How Do Dermatologists Handle “No-Show Appointments”?

Failed or no-show appointments (NSA) are an inconvenience to all medical practices. They are also, unfortunately, an all-too-familiar problem. Multiple articles have been written on this topic; however, most of them focus on socioeconomic status as the number one predictor of no-shows. The primary care studies also mention the use of appointment reminders as a way to reduce NSA. Most of these studies were performed in a primary care clinic. According to current studies, NSA rates for primary care clinics range anywhere from three percent to 80 percent.1 Two more specific studies referenced more accurate NSA rates of 25 percent and 31 percent.2,3 Another study exhibited that incorporating a messaging system to call patients and remind them of their upcoming office visit, along with the cost that they would be responsible for paying for a NSA, reduced the rate of NSA to 8.4 percent.4

With the high demand for dermatology care across the country, it can be assumed that there would be a lower NSA rate as patients wait longer than usual to see a dermatologist and do not want to forfeit this opportunity. However, an accurate NSA rate could not be found in the current dermatology literature. This study was designed to analyze the incidence of NSA in dermatology offices, specifically, and the methods that dermatology offices use to reduce NSA rates. It also analyzed the patient demographics regarding the frequency of NSA and focus on the techniques the dermatology offices implement to reduce their NSAs. The overarching goal of this study is to determine the success of those offices that do implement a cancelation policy, compared to those practices that do not.

An online survey was sent to random dermatologists, MDs and DOs, in all 50 states. As a part of the survey, respondents were asked if their office enforces a NSA penalty. Those respondents who do have a NSA penalty in their offices were then asked which type of penalty they enforce (monetary fee, patient firing, etc.). Reducing these NSA will not only increase dermatology practices’ bottom lines, but will also aid in the reduction of extremely long wait times to be seen by a dermatologist. Collectively, all of these methods would reduce the economic burden of the medical care cost that exists in our country.

Methods

Institutional Review Board (IRB) approval was granted from the A.T. Still University IRB. An online survey was sent out to random dermatologists in all 50 states and Washington, DC. Emails were chosen at random using the American Academy of Dermatology (AAD) website’s member directory. A total of 104 dermatologists responded, representing 48 states and Washington DC. The states that did not have a representative respondent included Delaware and North Dakota. Of the 104 respondents, 81 were included in this study. The other 23 were excluded because their surveys were incomplete. Of the 81 respondents, 57 percent (n=46) do not enforce a cancellation policy and 43 percent (n=35) do enforce a cancellation policy.

As part of the survey, respondents were asked the following questions:

1. On average, how many patients does your office schedule in a typical week?

2. On average, how many NSA does your office experience in a typical week?

Using this information, the percentage of dermatology office visits that result in NSA was calculated.

The next question asked:

3. Does your dermatology office have a NSA policy?

If the respondent said “no,” the survey ended. If the respondent answered “yes,” the survey continued.

The following questions were asked:

4. How long do you require patients notify the office if they are going to miss their scheduled appointment? Options of 12, 24, 48, 72 hrs or “other” were available for choosing.

5. How many times do you “forgive/warn” patients before enforcing a penalty?
Options of 0, 1, 2 or >2 were available for choosing.

6. What form of penalty does your office implement?
Options of monetary fee, patient firing, patient being seen after all other patients are first seen, or “other” were available for choosing.

For the respondents who selected their form of penalty as a monetary fee, one final question was asked:

7. How much do you charge as a fee for NSA?
A text box allowed the respondent to free type the monetary amount that they charge.

Results

Figure 1.

The responses were divided into one of four geographic regions of the United States, based on the state that the respondent practiced dermatology. (Figure 1) The geographic regions of West, Midwest, South, and Northeast had a total of 22, 13, 22, and 24 respondents, respectively. We averaged each question asked in the survey for each geographic area. (Table 1)

The overall national averages for NSA with and without a cancellation policy were 7.6 percent and 8.6 percent, respectively. However, when further extrapolated, the implementation of a monetary fee for NSA did not result in a decrease in NSA rates. The NSA rates for offices with monetary fees and those without were 7.6 percent and 6.8 percent, respectfully. The overall results of this study suggest it is beneficial to implement a NSA policy; however, having only a monetary fee does not seem to suggest a successful method of doing so.

Discussion

The demand for medical services in this country continues to grow every year. As a result of this increase in demand, the wait times for appointments also continues to rise. Subspecialties in medicine, such as dermatology, have longer-than-average wait times to get an appointment due to the smaller number of providers. It is not uncommon for wait times to approach and exceed 12 months for a new patient in dermatology practices. Reducing the rate of NSA could greatly impact these excessive wait times. Techniques to reduce NSA include electronic appointment reminder phone calls/texts/emails, appointment reminder cards given at checkout of previous visit, mailing appointment reminders, and enforcing a cancelation policy. The variety of these techniques provides methods suitable for patients of all demographics. Younger patients may prefer an electronic appointment reminder, whereas older patients may prefer a hard copy of an appointment reminder.

Many providers focus solely on the financial implications that NSA have on their practice, but it is equally important to consider the implications that they have on the overall healthcare in the United States. Reducing the rate of NSA could decrease long wait times to be seen by physicians and allow for better healthcare.

Many skin conditions are acute processes and it is unrealistic to have a patient wait up to 12 months to be seen by a dermatologist. Moreover, cutaneous manifestations of systemic diseases are often the initial presenting sign of said systemic diseases. Earlier recognition and appropriate treatment could greatly reduce morbidity and/or mortality associated with some of these more serious systemic disease.

This study has several limitations, including its small sample size, vague interpretation of policies and penalties, and reliance on estimations for the final results.

The NSA rates were extremely close in some of the regions of the United States; therefore, it is not reliable to make conclusions on the efficacy of cancelation policies. Larger samples and more specific numbers of patients and cancelled appointments would provide more accurate results. This survey only took, on average, two minutes to complete. Anything longer could have decreased the rate of responses.

Conclusion

Physicians need to evaluate their office’s NSA rate and consider how to reduce the number. There are not only financial implications from reducing these numbers, but this could also improve the larger picture of healthcare in this country. n

None of the authors have any relevant financial disclosures

Douglas M Richley, DO, is a third year dermatology resident at Northeast Regional Medical Center – A.T. Still University.

Jonathan Cleaver, DO is a dermatologist at Northeast Regional Medical Center – A.T. Still University.

Lloyd Cleaver, DO , is a dermatologist at Northeast Regional Medical Center – A.T. Still University.

David Cleaver, DO is the program director at Northeast Regional Medical Center – A.T. Still University.

Kheirkhan P, Feng Q, Travis L, et al. Prevalence, predictors and economic consequences of no-shows. BMC Health Services Research. (2016) 16:13. DOI 10.1186/s12913-015-1243-z

Xakellis Jr GC, Bennett A. Improving clinical efficiency of a family medicine teaching clinic. Fam Med. 2001;33:533-8

Moore CG, Wilson-Witherspoon P, Probst JC. Time and money: effects of no-shows at a family practice residency clinic. Fam Med. 2001;33:522-7

Hallsworth M, Berry D, Sanders M, et al. Stating appointment costs in SMS reminders reduce missing hospital appointments: findings from two randomized controlled trials. PLoS ONE 10(9): e0137306. Doi:10.1371/journal.pone.0137306