Arnon D. Cohen1,2 and Daniel A. Vardy1,2

1Clalit Health Services, and 2Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel. E-mail: arcohen@clalit.org.il

Accepted January 12, 2006.

Sir,

Non-attendance (failure to attend clinic appointments) is a common problem in dermatology clinics. Non-attendance proportions range from 15% to 25% and lead to inefficient use of space and personnel and increased costs (1–7).

To improve the management of dermatological clinics, factors that determine non-attendance should be identified and addressed. In the past, only a few studies were performed on non-attendance in general dermatology clinics. The factors that determine non-attendance in adult dermatology clinics include the payer type, inadequate communication between the hospital and patients, patients forgetting their appointment date or illness, and problems related to appointments (8–11). In paediatric dermatological patients, non-attendance was associated with male gender and referrals from emergency department as opposed to referrals from private physicians (12).

In this study we investigated factors that determine non-attendance in adults visiting an ambulatory dermatology clinic.

Materials and METHODS

The study was conducted in the southern district of Clalit Health Services. Clalit Health Services is the largest organization of managed care in Israel. In the southern district of Israel, Clalit Health Services serves a population of 470,000 enrollees. The dermatology service in this district includes 17 active dermatologists, working in 23 clinics, accounting for approximately 110,000 patient–physician encounters annually. The central ambulatory clinic resides in the district town Beer-Sheva.

Visits to district central ambulatory clinic were obtained from a computer-generated listing of scheduled appointments from January 1 to December 31, 2003. The list contained the patient’s age, gender, visit date and time, waiting time for an appointment and the treating dermatologist for all new appointments in the clinic. In this clinic, patients were not required to pre-authorize the appointment and did not receive a reminder of the scheduled appointment.

Statistical analysis

Results of continuous variables are shown as means. Results of categorical variables are described as frequencies. Chi-square tests were used to analyse statistically significant differences of categorical variables. Logistic regression was used for multivariate analyses. p-values ≤ 0.05 were considered statistically significant.

RESULTS

A total of 7580 visits were included in the study during a 12-month period. There were 4509 female (59.5%) and 3071 male (40.5%) patients. The mean age was 45.9 years (range 18–100 years).

The overall proportion of non-attendance at the dermatology clinic was 26.1%. Non-attendance was 27.2% in female and 24.5% in male patients (p = 0.009). Non-attendance was 30.1% in patients below 50 years, 21.4% in patients in the age range 50–70 years, 18.0% in patients in the age range 70–90 years and 31.7 in patients above 90 years (p <0.001). Non-attendance was 23.8% when there was a short waiting time for an appointment (1–7 days), 30.6% when there was an intermediate waiting time (8–14 days) and 34.0% when there was a long waiting time (15 days and above) (p <0.001). Non-attendance proportion varied between 13.0% and 30.8% depending on the treating dermatologist (p <0.001).

A multivariate logistic regression model demonstrated that the age and gender of the patients, waiting time for an appointment, and the treating dermatologist were factors that were significantly associated with non-attendance.

DISCUSSION

Overall non-attendance was 26%. Non-attendance was associated with age and gender of the patients, waiting time for an appointment and the treating dermatologist.

In previous studies, it has been shown that non-attendance is higher in men than women (1, 2, 11). However, in the current study it was observed that non-attendance was higher in women. It has been demonstrated that women attend melanoma screening programs more than men (13), therefore we assume that women visit dermatological clinics more often for cosmetic reasons, resulting in higher non-attendance proportions.

We observed that non-attendance was associated with younger age, as was observed in previous studies (1, 2, 11). It is suspected that the lower proportion of non-attendance in older age reflects poorer health and therefore a greater need to seek assistance from a physician. In younger persons, conflicting activities, such as work or family obligations, might have contributed to the higher non-attendance.

Non-attendance was associated with the waiting time for an appointment, as was observed in previous studies (12). Non-attendance varied between 13.0% and 30.8% according to the treating dermatologist. This probably reflects the prestige of the treating dermatologists, as all dermatologists were working in the same facility and had similar office services.

Several techniques have been used to assure attendance and to decrease non-attendance proportions. These techniques include reminder postcards, telephone calls and automated telephone reminders. Each technique requires additional cost to the clinic, either directly for postage or telephone costs, or in personnel time.

Managed overbooking may be used to deal with the problem of non-attendance. In this technique, local proportions of non-attendance for each clinic are identified and then appropriate proportions of overbooking are applied. Automatic overbooking may be planned for a specific clinic on the basis of non-attendance proportions. It should be noted that the strategy of overbooking appointments to allow for anticipated non-attendance might be counterproductive when a high attendance proportion occurs. In this situation, a lot of pressure is put on both patients and staff, appointment times are not met, and the quality of service decreases.

REFERENCES

1. George A, Rubin G. Non-attendance in general practice: a systematic review and its implications for access to primary health care. Fam Pract 2003; 20: 178–184.

2. Hamilton W, Round A, Sharp D. Patient, hospital, and general practitioner characteristics associated with non-attendance: a cohort study. Br J Gen Pract 2002; 52: 317–319.

3. Lacy NL, Paulman A, Reuter MD, Lovejoy B. Why we don’t come: patient perceptions on no-shows. Ann Fam Med 2004; 2: 541–545.

4. Leung GM, Castan-Cameo S, McGhee SM, Wong IO, Johnston JM. Waiting time, doctor shopping, and non-attendance at specialist outpatient clinics: case-control study of 6495 individuals in Hong Kong. Med Care 2003; 41: 1293–1300.

5. Adams LA, Pawlik J, Forbes GM. Nonattendance at outpatient endoscopy. Endoscopy 2004; 36: 402–404.

6. Campbell B, Staley D, Matas M. Who misses appointments? An empirical analysis. Can J Psychiatry 1991; 36: 223–225.

7. Frankel S, Farrow A, West R. Non-attendance or non-invitation? A case-control study of failed outpatient appointments. BMJ 1989; 298: 1343–1345.

8. Bottomley WW, Cotterill JA. An audit of the factors involved in new patient non-attendance in a dermatology out-patient department. Clin Exp Dermatol 1994; 19: 399–400.

9. Canizares MJ, Penneys NS. The incidence of nonattendance at an urgent care dermatology clinic. J Am Acad Dermatol 2002; 46: 457–459.

10. Penneys NS, Glaser DA. The incidence of cancellation and nonattendance at a dermatology clinic. J Am Acad Dermatol 1999; 40: 714–718.

11. Verbov J. Why 100 patients failed to keep an outpatient appointment-audit in a dermatology department. J R Soc Med 1992; 85: 277–278.

12. Hon KL, Leung TF, Ma KC. Issues regarding nonattendance at a paediatric dermatology centre. Clin Exp Dermatol 2002; 27: 711–713.

13. de Rooij MJ, Rampen FH, Schouten LJ, Neumann HA. Factors influencing participation among melanoma screening attenders. Acta Derm Venereol 1997; 77: 467–470.