Out Patient Non-Attendances - What Can We Do About This Major Problem?Jun 22, 2016 -
Author: Tony McNamara, CEO, Cork University Hospital Group
In CUH in 2015 there were 242,000 appointments issued by administrative staff and of that number, 26,000 did not subsequently attend this appointment (12%).
Have you ever considered the opportunity cost of patients who do not attend (DNA) at Out Patient Departments (OPD) in our hospitals and the resultant implications for our hospital services? Probably not and neither do commentators who regularly comment on waiting lists and related matters.
Using Cork University Hospital data I hope to demonstrate that there are significant opportunity costs foregone in clinical, service and financial terms as a result of DNAs which should prompt a discussion to educate the public on the value of an Out Patient appointment and treating it with respect.
In CUH in 2015 there were 242,000 appointments issued by administrative staff and of that number, 26,000 did not subsequently attend this appointment (12%). The respective costs for an OPD appointment in the Hospital are €129 in the case of a patient who attends for appointment and €44 in the case of a DNA for which the medical notes have to be obtained by administrative staff from the Records Library, a review of the referral/patient notes by the consultant, a record made in the notes to the effect that the patient did not attend plus communication by letter to the GP and patient of the decision and the notes have to be re-filed. In the Hospital, appointments are timed and overbooking of clinics is not a regular feature so clinic slots that are not filled are effectively lost opportunities to provide patient care.
The result is significant waste of scarce resources at a number of different levels;
(i) The opportunity cost foregone of up to 26,000 alternative appointments that could have issued to patients who attended, would have transformed the waiting times for Out Patient services and reduced the morbidity of many more patients on waiting lists;
(ii) Highly trained professional staff at multiple levels of seniority have their time wasted because of patients not attending and usually not advising the Out Patient Department, therefore preventing the appointment slot being given to another patient;
(iii) At a cost of €44 per visit these 26,000 DNAs represents a financial marginal cost of c. €1,150,000 which is the cost of employing over 50 clerical staff;
(iv) Clearly the efficient flow and management of clinics is adversely impacted upon;
(v) In accordance with national policy, a new appointment should not be issued to any patient unless deemed medically necessary by the patient’s consultant. Yet, where a further appointment is issued, this oftentimes results in another non – attendance at clinic.
(vi) To minimise DNAs, a process of validation of waiting lists is undertaken on a planned basis to ensure that every patient on the waiting list still requires an appointment. Despite a significant number of patients confirming the desire to be seen by a consultant many will still not attend the subsequent appointment;
(vii) It is quite incredible that even in relation to cancer clinic appointments a DNA rate of 7% is evident over time with opportunities foregone to allocate those appointments to other patients who are suspected of having cancer.
When one looks at the situation throughout all acute hospitals in Ireland the scale of lost opportunities to the health system nationally becomes ever more incredible:
OPD New and Return Appointments
New Appointments - DNA
Return appointments - DNA
349, 000 (15%)
In 2015 there were 3,300,000 new and return appointments issued to patients of which 488,000 Did not Attend - a 15% DNA rate with a financial opportunity cost of circa €21.5m (using the CUH average DNA cost). This equates to a staggering 1,000 clerical administrative staff and one can only imagine how much added value could be added to patient care if the system was able to achieve even a 50% reduction in the national DNA rate to 7.5%.
What does this say about the regard that the population have (or do not have) for Out Patient appointments that are given to them? It is said that if a good doesn’t have a price attached to it then it does not have a value and I contend that this is the case in relation to perhaps one in ten OPD appointments.
What needs to be done to address these significant challenges?
There is clearly an urgent need for an educational initiative to be undertaken by leaders in the political system, health service delivery entities and public commentators to increase awareness of the value of an opportunity to attend for a specialist medical opinion and to improve the health of individuals and society in general.
Furthermore it is evident that the health system needs to work more closely with the National Clinical Care Programmes to address the challenges in relation to Out Patient care in an innovative and joined up way with our acute hospitals.
The practice of outsourcing Out Patient appointments to private hospitals is sub-optimal and is not in the interests of the public system where targeted resources will yield greater results particularly if there is a change from a “blame culture” that is focused on achieving targets, to instead look at new innovative ways to reduce DNAs and use the resultant capacity to see more patients.
There is also a need for a more informed debate by commentators on the staggering numbers of patients seen in our Out Patient Departments and rather than focussing solely on waiting list numbers, a more nuanced commentary might be to explain to the public the need to advise Out Patient Departments in advance if they do not intend keeping an appointment in order that the appointment can be given to somebody else thereby enabling clinics to function more efficiently.
Surely that is not too much to ask?
Comments and feedback welcomed below. Thank you.