Characterising the nationwide burden and predictors of unkept outpatient appointments in the National Health Service in England: A cohort study using a machine learning approach

BackgroundUnkept outpatient hospital appointments cost the National Health Service £1 billion each year. Given the associated costs and morbidity of unkept appointments, this is an issue requiring urgent attention. We aimed to determine rates of unkept outpatient clinic appointments across hospital trusts in the England. In addition, we aimed to examine the predictors of unkept outpatient clinic appointments across specialties at Imperial College Healthcare NHS Trust (ICHT). Our final aim was to train machine learning models to determine the effectiveness of a potential intervention in reducing unkept appointments.Methods and findingsUK Hospital Episode Statistics outpatient data from 2016 to 2018 were used for this study. Machine learning models were trained to determine predictors of unkept appointments and their relative importance. These models were gradient boosting machines. In 2017–2018 there were approximately 85 million outpatient appointments, with an unkept appointment rate of 5.7%. Within ICHT, there were almost 1 million appointments, with an unkept appointment rate of 11.2%. Hepatology had the highest rate of unkept appointments (17%), and medical oncology had the lowest (6%). The most important predictors of unkept appointments included the recency (25%) and frequency (13%) of previous unkept appointments and age at appointment (10%). A sensitivity of 0.287 was calculated overall for specialties with at least 10,000 appointments in 2016–2017 (after data cleaning). This suggests that 28.7% of patients who do miss their appointment would be successfully targeted if the top 10% least likely to attend received an intervention. As a result, an intervention targeting the top 10% of likely non-attenders, in the full population of patients, would be able to capture 28.7% of unkept appointments if successful. Study limitations include that some unkept appointments may have been missed from the analysis because recording of unkept appointments is not mandatory in England. Furthermore, results here are based on a single trust in England, hence may not be generalisable to other locations.ConclusionsUnkept appointments remain an ongoing concern for healthcare systems internationally. Using machine learning, we can identify those most likely to miss their appointment and implement more targeted interventions to reduce unkept appointment rates.

Sion Phillpott-Morgan and co-workers study occurrence and possible predictors of unkept outpatient appointments in the UK.     

Referrals to hospital by general practitioners: a study of compliance and communication.

To determine the extent of non-attendance at first hospital appointments 269 hospital referrals made in one practice over 14 weeks were analysed retrospectively. Non-attendance was more likely among patients referred to outpatient departments than to casualty or for admission. Fifteen per cent (41/269) of all patients and 20% (33/167) of outpatients failed to keep their initial appointments. Prolonged waiting times from referral to appointment were significantly related to non-attendance. Twenty weeks after the last referral had been made no communication had been received by the practice for 24% (61/252) of all referral letters received by the hospital. Minimum delays to appointments and improved communication between hospitals and general practitioners would help general practitioners to make appropriate referrals and improve compliance.     

Recruitment methods for screening programmes: trial of a new method within a regional osteoporosis study.

OBJECTIVE--To estimate the response rates and operating costs of three recruitment methods within a regional osteoporosis screening programme. DESIGN--Randomised trial of three types of invitation letter: one offering fixed appointments with option to change time, one offering fixed appointments but requiring telephoned confirmation of intention to attend, and one inviting recipient to telephone to make an appointment. SETTING--Osteoporosis screening unit, Aberdeen. SUBJECTS--1200 women aged 45-49 years living within 32 km of Aberdeen and randomly selected from the community health index. 400 women were randomised to each appointment method. MAIN OUTCOME MEASURES--Numbers attending for screening; default rate among women who confirmed appointments; social class of attenders; cost per appointment slot and per completed scan. RESULTS--299 (75%), 277 (69%), and 217 (54%) women were scanned after fixed, confirmable, and open invitations respectively. Women who attended were given a questionnaire, and 694 (87.5%) returned it. No significant differences were found in the social class of attenders among the three methods. Of the 514 women who made or confirmed appointments, 494 attended for a scan. Total costs per scan were 25.00 pounds, 21.40 pounds, and 21.00 pounds for fixed, confirmable, and open invitations respectively. CONCLUSIONS--The offer of a fixed appointment requiring telephoned confirmation has the potential to reduce the costs of scanning without exaggerating any social bias or significantly reducing response rates provided that empty appointments can be rebooked at short notice.     

Appointment systems: evaluation of a flexible system offering patients limited choice

To test the efficiency of a flexible appointments system patients seeing one of the partners in a semirural dispensing practice were asked to choose whether they wanted appointments lasting five, 10, or 15 minutes. After seeing the doctor they were asked to fill in a questionnaire that asked, among other questions, how long an appointment they had booked, whether they had felt rushed, whether the doctor had seemed hurried, whether they had seen the doctor on the day they wanted, how long they had had to wait in the surgery, and whether they liked the system. Five minute appointments had been chosen by 124 of the 309 patients who returned completed questionnaires, 10 minute appointments by 155, and 15 minute appointments by 30. Mean consultation times were 6·1, 9·2, and 12·9 minutes, respectively. Altogether 298 patients liked the system.An appointment system that was flexible while remaining practical and efficient resulted from letting patients choose the length of their appointment. Such a system encourages patients to share in the responsibility of organising a practice efficiently.     

Nicotine chewing gum in general practice: effect of follow up appointments.

Two hundred smokers who were judged by their general practitioner to be motivated to stop smoking were allocated to one of two groups. All were offered an initial appointment at which they were advised to stop smoking and offered nicotine gum. One group then received no further appointments. The other was offered four further appointments over three months. Both groups were followed up at six and 12 months. At one year follow up 15.5% overall had stopped smoking, 14% in the low and 17% in the high contact group. This is better than most results so far reported for nicotine chewing gum in general practice, suggesting that general practitioners can use it to good effect. We compare this result with others achieved in general practice.     

Stating Appointment Costs in SMS Reminders Reduces Missed Hospital Appointments: Findings from Two Randomised Controlled Trials

Background

Missed hospital appointments are a major cause of inefficiency worldwide. Healthcare providers are increasingly using Short Message Service reminders to reduce ‘Did Not Attend’ (DNA) rates. Systematic reviews show that sending such reminders is effective, but there is no evidence on whether their impact is affected by their content. Accordingly, we undertook two randomised controlled trials that tested the impact of rephrasing appointment reminders on DNA rates in the United Kingdom.

Trial Methods

Participants were outpatients with a valid mobile telephone number and an outpatient appointment between November 2013 and January 2014 (Trial One, 10,111 participants) or March and May 2014 (Trial Two, 9,848 participants). Appointments were randomly allocated to one of four reminder messages, which were issued five days in advance. Message assignment was then compared against appointment outcomes (appointment attendance, DNA, cancellation by patient).

Results

In Trial One, a message including the cost of a missed appointment to the health system produced a DNA rate of 8.4%, compared to 11.1% for the existing message (OR 0.74, 95% CI 0.61–0.89, P<0.01). Trial Two replicated this effect (DNA rate 8.2%), but also found that expressing the same concept in general terms was significantly less effective (DNA rate 9.9%, OR 1.22, 95% CI 1.00–1.48, P<0.05). Moving from the existing reminder to the more effective costs message would result in 5,800 fewer missed appointments per year in the National Health Service Trust in question, at no additional cost. The study’s main limitations are that it took place in a single location in England, and that it required accurate phone records, which were only obtained for 20% of eligible patients. We conclude that missed appointments can be reduced, for no additional cost, by introducing persuasive messages to appointment reminders. Future studies could examine the impact of varying reminder messages in other health systems.

Trial Registration

Controlled-Trials.com 49432571     

Non-attendance or non-invitation? A case-control study of failed outpatient appointments.

OBJECTIVE--To determine the causes of non-attendance at new outpatient appointments. DESIGN--Case-control study of non-attenders and attenders. SETTING--Outpatient department of a general hospital. SUBJECTS--All non-attenders (n = 277) for first outpatient appointments in six specialties during a three month period were included. Controls (n = 135) were the attenders who followed every second non-attender; thus they attended the same consultant on the same day that the non-attenders were expected. INTERVENTIONS--None. MEASUREMENTS AND MAIN RESULTS--Information on the clinical problem, difficulties in attending the hospital, and reasons for non-attendance from the questionnaire were coded and classified. Non-attenders had received shorter notice of their appointment than attenders (14% v 1% had received three days'' notice or less). There were small differences in the seriousness of patients'' clinical condition. CONCLUSIONS--Client factors are less important than aspects of the service in explaining non-attendance at outpatient appointments.     

Health promotion in the general practice consultation: a minute makes a difference.

OBJECTIVE--To see whether extending appointment length from seven and a half minutes or less to 10 minutes per patient would increase health promotion in general practice consultations. DESIGN--Controlled trial of 10 minute appointments. Consultations were compared with control surgeries in which the same doctors booked patients at their normal rate (median six minutes per patient). SETTING--10 general practices in Nottinghamshire. SUBJECTS--16 general practitioners were recruited. Entry criteria were a booking rate of eight or more patients an hour, a wish for longer consultations, and plans to increase appointment length. MAIN OUTCOME MEASURES--Duration of consultations; recording of blood pressure, weight, and cervical cytology in the medical record; recording of advice about smoking, alcohol, diet, exercise, and immunisation in the medical record; reporting of the above activities by patients. RESULTS--Mean consultation times were 8.25 minutes in the experimental sessions and 7.04 and 7.16 minutes in the control sessions. Recording of blood pressure, smoking, alcohol consumption, and advice about immunisation was significantly more frequent in the experimental sessions, and the proportion of consultations in which one or more items of health education were recorded in the medical notes increased by an average of over 6% in these sessions. Patients more often reported discussion of smoking and alcohol consumption and coverage of previous health problems in the experimental sessions. There was little change in discussion of exercise, diet, and weight or cervical cytology activity. CONCLUSIONS--Shortage of time is a major factor in general practitioners'' failure to realise their potential in health promotion. General practice should be organised so that doctors can run 10 minute appointment sessions.     

Outreach Method Predicts Patient Re-engagement in Diabetes Care During Sustained Care Disruption

ObjectiveDuring the COVID-19 pandemic, visits for diabetes care were abruptly canceled without predefined procedures to re-engage patients. This study was designed to determine how outreach influences patients to maintain diabetes care and identify factors that might impact the intervention’s efficacy.MethodsA diabetes nursing team attempted outreach for patients who had a canceled appointment for diabetes between March 16, 2020, and June 19, 2020. Outreach status was defined as reached, message left, or no contact. Outcomes were defined as follows: (1) booking and (2) keeping a follow-up appointment.ResultsSeven hundred eighty-seven patients were included (384 [49%] were reached, 152 (19%) were left a message, and 251 (32%) had no contact). Reached patients were more likely to book [odds ratio (OR) = 2.43, P < .001] and keep an appointment (OR = 2.39, P < .001) than no-contact patients. Leaving a message did not increase the odds of booking (OR = 1.05, P = .84) or keeping (OR = 1.17, P = .568) an appointment compared with no contact. Older age was a significant predictor of booking an appointment (OR = 1.014 for each year of age, P = .037). Patients on insulin were more likely to keep their appointment (OR = 1.70, P = .008). Patients with a higher hemoglobin A1C level were less likely to keep their appointment (OR = 0.87 for each 1.0% increase in the hemoglobin A1C level, P = .011).ConclusionThese findings suggest that to optimize re-engagement during care disruption, 1-way communication is no better than no contact and that 2-way communication increases the likelihood that patients will maintain access to care. In addition, although higher-risk patients (eg, patients with older age or those on insulin) may be more incentivized to stay engaged, targeted outreach is needed for those with chronically poor glycemic control.     

Quality improvement report: Information given to patients before appointments and its effect on non-attendance rate

Problem Wasted outpatient appointments as a result of clinic non-attendance, exacerbating outpatient waiting times.DesignSingle centre, prospective, non-randomised, controlled study.

Background and setting

Diabetes clinic in a district general hospital run by a consultant, one or two diabetes nurse specialists, a dietitian, and a podiatrist. Clinic receives 10-15 new referrals a week in a health district with a population of 340 000.

Key measure for improvement

Non-attendance rate in 325 new patients who attended after the intervention compared with 1336 historical controls from the same clinic in the three years before the scheme.

Strategy for change

Two weeks before their outpatient appointment new patients were sent an information pack telling them when and where to come, where to park, what to bring, who they will see, and what to expect. One week before the appointment they received a supplementary phone call.

Effects of change

Telling patients what to expect reduced non-attendance rate overall from 15% (201/1336) to 4.6% (15/325), P<0.0001. Non-attendance rate was 7.3% (13/178) in those sent a pack but not phoned and 1.4% (2/147) in those sent a pack and phoned, P=0.01.

Lesson learnt

Giving new patients detailed information reduces non-attendance to almost 1%.     

General practice orthopaedic outpatient referrals in North Staffordshire.

A study was made of 813 orthopaedic referrals by 134 general practitioners in North Staffordshire. The referral rates showed no relation to practice list size or the doctors'' previous orthopaedic experience. The published waiting times did not accurately reflect clinic vacancies, and no effective priority rating of letters by consultants was shown. Less than 1% of patients had an appointment within four weeks. One quarter of the patients failed to attend and, of those who did, 27% received physiotherapy or a "simple" appliance, or both, while 16% received treatment already available from their general practitioner. Patients from high referring doctors showed the same pattern of distribution in body area affected and treatment outcome as those from low referring doctors, but had a significantly longer time to wait for their appointment. A survey of non-attenders showed that 56% of the patients failed to attend because the condition had resolved.     

Use of reminders to increase compliance with tetanus booster vaccination.

OBJECTIVE: To assess the effect of three computerized reminder systems on compliance with tetanus vaccination. DESIGN: Prospective randomized controlled trial. SETTING: Ottawa Civic Hospital Family Medicine Centre. PARTICIPANTS: Of 8069 patients 20 years of age or more who were not in a hospital or institution 5589 were randomly assigned, by family, to a control group, a physician reminder group, a telephone reminder group or a letter reminder group. The remaining 2480 patients were not included in the randomized portion of the study but were monitored. Results are presented for the 5242 randomized patients and the 2369 nonrandomized patients for whom there was no up-to-date record of tetanus vaccination at the start of the trial. INTERVENTIONS: For the patients in the physician reminder group the physician was reminded at an office visit to assess the patient''s tetanus vaccination status and to recommend vaccination; those in the other two reminder groups received a telephone call or letter enquiring about their tetanus vaccination status and recommending a booster dose. MAIN OUTCOME MEASURE: Proportion of patients who received tetanus toxoid during the study year or who had a claim of vaccination in the previous 10 years. MAIN RESULTS: The rate of recorded tetanus vaccination in the randomized control group was 3.2%. The difference between that rate and those for the three reminder groups was 19.6% in the physician reminder group (95% confidence interval [CI] 17.1% to 22.2%, p less than 0.00001), 20.8% in the telephone reminder group (95% CI 18.3% to 23.5%, p less than 0.00001) and 27.4% in the letter reminder group (95% CI 24.8% to 30.2%, p less than 0.00001)). The letter reminders were more effective than either the telephone reminders (p = 0.00013) or the physician reminders (p less than 0.00001) in improving compliance. The cost to the practice per additional vaccination recorded was 43 for the physician reminders, $5.43 for the telephone reminders and $6.05 for the letter reminders. CONCLUSIONS: Although all three reminder systems increased the rate of recorded tetanus vaccination they fell far short of achieving complete population coverage. More intensive interventions would be required to approach that goal. However, such interventions do not appear to be justified given the rarity of tetanus.     

Randomised controlled trial of computer assisted management of hypertension in primary care.

The hypothesis that general practitioners would obtain better outcomes for patients with hypertension using a computer than doctors not using a computer was tested. Sixty family physicians were randomised to two treatment strategies. "Test" physicians completed a data collection form after each visit from a patient with hypertension and mailed the forms to the test centre for processing. Computer feedback on management was mailed to the doctors. This encouraged doctors to apply the "stepped care" protocol, supplied charts of diastolic blood pressure v time, and ranked patients'' diastolic blood pressures by percentile. Letters were mailed to patients to remind them of appointments. "Control" doctors filled out the same data collection forms as test physicians, but neither doctors nor patients received computer feedback. Physicians who used the computer saw more patients per practice than control doctors (test 50 patients, control 40). For all patients the length of follow up was significantly longer in test practices (test 199 days, control 167), and a smaller percentage dropped out of active treatment in test practices (test 37.5%, control 42.1%). For patients with "moderate" hypertension of a baseline diastolic pressure of greater than 104 mm Hg the mean score of the last recorded pressure was below the goal of 90 mm Hg in test practices (88.5 mm Hg), but it failed to reach this goal in control practices (93.3 mm Hg). A greater average reduction of diastolic pressure was achieved in test practices (test 21.7 mm Hg, control 16.7 mm Hg). Though patients with "moderate" hypertension were better controlled in test practices than in control practices, the patients in test practices visited their doctors less often (test 13.3 visits per patient-year, control 17.4 visits). Among patients with newly detected hypertension test practices achieved a greater reduction in diastolic pressure than control practices (test 15.1 mm Hg v control 11.3 mm Hg) and more sustained control of hypertension (test 323 days per patient-year with a diastolic pressure of 90 mm Hg or less v control 259 days).     

Postal survey of patients' satisfaction with a general practice out of hours cooperative.

OBJECTIVE: To assess patients'' satisfaction with out of hours care by a general practice cooperative compared with that by a deputising service. DESIGN: Postal questionnaire survey. SETTING: A general practice cooperative in London and a deputising service operating in an overlapping area. SUBJECTS: Weighted samples of patients receiving telephone advice, a home visit, or attending a primary care centre after contacting either service in an eight week period. MAIN OUTCOME MEASURES: Patients'' overall satisfaction and scores for specific aspects of satisfaction. Satisfaction with telephone advice or attendance at centre compared with home visit. Relation between satisfaction and patient''s age, sex, ethnic group, car ownership, preference for consulting own doctor, and expectation of a visit. RESULTS: The overall response rate was 67% (1555/2312). There was little difference in overall satisfaction between patients contacting the cooperative or the deputising service, but patients contacting the latter were less satisfied with the explanation and advice received and the wait for a visit. There were significant differences between patients in different age and ethnic groups, with white patients and those aged over 60 years being more satisfied. Lower scores for overall satisfaction were reported by patients who received telephone advice, those who would have preferred to see their own doctor or who originally wanted a home visit, and those who waited longer for their consultation. Overall levels of patients'' satisfaction seemed to be lower than previously reported. CONCLUSIONS: There were larger differences in satisfaction between different groups of patients than between different models of organisation for out of hours care. A shift to a service based predominantly on telephone advice may lead to increased patient dissatisfaction.     

Popularity of less frequent follow up for breast cancer in randomised study: initial findings from the hotline study.

OBJECTIVE: To compare the experiences of patients with breast cancer who were conventionally monitored with those in whom routine follow up was restricted to the time of mammography. DESIGN: Randomisation to conventional schedule of clinic visits or to visits only after mammography. Both cohorts received identical mammography and were invited to telephone for immediate appointments if they detected symptoms. SETTING: Combined breast clinic, Chelsea and Westminster Hospital. SUBJECTS: 211 eligible outpatients with a history of breast cancer. MAIN OUTCOME MEASURES: Acceptability of randomisation, interim use of telephone and general practitioner, satisfaction with allocation to follow up. RESULTS: Of 211 eligible patients, 196 (93%) opted for randomisation in the study. Of these, 55 were under 50 years, 78 were diagnosed fewer than five years before, 90 had stage T2-4 tumours, and 71 had involved axillary nodes. Patients who did not participate were more likely to be under 50 years, to be two to five years after diagnosis, and to have had aggressive primary disease. Twice as many patients in both groups expressed a preference for reducing rather than increasing follow up. No increased use of local practitioner services or telephone triage was apparent in the cohort randomised to less frequent follow up by specialists. CONCLUSIONS: Reducing the frequency of routine follow up has so far proved popular among patients with breast cancer at standard risk in this cohort. A multicentre study is needed to determine the effectiveness and cost-effectiveness of routine follow up with respect to disease outcomes.     

Weekday Affects Attendance Rate for Medical Appointments: Large-Scale Data Analysis and Implications

The financial cost of missed appointments is so great that even a small percentage reduction in Did Not Attend (DNA) rate could save significant sums of money. Previous studies have identified many factors that predict DNA rate, including patient age, gender, and transport options. However, it is not obvious how healthcare providers can use this information to improve attendance, as such factors are not under their control. One factor that is under administrative control is appointment scheduling. Here we asked whether DNA rate could be reduced by altering scheduling policy. In Study 1, we examined attendance records for 4,538,294 outpatient hospital appointments across Scotland between January 1st 2008 and December 31st 2010. DNA rate was highest for Mondays (11%), lowest for Fridays (9.7%), and decreased monotonically over the week (Monday-Friday comparison [χ²(1, N  = 1,585,545)  = 722.33, p<0.0001]; Relative Risk Reduction 11.8%). This weekly decline was present for male and female patient groups of all ages, but was steeper for younger age groups. In Study 2, we examined attendance records for 10,895 appointments at a single GP clinic in Glasgow. Here again, DNA rate was highest for Mondays (6.2%), lowest for Fridays (4.2%), and decreased monotonically over the week (Monday-Friday comparison [χ²(1, N  = 4767)  = 9.20, p<0.01]; Relative Risk Reduction 32.3%). In two very different settings, appointments at the beginning of the week were more likely to be missed than appointments at the end of the week. We suggest that DNA rate could be significantly reduced by preferentially loading appointments onto high-attendance days.     

Dr. Steinhart replies

Despite recommendations supporting annual influenza vaccination for people aged 65 years or older, vaccination rates remain low. Several studies have evaluated the effect of sending mailed reminders, but few have compared alternative ways of reminding patients to receive the vaccine. In a randomized trial of 939 patients aged 65 years or older in four family practices carried out between Oct. 23 and Dec. 31, 1984, we compared three ways of reminding elderly patients to receive the vaccine: personal reminder by the physician, telephone reminder by the nurse and reminder by letter. The vaccination rates for the three groups were 22.9%, 37% and 35.1% respectively. No reminder was issued to a control group, and the rate was 9.8%. Some patients could not be reached by telephone, and some did not see the physician during the specified time. Among the patients whom the nurse actually contacted, the vaccination rate was 43.5%; the rate for patients whom the doctor actually saw was 45.1%. Overall, a telephone reminder by the nurse was the most effective method, and at an hourly salary of $16 or less this method would also be the most cost-effective. The reminders used in this study were automatically generated from a computerized medical record system. The study shows how a computerized system can be used to identify patients for whom preventive procedures are due.     

A study of patients attending without appointments in an urban general practice.

OBJECTIVE--To ascertain which social and psychological characteristics are associated with patients attending surgeries without appointments. DESIGN--Prospective study of patients attending an urban centre group practice. SETTING--Urban health centre group practice with five doctors and 12,000 patients in an area of high (greater than 20%) unemployment and social deprivation. PATIENTS--All attenders at the open access surgery and one in four consecutive attenders by appointment, selected sequentially from the first three appointments, during 10 days in January 1989. Patients participating in the pilot study, reattending during the study period, or attending antenatal clinics were excluded. MAIN OUTCOME MEASURES--Patients'' attitude to making appointments and reasons for attending, including perception of urgency, with respect to sociodemographic and psychosocial data obtained from a self completed questionnaire before the consultation. Doctors'' diagnosis and perception of urgency obtained from a separate questionnaire. RESULTS--86% (141/172) Of patients attending without appointments and 96% (139/145) with appointments responded to the questionnaire. The need for consultation was considered to be "very urgent" or "fairly urgent" in significantly more of the open access group than the appointments group (89%, 124/139 v 66%, 91/138; chi 2 = 27.04, df = 3; p less than 0.001), although the doctors did not share the same views. Significantly more patients had self limiting conditions of recent onset in the open access than in the appointments group (75%, 101/135 v 48%, 59/123: p less than 0.001). Overall, open access attendance was significantly linked with social support (39%, 48/124 v 26%, 32/123; p less than 0.05) and with marital separations or intentions to separate (10%, 9/87 v 0/92; 47%, 32/87 v 22%, 20/92 respectively; both p less than 0.001), but the doctors recorded significantly fewer psychological and social problems in these patients (p less than 0.05). Although almost half those in the appointments group considered that making appointments was inconvenient, more of those in the open access group agreed with this view (47%, 60/129 v 61%, 80/131). CONCLUSIONS--There was an important link between social support problems and a negative attitude to making appointments. In our previous experience encouraging patients to make appointments has been unsuccessful; practices serving areas with a high prevalence of social deprivation providing a mixed open access and appointments system may better serve patients'' needs.     

End-of-Life Decisions: A Cross-National Study of Treatment Preference Discussions and Surrogate Decision-Maker Appointments

Background

Making treatment decisions in anticipation of possible future incapacity is an important part of patient participation in end-of-life decision-making. This study estimates and compares the prevalence of GP-patient end-of-life treatment discussions and patients’ appointment of surrogate decision-makers in Italy, Spain, Belgium and the Netherlands and examines associated factors.

Methods

A cross-sectional, retrospective survey was conducted with representative GP networks in four countries. GPs recorded the health and care characteristics in the last three months of life of 4,396 patients who died non-suddenly. Prevalences were estimated and logistic regressions were used to examine between country differences and country-specific associated patient and care factors.

Results

GP-patient discussion of treatment preferences occurred for 10%, 7%, 25% and 47% of Italian, Spanish, Belgian and of Dutch patients respectively. Furthermore, 6%, 5%, 16% and 29% of Italian, Spanish, Belgian and Dutch patients had a surrogate decision-maker. Despite some country-specific differences, previous GP-patient discussion of primary diagnosis, more frequent GP contact, GP provision of palliative care, the importance of palliative care as a treatment aim and place of death were positively associated with preference discussions or surrogate appointments. A diagnosis of dementia was negatively associated with preference discussions and surrogate appointments.

Conclusions

The study revealed a higher prevalence of treatment preference discussions and surrogate appointments in the two northern compared to the two southern European countries. Factors associated with preference discussions and surrogate appointments suggest that delaying diagnosis discussions impedes anticipatory planning, whereas early preference discussions, particularly for dementia patients, and the provision of palliative care encourage participation.     

Impact of a new medical network system on the efficiency of treatment for eating disorders in Japan: a retrospective observational study

Background

In Japan, patients generally have free access to any hospital or clinic. This could lead to reduced efficiency in the treatment for eating disorders (EDs) because there are only a limited number of doctors who can treat ED patients. The objectives of this study were to examine the efficiency of a new trial system for consultation and appointments, a medical community network (MCN), in outpatient treatment for EDs. MCN schedules appointments for the first visit only by referral from another medical institution, not by patients themselves.

Methods

We analyzed the data of 342 outpatients (mean age = 28.9 ± 9.9 years; 328 female and 14 male) who visited the ED clinic at the University of Tokyo Hospital for the first time between January 2009 and July 2012 to investigate possible differences in treatment efficacy between the new (MCN+) system and the conventional (MCN-) system, which accepts reservations directly from patients.

Results

The no-show rate for MCN+ patients (0.8%) was significantly lower than that for the MCN- group (17.8%) (p < 0.001). MCN+ patients had a significantly shorter waiting period (8.4 days) for the first visit compared to MCN- patients (35.5 days, p < 0.001). In addition, the MCN+ group had a much higher rate of successive visits to the clinic (p < 0.05).

Conclusion

This new consultation system using a medical community network provided more efficient treatment for ED than did the appointment system in which the patients made their appointments by themselves.