Abstract
BackgroundNonattendance at scheduled appointments in public hospitals presents a challenge for efficient resource use and may ultimately affect health outcomes due to longer waiting times. Seven percent of all scheduled outpatient appointments in the United Kingdom are estimated to be nonattended. Various reminder systems have been shown to moderately reduce nonattendance, although the effect of issuing fines for nonattendance has not yet been tested in a randomized context. However, such use of financial incentives could impact access to care differently across the different socioeconomic groups. The aim of this study is to assess the effect of fines on hospital outpatient nonattendance.Methods/designA 1:1 randomized controlled trial of scheduled outpatient appointments was used, with follow-ups until the date of appointment. The setting is an orthopedic clinic at a regional hospital in Denmark. Appointments for users who are scheduled for diagnostics, treatment, surgery, or follow-ups were included from May 2015 to November 2015. Appointments assigned to the intervention arm include an attachment of the appointment letter explaining that a fine will be issued in the case of nonattendance without prior notice. Appointments assigned to the control arm follow usual practice (same system but no letter attachment). The primary outcome is the proportion of nonattendance. Secondary outcomes are proportions of cancellations, sociodemographics, and health-problem characteristics. Furthermore, the intervention costs and production value of nonattended appointments will be measured. An analysis of effect and cost-effectiveness will be conducted based on a 5 % significance level.DiscussionThe study is initiated and funded by the Danish Regions, which have the responsibility for the Danish public healthcare sector. The results are expected to inform future decisions about the introduction of fines for nonattendance at public hospitals.Trial registrationCurrent Controlled Trials, ISRCTN61925912. Registered on 6 July 2015.
Highlights
Nonattendance at scheduled appointments in public hospitals presents a challenge for efficient resource use and may affect health outcomes due to longer waiting times
The introduction of fines for nonattendance in Danish outpatient clinics has been debated for more than a decade, and stakeholders such as the Danish Regions, Danish Patients, and the Danish Medical Association have been involved in the debate
The ethics of selecting a particular group of users for nonvolunteer participation in this trial is atypical in comparison with, e.g., clinical experiments where participants are normally only included on giving informed consent
Summary
Nonattendance at scheduled appointments in public hospitals presents a challenge for efficient resource use and may affect health outcomes due to longer waiting times. Various reminder systems have been shown to moderately reduce nonattendance, the effect of issuing fines for nonattendance has not yet been tested in a randomized context Such use of financial incentives could impact access to care differently across the different socioeconomic groups. Stubbs et al conducted a systematic literature review to assess the efficacy of various reminder interventions for reducing outpatient nonattendance such as telephone, mail, text/short message service, e-mail reminders, and open-access scheduling [7]. They found that almost all of the assessed interventions moderately reduced nonattendance. The recognition of a need for further high-quality studies has been confirmed by similar systematic reviews [8,9,10]
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