Abstract
Healthcare providers and organizations are impacted by the challenge of patients missing scheduled medical appointments.However, past studies have shown that appointment no-shows are a persistent problem in the healthcare systems. This problem has many negative outcomes on healthcare practice both socially and economically. Therefore, the purpose of this paper was to investigate the effectiveness of utilizing appointment remainder systems to reduce no-show rates.There are several reminder methods that organizations can use to notify patients of their upcoming appointment, which include email, text messaging, and phone calls.An analysis of various studies reveals that these systems help in reduce no-show rates. The preferred reminder systems were automatic reminders such as text messages and e-mails. Data from Arkansas Children’s Hospital indicates positive outcomes of the appointment reminder system on no-show rates. However, research has also demonstrated the role of the systems in promoting cancellations and rescheduling of appointments.
Keywords: appointment reminder systems, no-show rates, appointment rescheduling, appointment cancellations, text message reminders, phone call reminders, email reminders.
Acknowledgements
I would like to thank God for all of the opportunities that he has provided throughout my life. I would like to thank and express my sincerest gratitude to my number one supporter, my husband. He has encouraged and supported me throughout this entire journey. I also would like to thank my peers for all of their help. A special thank you to the instructors that are dedicated to the success of the students in the Masters of Healthcare Administration. I am forever grateful for all of you and your significance in completing this program and further advancing my knowledge.
The Effectiveness of Appointment Reminder Systems in Reducing No-Show Rates
Introduction
Failure to attend healthcare appointments can aggravate health conditions, result in treatment failure and may even end in fatality, outcomes which impose undue costs on the families and friends of the sick as well as on the society as a whole. Understanding the reasons for healthcare appointment no-show can help in establishing effective processes for communicating patient appointments as well as for managing those appointments.
Definition of Terms
Appointment reminder system – Forms of technology through which patients are reminded of their healthcare service provider appointments in a timely manner to enable them show up for those appointments.
No-show – A situation in which a patient fails to turn up for an appointment without prior cancellation, resulting in time wastage for the medical practice,
Appointment scheduling – planning with a doctor or other medical practitioner to attend check-up sessions on a particular date and time in a scheduled facility based on past diagnosis or feelings of sickness.
Appointment cancellation – This is where a patient and/ or medical practitioner call off a planned meeting.
Background
Failure of scheduled patients to honor their appointments can cause an interruption in the healthcare delivery process. If schedulers are unable to fill the slotted time for no-show patients, losses incurred can be enormous, ranging from financial, time and even social implications. Accordingly, when they are able to fill the slots with other patients, inefficiencies arise from the additional work that they have to engage in. The no-shows cost healthcare facilities a revenue opportunity, hence measures must be put in place by the affected healthcare facilities to ensure that losses resulting from no-shows are limited. To realize process efficiency, optimum utilization of resources such as time has to be implemented. In an attempt to reduce no-show activities, healthcare facilities often implement various measures such as providing patient pre-exam notification or ensuring that patients are overbooked. These measures help by reminding patients of their appointments or slotting the overbooked patients into the no-show durations. The pre-exam notification also increases the probability that patients will attend their scheduled sessions. Such measures can control patient no-show consequences yet they do not increase efficiencies of the overall patient flow. The measures can even be considered to create non-value-added quality checking steps into the process of patient care. While doing this, the measures raise issues with patient flow bottlenecks without clearly identifying the causes of the no-show activity. Finding a strategy that would promote patient care, while at the same time improving the no-show rates, can help in achieving better healthcare outcomes.
Organization Review
The organizations that will beutilized for the proposed study include a multi-office orthodontic practice and Arkansas Children’s Hospital. The failure of patients to report for routine or scheduled check-up is prevalent in both adult and pediatric care settings. Arkansas Children’s Hospital provides healthcare services to a variety of patients among populations from different contexts. The hospital works with the objective of improving the overall quality of life for all patients, delivering quality healthcare services and to ensure that each child gets the best possible care. To achieve this objective, the hospital has to find strategies for promoting response to appointments by physicians and other care givers.
The Multi orthodontic practice of choice, Image Orthodontics, on the other hand, is a privately owned facility that provides a wide range of orthodontic services. The facility works with 4 doctors due to the large patient population, and needs to make appointments for most of its patients. As such, the doctors at the facility also complain about missed appointments, most of which they have no prior information about. The practice is in most aspects similar to a hospital based care in that the impacts of no-shows are similar to those in hospitals. The facility loses out on revenue opportunities since they waste time catering to patients who eventually do not appear.
Problem Statement
In healthcare, patients who fail to make their scheduled appointments in outpatient care departments are described as no- show patients. The rates of no-show in the global healthcare context are increasing, making them a cause for alarm. Since the importance of maintaining healthcare related appointments is a global concern, no-show rates in healthcare organizations are gaining interest globally. Missed appointments affect patients, providers, and organizations across the globe and have far-reaching consequences. Additionally, missing healthcare related appointments can have negative impacts in financial as well as social outcomes.
Purpose Statement
The purpose of the proposed study is to develop a valid tool for appointment reminders and the use in healthcare organizations. The proposed paper will provide analysis comparing appointment reminder systems in various healthcare settings to determine their effectiveness on no-show rates. This project will introduce the framework and plan for the evaluation of such systems.
Objectives of the Study
Healthcare organizations should stimulate a culture of promoting continuity of care and the importance of maintaining appointments. The objective of the proposed study is to evaluate the impact of appointment reminder systems in healthcare organizations. Additionally, the study will highlight the significance of reducing missed appointments.
Research Questions
This research project establishes data to answer the following questions: 1). Do appointment reminder systems reduce no-show rates? 2). which methods for receiving appointment reminders are preferred by patients? 3). which factors affect the effectiveness of reminder systems?
Hypotheses
The study hypotheses are that:
- Appointment reminder systems reduce no-show rates.
- Telephone calls are the most preferred method of reminder methods of patients.
Significance of the Study
By reducing the rates of no-show in healthcare settings, it will be possible to improve the health outcomes in outpatient healthcare delivery. The proposed study attempts to determine whether appointment reminder systems reduce no-show rates and which reminder systems patients prefer. One this goal is achieved; patient outcomes can be improved through implementation of the type of reminder systems that are confirmed effective. This implies that the findings of the proposed study can be applied in any given healthcare setting to improve no-show rates and to enhance healthcare outcomes. For the Arkansas Children’s Hospital, the findings will be even more relevant to the actual practices and patient population managed. Additionally, the study will expand the existing literature on appointment reminder systems, by touching on particular aspects such as customer preference among others.
Literature Review
There have been numerous studies that have examined the effectiveness of appointment reminder systems. No-show appointments refer to patient who do not come to their appointment nor cancel their scheduled appointment (Davies et al., 2016).The rate of no-show appointments varies in healthcare organizations and clinical settings. According to research, no-show rates are between 15% and 30%.Mohamed, Mustafa, Tahtamouni, Taha and Hassan (2016) conducted a study to establish the impacts of no-show in the healthcare setting and the related impacts of intervention as strategy for reducing no-show. In their study, the authors used a baseline of 49% no-show, from which they implemented an intervention to encourage more people to honor their healthcare appointments. This is similar to the finding by Davies et al. (2016), which showed that no-show rates can be as high as 50% in rural settings. In their definition, Davies et al. classify all patients who neither cancel nor keep appointments as no-show.
Mohamed et al. (2016) conclude that flexible appointment scheduling and better communication can reduce no-show rates in the general and outpatient healthcare contexts. The average no-show as reported by (Dantas, Fleck, Oliveira & Hamacher, 2018) is of the order of 23%, with higher rates observed in the African countries (over 49%) and lower no-show rates experienced in Oceania (13.2%). This difference across countries can be linked to various differences between the economic, political and social landscapes across the two continents. The report provided by Davies et al. (2016) also matches that given by Dantas et al. In privately funded clinics, the no-show rates are much lower, about 5% of the total patient population.
These findings indicate that text message reminders can be more effective. Patients’ cognitive ability, language, and literacy level are also determinants of the effectiveness of appointment reminder systems. Older patients, immigrants, and inner-city populations can have problems understanding the systems, requiring special help from caregivers or close people (McLean et al., 2016). Other issues that lead to underutilization of these systems include failure to customize the systems to high-risk populations and patients who do not cancel or reschedule appointments.
Causes of No-show among Patients
Various patient characteristics and behaviors impact negatively on the probability of no show. Various factors contribute to patient failure to appear for medical appointments. Several studies have been conducted to help explain the rationale behind no-show. In a study by Dantas et al. (2018), it is shown that factors such as socio-economic backgrounds, distance from healthcare facilities, lack of healthcare insurance, high lead time, previous medical history, and age, all contribute to the propensity for no-show. Davies et al. (2016) explored no-show patterns across the world, with the objective of determining the impacts of factors such as age, appointment age, gender and socio-economic status on the rates of no-show. According to the study, the rates of no-show increase as patient age increases. Older individuals are more prone to no-show relative to those who are younger. Moreover, males are also recorded to be more prone to no-show compared to females.
Boshers (2018), explores the approaches towards reducing no-show among patients. One of the major factors mentioned is the level of poverty among the populations. According to Boshers, low income individuals are most vulnerable to being no-show. This is because they are constrained in terms of expenditure, are more likely to be uninsured. They are also likely to experience worse health outcomes and to lack access to quality healthcare services. Such people are also likely to struggle with societal and physical barriers to healthcare access. With the poverty level at more than 14% of the total population, nearly 32% of the population is at a disadvantage when it comes to finding accessible and affordable healthcare solutions. To address the health disparities across different populations, community health clinics target healthcare service delivery to low-income communities. However, such communities are still at risk of missing their healthcare appointments and/ or not following up on the recommended actions after the scheduled healthcare appointments.
Emotional barriers also hinder access to healthcare and subsequently result in no-show cases. In regards to healthcare service delivery, negative emotions are often associated with doctor visits. According to Boshers (2018), approximately 65% of patients report that there are specific negative emotions associated with a visit to the doctor. In some cases, failure to visit can be attributed to the perception that patients have at a particular time about their health. Patients may book appointments at a time when they feel a sense of urgency in healthcare. However, when the time comes for their appointment, the patients may be feeling better and thus see no urgency in honoring their doctor appointments. On the other hand, patients may also lack an understanding of the scheduling system and thus be unable to tell the impacts of their no-show on other patients and medical practitioners. Most patients also assume that no-shows are beneficial to doctors who need to deal with the issue of overbooking. What patients do not know is that no-shows result in the incurrence of high costs, up to $ 3 million in a year as a result of more than 62 no-shows in a day (Boshers, 2018).
The lead time and no-show history of patients also influences their potential for missing appointments as reported by Dantas et al. (2018). No-show patients are likely to repeat the tendency because of lack of visible impacts on the healthcare providers and the patients. For instance, an individual who fails to appear for an appointment and faces no negative consequences in his health will most likely fail again in the next appointment. Other patients also report other reasons for not keeping appointments as shown in the chart below (Simple Texting, 2019). From the chart, more than 50% of no-show patients miss appointments as they forget to attend or cancel the meeting; around 28% of the no-shows are due to incorrectly noted times while only around 20% are due to other issues. Those who forget and those who note time incorrectly can be assisted by using appointment reminder systems.
Figure 1: Reasons for No-shows in Healthcare (Simply Texting, 2019)
Impacts of No-Show in Healthcare Settings
Patients not showing up for their appointment can disrupt operations, reduced productivity of providers, causes underutilization of staff, and disrupts continuity of care for patients (Nelson, Berg, Bell, Leggott, & Seminario, 2011).This can also lead to decreased patient satisfaction, increased costs of delivery of care, and poor relationships between clinicians and the patient.Dantas et al. (2018) also points out that patient no-show in clinical environments hampers delivery of healthcare by misusing healthcare facility resources, wasting time for physicians and other healthcare practitioners and increasing the waiting time for patients on out-patient treatment services. Although the magnitude of the economic impact of non-attendance varies, the overall financial cost is substantial. Missed appointments can delay presentation at healthcare facilities, which may, in turn, lead to lack of follow-up of severe conditions that may lead to acute complications and costly hospital admissions (Bos, Hoogstraten, & Prahl-Andersen, 2005). Medical employees who face pressure from referring agents to manage waiting lists can cause them anxiety, stress, and fatigue (McLean et al., 2016).
Bashers (2018) also discussed some implications associated with no-show cases both to the patient health and to the healthcare facilities and medical practitioners. Additionally, the economic implications of no-show are mentioned. According to Samuels et al. (2015), no-show results in increased medical service delivery costs, decreased productivity, and wasteful use of healthcare manpower and disruption of patient care among others. Significant costs of medical practice result from non-attendance of scheduled appointments. This is in terms of both financial implications and the lost time. Samuels et al. (2015) also point out that a positive correlation has been observed between the number of emergency room visits and the rate of no-show. Patients who are prone to missing out on their scheduled appointments are more likely to need emergency room care. This is a proof of the negative implications of no-show on patient health.
Appointment Reminder Systems
Due to the undesirable effects of no-shows, it is essential to examine the effectiveness of appointment reminders systems to increase the likelihood of patients keeping their appointment. Various studies have investigated the effectiveness of appointment reminder systems. McLean et al., (2016) found that appointment reminder systems improve attendance in various healthcare settings and different patient populations. Out of 31 randomized controlled trials, only one failed to show an increase in attendance rates (McLean et al., 2016).The study demonstrated that “plus reminders” (those that include orientation or health information besides date, time, and location) are more effective than simple reminders (those that show date, time, and location). A study conducted at Arkansas Children’s Hospital utilizing voice appointments also showed positive outcomes on no-show rates. Approximately 20% of children missed their appointment annually, which poses a threat to their ongoing care (Twilio, 2019).To help decrease the number of children missing their appointment, the hospital began utilizing the Twilio Programmable Voice appointment reminder to allow patients to confirm appointments by responding yes or no.This system had a positive impact on the organization by saving over $250,000 that was previously spent on appointment reminders sent in the mail. Within a few months after the installation of the system, the hospital had reduced no-show rates by 2%, which led to20 additional children to receiving quality care each day (Twilio, 2019).
McLean et al. (2016) confirmed that consistent use of different types of reminder systems can be beneficial for patients. Such reminder systems are effective in improving no-show outcomes across different patient populations and in different healthcare context. From three interrelated literature reviews, the authors determined that reminders can also increase appointment cancellation or rescheduling unneeded appointments. Other reminder systems described as “reminder plus” provide information beyond reminding a patient of an appointment. They provide the details of the appointment date, time and location (McLean et al., 2016). Additionally, reminder systems solve six specific areas of inefficiency in managing healthcare appointments. With focus on utilizing these six areas, healthcare providers can help in managing patient appointments and improving health outcomes. All patients who have appointments with healthcare providers should be issued with a reminder system that can facilitate their attendance of clinic sessions. Optimizing the appointment and reminder systems requires healthcare providers to tailor the reminder systems to the individual patient service.
The particular reminder system of choice should also meet the needs of specific patient conditions. Healthcare services also need supportive administrative process to go with the reminder systems and in order to help manage the rescheduling, cancellation, and attendance of appointments (McLean et al., 2016).Parikh et al. (2010) attempted to establish the impacts of appointment reminder systems on no-show rates. The chart below shows the results obtained when using different types of appointment reminder systems relative to the use of no reminder system. STAFF and AUTO were terms used to describe different types of appointment reminders while NONE meant any reminder system. The chart shows that with no reminders, 23.1% are likely to be a no-show for their appointments; 17.3% prefer automatic reminders while 13.6% prefer to be reminded of their appointments by the healthcare staffs. The automatic reminder systems may include features such as text message and/ or e-mail reminders. Calendar reminders also fall in this category.
Figure 2: No-Show Rate versus Appointment Reminder Systems (Source: Parikh et al., 2010)
A study conducted by Wegrzyniak, Hedderly, Charudry, & Bollu (2018) focused on patient preference when exploring the effectiveness of appointment reminder systems. The study collected six months of data from patients and appointments at a multi-office orthodontic practice. The participants in the study were required to select from one of the three methods of appointment reminders including email, text message, or a phone call. Inconsistent with the hypothesis, e-mails received the highest number of ratings, followed by text messages, then phone calls. The study also revealed that early morning appointments (between 7.00 AM and 9:45 AM) had the lowest attendance rates (Wegrzyniak et al., 2018). This indicates that appointments scheduled past 10.00 AM are more likely to receive a low no-show rate. Davies et al., (2016) revealed that appointment age plays a significant role in reducing no-show rates. The team demonstrated that no-show rates increased as the appointment period increases, requiring the systems to send reminders in a short timeframe for the appointment.
The specific type of reminder that a patient considers effective is linked to the specific response potential to that reminder system. For instance, Finkelstein, Liu, Jani, Rosenthal, and Poghosyan (2013) conducted a cross- sectional study in which they had the objective of finding out the preferences of patients in the use of appointment reminder systems. Through the study, it was confirmed that patients preferred text messages and e-mails as reminder systems due to their effectiveness and probability of response. Such systems when used have to be accounted for age and other demographic factors to ensure that they predict actual responsiveness to the system is reflective of the particular targeted population. Technology usage among patients and their familiarity with various service providers can help to establish particular systems for use for specific patients such as the disabled or the learning impaired.
While appointment reminder systems have shown to be effective in reducing no-show rates in hospitals, the systems also have their challenges. McLean et al., (2016) in their review, revealed that the appointment reminder systems promote appointment cancellations and that they are not optimally used. The study showed that 17% – 26% of patients who received appointment calls were more likely to cancel or reschedule their medical appointment relative to the 8% – 12% control group. Telephone reminders were found to attract the highest number of cancellations and rescheduled appointments compared to text message reminders (McLean et al., 2016). Text message reminders were found to reduce cancellations and rescheduling actively.
The researchers also revealed six important areas where the appointment reminder systems are underutilized. For most systems, patient details may be inaccurate or out-of-date, with groups that are socio-economically underprivileged and less geographic being more vulnerable. These groups, which include young adults and students, frequently change telephone numbers and addresses. Since most landline calls are made during work hours (9 am – 5 pm), patients are likely to miss the reminders since most of them usually are not home (McLean et al., 2016).
Research Methodology
The proposed study will analyze and compare data from a private orthodontic practice and a large hospital organization. With the objective of understanding the impacts of appointment reminder systems on no-show, the study will be conducted using a qualitative research methodology, in which data collection will be done using a survey questionnaire. The data collected will be mainly on the subject of appointment reminder systems, in a bid to understand the patient preferences for reminder system and the practitioners’ perception about the capacity of reminders to reduce no-show incidents in healthcare facilities. The qualitative approach to research focused on literature reviews in addition to the collected survey information. For instance, there are data about past approaches that have been used in managing healthcare appointments, data on various outcomes associated with no-show statistics, financial and social impacts. The primary data collection process entails collection of first-hand information from the patients and the medical practitioners at Arkansas Children’s Hospital and a private orthodontic practitioner.
Data Collection
Data collection was done using a survey questionnaire. The questionnaire was designed to contain questions seeking answers to respond to each of the research questions. For instance, the question as to whether appointment reminder systems can help to improve no-show outcomes among patients was addressed by asking patients to mention the most probable causes of no-show activity. They were also asked whether they forget doctors’ appointments. To answer the question on the preferred type of appointment reminder systems, the participants were asked to select the method they most preferred for communication when being reminded of their doctor’s appointments and which method they responded most effectively to. During the data collections, the questionnaires were issued to potential participants and the responses were analyzed thematically and classified into clusters aligned to specific research questions.
Ethical Issues
While conducting the primary research, various ethical considerations will be made. CIRT (2018) describes the considerations that researchers have to take while working particularly with human participants. The first consideration is that the researcher should keep all private information confidential. To accomplish this, the researcher will consider all information about the participants confidential. Information on the participant names, contact details and residential information and job roles will be eliminated from the questionnaires. All participants will be referred to using codes that will be specifically assigned to individual participants. Furthermore, no individual participant’s details have been presented in the research paper. No identities of patients or providers have been included in the final paper.
Findings
The findings from the primary research also confirmed some of the literature findings. For instance, most of the patients who participated reported that having a reminder system can help them recall their appointments since they are more likely to forget. Various literatures also confirmed that patients who had missed appointments in the past were likely to miss other appointments. For some of the patients, the reasons for missing appointments included lack of emotional need for planned treatment procedures, socio-economic characteristics and others. However, the percentage of those who miss appointments because they forget is higher than that of those who miss because of other reasons. For this reason, there is an imperative need to put in place effective reminder systems for patient appointments.
Patients reported that they the addition of a reminder system to their scheduled appointments would be useful in helping them avoid no-show outcomes. They also reported that various types of appointment reminder systems can be used successfully. For instance, contrary to the initial hypothesis, it was reported that-mails are capable of attracting greater responsiveness since they are mostly automatically added to calendars, which are visible in real time. On the other hand, short messages can be easily dismissed and are more likely to go unread.
Conclusion
No-shows are a common occurrence in healthcare facilities, and they result in multiple losses both financially and in social connections. Healthcare facilities such as Arkansas Children’s Hospital lose a lot of revenue through missed appointments. It is based on this background that the present paper will be aimed at determining whether appointment reminder systems can improve no-show situations and which type of appointment reminder systems are preferred by patients. Through a qualitative research, the study will attempt to confirm from healthcare providers and from patients which types of appointment reminder systems they prefer and whether they feel that those system would help them reduce the potential for no-shows. From the research findings, the study hypotheses have been confirmed. The first hypothesis was that appointment reminder systems are capable of improving no-show activities in healthcare systems. The second hypothesis was that patients preferred text messages as the best form of appointment reminder systems. However, this was countered by the research findings since literature already shows that patients would prefer e-mails as appointment reminders.
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