Can what we learned about reducing no-shows in our clinic work for you?

Discussion
We attempted a literature review of research exploring approaches to reduc­ing the no-show rate but found few studies that explored this critical concern in patient treatment.¹⁵ Some data suggested that, in the setting studied, the no-show rate:
   • was higher among younger patients (age 20 to 39) than older ones (age 60 to 79)
   • was slightly higher in women than in men
   • varied by diagnosis.

We found a paucity of data regarding interventions that can reduce the no-show rate.

Among the changes we made, the one that had the greatest impact was person­alized appointment reminder calls, as evi­denced by our patients’ reports and the increase in the no-show rate when per­sonal calls were not made.

We also realized that, although we had several departmental policies in place regarding appointments, they were not being followed. Raising awareness among team members and their patients also was an effective deterrent to a no-show for an appointment. For example, patients were informed that 3 consecutive no-shows could lead to termination of care. Often, they reacted with surprise to this caution but also voiced a desire to improve their attendance to avoid such an outcome.

We found that establishing common operational definitions is important. It also was important to have a cohesive team, with every member agreeing on goals and changes to operational policies that needed to be implemented. Support from the department chair and the administra­tion, we learned, is vital to the success of such an intervention.

A note about limitations. The goal of the project was limited to reducing the no-show rate. We demonstrated that this is possible among patients who have a severe mental ill­ness, and that reducing the associated waste of time and resources can improve finances in an academic department of psychiatry. We would need additional measures, however, to quantify medication adherence and hos­pitalization; a larger, more inclusive project is needed to demonstrate that reducing the no-show rate reduces the symptomatic bur­den of psychiatric illness.

Comments in conclusion
This project was designed and conducted as a required part of a Clinical Safety and Effectiveness Program at Memorial Hermann Texas Medical Center and the UT Medical School at Houston.¹⁷ Although there was initial hesitancy about attempt­ing to reduce the no-show rate in a chroni­cally mentally ill population, the success of this project—indeed, it surpassed its proposed goals—demonstrates that opera­tional changes in any clinic can reduce the no-show rate. It also is important to main­tain operational changes, however; with­out consistent effort, desired results cannot be sustained.

Last, it is possible to replicate the meth­odology of this project and thereby attempt to reduce the no-show rate in other divi­sions of medicine that offer care to chroni­cally ill patients, such as pediatrics and family medicine.

Bottom Line
Failure to attend routinely scheduled outpatient appointments increases a patient’s functional impairment and risk of hospitalization. Patient education, appointment reminder phone calls, revised policies and procedures, and transparency regarding the no-show rate can reduce the number of missed appointments and improve patient outcomes.

Related Resources
• Mitchell AJ, Selmes T. Why don’t patients attend their ap­pointments? Maintaining engagement with psychiatric ser­vices. Advances in Psychiatric Treatment. 2007;13:423-434.
• Molfenter T. Reducing appointment no-shows: going from theory to practice. Subst Use Misuse. 2013;48(9):743-749.
• Williston MA, Block-Lerner J, Wolanin A, et al. Brief acceptance-based intervention for increasing intake attendance at a com­munity mental health center. Psychol Serv. 2014;11(3):324-332.

Disclosure
Dr. Gajwani receives grant or research support from the National Institute on Mental Health, the National Institute of Drug Abuse, The Stanley Foundation, and Forest Laboratories, Inc. He is a member of the speakers’ bureau of AstraZeneca, Merck, Otsuka America Pharmaceutical, and Sunovion Pharmaceuticals.