Who Misses Appointments? An Empirical Analysis* BARRY CAMPBELL, M.D. I, DOUGLAS STALEY, M.A. 2 AND MANUEL MATAS, M.D.]
patient noncompliance is a major problem in clinical practice. In order to better understand this issue, 236 appointments at an outpatient psychiatry clinic of a large urban general hospital were examined. Five variables significantly discriminated patients who kept their appointments from patients who did not. Patients who were younger; had a history of missed appointments, were scheduled to see a resident physician, had a routine appointment and lived a distance from the hospital, were at greater risk of missing their appointment. This information helps to identify patients at high risk of nonattendance and allows clinicians to plan schedules and appointments more efficiently.
P
atient' s adherence totreatment is often a neglected aspect of clinical practice. There is much more emphasis placed on diagnostic accuracy and choice of appropriate therapy. The result of ignoring this third factor in patient care lessens the likelihood of successful therapy, given that a significant number of patients are noncompliant ( I-I 0). An important form of noncompliance is missed patient appointments. The cost of this occurrence is far reaching, affecting patient, physician and society. In a 1983 study by Pekarik (II) it was shown that treatment dropouts had a worse outcome than those who completed treatment. Other ripple effects of a patient's nonattendance include unnecessarily long waiting lists, the wasting of professional resources, decreased exposure of trainees to patients, missing data in research studies and financial loss to the physician (1-4). With most studies reporting miss rates between ten percent and 30%, these costs, although often unseen, can be significant. Several investigations have attempts to identify characteristics of patients who do not attend (1-5). The research suggests that patients who miss appointments tend to be young, of low socioeconomic status, have a low level of education, have a history of missed appointments and have a poor relationship with their physician. Also associated with
*Manuscript received November 1986; revised May 1990. I Assistant Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba. 2 Research Associate, Department of Psychiatry, St. Boniface General Hospital, Winnipeg, Manitoba. ] Associate Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba. Address reprint requests to: Barry Campbell, M.D., Department of Psychiatry, St. Boniface General Hospital, MS - 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6 Can. J, Psychiatry Vol. 36, April 1991
missed appointments are routine rather than urgent appointments, referrals from emergency rooms, and a long periods between initial contact and actual appointment (7,12,13). Some researchers (4,5) have found that simply having a psychiatric or psychosocial diagnosis places a patient at higher risk of nonattendance. Although several variables predictive of noncompliance have been identified for general medical patients, there is little research on specific variables related to missed appointments by psychiatric patients. This study was designed to address this issue and provide an empirical basis for specific interventions aimed at improving overall attendance rates in psychiatric patient populations. Method Data forms were sent to all physicians (II staff psychiatrists and five residents in psychiatry) working in the outpatient psychiatry department of St. Boniface General Hospital in Winnipeg. Physicians were instructed to record, for 25 consecutive appointments, the following 15 variables: age, education, employment, postal code, time of day, clinician, referral source, diagnosis on Axis lor II and V, time since last appointment, number of previous appointments, history of missed appointments, urgency of the appointment, kept or missed appointments and amount of notice given of missing. The physician-rated urgency of the appointment was scored on a 6 point scale with higher scores reflecting more routine appointments. History of missed appointments was defined as having missed one or more appointments in the past. The patient's proximity to hospital was determined from the postal code of the residence. In addition to the 15 recorded variables, physicians were also asked to note the reasons they felt were responsible for a patient missing an appointment. All subjects were outpatients at the time of their scheduled visit and were being seen for both initial and subsequent appointments. Only the first visit of a patient during the time period of the study was included in the data. All variables were converted to numerical values and analyzed by discriminant function analysis. The discriminant analysis procedure classified subjects into two groups (kept or missed) and computed univariate F-ratios for each measure to determine which variables significantly discriminated between patients who kept or did not keep appointments. Results Responses were received from ten physicians working in the outpatient psychiatry clinic, a response rate of 63%. This 223
224
provided 236 appointments for statistical analysis (two physicians completed data for less than 25 appointments). The overall rate of missed appointments was 19.5% (46 out of 236) for the psychiatric patients. The results of the discriminant function analysis indicated that five variables (age, history of missed appointments, physician-rated urgency of the appointment, proximity to hospital, type of clinician) significantly discriminated between patients who kept and those who missed their appointment. Patients who missed their appointment were younger (mean age 32.3 years) than patients who kept their appointment (mean age 41.5 years), a difference which was statistically significant (F( I,234) =7.53, P
patient noncompliance is a major problem in clinical practice. In order to better understand this issue, 236 appointments at an outpatient psychiatry clinic of a large urban general hospital were examined. Five variables significantly discriminated patients who kept their appointments from patients who did not. Patients who were younger; had a history of missed appointments, were scheduled to see a resident physician, had a routine appointment and lived a distance from the hospital, were at greater risk of missing their appointment. This information helps to identify patients at high risk of nonattendance and allows clinicians to plan schedules and appointments more efficiently.
P
atient' s adherence totreatment is often a neglected aspect of clinical practice. There is much more emphasis placed on diagnostic accuracy and choice of appropriate therapy. The result of ignoring this third factor in patient care lessens the likelihood of successful therapy, given that a significant number of patients are noncompliant ( I-I 0). An important form of noncompliance is missed patient appointments. The cost of this occurrence is far reaching, affecting patient, physician and society. In a 1983 study by Pekarik (II) it was shown that treatment dropouts had a worse outcome than those who completed treatment. Other ripple effects of a patient's nonattendance include unnecessarily long waiting lists, the wasting of professional resources, decreased exposure of trainees to patients, missing data in research studies and financial loss to the physician (1-4). With most studies reporting miss rates between ten percent and 30%, these costs, although often unseen, can be significant. Several investigations have attempts to identify characteristics of patients who do not attend (1-5). The research suggests that patients who miss appointments tend to be young, of low socioeconomic status, have a low level of education, have a history of missed appointments and have a poor relationship with their physician. Also associated with
*Manuscript received November 1986; revised May 1990. I Assistant Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba. 2 Research Associate, Department of Psychiatry, St. Boniface General Hospital, Winnipeg, Manitoba. ] Associate Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba. Address reprint requests to: Barry Campbell, M.D., Department of Psychiatry, St. Boniface General Hospital, MS - 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6 Can. J, Psychiatry Vol. 36, April 1991
missed appointments are routine rather than urgent appointments, referrals from emergency rooms, and a long periods between initial contact and actual appointment (7,12,13). Some researchers (4,5) have found that simply having a psychiatric or psychosocial diagnosis places a patient at higher risk of nonattendance. Although several variables predictive of noncompliance have been identified for general medical patients, there is little research on specific variables related to missed appointments by psychiatric patients. This study was designed to address this issue and provide an empirical basis for specific interventions aimed at improving overall attendance rates in psychiatric patient populations. Method Data forms were sent to all physicians (II staff psychiatrists and five residents in psychiatry) working in the outpatient psychiatry department of St. Boniface General Hospital in Winnipeg. Physicians were instructed to record, for 25 consecutive appointments, the following 15 variables: age, education, employment, postal code, time of day, clinician, referral source, diagnosis on Axis lor II and V, time since last appointment, number of previous appointments, history of missed appointments, urgency of the appointment, kept or missed appointments and amount of notice given of missing. The physician-rated urgency of the appointment was scored on a 6 point scale with higher scores reflecting more routine appointments. History of missed appointments was defined as having missed one or more appointments in the past. The patient's proximity to hospital was determined from the postal code of the residence. In addition to the 15 recorded variables, physicians were also asked to note the reasons they felt were responsible for a patient missing an appointment. All subjects were outpatients at the time of their scheduled visit and were being seen for both initial and subsequent appointments. Only the first visit of a patient during the time period of the study was included in the data. All variables were converted to numerical values and analyzed by discriminant function analysis. The discriminant analysis procedure classified subjects into two groups (kept or missed) and computed univariate F-ratios for each measure to determine which variables significantly discriminated between patients who kept or did not keep appointments. Results Responses were received from ten physicians working in the outpatient psychiatry clinic, a response rate of 63%. This 223
224
provided 236 appointments for statistical analysis (two physicians completed data for less than 25 appointments). The overall rate of missed appointments was 19.5% (46 out of 236) for the psychiatric patients. The results of the discriminant function analysis indicated that five variables (age, history of missed appointments, physician-rated urgency of the appointment, proximity to hospital, type of clinician) significantly discriminated between patients who kept and those who missed their appointment. Patients who missed their appointment were younger (mean age 32.3 years) than patients who kept their appointment (mean age 41.5 years), a difference which was statistically significant (F( I,234) =7.53, P
