A Quality Improvement Project to Reduce No-Show Rates in a Community Pediatric Subspecialty Clinics

From the 2023 HVPA National Conference

Olushola Fapo M.B.B.S, MPH (Pediatric Department, Harlem Hospital Center), Sumitha Tarur M.D, Rayana Johnson M.D, Priscila Lisboa M.D, Cyndee Jocson M.D, Kirsty Lim M.D, Sheetal Chepuri M.D, Agrawal Prerna M.D, Audrie Lazaga M.D, Sundari Periasamy M.D

Background:
Patient no-shows or missed appointments continue to be a long-standing problem in preventive medicine. A no-show is defined as when patients fail to attend their scheduled clinic appointments without cancellation or rescheduling notice. Target no-show rate for New York City Health and Hospitals System is less than 20%. Recognizing its immense effect on patient’s health and daily healthcare operations, several studies and interventions have been employed to mitigate the negative patient health outcomes, decreased access to care and the increased cost that no-shows can cause. This further negatively impacts health care delivery to our patient population, worsening health disparities and health outcomes.

Objectives:
Determine the rate and establish reasons for patient no-shows in the pediatric subspecialty clinics at Harlem Hospital Center (HHC). Implement strategic action plans to improve show rates in all 8 pediatric subspecialty clinics.

Methods:
Retrospective chart review of clinic no-shows obtained from EHR across 8 pediatric subspecialty clinics in a 3-year period (2020-2022). No-show was measured as the percentage of patients who did not attend their appointments, compared to all scheduled patients. We excluded cancelled or rescheduled appointments. Survey administered to 74 patients with no-shows. Study was IRB exempt.

Results:
The average no-show rate for the 8 subspecialties clinics (adolescent medicine, cardiology, developmental, endocrinology, genetics, hematology, neurology, and pulmonology) in 2020, 2021, and 2022 were 37%, 43.5%, and 42.5% respectively, higher in 2021 and 2022 compared to 2020. The rates are still far from the NYCHHC’s goal of no-show rate of 20%. However, the rate of no show at the general pediatric clinic during the same time period stands at 23.7%, 19.7%, and 21.4% respectively. The no-show rates for the 8 subspecialty clinics were: Adolescent (31%, 30%, 36%), Cardiology (36%, 37%, 38%), Development (35%, 41%, 42%), Endocrinology (38%, 51%, 54%), Genetics (43%, 43%, 42%), Hematology (32%, 39%, 37%), Neurology (39%, 42%, 41%), and, Pulmonology (42%, 64%, 49%).

Interestingly, some of the specialty clinics, genetics -1.2%, hematology -2.7%, neurology -0.9%, pulmonology -15.5% improved in no- show rates in 2022 compared to 2021, while the no-shows increased for adolescent +5.7%, cardiology +1.2%, development +0.5%, endocrinology +2.7% during same period.

A survey of subspecialty clinic patients with no-shows (n=74) carried out to determine the reasons for no-shows found out that 47% received no reminders about their appointment. Majority that received reminders were through phone calls and 59% of those received one 3 days before their appointment. The most common reason for no-shows were forgetting appointment 35%, followed by 20% due to personal or family reasons, and 7% were not aware of the appointment. When asked about ways to improve no-shows, 34% of patients had no suggestions, 19% requested call reminders, 10% call and text reminders, 5% MyChart reminders, 3% want evening clinics and 3% shorter wait for appointments.

Conclusion:
This study found high no-show rates for subspecialty clinics over a 3-year period, significantly higher than the general pediatric clinic and far from the target rate of 20%. We also explored reasons for no-shows as elucidated above. We are currently employing valid interventions relevant to our patient population to reduce the no-show rates in the pediatric subspecialty clinics, after which, we will evaluate for improvement in no-show rates post intervention.

Clinical Implications:
Improved access to preventive visits leading to decrease in ER visits and hospitalizations.

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