BROKEN
APPOINTMENTS
Joel J. Alpert, M.D.
Department of Pediatrics, Harvard Medical School, and the Child Health Division,
Children’s Hospital Medical Center, Boston, Massachusetts
(Submitted August 16; accepted for publication September 13, 1963.)
Supported by a grant from the United States Children’s Bureau, Social Security Administration,
Department of Health, Education and WeLfare.
ADDRESS: Family Health Care Program, 1 Blackfan Street, Boston 15, Massachusetts.
SPECIAL
ARTICLES
127
Pmwrnscs, July 1964
P
ATIENTS who do not keep appointments have been the subject of recent and con-tinuing study since they can account forone-quarter16 or more of clinic appoint-ments. Stuart7 noted that the introduction of the appointment system to clinic
prac-lice provided better service to the patient, improved teaching of medical students, and protected the physician from lowering standards of care because of volume. These
benefits persist but are diminished by ap-pointment breaking which indicates a
fail-ure of continuity of patient 2 5 may
jeopardize teaching and research,6 and, in
addition, waste professional time. It has
also been suggested that appointment breaking may be a variable of importance in the study of the doctor-patient
relation-ship.
This study was designed as a further at-tempt to define those factors which might
contribute to appointment breaking and to identify the patients and their families who break the appointments (DNKS). It seemed
that if the broken appointment rate could be lowered, patient care would be improved and clinic operation made more efficient.
DESCRIPTION OF CLINIC
The Children’s Hospital Medical Center Medical Out-Patient Department functions
primarily as a referral clinic for physicians
and community agencies, as well as for other clinics within the hospital. Of the
pa-tients, 40% come from Boston and 55% from
elsewhere in Massachusetts. Patients are
seen by appointment. The general medical clinic operates half days with the specialty
clinics functioning the remainder of the
time. These clinics are staffed by third-year medical students, pediatric interns and resi-dents, fellows, and available medical and
specialty consultants. Approximately 200
patients per week are seen. One hundred of
these are new, i.e., patients who have never been in the clinic before or have not been
seen for one or more years. The remaining 100 are return patients who are either
per-sonal (coming back to see a particular phy-sician) or general (coming back to see any
physician).
STUDY DESIGN
For the purposes of this study a patient was classified as a “did not keep” (DNK) if he did not keep his appointment and failed to notify the clinic in advance. Pa-tients who called and canceled were not
interviewed and a separate cancellation rate
was determined.
The study undertaken was divided into
two phases. In Phase I, a chart survey was made to determine the actual percentage of DNKS and cancellations as well as some
of the characteristics of the clinic patients. This was done in February and March,
1962.
In Phase II, a standard interview0 was
administered by a student social worker to
0 Mimeographed copies of the standard
ques-tionnaire used are available from the author.
There were 82 items of which 21 were felt to
measure patient attitudes and tile remainder were
directed at acquiring factual information.
Ques-lions were related to the previous kept
70
61
PATIENTS IN MEDICAL OUTPATIENT
DEPART-MENT, .JVI.Y-AUGUST 1962
the DNK group and to a group of families viio kept their appointments (“keepers”).
The keeper was defined as having had at least three appointments in the preceding year and to have broken none. The keeper
was interviewed in tile clinic and the DNK interviewed at home or by telepilone. The
DNKS were compared witil the keepers. New patients wilo broke their appointments
s’ere also interviewed but were not used
for direct comparison as they, for the most part, had not been to the hospital before. A survey was made of broken appointments
in other hospital clinics as well as in the
offices of private pediatricians and com-pared for both DNK and, where possible,
cancellation rates. Because of the small numbers and relatively short period of time, an attempt was made to interview all ap-pointment breakers. The charts of clinic keepers were reviewed each day and the first patient who met the definition was
in-terviewed. The data obtained was coded and transferred to standard McBee cards
for analysis. Phase II was accomplished in July and August, 1962.
RESULTS OF STUDY
In Phase I, there was an over-all clinic
DNK rate of 19.1%. At this time there was a waiting period of six weeks for appoint-ments. The survey showed that 16% of the new patients, 14% of the personal returns, and 34% of the general returns did not keep their appointments.
TABLE I
Appoint-men/s New Return Total
Kept Broken 74 (90%) 8t (10%) 564 (74%) tOO (t6%) 1306 (8.%) 8* (17.8%)
Total 824 (100%) 764 (100%) 1588 (100.0%)
* patients broke 3 appointments.
15 patients broke appointments. Q46patients broke 1 appointment.
63 patients broke appointments.
TABLE 11
REASONS FOR NOT BEING INTERVIEWED (ii-134) Distance No contact No attempt Refusal I Total 134
In Phase II, 282 appointments were broken by 263 families, or 17.8% of the total
appointments scheduled. Of the new
pa-tients 10%, and of the return patients 26%, did not keep. Some patients broke more
than one appointment (Table I).
It was possible to interview 49% of the DNKS. The reasons for not being
inter-viewed were distance, inability to make
contact, no attempt, and refusal (Table II). Although a home interview was
pre-ferred 45% were eventually accomplished
by telephone. The telephone was used if
there had been a previous home visit, or because of distance, refusal of a home visit, and inability to arrange a mutually con-venient time for the home interview (Table
III).
Because 50% of the DNKS were not
in-terviewed these hospital charts were studied and compared with the interviewed group
to
see if there were important differences. More of those not interviewed had no tele-phone (which was a major reason for not being interviewed), had less hospitalin-surance, but were otherwise similar to the interviewed group.
The DNKS interviewed by telephone
were compared with those interviewed at
TABLE III
REASONS FOR BEING INTERVIEWED BY TELEPHONE
(n-6’2)
Previous home visit 7
1)istanee 35
Refusal of home visit 5
Inability to arrange time 15
SPECIAL ARTICLES
* p<0.05. TABLE IV
PATIENTS WHO BROKE APPOINTMENTS Comparison of home vs. phone interviews
Home (n-f7) (%) Phone (n-t;2) (%)
From Boston 91 5.2*
Social Class V 0 18
Negro 7 ‘3
Been to other hospital clinics 77 51
MECL visits/pt. in past year 4.5 .45
* p<0.05.
home. Logically the home interview was
accomplished on the DNKS who lived close
to the hospital. In addition, more were Negro, seemed to make wider use of the hospital, and were in social class V#{176}(Table IV). Despite these differences the data on all interviewed return DNK patients was
grouped for final analysis.
Comparison of the DNKS with the
keepers shoved no difference as regards
duration of symptoms, the time elapsed since the last appointment, or the waiting
time for the appointment. Of the keepers 79% compared with 63% of the DNKS felt
they had a doctor in the hospital to whom they could talk. In both groups, 25% waited 3 or more hours to see the doctor. Of the
DNKS 29% compared with 16% of the
keepers were in the hospital 4 or more ilours. Of the keepers 77% felt that the
doc-tors in general were interested in their
pa-tients, as compared with only 54% of the
DNKS. Of the broken appointments 20% by
subjective review of records had no obvious reason for seeing a physician compared
with none of the keepers. Those families
\VllO broke appointments (Table V) were
niore likely to have a psychiatric diagnosis,
to come from Social Class V, to have
medi-cal debts, to have found coming expensive,
not to llave hospital insurance, and to come
from large families. More of the DNK
pa-tients came from broken homes (12% vs. 6%),
0Social class was determined by the
Hollings-head two factor scale.’
a home where the mother was working (17%
vs. 11%), or were Negro families (17% vs.
8%). Only 50% of those in either group were by current definition9 effectively im-munized.
Reasons Patients Gave for Not Keeping
Of the DNKS 23% never intended to
come hack, 38% forgot or were indifferent, 29% gave family reasons (no sitter, an
ill-ness, no transportation, or inadequate fi-nances). There was a hospital error in ap-pointment arrangements in 9%. Among the new patients, 29.5% never intended to keep their appointment, 21% were indifferent, and
44% gave family reasons. There was a hos-pital error in 5.2%.
Survey of Other Clinics and Private Pediatricians
There was a significantly higher broken appointment rate in those clinics where no attempt was made to provide personal
phy-sician care (i.e., a patient followed by the
same physician) (Fig. 1). The DNK rate
ranged from 0.7% in the Family Health Clinic, which provides continuing preven-tive and curative care to families through a
single physician, to 44% in the Well-Baby Clinic, operated for the City of Boston without continuity of care by any one
phy-sician. Those clinics that did provide per-sonal physician care had a higher
cancella-lion rate than the multiphysician clinics. The low broken appointment, high
can-TABLE V
APPOINTMENT KEEPERS COMPARED TO RETURN DNK
Keepers (n-.) (%) DNK (n-94) (%)
Psychiatric diagnosis 7.5 26 5*
Social Class V 5.7 4 5*
Medicaldebts 37.4) 66.0*
Found cost high 3.5 29 .0
Previous visit cost >$1I. 13 .0 31 .0
No hospital insurance 15 .1) 6 .O
S CANCELLATIONS % DID NOT KEEP
PERSONAL
PHYSICIAN
MULTI PHYSICIAN
FIC;. 1. Relationship of cancellations aIld I)NKS to j)ersollal lIld multi-physician care.
The average DNK rate for the multi-physician clinics ‘as 22.7% and tile’ pe’rsoI1tl physician clinics
7.5. The average cailceliatioll rate’ for the multi-physician clinic \as 7.8% and the l)’r5n1l clinic 14.5c.
‘Fl’s (iiflercll(ts are highly significant (p < .07). Tile’ relatiolisilip is illustrated b’ plotting ptrs11tl
and IIIulti-pil\ieian clinics on the V axis and % cancellations dIl(l DNKS Oil tllc X axis.
cellation rate of the iersoiial p11ysicia11
ClilliC \\tS almost identical to that observed
ill the offices of priate pediatriciaiis.
More-over, ill the general medical clinic, 85 of
the cancellations came from the persoIl1l
return group.
COMMENT
Other studies llave suggested factors
which Illight contribute to the DNK rate. Hansen ,‘ studying vell-babv clinics, noted that colllpletion of iInmunizations,
unfavor-able weather, and being seen by many
pllv-sicians ere factors associated with DNK
fanlilies. Badgle’2 studied a general
1edi-atric clinic and found tilat race, class, and age ‘ere related to broken appointments,
\Vitll lower-class Negro fanlilies alld
fam-ilies where tile patient ‘as under age 2 more likely to be DNKS. Oleiicki found
race, age, cost. and nationality backgrounds
to be of significance ill au adult clinic
pop-ulation. She could not demonstrate a
rela-tionship Witil the 1)r0\’isioIl of continuity of
care. ‘ interviewed ortilopedic clinic
I)atients and found financial factors and
im-I)ersOnalitv of care to be of most concern.
Iii this studs’ there appear to be two
groups of patients who break appointments.
One is a lower-class white or Negro family
\Vll() live near the hospital and use its clinics
as a major source of medical care. These
patients are usually referred by wa of
other hospital facilities, particularly the
emergency clinic. The second group is of
higher social class, come from a distance, have modest niedical debts, and use tile
hospital as a referral center. They find
corn-ing expensive, that it does not meet their
needs, and do 1U)t inteild to return.
Altilough the interview was Ilot meant
131
was more evidence of patient dissatisfaction with medical care and doctors in general
in the DNK group. DNK patients found
coming upsetting, could not accept the diagnosis made, objected to hospital proce-dures, and could not understand what the
doctor said.
Recent studies by Elling, Whittemore, and Green1’ have shown that following
through with an effective medical care pro-gram involving protracted treatment such
as taking prophylactic penicillin may
de-pend on what a mother feels that clinic
per-sonnel think of her. They suggest that posi-live identification with the clinic may un-derlie good participation in care. MacDon-aid, Hagberg, and Grossma&2 found that
the presence of problems of interpersonal
relationships enabled them to predict poor co-operation in a program of outpatient
care following hospitalization for rheumatic fever. There was no correlation with medi-cal factors such as the seriousness of the disease. In a similar fashion, the broken ap-pointment may indicate a poor doctor-pa-tient relationship for some patients.
Increasing the personalization of care can lower the DNK rate. Williams,13 at
University Hospitals of Cleveland, noted
that the DNK rate was lowered by such
measures as posters, secretarial reminders,
and enthusiasm of clinic personnel. A very low DNK rate was in a clinic staffed
pri-manly by medical students where the stu-dent kept his own appointment book and
talked to the patient about the next ap-pointment. He concluded that having the patient see the same physician on each visit was most important and that a 15% DNK
rate meant that a clinic was doing very well. This 15% rate is exactly the
cancella-lion rate in the private offices surveyed in the present study. The cancellation rate in the Adolescent and Family Health Clinics
(both personal physician clinics) also
ap-proximated 15%. Sussman and Caplanl4 noted that the more clinic care was like the
patient’s concepts of private care, the more
likely the patients would be to continue
their care. Badgley and Furnal2 felt that dif-ferent values of time are held by those
pa-tients who break appointments. It seems,
however, that a certain number of appoint-ments will always be broken for what might be considered legitimate reasons and that in
such circumstances as a personal physician
clinic this would be a cancellation.
While the appointment system has been one additional step toward providing bet-ter and perhaps more personal care in hos-pital clinics, it makes obvious those pa-tients who fail to keep. These patients in-dicate a need to continually re-examine
techniques of patient care. The exact solti-tion will differ from one clinic to the next,
but from this study at least, it would seem
that providing personal care would de-crease the likelihood of failure of patients
to keep their appointments.
SUMMARY
A survey of appointment breaking in the Medical Clinic of the Boston Children’s
Hospital Medical Center showed that ap-proximately 20% of patients broke their
ap-pointments.
These patients were more likely to have
shown evidence of social disorganization. Personal physician care appeared to lower
the broken appointment rate although there
appeared to be an irreducible minimum
which in either the personal physician clinic or in the private office was a
cancella-tion. Additional gaps in medical care noted
in those who broke their appointments
in-cluded inadequate immunizations,
dissatis-factions with medical care, and ill-defined
need to see a pilysician.
REFERENCES
1. Hansen, A. C. : Broken appointments in a
child health conference. Nurs. Outlook, 1:
417, 1953.
2. Badgley, H. F., and Furnai, M. A. :
Appoint-ment breaking in a pediatric clinic. Yale J.
Bioi. Med., 34:117, 1961.
3. Barbono, J., and Solon, J.: Broken
appoint-ments in the out-patient (Iepartment.
BROKEN APPOINTMENTS
Boston : Medical Care Studies Unit, Beth
Israel Hospital, 1961.
4. Wadhwani, P. M., Ambuel, J. P., and Thrush, R. S. : Research working papers on broken
appointments, I-IV. Columbus: Columbus Children’s Hospital, 1961.
5. Olencki, M. : Appointment-breaking in a gen-eral medical clinic. Research Memorandum
No. 5, Series C. New York: Cornell
Corn-prehensive Care and Teaching Program, 1959.
6. Bakst, H. J., and Marra, E. : Study of out-patient department demography morbidity,
services and patient motivation. Division of Preventive Medicine, Massachusetts Me-morial Hospital and Department of Preven-tive Medicine, Boston University School of Medicine, Boston, 1960.
7. Stuart, H. C. : Teaching in out-patient clinics.
Application of the appointment system.
Bos-ton Med. Surg. J., 193:833, 1925.
8. Hollingshead, A. B., and Redlich, F. C. :
So-cial Class and Mental Illness. New York: John B. Wiley & Sons, 1958.
9. Redbook, Report of the Committee on the
Control of Infectious Diseases. Evanston, Illinois: American Academy of Pediatrics, 1961.
10. Ross, M. : Survey of broken appointments, Orthopedic Clinic. Boston : Children’s Hos-pita! Medical Center, 1957.
11. Elling, R., Whittemore, R., and Green, M.: Patient participation in a pediatric program.
J. Health and Human Behavior, 1:183,
1960.
12. MacDonald, M. E., Hagberg, A. M., and
Grossman, B. J.: Social factors in relation to participation in follow-up care of
rheu-matic fever. J. Pediat., 62:503, 1963.
13. Williams, R. F. : Personal Communication. 14. Sussman, M. B., et al.: Social class and the
hospital clinic, a pilot project
(Mimeo-graphed Report.) Cleveland: Western
Re-serve University, School of Medicine and
University Hospital, 1959.
Acknowledgments
The author wishes to thank Miss Barbara Cohen,
