Reduction and Management of No-Shows by Family Medicine Residency Practice Exemplars

Bradley J. Johnson; James W. Mold; J. Michael Pontious

doi:10.1370/afm.752

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Table 1.

Descriptive Statistics for Residency Program Practices (n=135)

Variable	Mean (SD)	Median	Range
* Where 1 = very dissatisfied and 5 = very satisfied.
† Where 1 = minor impact and 5 = major impact.
Patients’ health insurance type
Medicaid, %	0.35 (0.19)	0.30	0.0 – 0.80
Medicare, %	0.20 (0.10)	0.20	0.01 – 0.48
Private insurance, %	0.31 (0.21)	0.27	0.01 – 1.00
Self-pay, %	0.12 (0.11)	0.10	0.0 – 0.60
Patients’ age distribution
0–18 years, %	0.23 (0.11)	0.20	0.02 – 0.60
19–45 years, %	0.30 (0.11)	0.30	0.1 – 0.75
46–64 years, %	0.27 (0.10)	0.25	0.03 – 0.60
65–79 years, %	0.16 (0.09)	0.15	0.0 – 0.55
80 years +, %	0.06 (0.06)	0.05	0.0 – 0.50
Patients seen per half-day
New patients, n	1.77 (0.79)	2.0	0 – 4
Established patients, n	7.08 (2.02)	7.0	1 – 12
Total No. of patients, n	8.81 (2.23)	8.0	3.5 – 15
No-shows per half-day, n	1.83 (0.98)	2.0	0.4 – 5.0
No-show rate, %	0.17 (0.07)	0.15	0.03 – 0.42
Administrator satisfaction score*
Reducing no-shows	2.79 (1.00)	3	1 – 5
Managing no-shows	2.93 (0.97)	3	1 – 5
Impact of no-shows score^†
Overall	3.05 (1.20)	3	1 – 5
Resident education	2.76 (1.07)	3	1 – 5
Continuity of care	3.06 (1.11)	3	1 – 5
Access to care	3.31 (1.10)	3	1 – 5
Income	3.09 (1.05)	3	1 – 5

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Table 2.

Strategies Used by Exemplary Practices to Reduce No-Shows Rates (n = 11)

Method	Practices Using Method No. (%)
*Open access defined as no appointments made beyond 1 week ahead; complete open access defined as no advance appointments; partial open access defined as some advance appointments.
Patient education	10 (91)
On enrollment in practice	7 (64)
When each appointment is made	6 (55)
When reminded of appointment	4 (36)
After each no-show	7 (64)
After repeated no-shows	5 (45)
No. of education strategies, median (range)	3 (0–5)
Patient reminders	9 (82)
Telephone call to all patients	9 (82)
Telephone call to high-risk patients	2 (18)
Letter/card to all patients	1 (9)
Letter/card to high-risk patients	1 (9)
No. of reminder strategies, median (range)	1 (0–3)
Patient sanctions	9 (82)
Expelled from practice	9 (82)
Required to walk-in (no appointments)	1 (9)
Open access*	9 (82)
Complete	3 (27)
Partial (lots of work-in slots)	6 (55)
Continuity emphasis
Residents work in small teams	7 (64)
Scheduling rules
Residents cannot schedule appointments	6 (55)
Work with individual residents
Try to determine cause for no-shows	2(25)

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Table 3.

Strategies Used by Management Exemplar Practices (n = 8)

Method	Practices Using Method No. (%)
* Patients more likely to miss a scheduled appointment.
Overbooking	5 (63)
Overbook all residents equally	3 (38)
Overbook based upon no-show rate	2 (25)
Overbook high-risk patients	2 (25)
Walk-ins and work-ins	8 (100)
Encourage/allow walk-ins/work-ins	7 (88)
Make high-risk patients* walk-in/work-in	2 (25)
Adjust schedule to demand
See all patients wanting to be seen	2 (25)

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The Article in Brief

Reduction and Management of No-Shows by Family Medicine Residency Practice Exemplars

Bradley J. Johnson, MD , and colleagues

Background Patients? failure to keep scheduled appointments (?no-shows?) is a significant problem in family medicine residency practices. This study looks at methods used by family medicine residency practices that have low no-show rates or who manage no-shows well when they occur.

What This Study Found It is possible to reduce no-show rates in residency practices to below 10% by using combinations of well-established methods when they are used consistently and effectively. These methods include patient education, patient reminders, patient sanctions, and open-access scheduling. Reducing the impact of no-shows once they occur is best accomplished by increasing the numbers of walk-ins and work-ins.

Implications

This study contributes to the existing literature on no-shows in primary care residency program practices and may be helpful to those who are struggling with this important challenge.
Annals Journal Club Selection:

Nov/Dec 2007

The Annals Journal Club is designed to encourage a learning community of those seeking to improve health care and health through enhanced primary care. Additional information is available on the Journal Club home page.
The Annals of Family Medicine encourages readers to develop the learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club, and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for: Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care, and then acting on those discussions.¹
Article for Discussion

Johnson BJ, Mold JW, Pontious JM. Reduction and management of no-shows in family medicine residency program practice exemplars. Ann Fam Med. 2007;5(6):534-539.

Discussion Tips
Consider the articles in the context of your own practice and patient population. Also consider the pros and cons of the novel method of identifying and studying exemplars.
Discussion Questions

What questions are addressed by the article? Why do they matter?
What purpose is served by the 2-stage sampling design of the study? Are there better alternatives for answering the research questions?
What are the main findings?
To what degree can the findings be accounted for by:
How participants were selected?
How critical variables were measured?
Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
How participant responses were interpreted?
Chance?

How transportable are the findings to your practice setting? How might they be adapted?
What are the challenges in disseminating findings from a study of exemplars?
How might the information be used to change practice or policy?
How do these findings relate to what already is known about methods to reduce no-show rates and enhance patient volume?
What questions do you have for further research or application?

Reference

Stange KC, Miller WL, McLellan LA, et al. Annals journal club: It�s time to get RADICAL. Ann Fam Med. 2006;4:196-197. Available at: http://annfammed.org/cgi/content/full/4/3/196.