Why Patients Miss Scheduled Outpatient Appointments at Urban Academic Residency Clinics: A Qualitative Evaluation

Abstract

Introduction

Missed outpatient appointments are a common problem for academic residency clinics, and reducing their rate improves office efficiency, income, and resident education. Identifying specific reasons why some patients miss outpatient appointments may provide insight into developing targeted approaches to reducing their rates. This study sought to find reasons associated with patients’ missed appointments at two family medicine residency clinics.

Methods

The study utilized a qualitative research design involving patients at two urban, university-affiliated family medicine residency outpatient clinics. Twenty-five randomly selected patients who were dismissed from the clinics for missing three or more scheduled appointments during a five-year span (July 2012 to July 2017) were interviewed over the phone about reasons they did not keep their scheduled clinic appointments. The authors, individually and as a group, used an immersion-crystalization approach to analyze the content of the interviews.

Results

Responses from 25 participants (21 females and four males) are presented. Fifty-two percent of patients were Caucasian, 32% Black, 12% Hispanic, and 4% Asian. Five themes emerged from the data analysis as major reasons the patients missed their scheduled outpatient appointments: forgetfulness, transportation issues, personal health issues, family and employer obligations, and other issues, such as anticipated long clinic wait times, bad weather, and financial problems.

Conclusions

The findings showed there are several logistical, situational, and clinical reasons for patients’ missed scheduled outpatient appointments.

INTRODUCTION

Patients who miss scheduled appointments, commonly called “no-shows,” are a problem for most clinics, and reducing their rate not only increases efficiency and workflow,1 but also revenue.2 Other benefits of reduced no-show rates include improved patient-provider relationships and improved quality of care.2,3 Over the last seven years, reasons that patients miss their scheduled appointments have been examined in an outpatient pediatric neurology clinic,2 urban pediatric medical center,4 outpatient psychiatry clinic in a primary care safety-net hospital,5 community health center serving patients who were predominantly from a Latino, immigrant, low-income population,6 and a substance abuse outpatient clinic.7 The aforementioned studies have shown varied reasons patients miss appointments.

There is a paucity of studies assessing the reasons patients miss their scheduled outpatient appointments at urban academic family medicine residency clinics. To our knowledge, no study had examined reasons patients miss outpatient appointments in academic family medicine residency programs. Lacy and colleagues8 examined the reasons patients missed outpatient appointments in academic faculty practice. The study documented interconnected themes for missed outpatient appointments, including: emotional reasons, such as fear of enduring an uncomfortable procedure or fear of the unknown, perceived disrespect of the patient’s beliefs and time by the health care system, and not understanding the scheduling system.

Our study sought to find the reasons patients at two family medicine residency clinics missed their scheduled appointments. The Via Christi Hospital operates two outpatient sites which serve as the continuity clinics for 54 residents and 24 faculty (22 family physicians and two pediatricians). These clinics have been serving culturally diverse low-income patients since the early 1970s. Over the years, these clinics have struggled with high no-show rates even though each patient receives an automated phone appointment reminder 48 hours prior to the scheduled appointment. For the last three years, the no-show rates of the clinics have ranged from 17.1% to 19.3%, which is consistent with other studies of family medicine residency programs.9,10 The mission of residency clinics is to provide education as well as patient care, and high no-show rates could impact resident education and learning negatively.10–13 Missed outpatient clinic appointments are missed opportunities for residents to see the outcome of their treatment plans.10 A high frequency of missed appointments disrupts the flow of revenue, decreases quality of care, and hinders patient-physician relationship building, and could lead to unsatisfactory patient care.2,3

Identifying specific reasons for patients’ missed outpatient clinic appointments may provide insight into how to reduce no-show rates, and reduced no-show rates may improve resident education and patient care. The purpose of this study was to elicit the reasons patients miss appointments at two family medicine residency clinics.

METHODS

The Ascension Via Christi and the University of Kansas School of Medicine-Wichita Institutional Review Boards approved the study. All data collected in conjunction with the study were de-identified.

Study Design and Setting

This study utilized a qualitative research design to study patients who missed three or more scheduled clinic appointments at two urban, university-affiliated family medicine residency clinics. The qualitative approach allowed an in-depth understanding of the patients’ perspective into why they missed their scheduled appointments.

Procedure

Adult English-speaking patients (excluding those who had a legally authorized representative) who were dismissed from two family medicine residency clinics during a five-year span (July 2012 to July 2017) for missing three or more of their scheduled clinic appointments were studied. A list consisting of 164 patients who met the aforementioned inclusion criteria was compiled and randomized. We systematically called the patients on the list. Patients who did not have a working phone number or declined to participate were excluded and the next patient on the list was called. Sixteen patients did not have working phone numbers and 13 declined to participate. Upon receiving verbal consent to participate, patients were asked a series of open-ended questions that were adapted from a study by Lacy and colleagues8 (Appendix A). The respondents were asked about reasons they missed their scheduled outpatient appointments. After 25 patients were interviewed, saturation of the question responses was reached and the interviews were terminated.

Data Analysis

The study authors, individually and as a group, examined the content of the interviews using an immersion-crystallization approach.14–16 Immersion-crystallization is a process where researchers examine collected data in detail and periodically suspend the immersion process to reflect on emerging findings until consistent themes are identified.15–16

RESULTS

Data from 25 participants (21 females and four males) were included in the study. Fifty-two percent of the participants were Caucasian, 32% Black, 12% Hispanic, and 4% Asian. Five themes emerged from the data analysis as major reasons the patients missed scheduled appointments: forgetfulness, transportation issues, personal health issues, family and employer obligations, and other issues, such as anticipated long clinic wait times, bad weather, and financial problems. The identified reasons were based on the patients’ responses. Some patients had more than one reason for missed appointments.

Forgetfulness

Many of the responses demonstrated that patients often forgot about their appointments. Patient A stated, “[I] had a lot going on and forgot.” Patient B offered more detail when she said: “sometimes the people that live in my home just forget, you get busy with life (children and other appointments) and you just end up not making it. There’s a lot of information being thrown out at us every single day and we just forget.”

Transportation Issues

Unreliable transportation was another reason patients missed their scheduled appointments. Many of the patients do not own a vehicle and have to depend on family members and/or friends to take them to and from their clinic appointments. If these “good Samaritans” fail to take them, the patients miss the appointment. Patient C explained, “I did not show for my appointment because [I have] no car, no transportation, or transportation doesn’t follow through.” Patient D explained her reason for missing her appointment: “[I] had an appointment, set up a ride with a transportation company from the insurance company and they showed up an hour late.” Others have to depend on public transportation, which is often inflexible or runs on a different time schedule than the appointment time. When asked why she missed a scheduled clinic appointment, Patient E stated, “I have to use the city bus to get to my appointment which made me late and [the] people refuse[d] to see me because I was late.”

Personal Health Issues

Personal health issues were one of the reasons for missing an appointment. A good number of the responses explained that due to worsened clinical symptoms, some patients lacked the physical strength to make their scheduled appointments. Patient F stated, “[I have] a lot of health issues that keep me up at night, so I have been up all night.” Patient G said, “I injured my leg and it was hard to walk on, so I did not want to leave the house.”

Family and Employer Obligations

Work, family and other commitments often take precedence over personal health, especially when it comes to outpatient care. Some patients perceived these competing priorities as more important than keeping their scheduled appointments. Several of the respondents indicated that they missed the appointments because of work, family, and other obligations. Patient H’s statement typified family obligations as a reason for no-show: “One time I was unable to go to my appointment because my mother was rushed to the hospital in an ambulance and I had to be with her.” Some patients are employed on a temporary or seasonal basis and would rather go to work than keep their scheduled appointments. Impromptu work assignments are a reason for missed clinic appointments. Thus, work often takes precedence over keeping the appointments. For example, Patient I stated: “I couldn’t go to my clinic appointment because I had to work instead.”

Other Reasons

Some of the patients shared that they did not keep their clinic appointments because of long wait times in the waiting and consultation rooms. This concern was shared by Patient J, who stated: “I don’t show up for my appointment because I don’t want to sit in the waiting room, waiting for more than 30 minutes or within the clinic room itself.” Other patients shared that financial problems (e.g., inability to afford the co-pay) were a reason. Patient K explained that, “My insurance ran out and I didn’t have money for the visit.” Others attributed their missed appointments to unpredictable weather changes. When asked about some of the difficulties in keeping scheduled outpatient appointments, Patient L indicated, “winter weather, not able to drive on snow.”

DISCUSSION

This study was unique for two reasons. First, it studied patients dismissed from practice for multiple missed appointments. Second, it examined reasons patients missed their appointments at two family medicine residency clinics. The findings of this study provided some of the reasons patients miss their scheduled outpatient clinic appointments. Patients may miss an appointment for more than one reason.

Patients who missed scheduled outpatient appointments most commonly reported forgetfulness, lack of reliable transportation, and personal health issues, as well as work and family obligations as major reasons for missing scheduled outpatient appointments. These reasons are similar to those reported in studies conducted at a community health center serving a predominantly Latino, immigrant, low-income population,5 urban pediatric medical center,4 and urban, university-affiliated family practice clinic. Our study’s findings of logistical and situational reasons for missed appointments, such as unreliable transportation and family and work obligations were consistent with findings from Lacy et al.8

These findings may offer insights into developing ways to reduce no-show rates. Our data captured forgetfulness as a reason for missed outpatient appointments. This might be addressed by using electronic forms of appointment reminders, such as text messaging, phone calls, or emails. During the initial appointment check-in, patients should be asked about their preferred method of contact. A reminder message to the patient should be sent one to three days prior to the appointment. Prior studies have reported success with these forms of reminders.17–20 Another way potentially to decrease the no-show rate is to educate patients on how to cancel an appointment if they know that they cannot make it. Simplified means of canceling appointments could be explored, such as sending a text message to cancel.

Many patients who utilize academic residency clinics are low-income and recipients of Medicaid who lack the disposable income necessary to maintain a working motor vehicle, or may lack access to public transportation that could take them to and from their clinic appointments. An area of opportunity is to provide Medicaid beneficiary patients with affordable access to reliable non-emergency medical transportation such as taxis, vans, and public transit. Another area of opportunity is to petition the city government and public transportation companies to locate public transportation routes and stops in proximity to the clinics that serve these patients. The managers at these clinics could work with patients by trying to schedule appointments to coincide with public transportation run times. Additionally, options for home visits or teleconferencing could be a solution to missed appointments due to transportation difficulties.

Consistent with findings of prior studies,6,21 our study found competing interests, such as family and employer obligations, as reasons for missed clinic appointments. Patients may have part-time or seasonal jobs that do not qualify for benefits, such as paid time-off. Our data underscored the influence of family obligations (e.g., caring for children, siblings, and parents) in keeping outpatient appointments. Home visits or teleconferencing with patients who have obligations that prevent them from keeping their appointment could be an alternative.

A paradoxical reason for no-shows among the study sample was poor personal health. Our results showed worsened clinical symptoms were reasons for missed outpatient appointments. This finding is different from Lacy et al.8 where improved clinical symptoms were reasons for missed appointments. Better communication, home visits, nurse home calls, or teleconferencing could provide an alternative for these patients.

The amount of time patients wait in the lobby and consultation rooms before they are seen by the physician contribute to missed outpatient appointments. This finding is consistent with the result of a study that found anticipated long wait times as a major reason for missed appointments.8 Rodríguez-García and colleagues22 showed that long waiting times negatively impact patients’ appointment-keeping behaviors. An opportunity to address the long waiting time could be through the use of wave or modified wave appointment scheduling where patients are double booked at the beginning of each hour, leaving the end of the hour open to allow the physician to catch up should there be the need. This approach could reduce the long waiting time and meet patients’ needs efficiently.

This study has limitations. First, the study was completed at two family medicine residency clinics and the findings may not be applicable to other specialties or programs. Second, some patients did not have working phones, so we were unable to contact them for the study. Third, most of the participants were females and men might have different reasons for not keeping outpatient appointments. Fourth, the sample profile did not allow comparison of reasons by age or ethnic group. Prior no-show studies have found that younger adults are more likely to miss their appointments.23,24

In conclusion, the qualitative approach of this study allowed an understanding of the patients’ perspective into why scheduled clinic appointments most commonly are missed. The findings showed there are several logistical, situational, and clinical reasons for patients’ missed scheduled outpatient appointments. Identifying the reasons why patients missed outpatient appointments could help clinic administrators and physicians develop targeted approaches to reduce the no-show rates.

Appendix A.