Why are we conducting this study?
Appointment no-shows (i.e., not cancelled ≥ 24 hours of appointment) can adversely affect the health of clients and reduce productivity for healthcare centres. No-show rates vary widely depending on healthcare setting, type of healthcare services and health issues (Davies et al, 2015). Studies show that no-show rates range from 15% to 30% in community centres and other general medicine/primary care settings (Davies et al, 2015; Kaplan-Lewis, E and S. Percac-Lima, 2013; Parikh, 2010). In some cases, no-show rates can reach as high as 50% (Lacy et al, 2004). There is small but growing research on potential interventions/solutions for reducing appointment no-shows. Studies have documented positive effect in reducing appointment no-shows from a range of interventions including staff reminder calls, automated reminder calls, more clear information about how to reschedule or cancel appointments, reducing wait times, increasing number of appointments, and “open” access scheduling. Our study seeks to contribute to this body of evidence with a focus identifying evidence-informed solutions for reducing appointment no-shows among vulnerable clients in a community healthcare setting.

Our Project Team
The study will be led by an internal research team at Access Alliance comprising of researchers/data analysts and colleagues from primary healthcare leadership. The team includes Axelle Janczur (Executive Director), Dr Yogendra Shakya (Senior Research Scientist), Dr Akm Alamgir (Manager, Quality and Accountability), Khanh Le (Manager, Primary Care Service), Cliff Ledwos (Director, Primary Care Services), Neil Mentuch (Data Management Coordinator), and Tayyeba Darr (Research Coordinator). An epidemiologist, Dr. Susitha Wanigaratna, was recruited as a consultant Project Lead to analyze the data and write the report based on directions from the project team.

Our Research Goals and Methods
The key objective of this study was to better understand the client and institutional level factors which contribute to appointment no-shows at Access Alliance (a community health centre). The overall goal of this work was to identify evidence-informed institutional solutions and best practices for reducing appointment no-shows. This study utilized a mixed methods approach. We conducted retrospective chart review analysis of appointment and client level data from Access Alliance over a three year period (2014/15, 2015/16 and 2016/17). We also conducted focus group discussions (in the summer of 2017) with primary care providers and secretarial staff of Access Alliance. From February to May 2018, we conducted one-on-one telephone interviews with 30 clients selected based on convenience sampling stratified (10 each) to represent three different groups based on appointment no-show rate: Group 1) those that attended all of their appointments (no no-shows); Group 2) those with a moderate no-show rate (50th-75th percentile of no-show %); and Group 3) those with a high no show rate (≥ 90th percentile of no-show %).

What we found
Generally, the no-show rate among rostered primary care clients increased between 2014-2015 and 2016-2017 for all provider groups at Access Alliance from 20% to 22%. A combination of institutional factors and client-level determinants were found to be associated with appointment no-shows for vulnerable clients. The longer a client waited for their appointment (the time between the date of making the appointment and the scheduled appointment) the more likely the client was not to show up. The no-show rate for wait times between 0-6 days was significantly lower (15%) than the no-show % at all other wait time categories; no-show rates for same day or next day appointment was 11%.

Compared to other groups, male clients, clients <40 years of age, and clients who were refugee claimants were more likely to no-show for ≥30% of their appointments. Clients who indicated they needed an interpreter and used an interpreter were less likely to no-show for ≥30% of their appointments than clients who indicated no need for an interpreter. Clients with chronic health issues (diabetes and/or high blood pressure) were less likely to no-show for ≥30% of their appointments compared to clients without these conditions.

Focus group discussion with primary care providers and secretarial staff suggest the need for better support and training for medical secretaries to effectively manage appointment re/scheduling and reminder calls, strengthening same day appointment, and better use of technology (telephone and text reminders). Interviews with clients captured economic/structural causes for appointment no-shows (e.g precarious jobs, lack of paid sick days), highlighting the need to continue advocacy for legislation in favor of decent work and paid sick days.

Our research report will be ready for release in December 2018.

Our Knowledge Translation Activities
The project team is working closely with relevant decision makers at Access Alliance to review and implement the study recommendations to reduce the appointment no-show rate at the agency. Study results have been shared in relevant service provider tables and forums/conferences. 

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