No-shows in ambulatory clinics and non-utilized appointments for elective operations in selected surgical departments at a tertiary hospital in Israel

An event during which a patient does not arrive for a scheduled appointment is defined as a “no-show”. This phenomenon is common in primary and secondary care [1] and can be seen in a variety of population groups [2]. No-show events have been shown to be associated with poor results in the treatment of both sporadic medical appointments, and in cases of chronic disease management [3].

It is estimated that between 10 and 30% of scheduled hospital medical ambulatory appointments end-up as no-show events [4], and this rate could even reach 50% in primary care [5]. It appears that only a small percentage of patients (between 10 and 20%) is responsible for a significant proportion of the no-show events - approximately 30 to 40% of them [2].

No-show events can compromise patient health; for example, they can be a missed opportunity for medical diagnosis [3]. A high incidence of no-show events reduces the availability of appointments and increases the waiting time for appointments [2]. Consequently, many other patients who are waiting for an appointment may become displeased and in some cases the quality of their care could be adversely affected.

No-shows can also be costly. In a nationwide study in Britain, the cost of no-show events during 2004 was estimated at £790 million [6], which constitutes 1% of national health expenditures in the UK in that year [7].

In contrast, non-utilized appointments are a broader phenomenon than “no shows”. They include all appointments that did not occur as registered, whether due to patient or provider actions. They include both no-show events and other events in which planned appointments did not take place and resources were left un-utilized. The latter included cases in which the hospital re-assigned the operating room slot to another surgeon, the patient was not fit to undergo surgery after all, or the surgery schedule was too busy for the elective surgery to take place.

The study team sought to assess and characterize the no-show events in ambulatory clinics and the non-utilized appointments for elective operations in a public hospital in Israel.

The study was carried out between August 2016 and January 2017 in the ENT, Orthopedics and General Surgery Departments of the Jerusalem-based Shaare Zedek Medical Center (SZMC). These high-volume departments receive approximately 358,000 outpatient visits annually and operate on roughly 10,000 patients annually. The study team examined no-shows in the outpatient clinics and non-utilized appointments in the operating theater.

The first phase was conducted in the orthopedics and ENT services, both operating room and ambulatory care. The second phase included ambulatory care only in general surgery, ENT and orthopedics services.

The study was conducted using the hospital’s database in order to retrieve information regarding all visits and operations that were scheduled to occur in the six months between August 2016 and January 2017. The events categorized as no-shows were those outpatient appointments to which patients did not arrive as scheduled, leaving the appointment slot empty at the hospital’s outpatient clinics. The events categorized as non-utilized involved patients who were registered in the surgery schedule on a particular morning, but whose procedures did not take place on that particular day.

In the operating rooms, the documentation of the causes of non-utilized appointments cases was recorded at the end of each workday by staff. The study team collected these reports for analysis.

For missed ambulatory care visits, we contacted no-show patients chronologically and sequentially until 50 patients replied (25 in each clinic) by telephone. Responders were first asked their reason for not arriving at their scheduled appointments and they were then asked additional questions relating to their medical concerns, method of arrival, reminder status and level of satisfaction with the service (Appendix).

In the second phase, we reviewed a complete working week in Orthopedics, ENT and General Surgery ambulatory clinics, to asses all missed scheduled appointments and determined the type of no-show appointments according to the summary of each patients’ medical file.

It’s important to note, that there is no overbooking policy at the hospital’s ambulatory care clinics.

Our study results indicated that in SZMC, the extent of non-utilized appointments is lower than reported in the literature on operating rooms (6%).

The rate of no-show phenomenon in the clinics is similar to that reported in the literature (15 to 19%) [8, 9].

Some interviewed patients revealed that the process of cancelling an appointment by the patient was difficult and sometimes generated a no-show case because the patient couldn’t reach an operator to cancel the scheduled appointment successfully. In addition, an important finding in our study was that there were several patients who arrived at their scheduled appointments and the appointment took place, but due to a system registration error, it was registered as a no-show case.

Interestingly, the results of the telephone questionnaire show that most of the patients who did not arrive at the clinic were satisfied with the service they received at the SZMC and would recommend this hospital to a friend/relative. This suggests that the majority of no-show events were not due to dissatisfaction.

We did not measure unused OR (operating room) time during workdays and cannot report whether non-utilization resulted in reduced efficiency of the OR. There are no available comparative data from other medical centers in Israel from which we can learn whether the surgery cancellation rates reflect hospital efficiency or lack of efficiency. Focused assessment and methodology are required in order to develop strategies to cope with surgery cancellation.

We note that the reason for approximately 30% of all cancelled surgeries was unknown. This indicates that there is a weakness in the documentation process and this limits the ability of the hospital to cope with the phenomena. As mentioned previously, ambulatory clinic records are also not always correct. Improving the documentation process, as well as training the staff to record the reason for the cancellation of an operation, are important elements for optimal management.

The outpatient clinics’ no-show rates are in the lower range of what has been published in the literature (10–30% [4]). Still, in terms of financial cost and exploitation of resources, they nonetheless translate into an immense amount of waste. A Canadian study estimated that the average cost per missed visit to the hospital was $95 and that the total cost to the economy was estimated at $211 per missed visit [10]. Assessing the economic efficiency of a medical service requires additional data regarding throughput – we can have few scheduled appointments with low cancellation rates or many scheduled appointments with higher cancelation rates, but with an overall provision of more medical care to more patients per day.

The search for a solution to reduce no-show rates requires us to face the particular reasons for which the patients did not arrive. Facing forgetfulness by patient-reminders through various forms (post, telephone, text messages, or e-mail) for a scheduled appointment have proven to significantly lower the frequency of no-show cases. However, it has not been established which type of reminder is the most effective [11]. A positive outcome of appointment reminders is an increase in the rate of initiated cancellations by patients who did not intend to arrive at the appointment [12]. This would be particularly relevant at SZMC since in the telephone questionnaire we conducted, patients noted that they tried to cancel the appointment and couldn’t reach the calling center.

A widespread method of dealing with the no-show phenomenon is deliberately overbooking appointments [13]. Overbooking can significantly increase clinic service volume by increasing the availability for patients and the overall productivity of the clinic, which leads to a reduction in costs and improved patient satisfaction. In contrast, overbooking can prolong queues in clinics and increase patient dissatisfaction prior to the appointment in hand. As mentioned before, SZMC does not currently have an overbooking policy.

Another method of coping with the no-show phenomenon is the use of probability models that consider a patient’s personal data, such as social characteristics, gender, previous no-show cases, in order to predict the likelihood of future no-show cases [13, 14]. Coupling this with reminders to these “high-risk” might prove useful.

One can suggest lowering the no-show rates by introducing fines or penalties when receiving treatment after not arriving for the scheduled appointment, for example transferring the patient to the end of the queue. There is limited empiric literature on no-show penalties, various ethical dilemmas, and unclear profit and productivity consequences [15]. Additionally, penalties are illegal in Israel because they lead to inequality in healthcare provision [16].

The computer information systems and staff documentation in SZMC should be improved. With valid data, the system could locate patients with higher risk factors for no-show cases, particularly those who have already had a no-show case in the past, as described by others [2]. This will also help lower false no-show/non-utilized appointments (appointments that were registered as no-shows but which actually took place).

An important finding in our research is that many of the appointments that did not take place were post-operative follow-up appointments (32% of all causes for no-show cases and 44% of known causes). Perhaps there is a need for a closer consideration of the importance of these appointments, particularly beyond the first post-operative follow-up. In many cases, the post-surgery follow-up appointments are crucial for monitoring clinical improvements, including wound healing, rehabilitation, and so on. However, in some cases, surgery is the definitive solution to the problem and therefore patients who no longer suffer from the original problem do not feel the need to attend the scheduled post-surgery appointment, particularly when the appointment was scheduled a long time in advance. By judiciously removing unnecessary appointments from the appointment schedule, it should be possible to significantly shorten waiting periods for patients and leave regular intervals for receiving patients after surgery who need medical treatment. We suggest that beyond the first post-operation visit – surgeons need to provide the rationale for additional visits – this would limit the frequency of appointments which are automatically proposed without attention to their necessity. However, we do not have the overall rate of such appointments in the surgical clinics, and our conclusion should be considered with that limitation in mind. Modern telemedicine tools can present alternative strategies for post-operative surveillance [10].

In our exploratory research, we demonstrated that the rates of operation non-utilization in ENT and Orthopedics departments in SZMC were lower than those documented in the literature, and the rates of no-show events at the ambulatory clinics are similar to rates in the lower range of rates reported in the literature.

In order to reduce no-show rates, we suggest careful consideration of the necessity of post-operative appointments, since these appointments are common among no-show events and possess the lowest risk for clinical damage.

The findings presented can help identify appointments with a higher probability of no-show, and can aid appointment management, reducing the allocation of resources to appointments with a high probability of low utility, improve the quality and performance at hospitals, and, more importantly, improve the provision of medical services and the health of our patients.