Last-Minute Scheduling Can Reduce No-Shows

Jim Kling

April 26, 2011

April 26, 2011 — Advanced ("open") access scheduling, which is patient driven, rather than prearranged, reduces wait time and no-show rates, according to a study published online April 25 in the Archives of Internal Medicine.

Advanced access scheduling has been widely adopted in the United Kingdom and the US Veterans Health Administration, and among some US private practices. Under the system, physician offices attempt to offer appointments on the day a patient calls or within 24 hours. It contrasts with traditional systems, in which appointments may be made well in advance, leading to long wait times and possibly increasing the frequency of missed appointments.

In recent years, the waiting time for routine appointments has increased and has been associated with negative health outcomes and increased emergency room crowding. This has led to increased interest in advanced access, but some critics maintain that it is difficult to implement, and that it could reduce continuity of care, although others maintain that it should improve it.

To examine the effects of advanced access scheduling on outcomes, the researchers, led by Katherine D. Rose, MD, from Brigham and Women’s Hospital, Boston, Massachusetts, conducted a meta-analysis of studies. Each study was analyzed twice, with reviewers blinded to author, journal, and date of publication. The analysis included 28 English-language articles describing 24 studies, both controlled and uncontrolled, performed in a primary care setting.

The researchers tested the studies for bias using the Cochrane Effective Practice and Organisation of Care Group Risk of Bias criteria. They found at least 1 potential bias in all of the studies.

Eight of the studies looked at the time until the third next available appointment time, and all of the studies identified reductions in appointment wait time ranging from 1.1 to 32 days, but the goal of a time of less than 2 days was achieved in only 2 of the studies.

Among practices with baseline no-show rates of 15% or higher, advanced access scheduling led to a significant reduction, but no such improvement was seen in practices with baseline no-show rates lower than 15%. Trends in patient satisfaction varied, and there were few data on clinical outcomes and loss to follow-up.

In an accompanying editorial by Leif I. Solberg, MD, from the HealthPartners Research Foundation, Minneapolis, Minnesota, the author suggests that outcomes research is critical. The author writes: "The harder question is whether there is evidence that improving access also improves safety, effectiveness, efficiency, or equity and whether any such improvements are due specifically to the access change or to other causes."

The researchers suggest that to improve understanding of advanced access scheduling, a large randomized trial should be conducted. It should measure outcomes including satisfaction, continuity of care, quality of care, healthcare utilization, and loss to follow-up.

The research was supported by a Clinical and Translational Science Award from the National Center for Research Resources, National Institutes of Health, and the National Institutes of Health Roadmap for Medical Research as well as grants from the National Institute on Aging and by the Paul B. Beeson Career Development Award Program from the American Federation of Aging Research. The authors and the editorialist have disclosed no relevant financial relationships.

Arch Intern Med. Published online April 25, 2011. Abstract, Abstract

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