Recent research suggests many missed appointments aren't due to flaky patients but to scheduling errors or a doctor's failure to consider transportation and other logistical challenges for the most at-risk patients. These findings are leading some practices to rethink the way they handle referrals from low-tech methods such as reminder calls to utilizing the latest health-information technology.
Of those, 70 percent were actually seen at the specialist's office, meaning that just 50 percent received the treatment that their primary-care doctor intended them to have, according to the study, published in the February 2010 issue of the Journal of Evaluation in Clinical Practice.
Because of the high percentage, researchers called missed specialist referrals the most frequent error in medicine. The adverse consequences can be significant, whether resulting in a worsened medical condition or higher costs, said Michael Weiner, associate professor of medicine at Indiana University and director of the Regenstrief Institute's Health Services Research Program.
"The most obvious one is the immediate care that would be provided is delayed," he said. "Rescheduling could take several months if it's a busy clinic or specialist."
Some unscheduled appointments and no-shows could be attributed to patient forgetfulness or anxiety about disability, transportation or the time and effort it would take to attend an appointment, issues which might apply disproportionately to seniors, he added.
But just as important was lack of a system to track whether specialist appointments were made and to avoid breaks in communication between the primary-care physician and specialist offices, Weiner said. The chain can break down because of such mundane things as the specialist never receiving the referral because a fax machine ran out of paper.
Now a new computer-based scheduling system generates automated reminders to primary-care physicians if specialist scheduling doesn't happen in a timely manner. The tool also facilitates communication between the two to ensure the specialist understands the reason for referral and the primary-care doctor receives a report on the results.
Since instituting the system, the clinic has reduced its lack of completion rate to less than 20 percent.
The problem of missed appointments is hardly limited to seniors. The Sibley Heart Center at Children's Healthcare of Atlanta, which handles 30,000 outpatient appointments at 18 facilities annually, rolled out a new initiative two months ago to reduce a 16.7 percent same-day cancellation and no-show rate.
The types of patients who were least likely to show often came from low-income families either on government coverage such as Medicaid or who were uninsured and self-pay, said Dr. Patrick Frias, a pediatric cardiologist and director of outpatient operations at the center.
"We hear it all," he said. "'We couldn't find the place. The directions were bad.' Some people didn't have a ride and didn't realize that Medicaid rides are available. Other patients say they forgot or they didn't like the parking."
Every patient's family routinely receives an automated reminder call 48 hours before the appointment. But for the five historically worst clinics for attendance, staff members now make a personal call five to seven days in advance to families from the two main no-show categories and anyone else who has missed an appointment previously, Frias said. The caller not only provides a reminder but also checks to see if directions are needed and the child has a ride, he added.
The program is in too early a stage for any comprehensive data to be available, but no-shows appear to be declining, he added.
Medicaid patients were most likely also not to show up at an outpatient psychiatry clinic that reported a 19 percent to 22 percent no-show rate among 11,000 scheduled appointments in a 2009 University of Missouri study. Logistical issues, such as when the appointment was scheduled, were also significant predictors.
Medicaid patients never showed up for an appointment after 3 p.m. when local public transportation stopped for the day, and patients coming from a long distance rarely arrived for early morning appointments.
Schedulers with the least no-shows directly asked patients: "When would you like to come in?"