Evidence-Based Reviews

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

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Novel strategies led to better follow-up among patients with chronic, severe mental illness



The no-show rate is high in ambulatory psychiatric clinics, especially those associated with academic medical institutions, which usually accept all public insurance providers and do not maintain a strict rule by which patients are charged a penalty when they fail to keep a scheduled appointment—a policy that, to the contrary, is customary in private practice. The University of Texas (UT) Health Sciences Center at Houston is primarily an academic medical center with resident-managed, faculty-supervised clinics that provide care to a large volume of patients.

At the UT clinics, we have struggled with a high no-show rate, and were challenged to reduce that rate. Our study of the problem, formulation and application of strat­egies to reduce that rate, and a discussion of our results are provided here for the benefit of psychiatric clinicians who struggle with this problem, to the detriment of their patients’ health and the financial well-being of the practice.

For patients who have a severe psychiatric illness, such as schizophrenia or bipolar disorder, 60% to 70% of the direct cost of their care is attributable to inpatient services.1,2 Poor medication adherence is a critical factor: It results in exacerbation of symptoms, relapse, and hospitalization. The matter is compounded by patients’ failure to show up for scheduled follow-up appointments.

Studies show that failure to attend routinely scheduled outpatient appointments increases the risk of hospitaliza­tion. Recent research has shown that, among all causes of hospitalization, length of stay and relapse hospitalization are increased in patients with low adherence to their treatment regimen.3 Patients who miss an appoint­ment also are more unwell and more func­tionally impaired—also contributing to a higher risk and rate of rehospitalization.4,5

To begin to address the problem at UT, we acknowledged that an elevated no-show rate is linked to medication nonadherence, increased risk of re-hospitalization, and increased costs associated with poor care.

Impact of nonadherence

Significant evidence supports the efficacy of antipsychotic medications for treating schizophrenia, of course,6 but that success story is undermined by the mean rate of medication nonadherence among schizo­phrenia patients, which can be as high as 49% in studies.7 (The actual rate might be higher because those studies do not account for persons who refuse treatment or drop out.)

Nonadherence increases the risk of relapse 3.7-fold, compared with what is seen in patients who adhere to treatment.8 Nonadherence to a medication regimen also can increase patients’ risk of engaging in assault and other dangerous behaviors, especially during periods of psychosis.8 Variables consistently associated with nonadherence include poor insight, nega­tive attitude or subjective response toward medication, previous nonadherence, sub­stance abuse, shorter duration of illness, inadequate discharge planning or after-care environment, and poorer therapeutic alliance.7,8

Investigation of medication adher­ence in bipolar disorder suggests that 1 in 3 patients fail to take at least 30% of their medication.9 In such patients, medi­cation nonadherence can lead to mania, depression, hospital readmission, sui­cide, increased substance abuse, and nonresponse to treatment.10,11

Depression also is associated with an increased rate of health care utilization and severe limitation in daily functioning.12 Compared with non-depressed patients, depressed patients are 3 times more likely to be nonadherent with medical treatment recommendations.13 Estimates of medi­cation nonadherence for unipolar and bipolar disorders range from 10% to 60% (median, 40%). This prevalence has not changed significantly with the introduc­tion of new medications.14

Our literature review of research devoted to reducing no-shows found that few stud­ies have explored this critical treatment con­cern. The no-show rate was higher among younger patients and slightly higher among women, but varied by diagno­sis.15 The most common reason psychiatric patients gave for missing an appointment was “forgetting”—a response heard twice as often among no-show patients in psy­chiatry than in other specialties.4

Little has been tried to solve the prob­lem. Often, community mental health centers and private practices double-book appointments. Double-booking is intended to reduce the financial burden on the prac­tice when a patient misses an appointment. This approach fails to address nonadher­ence or the poor care that usually results when a patient misses regular outpatient appointments.

Several methods have been employed to improve adherence, such as electronic pill dispensing.16 Increasing medication adher­ence appears to be a key factor in improv­ing quality-of-life measures in patients with schizophrenia.6

The UT project

. This project was completed at the ambulatory psychiatry clinic at the UT Medical School at Houston. The clinic staff comprises residents and faculty members who provide outpatient care. During the study period, the clinic was scheduling as many as 800 office visits a month, includ­ing a mix of new and follow-up appoint­ments. Two weeks’ retrospective data revealed a no-show rate of 31%.

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