Original Article: Creps J, Lotfi V. A dynamic approach for outpatient scheduling. J Med Econ 2017;20:786-798
We found the research done by Creps and LotfiCitation1 on addressing the global problem of missed appointments a thoughtful and original method to reduce the economic drain of missed appointments. One area highlighted by this study discussion was the ethics of double booking appointments—what would be the impact on patient satisfaction of the service were they to know that they had a double-booked slot? In healthcare, the balance between effective throughput in a service and good quality care must be carefully weighed.
Appleton et al.Citation2 recently identified “long waiting times” and “limited weekend and evening clinics” as being contributory reasons for missed appointments.
Indeed, in our unit, scheduling and optimal service deliverance was the focus of a recent time and motion study we did between morning and evening pediatric allergy clinics. The “evening clinic” was piloted to release the pressures of an overwhelmed service, with an ever-growing waiting list and constrained U.K National Health Service (NHS) resources.
Our pediatric allergy service sees more than 3,000 children in 250 clinics per year. The annual missed appointment rate is between 9–15%.
A typical appointment is often multi-disciplinary, with a child seeing up to 4–5 personnel (including doctors, dieticians, phlebotomists, and skin prick testing allergy nurses), depending on the needs of the child. Each appointment can be expected to last between 1–2 h, with a delay in each component part of the appointment having a knock-on effect on following patients. This then causes dissatisfaction with long waiting times in the service and potential subsequent missed appointments. A service questionnaire filled in by parents frequently highlighted this issue of delay.
During December 2015 we piloted an evening out-of-hours service for 4 weeks. A time and motion study method was used to analyze the movement of a patient from entering the reception until leaving the department, recording time-points of every component part of the service to identify service delays. This was measured in both the morning and evening clinic. Overall, there was a decrease in the average amount of time spent in the department in the evening clinic (from a median of 1 h 42 min in the evening clinics to 1 h 14 min during day time clinics). Factors influencing the change in numbers may include a more streamlined system (the allergy clinic was the sole evening clinic, compared to the morning, where several other pediatric clinics were going on in that departmental area), and also the strategic scheduling of patients with 20-min slots booked in the first hour and a half after 5 pm. As an observational point, children were also more often seen with both parents (able to attend after work), and there was good patient feedback on this service.
Our small study enabled us to understand the importance of family perspective and recognize that one size does not fit all. Offering choices (e.g. morning appointments and evening appointments) may well improve adherence to appointments, which is crucial in chronic conditions.
Further research will need to be done to specifically analyze the economic value of evening clinics on missed appointment rates, but it should be considered as an under-utilized resource. Outpatient building space that would not otherwise be used at that time could be potentially rotated by different services, to not only lessen service pressures, but also decrease missed appointment rates—particularly if accessibility, time off work, parking, and choice of appointment times were all common reasons for missed appointments.
Although our example is via a pediatric allergy service, it is applicable across many chronic conditions. The modern world has made parents busy and it would help if the health service were responsive.
The solution to decrease missed appointments is not an easy one—it is likely to be multi-factorial. However, careful consideration should be made both of strategic scheduling and understanding patient reasoning and behavior in order to tackle this universal expensive outpatient issue.
Transparency
Declaration of funding
This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of financial/other interests
None of the authors have any potential financial conflict of interests.
Acknowledgments
None reported.
References
- Creps J, Lofti V. A dynamic approach to outpatient scheduling. J Med Econ 2017;20:786-98
- Appleton J, Powell C, Coombes L. Children’s missed healthcare appointments: professional and organisational responses. Arch Dis Child 2016;101:814-8.