Original Article
A Pilot Study of Reasons and Risk Factors for ‘‘No-Shows’’ in a Pediatric Neurology Clinic
Journal of Child Neurology 2015, Vol. 30(10) 1295-1299 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0883073814559098 jcn.sagepub.com
Lindsay M. Guzek, BS1, William F. Fadel, MS2, and Meredith R. Golomb, MD, MSc1
Abstract Missed clinic appointments lead to decreased patient access, worse patient outcomes, and increased healthcare costs. The goal of this pilot study was to identify reasons for and risk factors associated with missed pediatric neurology outpatient appointments (‘‘no-shows’’). This was a prospective cohort study of patients scheduled for 1 week of clinic. Data on patient clinical and demographic information were collected by record review; data on reasons for missed appointments were collected by phone interviews. Univariate and multivariate analyses were conducted using chi-square tests and multiple logistic regression to assess risk factors for missed appointments. Fifty-nine (25%) of 236 scheduled patients were no-shows. Scheduling conflicts (25.9%) and forgetting (20.4%) were the most common reasons for missed appointments. When controlling for confounding factors in the logistic regression, Medicaid (odds ratio 2.36), distance from clinic, and time since appointment was scheduled were associated with missed appointments. Further work in this area is needed. Keywords compliance, access, insurance status, scheduling, risk factors Received July 21, 2014. Received revised October 13, 2014. Accepted for publication October 14, 2014.
Neurologists face increasing pressure to improve patient access, see more patients, minimize costs, and improve patient outcomes. Missed patient appointments, often called ‘‘no-shows,’’ present an obstacle to reaching those goals. Missed appointments take away time that could have been spent with other patients, increase the costs of patient care, and are associated with worse patient outcomes.1,2 Patient noshows are a top complaint among neurologists because of the lost time and extra costs incurred.1 Although there have been studies on the subject of missed appointments in areas such as pediatric primary care3,4 and dentistry,5,6 there are few studies in this area in neurology and neurology subspecialties. Pediatric neurology has been particularly affected by physician shortages. Currently, the number of pediatric neurologists is estimated to be 20% below demand.7 The shortage of pediatric neurologists is expected to get worse as older pediatric neurologists retire. Minimizing missed appointments will aid in maximizing access to a shrinking pool of pediatric neurologists. The pediatric neurology outpatient clinic at Riley Hospital for Children at Indiana University Health is the largest provider of outpatient pediatric neurology care in Indiana, but the outpatient clinic consistently has a 20% to 30% no-show rate. The goals of this pilot study were to identify reasons families
miss pediatric neurology appointments and assess risk factors associated with missed pediatric neurology appointments.
Methods Participants and Design This was a prospective cohort study of all patients scheduled for outpatient pediatric neurology appointments at Riley Hospital for Children at Indiana University Health in Indianapolis, Indiana, between June 9 and 13, 2014. This week was chosen because very few of the clinic physicians were going to be on vacation, and we had a medical student summer volunteer researcher (LMG) available to perform data collection and participate in data analysis and paper writing. Each day that week, the schedule was reviewed at the end
1
Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA 2 Department of Biostatistics, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA Corresponding Author: Meredith R. Golomb, MD, MSc, Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine, 705 Riley Hospital Dr. RI 1340, Indianapolis, IN 46202, USA. Email: [email protected]
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of the day to determine which patients had no-showed. Clinic data and electronic medical records for all scheduled patients (shows and no-shows) were reviewed to gather data on the following variables: patient age; patient gender; race; insurance status; distance from clinic; type of appointment (new to clinic, clinic follow-up, or new to clinic after hospital discharge); history of previous no-shows in the past 2 years; lag time from referral to appointment; and neurologic diagnoses. Previous no-shows were only recorded if they were entered in the electronic medical database used across many Indiana University Health clinics. Patients were classified as no-shows if they did not show up to their appointment without prior notification to the clinic. Cancelations were not included in the no-show population. This study was limited to 1 week of data because of limitations in resources and lack of funding; this study was designed to be pilot work providing preliminary data for future larger, funded studies. In our clinic, each patient receives 2 reminders of the clinic visit. The first is a call from clinic staff 3 days before the visit; the second is an automated call 2 days before the visit. Both calls give the family the option to cancel the appointment; if the appointment is canceled during either phone call, that is not counted as a no-show.
Interview Procedure for No-Show Families All families were called up to 3 times to ask the reason for the missed appointment, using a standardized script. To maximize the chances of reaching a parent or guardian when they would recall why the appointment was missed, at least one call was made within 24 hours of the missed appointment; at least one call was made between 5 and 7 PM; 2 calls were at least 24 hours apart, and all calls were made within 7 days of the missed appointment. A clinic voicemail box where messages could be left was set up for the study, for families who called back.
Data Analysis Descriptive statistics were used to describe the missed appointment population and reasons for missed appointments. The show and no-show (missed appointment) populations were assessed and compared using univariate and multivariate analyses. Chi-square tests were used to compare show and no-show populations on a univariate level. Multiple logistic regression was used to predict the probability of a missed appointment. Stepwise variable selection was implemented to determine which variables to include in the predictive model. All analyses were performed at a 5% significance level using SAS, version 9.3 (SAS Institute, Cary, NC).
Ethics This study was approved by the Indiana University Institutional Review Board.
Results Clinic Patient Population For the week studied, 236 patients were scheduled, 177 (75%) patients showed, and 59 (25%) missed their appointments (noshowed) (See Table 1 for clinical and demographic characteristics of the scheduled clinic population.) A total of 122 phone calls were made, 38 families were reached (64.4%), 21 families were not reached (35.6%), and none refused participation. Of the 21 not reached, 4 (16.7%)
Table 1. Clinical and Demographic Characteristics of Scheduled Population. Overall n (%) Age (y) 5 6-11 >12 Gender Male Female Race African American Other Insurance Medicaid Other Distance from clinic (miles) 100 Patient status Return New New post-hospital Previous no-shows 0 or 1 2 or more Time since scheduled 0-14 d 15 d-1 mo 1 mo-2 mo 2 mo-3 mo 3 mo-4 mo 4 mo-5 mo >5 mo
No-show
72 (30.5) 18 (30.5) 80 (33.9) 17 (28.8) 84 (35.6) 24 (40.7)
Show
P value
54 (30.5) .557 63 (35.6) 60 (33.9)
137 (58.1) 35 (59.3) 102 (57.6) .819 99 (41.9) 24 (40.7) 75 (42.4) 30 (12.7) 13 (22.0) 17 (9.6) .013 206 (87.3) 46 (78.0) 160 (90.4) 117 (49.6) 37 (62.7) 119 (50.4) 22 (37.3)
80 (45.2) .020 97 (54.8)
140 (59.3) 43 (72.9) 55 (23.3) 6 (10.2) 41 (17.4) 10 (16.9)
97 (54.8) .016 49 (27.7) 31 (17.5)
180 (76.3) 46 (78.0) 134 (75.7) .412 52 (22.0) 11 (18.6) 41 (23.2) 4 (1.7) 2 (3.4) 2 (1.1) 198 (83.9) 44 (74.6) 154 (87.0) .025 38 (16.1) 15 (25.4) 23 (13.0) 49 15 14 51 41 20 46
(20.8) 2 (3.4) (6.4) 3 (5.1) (5.9) 4 (6.8) (21.6) 21 (35.6) (17.4) 11 (18.6) (8.5) 8 (13.6) (19.5) 10 (16.9)
47 (26.6) .001 12 (6.8) 10 (5.7) 30 (16.9) 30 (16.9) 12 (6.8) 36 (20.3)
had no working phone, 3 (12.5%) had no voicemail, 2 (8.3%) had wrong numbers, and 11 (45.8%) did not respond to messages. No families left voicemail messages calling back.
Reasons for Missed Appointments The 38 parents/guardians reached gave 54 reasons why the appointment was missed. The 2 most common reasons were scheduling conflicts or being busy (25.9%) and forgetting the appointment (20.4%). Some of the scheduling conflicts described included school still being in session (the Indiana school year was extended because of multiple snow days), another family member having an appointment, and being on vacation. Some parents or guardians said they did not know they had an appointment with the pediatric neurology clinic (9.3%) (Table 2).
Risk Factors Associated With Missed Appointments The univariate analyses of clinical and demographic characteristics of the clinic population are shown in Table 1. The rate of no-shows for African Americans was nearly double that of
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Table 2. Reasons Given for Missed Appointments.
Table 3. Results of Multiple Logistic Regression Model.
Reasons for missed appointment
Number (n ¼ 54)
Percent
Scheduling conflict/busy Forgot Didn’t know about appointment Financial reasons Wrongly registered Sick Transportation Other Overslept Parking No longer has symptoms Parental conflict Recently hospitalized
14 11 5 4 4 3 3 3 2 2 1 1 1
25.9 20.4 9.3 7.4 7.4 5.6 5.6 5.6 3.7 3.7 1.9 1.9 1.9
non–African Americans (43% vs 22%, P ¼ .013). The rate of no-shows for patients with Medicaid insurance was higher than for those with other coverage (private insurance, combination, or self-pay; 32% vs 18%, P ¼ .020). No-show rates were highest among patients who live less than 50 miles from the clinic, followed by those living more than 100 miles away and those between 50 and 100 miles (31% vs 24% vs 11%, P ¼ .016). Lag time since appointment scheduled was significantly associated with no-show rates, with a lag time of less than 2 weeks having the lowest rate (4%, P ¼ .001). The noshow rate for patients with 2 or more previous no-shows was nearly double the rate for patients with fewer than 2 previous no-shows (39% vs 22%, P ¼ .025). Patient age, gender, and appointment type (new, clinic follow-up, or new to clinic post hospital discharge) were not associated with no-show rate. Neurologic diagnosis could not be assessed as a risk factor because of the variety of diagnoses, the fact that many patients had 2 or more diagnoses, and limited sample size. The results of the multivariate analysis are shown in Table 3. Medicaid (odds ratio 2.36, 95% CI 1.11-5.04), distance from clinic less than 50 miles (odds ratio 5.43, 95% CI 1.90-15.38) and greater than 100 miles (odds ratio 4.13, 95% CI 1.1714.49) compared to 50 to 100 miles, and lag time since scheduled (see Table 3 for results) were associated with no-shows while controlling for age, gender, race, new patient status, previous no-shows, weather, and day of week.
Discussion Missed appointments are a major problem in medical care. Understanding reasons for missed appointments presents special challenges in pediatric neurology, where a patient’s guardians, not the patient, are responsible for bringing the patient to clinic. The shortage of pediatric neurologists means that there are limited numbers of locations and appointment slots for pediatric neurology care, which creates additional medical access obstacles. These issues have presented significant problems in our own clinic and motivated this pilot study. Collins and colleagues looked at reasons Australian adult patients gave for missing neurology and orthopedic outpatient
Odds ratio Age (y) 5 6-11 >12 Gender Male Female Race Black Other Insurance Medicaid Other Distance from clinic (miles) 100 Patient status Return New Previous no-shows 0 or 1 2 or more Time since scheduled 0-14 d 15 d-1 mo 1 mo-2 mo 2 mo-3 mo 3 mo-4 mo 4 mo-5 mo >5 mo Day of visit Monday Tuesday Wednesday Thursday Friday Weather Sunny, pleasant Overcast, pleasant Light rain Time of day Morning Afternoon
95% Confidence interval
1.00 0.74 1.27
Referent 0.30-1.83 0.53-3.04
1.00 0.77
Referent 0.36-1.64
1.06 1.00
0.41-2.78 Referent
2.36 1.00
1.11-5.04 Referent
5.43 1.00 4.13
1.90-15.38 Referent 1.17-14.49
1.00 2.50
Referent 0.94-6.67
0.60 1.00
0.23-1.55 Referent
1.00 10.80 19.39 33.33 9.52 37.04 9.90
Referent 1.36-85.73 2.62-143.63 5.92-200.00 1.77-50.00 5.49-250.00 1.69-58.82
0.76 0.90 0.19 0.51 1.00
0.24-2.39 0.18-4.52 0.02-1.77 0.16-1.60 Referent
1.00 0.51 1.00
Referent 0.19-1.32 0.12-8.21
1.00 0.86
Referent 0.37-1.99
clinic visits. The most common reasons given were forgetting the appointments, being unaware of the appointment, being too sick to attend the appointment, and having difficulty with parking. Financial concerns and work conflicts were also mentioned.8 Al-Faris and colleagues looked at the reasons families missed their pediatric epilepsy outpatient appointments in a Saudi Arabian clinic. Clinic error, forgetting the appointment, and being busy were common reasons; financial concerns did not appear to be a factor, probably because the Saudi government attempts to cover health care costs for all citizens.9,10 Although this issue has not been previously well studied in US pediatric neurology clinics, studies in other US pediatric fields such as general pediatrics and pediatric
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dentistry have identified several reasons parents and guardians have for failing to make it to their child’s appointment. Parents and guardians identify scheduling problems or conflicts, forgetting about the appointment, beliefs that the appointment was no longer necessary, and weather as reasons for missing appointments.11,12 Parents identify financial factors as important, including barriers such as lack of transportation.11 In our study population, forgetting an appointment or having scheduling conflicts were the most common reasons for missing appointments, but financial concerns and specific transportation problems were also mentioned by several patients. Identifying variables associated with patients that miss appointments is key if this population is to be targeted for interventions. Multiple studies have suggested that patient beliefs, culture, and socioeconomic factors appear to play a role. For Australian adult neurology patients, Collins and colleagues identified a previous history of missed appointments and patient opinion about their appointments as the variables most associated with missing appointments.8 For the families of Saudi Arabian pediatric epilepsy patients, missed appointments were associated with parental concern about their children’s’ medication side effects, unhappiness with the clinic, belief that traditional medications were more effective than conventional anticonvulsants, and belief that their children did not really need the care.9 Variables associated with missed pediatric appointments in American clinics have included insurance status, patient age and ethnicity, patient diagnosis, and clinic setting. Medicaid has been associated with a higher rate of missed appointments compared to private insurance.13-15 Patient age >10 years4 and African American race14 have been associated with higher rates of missed appointments in some studies. The severity of diagnoses seems to have a role in missed appointments in pediatric dentistry; in one hospital dental clinic, increased severity increased the likelihood of a missed appointment.6 We found it surprising that patients who lived closest to the hospital were more likely to no-show than patients who lived farther away, but suspected it may have been that patients in Indianapolis had more pediatric neurology clinic options, whereas patients who lived farther away had less access to pediatric neurologists. Although data were gathered on diagnoses, the diagnoses seen in 1 week were too diverse and subpopulations too small to identify associations. We found it interesting that when adjusting for confounders, insurance type, distance from the hospital, and lag time from scheduling to appointment were the only predictors; race dropped out as a predictor. There were several limitations to this study. This was a pilot study, and only 1 week of summer data was collected. Although the clinic staff reports the no-show rate during the studied week was similar to the rate at many other times of the year (personal communication, A. Spicer), the summer no-show population may vary from the autumn, winter, and spring no-show populations. The weather was not highly variable during the studied week, making it difficult to assess weather as a risk factor. Indiana is not as diverse as some other
states, so there may be limitations in applying these data to all other states. Compared to the United States as a whole, Indiana has lower African American (13.1% US, 9.4% Indiana), Asian (5.1% US, 1.8% Indiana), and Hispanic populations (16.9% US, 6.3% Indiana) according to 2012 Census data.16 Future studies including data from multiple times of the year and from multiple states will be needed to see if these results can be generalized. In addition, no ethnicity data could be accessed on the electronic database, leaving out a potentially important variable, Hispanic or Latino ethnicity. The initial data from this preliminary study suggest that interventions to decrease no-show rates should target Medicaid patients, patients who live closest and farthest from the hospital, and lag time from scheduling to appointment. In the past few months, our division has addressed that third issue for new patients, hiring 2 new neurologists and redesigning the scheduling protocol. This has resulted in a decrease of wait time for new appointments from 2 months to 2 weeks. Initial data suggest that the no-show rates have decreased, but it will take another few months of data to determine if the shorter wait time for new appointments can be maintained, and if the decrease in no-show rates for new patients is permanent. Our division is discussing initiating additional email or text reminders to try to decrease no-show rates for both new and follow-up patients, but there are many details to work out because of patient privacy laws. Also, this would not reach the Medicaid patients who do not have text-capable phones or regular Internet access. Reminder postcards or letters are not used because our Medicaid patients tend to move frequently. In an era of increasing healthcare demand and costs, decreasing the rate of missed appointments could be a key component of improving access to neurology care without significantly increasing costs. Further work is needed to clarify the reasons for missed appointments in our clinic and other neurology clinics so interventions can be designed to decrease missed appointments and optimize patient access to neurologic care. Acknowledgments The authors would like to thank Anne Spicer, RN, BSN, and the Pediatric Neurology clinic staff for advice and technical assistance. Anne is the Ambulatory Nurse Manager for the Pediatric Neurology Clinic at Indiana University Health Riley Outpatient Center.
Author Contributions LMG and WFF drafted the manuscript and analyzed and interpreted the data. LMG designed and completed the study and collected the data. MRG, who was the senior author and supervising mentor, designed and conceived the study and revised the manuscript.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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Ethical Approval This study was approved by the Indiana University Institutional Review Board.
9.
References 1. Evans RW ER, Evans RI. A survey of neurologists on bothersome patient behaviors. MedGenMed. 2006;16:35. 2. Nguyen DL, Dejesus RS, Wieland ML. Missed appointments in resident continuity clinic: patient characteristics and health care outcomes. J Grad Med Educ. 3:350-355. 3. Specht EM, Powell KR, Dormo CA. Factors affecting missed appointment rates for pediatric patients insured by medicaid in a traditional hospital-based resident clinic and hospital-owned practice settings. Clin Pediatr. 2004;43:749-752. 4. Pearce T, O’shea JS, Wessen AF. Correlations between appointment keeping and reorganization of hospital ambulatory pediatric services. Pediatrics. 1979;64:81-87. 5. Skaret E, Raadal M, Kvale G, Berg E. Factors related to missed and cancelled dental appointments among adolescents in Norway. Eur J Oral Sci. 2000;108:175-183. 6. Rodd HD, Clark EL, Stern MR, Baker SR. Failed attendances at hospital dental clinics among young patients with cleft lip and palate. Cleft Palate Craniofac J. 2007;44:92-94. 7. Council of Pediatric Subspecialties. Pediatric Neurology. 2014; Available at: http://www.pedsubs.org/subdes/Neurology.cfm. 8. Collins J, Santamaria N, Clayton L. Why outpatients fail to attend their scheduled appointments: a prospective comparison
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of differences between attenders and non-attenders. Australian Health Rev. 2003;26:52-63. Al-Faris EA, Abdulghani HM, Mahdi AH, Salih MA, Al-Kordi AG. Compliance with appointments and medications in a pediatric neurology clinic at a University Hospital in Riyadh, Saudi Arabia. Saudi Med J. 2002;23:969-974. Aldossary A, While A, Barriball L. Health care and nursing in Saudi Arabia. Int Nurs Rev. 2008;55:125-128. Maserejian NN, Trachtenberg F, Link C, Tavares M. Underutilization of dental care when it is freely available: a prospective study of the New England Children’s Amalgam Trial. J Public Health Dent. 2008;68:139-148. Sawyer SM, Zalan A, Bond LM. Telephone reminders improve adolescent clinic attendance: a randomized controlled trial. J Paediatr Child Health. 2002;38:79-83. Lamberth EF, Rothstein EP, Hipp TJ, et al. Rates of missed appointments among pediatric patients in a private practice: medicaid compared with private insurance. Arch Pediatr Adolesc Med. 2002;156:86-87. Schwartz DD, Cline VD, Axelrad ME, Anderson BJ. Feasibility, acceptability, and predictive validity of a psychosocial screening program for children and youth newly diagnosed with type 1 diabetes. Diabetes Care. 2011;34:326-331. Yoon EY, Davis MM, Van Cleave J, Maheshwari S, Cabana MD. Factors associated with non-attendance at pediatric subspecialty asthma clinics. J Asthma. 2005;42:555-559. Bureau USC. State and County QuickFacts: Indiana Quicklinks. 2012; Available at: http://quickfacts.census.gov/qfd/states/18000lk.html.
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A Pilot Study of Reasons and Risk Factors for ‘‘No-Shows’’ in a Pediatric Neurology Clinic
Journal of Child Neurology 2015, Vol. 30(10) 1295-1299 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0883073814559098 jcn.sagepub.com
Lindsay M. Guzek, BS1, William F. Fadel, MS2, and Meredith R. Golomb, MD, MSc1
Abstract Missed clinic appointments lead to decreased patient access, worse patient outcomes, and increased healthcare costs. The goal of this pilot study was to identify reasons for and risk factors associated with missed pediatric neurology outpatient appointments (‘‘no-shows’’). This was a prospective cohort study of patients scheduled for 1 week of clinic. Data on patient clinical and demographic information were collected by record review; data on reasons for missed appointments were collected by phone interviews. Univariate and multivariate analyses were conducted using chi-square tests and multiple logistic regression to assess risk factors for missed appointments. Fifty-nine (25%) of 236 scheduled patients were no-shows. Scheduling conflicts (25.9%) and forgetting (20.4%) were the most common reasons for missed appointments. When controlling for confounding factors in the logistic regression, Medicaid (odds ratio 2.36), distance from clinic, and time since appointment was scheduled were associated with missed appointments. Further work in this area is needed. Keywords compliance, access, insurance status, scheduling, risk factors Received July 21, 2014. Received revised October 13, 2014. Accepted for publication October 14, 2014.
Neurologists face increasing pressure to improve patient access, see more patients, minimize costs, and improve patient outcomes. Missed patient appointments, often called ‘‘no-shows,’’ present an obstacle to reaching those goals. Missed appointments take away time that could have been spent with other patients, increase the costs of patient care, and are associated with worse patient outcomes.1,2 Patient noshows are a top complaint among neurologists because of the lost time and extra costs incurred.1 Although there have been studies on the subject of missed appointments in areas such as pediatric primary care3,4 and dentistry,5,6 there are few studies in this area in neurology and neurology subspecialties. Pediatric neurology has been particularly affected by physician shortages. Currently, the number of pediatric neurologists is estimated to be 20% below demand.7 The shortage of pediatric neurologists is expected to get worse as older pediatric neurologists retire. Minimizing missed appointments will aid in maximizing access to a shrinking pool of pediatric neurologists. The pediatric neurology outpatient clinic at Riley Hospital for Children at Indiana University Health is the largest provider of outpatient pediatric neurology care in Indiana, but the outpatient clinic consistently has a 20% to 30% no-show rate. The goals of this pilot study were to identify reasons families
miss pediatric neurology appointments and assess risk factors associated with missed pediatric neurology appointments.
Methods Participants and Design This was a prospective cohort study of all patients scheduled for outpatient pediatric neurology appointments at Riley Hospital for Children at Indiana University Health in Indianapolis, Indiana, between June 9 and 13, 2014. This week was chosen because very few of the clinic physicians were going to be on vacation, and we had a medical student summer volunteer researcher (LMG) available to perform data collection and participate in data analysis and paper writing. Each day that week, the schedule was reviewed at the end
1
Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA 2 Department of Biostatistics, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA Corresponding Author: Meredith R. Golomb, MD, MSc, Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine, 705 Riley Hospital Dr. RI 1340, Indianapolis, IN 46202, USA. Email: [email protected]
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of the day to determine which patients had no-showed. Clinic data and electronic medical records for all scheduled patients (shows and no-shows) were reviewed to gather data on the following variables: patient age; patient gender; race; insurance status; distance from clinic; type of appointment (new to clinic, clinic follow-up, or new to clinic after hospital discharge); history of previous no-shows in the past 2 years; lag time from referral to appointment; and neurologic diagnoses. Previous no-shows were only recorded if they were entered in the electronic medical database used across many Indiana University Health clinics. Patients were classified as no-shows if they did not show up to their appointment without prior notification to the clinic. Cancelations were not included in the no-show population. This study was limited to 1 week of data because of limitations in resources and lack of funding; this study was designed to be pilot work providing preliminary data for future larger, funded studies. In our clinic, each patient receives 2 reminders of the clinic visit. The first is a call from clinic staff 3 days before the visit; the second is an automated call 2 days before the visit. Both calls give the family the option to cancel the appointment; if the appointment is canceled during either phone call, that is not counted as a no-show.
Interview Procedure for No-Show Families All families were called up to 3 times to ask the reason for the missed appointment, using a standardized script. To maximize the chances of reaching a parent or guardian when they would recall why the appointment was missed, at least one call was made within 24 hours of the missed appointment; at least one call was made between 5 and 7 PM; 2 calls were at least 24 hours apart, and all calls were made within 7 days of the missed appointment. A clinic voicemail box where messages could be left was set up for the study, for families who called back.
Data Analysis Descriptive statistics were used to describe the missed appointment population and reasons for missed appointments. The show and no-show (missed appointment) populations were assessed and compared using univariate and multivariate analyses. Chi-square tests were used to compare show and no-show populations on a univariate level. Multiple logistic regression was used to predict the probability of a missed appointment. Stepwise variable selection was implemented to determine which variables to include in the predictive model. All analyses were performed at a 5% significance level using SAS, version 9.3 (SAS Institute, Cary, NC).
Ethics This study was approved by the Indiana University Institutional Review Board.
Results Clinic Patient Population For the week studied, 236 patients were scheduled, 177 (75%) patients showed, and 59 (25%) missed their appointments (noshowed) (See Table 1 for clinical and demographic characteristics of the scheduled clinic population.) A total of 122 phone calls were made, 38 families were reached (64.4%), 21 families were not reached (35.6%), and none refused participation. Of the 21 not reached, 4 (16.7%)
Table 1. Clinical and Demographic Characteristics of Scheduled Population. Overall n (%) Age (y) 5 6-11 >12 Gender Male Female Race African American Other Insurance Medicaid Other Distance from clinic (miles) 100 Patient status Return New New post-hospital Previous no-shows 0 or 1 2 or more Time since scheduled 0-14 d 15 d-1 mo 1 mo-2 mo 2 mo-3 mo 3 mo-4 mo 4 mo-5 mo >5 mo
No-show
72 (30.5) 18 (30.5) 80 (33.9) 17 (28.8) 84 (35.6) 24 (40.7)
Show
P value
54 (30.5) .557 63 (35.6) 60 (33.9)
137 (58.1) 35 (59.3) 102 (57.6) .819 99 (41.9) 24 (40.7) 75 (42.4) 30 (12.7) 13 (22.0) 17 (9.6) .013 206 (87.3) 46 (78.0) 160 (90.4) 117 (49.6) 37 (62.7) 119 (50.4) 22 (37.3)
80 (45.2) .020 97 (54.8)
140 (59.3) 43 (72.9) 55 (23.3) 6 (10.2) 41 (17.4) 10 (16.9)
97 (54.8) .016 49 (27.7) 31 (17.5)
180 (76.3) 46 (78.0) 134 (75.7) .412 52 (22.0) 11 (18.6) 41 (23.2) 4 (1.7) 2 (3.4) 2 (1.1) 198 (83.9) 44 (74.6) 154 (87.0) .025 38 (16.1) 15 (25.4) 23 (13.0) 49 15 14 51 41 20 46
(20.8) 2 (3.4) (6.4) 3 (5.1) (5.9) 4 (6.8) (21.6) 21 (35.6) (17.4) 11 (18.6) (8.5) 8 (13.6) (19.5) 10 (16.9)
47 (26.6) .001 12 (6.8) 10 (5.7) 30 (16.9) 30 (16.9) 12 (6.8) 36 (20.3)
had no working phone, 3 (12.5%) had no voicemail, 2 (8.3%) had wrong numbers, and 11 (45.8%) did not respond to messages. No families left voicemail messages calling back.
Reasons for Missed Appointments The 38 parents/guardians reached gave 54 reasons why the appointment was missed. The 2 most common reasons were scheduling conflicts or being busy (25.9%) and forgetting the appointment (20.4%). Some of the scheduling conflicts described included school still being in session (the Indiana school year was extended because of multiple snow days), another family member having an appointment, and being on vacation. Some parents or guardians said they did not know they had an appointment with the pediatric neurology clinic (9.3%) (Table 2).
Risk Factors Associated With Missed Appointments The univariate analyses of clinical and demographic characteristics of the clinic population are shown in Table 1. The rate of no-shows for African Americans was nearly double that of
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Table 2. Reasons Given for Missed Appointments.
Table 3. Results of Multiple Logistic Regression Model.
Reasons for missed appointment
Number (n ¼ 54)
Percent
Scheduling conflict/busy Forgot Didn’t know about appointment Financial reasons Wrongly registered Sick Transportation Other Overslept Parking No longer has symptoms Parental conflict Recently hospitalized
14 11 5 4 4 3 3 3 2 2 1 1 1
25.9 20.4 9.3 7.4 7.4 5.6 5.6 5.6 3.7 3.7 1.9 1.9 1.9
non–African Americans (43% vs 22%, P ¼ .013). The rate of no-shows for patients with Medicaid insurance was higher than for those with other coverage (private insurance, combination, or self-pay; 32% vs 18%, P ¼ .020). No-show rates were highest among patients who live less than 50 miles from the clinic, followed by those living more than 100 miles away and those between 50 and 100 miles (31% vs 24% vs 11%, P ¼ .016). Lag time since appointment scheduled was significantly associated with no-show rates, with a lag time of less than 2 weeks having the lowest rate (4%, P ¼ .001). The noshow rate for patients with 2 or more previous no-shows was nearly double the rate for patients with fewer than 2 previous no-shows (39% vs 22%, P ¼ .025). Patient age, gender, and appointment type (new, clinic follow-up, or new to clinic post hospital discharge) were not associated with no-show rate. Neurologic diagnosis could not be assessed as a risk factor because of the variety of diagnoses, the fact that many patients had 2 or more diagnoses, and limited sample size. The results of the multivariate analysis are shown in Table 3. Medicaid (odds ratio 2.36, 95% CI 1.11-5.04), distance from clinic less than 50 miles (odds ratio 5.43, 95% CI 1.90-15.38) and greater than 100 miles (odds ratio 4.13, 95% CI 1.1714.49) compared to 50 to 100 miles, and lag time since scheduled (see Table 3 for results) were associated with no-shows while controlling for age, gender, race, new patient status, previous no-shows, weather, and day of week.
Discussion Missed appointments are a major problem in medical care. Understanding reasons for missed appointments presents special challenges in pediatric neurology, where a patient’s guardians, not the patient, are responsible for bringing the patient to clinic. The shortage of pediatric neurologists means that there are limited numbers of locations and appointment slots for pediatric neurology care, which creates additional medical access obstacles. These issues have presented significant problems in our own clinic and motivated this pilot study. Collins and colleagues looked at reasons Australian adult patients gave for missing neurology and orthopedic outpatient
Odds ratio Age (y) 5 6-11 >12 Gender Male Female Race Black Other Insurance Medicaid Other Distance from clinic (miles) 100 Patient status Return New Previous no-shows 0 or 1 2 or more Time since scheduled 0-14 d 15 d-1 mo 1 mo-2 mo 2 mo-3 mo 3 mo-4 mo 4 mo-5 mo >5 mo Day of visit Monday Tuesday Wednesday Thursday Friday Weather Sunny, pleasant Overcast, pleasant Light rain Time of day Morning Afternoon
95% Confidence interval
1.00 0.74 1.27
Referent 0.30-1.83 0.53-3.04
1.00 0.77
Referent 0.36-1.64
1.06 1.00
0.41-2.78 Referent
2.36 1.00
1.11-5.04 Referent
5.43 1.00 4.13
1.90-15.38 Referent 1.17-14.49
1.00 2.50
Referent 0.94-6.67
0.60 1.00
0.23-1.55 Referent
1.00 10.80 19.39 33.33 9.52 37.04 9.90
Referent 1.36-85.73 2.62-143.63 5.92-200.00 1.77-50.00 5.49-250.00 1.69-58.82
0.76 0.90 0.19 0.51 1.00
0.24-2.39 0.18-4.52 0.02-1.77 0.16-1.60 Referent
1.00 0.51 1.00
Referent 0.19-1.32 0.12-8.21
1.00 0.86
Referent 0.37-1.99
clinic visits. The most common reasons given were forgetting the appointments, being unaware of the appointment, being too sick to attend the appointment, and having difficulty with parking. Financial concerns and work conflicts were also mentioned.8 Al-Faris and colleagues looked at the reasons families missed their pediatric epilepsy outpatient appointments in a Saudi Arabian clinic. Clinic error, forgetting the appointment, and being busy were common reasons; financial concerns did not appear to be a factor, probably because the Saudi government attempts to cover health care costs for all citizens.9,10 Although this issue has not been previously well studied in US pediatric neurology clinics, studies in other US pediatric fields such as general pediatrics and pediatric
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Journal of Child Neurology 30(10)
dentistry have identified several reasons parents and guardians have for failing to make it to their child’s appointment. Parents and guardians identify scheduling problems or conflicts, forgetting about the appointment, beliefs that the appointment was no longer necessary, and weather as reasons for missing appointments.11,12 Parents identify financial factors as important, including barriers such as lack of transportation.11 In our study population, forgetting an appointment or having scheduling conflicts were the most common reasons for missing appointments, but financial concerns and specific transportation problems were also mentioned by several patients. Identifying variables associated with patients that miss appointments is key if this population is to be targeted for interventions. Multiple studies have suggested that patient beliefs, culture, and socioeconomic factors appear to play a role. For Australian adult neurology patients, Collins and colleagues identified a previous history of missed appointments and patient opinion about their appointments as the variables most associated with missing appointments.8 For the families of Saudi Arabian pediatric epilepsy patients, missed appointments were associated with parental concern about their children’s’ medication side effects, unhappiness with the clinic, belief that traditional medications were more effective than conventional anticonvulsants, and belief that their children did not really need the care.9 Variables associated with missed pediatric appointments in American clinics have included insurance status, patient age and ethnicity, patient diagnosis, and clinic setting. Medicaid has been associated with a higher rate of missed appointments compared to private insurance.13-15 Patient age >10 years4 and African American race14 have been associated with higher rates of missed appointments in some studies. The severity of diagnoses seems to have a role in missed appointments in pediatric dentistry; in one hospital dental clinic, increased severity increased the likelihood of a missed appointment.6 We found it surprising that patients who lived closest to the hospital were more likely to no-show than patients who lived farther away, but suspected it may have been that patients in Indianapolis had more pediatric neurology clinic options, whereas patients who lived farther away had less access to pediatric neurologists. Although data were gathered on diagnoses, the diagnoses seen in 1 week were too diverse and subpopulations too small to identify associations. We found it interesting that when adjusting for confounders, insurance type, distance from the hospital, and lag time from scheduling to appointment were the only predictors; race dropped out as a predictor. There were several limitations to this study. This was a pilot study, and only 1 week of summer data was collected. Although the clinic staff reports the no-show rate during the studied week was similar to the rate at many other times of the year (personal communication, A. Spicer), the summer no-show population may vary from the autumn, winter, and spring no-show populations. The weather was not highly variable during the studied week, making it difficult to assess weather as a risk factor. Indiana is not as diverse as some other
states, so there may be limitations in applying these data to all other states. Compared to the United States as a whole, Indiana has lower African American (13.1% US, 9.4% Indiana), Asian (5.1% US, 1.8% Indiana), and Hispanic populations (16.9% US, 6.3% Indiana) according to 2012 Census data.16 Future studies including data from multiple times of the year and from multiple states will be needed to see if these results can be generalized. In addition, no ethnicity data could be accessed on the electronic database, leaving out a potentially important variable, Hispanic or Latino ethnicity. The initial data from this preliminary study suggest that interventions to decrease no-show rates should target Medicaid patients, patients who live closest and farthest from the hospital, and lag time from scheduling to appointment. In the past few months, our division has addressed that third issue for new patients, hiring 2 new neurologists and redesigning the scheduling protocol. This has resulted in a decrease of wait time for new appointments from 2 months to 2 weeks. Initial data suggest that the no-show rates have decreased, but it will take another few months of data to determine if the shorter wait time for new appointments can be maintained, and if the decrease in no-show rates for new patients is permanent. Our division is discussing initiating additional email or text reminders to try to decrease no-show rates for both new and follow-up patients, but there are many details to work out because of patient privacy laws. Also, this would not reach the Medicaid patients who do not have text-capable phones or regular Internet access. Reminder postcards or letters are not used because our Medicaid patients tend to move frequently. In an era of increasing healthcare demand and costs, decreasing the rate of missed appointments could be a key component of improving access to neurology care without significantly increasing costs. Further work is needed to clarify the reasons for missed appointments in our clinic and other neurology clinics so interventions can be designed to decrease missed appointments and optimize patient access to neurologic care. Acknowledgments The authors would like to thank Anne Spicer, RN, BSN, and the Pediatric Neurology clinic staff for advice and technical assistance. Anne is the Ambulatory Nurse Manager for the Pediatric Neurology Clinic at Indiana University Health Riley Outpatient Center.
Author Contributions LMG and WFF drafted the manuscript and analyzed and interpreted the data. LMG designed and completed the study and collected the data. MRG, who was the senior author and supervising mentor, designed and conceived the study and revised the manuscript.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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Ethical Approval This study was approved by the Indiana University Institutional Review Board.
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