Improving First Appointment Attendance Rates in Child Psychiatry Outpatient Clinics RONALD F. C. KOURANY, M.D. , JUDY GARBER , PH.D. ,
AND
GABRIEL TORNUSCIOLO, B.A .
Abstract. This study tested the efficacy of several interventions for reducing the rate of " no shows " to first appointments to a child psychiatry outpatient clinic. After their initial telephone contact with the clinic, patients were randomly assigned to one of four conditions: (1) a reminder telephone call, (2) an orientation letter , (3) both a telephone prompt and an orientation letter, and (4) no contact. Results indicated that any contact was significantly more likely to reduce the "no show" rate than no contact. Those who "no showed " or cancelled had to wait significantly longer for an appointment than did those who showed. Parents' primary reason for not making their appointments was that the scheduled time interfered with their work schedule. Implications of these results for improving clinic services are discussed. J. Am. Acad. Child Adolesc, Psychiatry, 1990,29,4:657-660. Key Words: "no show" rate, clinic attendance, first appointments , waiting period.
The problem of "no shows" (failures to keep initial appointments) in outpatient psychiatry clinics is a serious and costly concern for mental health service providers . The base rate for this phenomenon has been reported to range from 20 to 57 percent (Overall and Aronson , 1963; Krause, 1966; Gould et al., 1970; Raynes and Warren , 1971; Gottesfeld and Martinez, 1972; Larsen et al. , 1983). Such missed initial appointments not only lead to the inefficient use of professional staff time, but also to the reduced availability of services to others in need. Therefore , decreasing the number of no shows is a logical target for intervention for those interested in improving the delivery of mental health services to child and adolescent populations . Although a great deal has been written about the topic of dropouts from therapy once treatment has begun (Levitt, 1957; Tuckman and Lavell , 1959; Ross and Lacey, 1961; Cole and Magnussen, 1967; Cohen and Richardson, 1970; Ewalt et al., 1972; McAdoo and Roeske, 1973; Baekeland and Lundwall, 1975; Del Gaudio et al., 1977; Smart and Gray, 1978; Saltzman, 1984), considerably less is known about the problem of initial appointment failures, particularly in a child psychiatric outpatient clinic. Two aspects of this issue that need further investigation are: (a) what distinguishes those patients and families that show for their initial clinic appointment from those who fail to show; and
(b) what can be done to reduce the rate of first appointment failures in a child psychiatric clinic . Several factors have been studied in association with initial appointment failures and treatment attrition including socioeconomic status (Ross and Lacey, 1961; Adler et al. , 1963; Errera et al. , 1965; Gould et al. , 1970; Noonan , 1973; Rosenberg and Raynes, 1973; Gaines , 1978; Carpenter et al., 1981; Burgoyne et al. , 1983; Gould et al., 1985), length of waiting time between initial contact with the clinic and the scheduled initial appointment (Lake and Levinger , 1960; Gould et al., 1970; Raynes and Warren , 1971; Wolkon , 1972; Gaines , 1978; Lowman et al. , 1984), referral source (Tuckman and Lavell , 1959; Errera et al. , 1965; Raynes and Warren, 1971; Gaines, 1978; Carpenter et al., 1981), history of previous treatment (Errera et al., 1965; Raynes and Warren, 1971; Rogawksi and Edmundson, 1971; Carpenter et al., 1981), clinical characteristics (Cohen and Richardson, 1970; Gould et al., 1985), distance from the clinic (Tuckman and Lavell , 1959; Gaines, 1978; Carpenter et al., 1981), and demographic characteristics including age, sex, and race (Tuckman and Lavell , 1959; Errera et al. , 1965; Cohen and Richardson, 1970; Raynes and Warren , 1971; Noonan, 1973; Carpenter et al. , 1981; Gould et al., 1985). Results of these various investigations have been inconclusive and sometimes conflicting. For example, whereas several studies have found a significant association between wait time and initial appointment " no show " (Raynes and Warren, 1971; Wolkon, 1972), others have failed to find such a relation (Gould et al., 1970; Lowman et al., 1984). One purpose of the present study was to further explore the relation between these various factors and the " no show" rate to initial appointments in a child psychiatric outpatient clinic. The second purpose of the present study was to test the 'efficacy of several different interventions for improving the rates of initial clinic attendance . Various procedures have been tried in order to reduce initial appointment failures including written and oral orientation statements (Garrison, 1978; Witkower, 1981; Kluger and Karras, 1983), telephone preparations and prompts (Turner and Vernon, 1976; Hochstadt and Trybula, 1980; Burgoyne et al., 1983; Kluger and Karras, 1983), and letter prompts (Hochstadt and Trybula ,
Accepted August 10, 1989 . Dr. Kourany is Associate Prof essor ofPsychiatry, Division of Child and Adolescent Psychiatry at Vanderbilt University Medical School. Dr . Garber is Assistant Professor of Psychology and Human Development and Assistant Professor ofPsychiatry at Vanderbilt University. Gabriel Tornusciolo was an undergraduate at Vanderbilt University at the time of the study. The authors would like to acknowledge the assistance of Sherron Buchanan in the collection of these data and would like to thank Bahr Weiss f or his statistical consultation . Portions of this pap er were presented at the annual meeting of the Ameri can Academy ofChild and Adolescent Psychiatry, Seattle, Wash· ington, October, 1988. Reprint requests to Judy Garber, Department of Psychol ogy and Human Development, Box 512 Peabody , Vanderbilt University , Nashville, Tennessee 37203. 0890-8567/90/2904-0657$02 .00/0© 1990 by the American Academy of Child and Adolescent Psychiatry.
657
KOURANY ET AL.
1980; Swenson and Pekarik, 1988). Although oral preparatory orientations and telephone prompts have been found to be effective in reducing initial appointment failures, they tend to be inefficient and labor intensive. Results of written orientation statements and mailed prompts have been generally positive, although there is some suggestion that the efficacy of these letters may depend upon the timing of when they are received (Hochstadt and Trybu1a, 1980; Swenson and Pekarik, 1988). The present study was designed to test further the efficacy of alternative procedures for improving initial clinic attendance in a child and adolescent psychiatric clinic. Since most of the existing studies have been conducted with respect to adult psychiatric populations, the extent to which these various procedures are effective with child and adolescent populations is less clear. Therefore, the present study compared the efficacy of an orientation letter, a telephone prompt, a combined orientation letter and telephone prompt, and no contact for improving the initial appointment attendance rate in a child and adolescent psychiatric clinic. The final purpose of this study was to assess parents' reasons for not attending their initial clinic appointments. Following the work of Gould et al. (1985), the present study investigated the explanations parents gave for their appointment failure in order to identify possible reasons for these "no shows" that could be the target of future interventions. Method Subjects. Subjects were consecutive patients who called to make an appointment in the outpatient child psychiatry clinic of Vanderbilt University between January and June, 1987. Basic demographic and referral information about the child and family was obtained by the staff person who scheduled the appointment. The sample was 69% male and 79% caucasian, ranging in age from 2.25 to 17.75 years (X = 10.38 years). The children were referred predominantly for behavioral problems (47.4%), emotional problems (27%), or educational concerns (12.1 %). Fifty-three percent of the parents were currently married; thirty-three percent of the families were on Medicaid. Forty percent of the sample had been in treatment before. Intervention. The 111 patients were randomly assigned to one of four conditions: (1) a telephone call reminder 1 to 2 days before their appointment (N = 28); (2) a letter describing what would happen on their first visit to the clinic was sent out a few days after the appointment was made (N = 27); (3) a phone call and a letter as described in the previous two conditions (N = 30); and (4) no contact between their initial phone call and their scheduled appointment day (N = 26). There were no significant differences among the four treatment groups with regard to any of the demographic characteristics. The orientation letter was a two-sided single sheet that contained information about what parents and children would experience at their first clinic appointment. It briefly described business (insurance) matters, outlined the clinical assessment procedures that would occur, told the expected amount of time patients would be seen, and the nature of the feedback they were likely to get upon completion of the
658
intake procedures. Finally, parents were requested to call the clinic if they needed to cancel their appointment. Follow-up. Those patients who did not come to their appointment (either "no shows" or cancellations) were recontacted by telephone several weeks after their appointment time in order to inquire about their reasons for not coming. The follow-up questionnaire was based upon the work of Carpenter et al. (1981) and Gould et al. (1985). Parents were first asked an open-ended question: "Can you tell us what prevented you from keeping the appointment on (date)?" Next, they were asked to rate on a three point scale (0 = Not True; 1 = Somewhat True; 3 = Very True) 24 possible reasons for not coming for their appointment. Results Intervention. Table 1 presents the number of "no shows," cancellations, and shows to the clinic appointment in each of the four treatment conditions. "No shows" were defined here as those individuals who did not come to their scheduled clinic visit and who did not cancel the appointment. Cancellations were defined as those individuals who either called the clinic to cancel their appointment, or who cancelled their appointment when they were called by the clinic to confirm it. Although the chi-square analysis comparing the rate of "no shows," cancellations, and shows as a function of the four interventions was not significant, X2 (6) = 7.76, the analysis comparing the effect of any kind of contact (call, letter, or both) versus no contact was significant, X2 (2) = 7.05, P < 0.03. These results suggest that, although it did not seem to matter what was the nature of the contact, any contact was better than no contact with regard to the "no show" rate. Contact did not significantly affect the rate of cancellations, however, Of course, since these analyses involved a second comparison without correcting the alpha level, the results should be interpreted with caution (although see the results below of the logit categorical data modeling procedures that are consistent with this conclusion). Characteristics of "no shows" and cancellations. There was a significant difference among those families who failed, cancelled, or showed for their first clinic appointment with regard to their history of prior treatment, X2 (2) = 6.92, p < 0.03, and the number of days they had to wait between their initial contact phone call and their appointment day, F(2,106) = 7.76, P < 0.0008. Additional analyses of these results indicated that those families who came to their appointment were significantly more likely to have been in treatment before than were the families who failed or cancelled their initial appointment. Post hoc analyses using the Student Newman-Keuls procedures on the number of days required to wait for their appointment revealed that the families who failed to show
AND
GABRIEL TORNUSCIOLO, B.A .
Abstract. This study tested the efficacy of several interventions for reducing the rate of " no shows " to first appointments to a child psychiatry outpatient clinic. After their initial telephone contact with the clinic, patients were randomly assigned to one of four conditions: (1) a reminder telephone call, (2) an orientation letter , (3) both a telephone prompt and an orientation letter, and (4) no contact. Results indicated that any contact was significantly more likely to reduce the "no show" rate than no contact. Those who "no showed " or cancelled had to wait significantly longer for an appointment than did those who showed. Parents' primary reason for not making their appointments was that the scheduled time interfered with their work schedule. Implications of these results for improving clinic services are discussed. J. Am. Acad. Child Adolesc, Psychiatry, 1990,29,4:657-660. Key Words: "no show" rate, clinic attendance, first appointments , waiting period.
The problem of "no shows" (failures to keep initial appointments) in outpatient psychiatry clinics is a serious and costly concern for mental health service providers . The base rate for this phenomenon has been reported to range from 20 to 57 percent (Overall and Aronson , 1963; Krause, 1966; Gould et al., 1970; Raynes and Warren , 1971; Gottesfeld and Martinez, 1972; Larsen et al. , 1983). Such missed initial appointments not only lead to the inefficient use of professional staff time, but also to the reduced availability of services to others in need. Therefore , decreasing the number of no shows is a logical target for intervention for those interested in improving the delivery of mental health services to child and adolescent populations . Although a great deal has been written about the topic of dropouts from therapy once treatment has begun (Levitt, 1957; Tuckman and Lavell , 1959; Ross and Lacey, 1961; Cole and Magnussen, 1967; Cohen and Richardson, 1970; Ewalt et al., 1972; McAdoo and Roeske, 1973; Baekeland and Lundwall, 1975; Del Gaudio et al., 1977; Smart and Gray, 1978; Saltzman, 1984), considerably less is known about the problem of initial appointment failures, particularly in a child psychiatric outpatient clinic. Two aspects of this issue that need further investigation are: (a) what distinguishes those patients and families that show for their initial clinic appointment from those who fail to show; and
(b) what can be done to reduce the rate of first appointment failures in a child psychiatric clinic . Several factors have been studied in association with initial appointment failures and treatment attrition including socioeconomic status (Ross and Lacey, 1961; Adler et al. , 1963; Errera et al. , 1965; Gould et al. , 1970; Noonan , 1973; Rosenberg and Raynes, 1973; Gaines , 1978; Carpenter et al., 1981; Burgoyne et al. , 1983; Gould et al., 1985), length of waiting time between initial contact with the clinic and the scheduled initial appointment (Lake and Levinger , 1960; Gould et al., 1970; Raynes and Warren , 1971; Wolkon , 1972; Gaines , 1978; Lowman et al. , 1984), referral source (Tuckman and Lavell , 1959; Errera et al. , 1965; Raynes and Warren, 1971; Gaines, 1978; Carpenter et al., 1981), history of previous treatment (Errera et al., 1965; Raynes and Warren, 1971; Rogawksi and Edmundson, 1971; Carpenter et al., 1981), clinical characteristics (Cohen and Richardson, 1970; Gould et al., 1985), distance from the clinic (Tuckman and Lavell , 1959; Gaines, 1978; Carpenter et al., 1981), and demographic characteristics including age, sex, and race (Tuckman and Lavell , 1959; Errera et al. , 1965; Cohen and Richardson, 1970; Raynes and Warren , 1971; Noonan, 1973; Carpenter et al. , 1981; Gould et al., 1985). Results of these various investigations have been inconclusive and sometimes conflicting. For example, whereas several studies have found a significant association between wait time and initial appointment " no show " (Raynes and Warren, 1971; Wolkon, 1972), others have failed to find such a relation (Gould et al., 1970; Lowman et al., 1984). One purpose of the present study was to further explore the relation between these various factors and the " no show" rate to initial appointments in a child psychiatric outpatient clinic. The second purpose of the present study was to test the 'efficacy of several different interventions for improving the rates of initial clinic attendance . Various procedures have been tried in order to reduce initial appointment failures including written and oral orientation statements (Garrison, 1978; Witkower, 1981; Kluger and Karras, 1983), telephone preparations and prompts (Turner and Vernon, 1976; Hochstadt and Trybula, 1980; Burgoyne et al., 1983; Kluger and Karras, 1983), and letter prompts (Hochstadt and Trybula ,
Accepted August 10, 1989 . Dr. Kourany is Associate Prof essor ofPsychiatry, Division of Child and Adolescent Psychiatry at Vanderbilt University Medical School. Dr . Garber is Assistant Professor of Psychology and Human Development and Assistant Professor ofPsychiatry at Vanderbilt University. Gabriel Tornusciolo was an undergraduate at Vanderbilt University at the time of the study. The authors would like to acknowledge the assistance of Sherron Buchanan in the collection of these data and would like to thank Bahr Weiss f or his statistical consultation . Portions of this pap er were presented at the annual meeting of the Ameri can Academy ofChild and Adolescent Psychiatry, Seattle, Wash· ington, October, 1988. Reprint requests to Judy Garber, Department of Psychol ogy and Human Development, Box 512 Peabody , Vanderbilt University , Nashville, Tennessee 37203. 0890-8567/90/2904-0657$02 .00/0© 1990 by the American Academy of Child and Adolescent Psychiatry.
657
KOURANY ET AL.
1980; Swenson and Pekarik, 1988). Although oral preparatory orientations and telephone prompts have been found to be effective in reducing initial appointment failures, they tend to be inefficient and labor intensive. Results of written orientation statements and mailed prompts have been generally positive, although there is some suggestion that the efficacy of these letters may depend upon the timing of when they are received (Hochstadt and Trybu1a, 1980; Swenson and Pekarik, 1988). The present study was designed to test further the efficacy of alternative procedures for improving initial clinic attendance in a child and adolescent psychiatric clinic. Since most of the existing studies have been conducted with respect to adult psychiatric populations, the extent to which these various procedures are effective with child and adolescent populations is less clear. Therefore, the present study compared the efficacy of an orientation letter, a telephone prompt, a combined orientation letter and telephone prompt, and no contact for improving the initial appointment attendance rate in a child and adolescent psychiatric clinic. The final purpose of this study was to assess parents' reasons for not attending their initial clinic appointments. Following the work of Gould et al. (1985), the present study investigated the explanations parents gave for their appointment failure in order to identify possible reasons for these "no shows" that could be the target of future interventions. Method Subjects. Subjects were consecutive patients who called to make an appointment in the outpatient child psychiatry clinic of Vanderbilt University between January and June, 1987. Basic demographic and referral information about the child and family was obtained by the staff person who scheduled the appointment. The sample was 69% male and 79% caucasian, ranging in age from 2.25 to 17.75 years (X = 10.38 years). The children were referred predominantly for behavioral problems (47.4%), emotional problems (27%), or educational concerns (12.1 %). Fifty-three percent of the parents were currently married; thirty-three percent of the families were on Medicaid. Forty percent of the sample had been in treatment before. Intervention. The 111 patients were randomly assigned to one of four conditions: (1) a telephone call reminder 1 to 2 days before their appointment (N = 28); (2) a letter describing what would happen on their first visit to the clinic was sent out a few days after the appointment was made (N = 27); (3) a phone call and a letter as described in the previous two conditions (N = 30); and (4) no contact between their initial phone call and their scheduled appointment day (N = 26). There were no significant differences among the four treatment groups with regard to any of the demographic characteristics. The orientation letter was a two-sided single sheet that contained information about what parents and children would experience at their first clinic appointment. It briefly described business (insurance) matters, outlined the clinical assessment procedures that would occur, told the expected amount of time patients would be seen, and the nature of the feedback they were likely to get upon completion of the
658
intake procedures. Finally, parents were requested to call the clinic if they needed to cancel their appointment. Follow-up. Those patients who did not come to their appointment (either "no shows" or cancellations) were recontacted by telephone several weeks after their appointment time in order to inquire about their reasons for not coming. The follow-up questionnaire was based upon the work of Carpenter et al. (1981) and Gould et al. (1985). Parents were first asked an open-ended question: "Can you tell us what prevented you from keeping the appointment on (date)?" Next, they were asked to rate on a three point scale (0 = Not True; 1 = Somewhat True; 3 = Very True) 24 possible reasons for not coming for their appointment. Results Intervention. Table 1 presents the number of "no shows," cancellations, and shows to the clinic appointment in each of the four treatment conditions. "No shows" were defined here as those individuals who did not come to their scheduled clinic visit and who did not cancel the appointment. Cancellations were defined as those individuals who either called the clinic to cancel their appointment, or who cancelled their appointment when they were called by the clinic to confirm it. Although the chi-square analysis comparing the rate of "no shows," cancellations, and shows as a function of the four interventions was not significant, X2 (6) = 7.76, the analysis comparing the effect of any kind of contact (call, letter, or both) versus no contact was significant, X2 (2) = 7.05, P < 0.03. These results suggest that, although it did not seem to matter what was the nature of the contact, any contact was better than no contact with regard to the "no show" rate. Contact did not significantly affect the rate of cancellations, however, Of course, since these analyses involved a second comparison without correcting the alpha level, the results should be interpreted with caution (although see the results below of the logit categorical data modeling procedures that are consistent with this conclusion). Characteristics of "no shows" and cancellations. There was a significant difference among those families who failed, cancelled, or showed for their first clinic appointment with regard to their history of prior treatment, X2 (2) = 6.92, p < 0.03, and the number of days they had to wait between their initial contact phone call and their appointment day, F(2,106) = 7.76, P < 0.0008. Additional analyses of these results indicated that those families who came to their appointment were significantly more likely to have been in treatment before than were the families who failed or cancelled their initial appointment. Post hoc analyses using the Student Newman-Keuls procedures on the number of days required to wait for their appointment revealed that the families who failed to show
