 |
 |
|
|
|
Nonattendance at mental health clinic appointments, particularly first-time no-shows (FTNS), waste health care resources. However, we could find no Canadian research on FTNS in urgent settings. Research problems include defining nonattendance (1,2) and variations in setting, expertise, and types of therapy (3). The reported adult rate for FTNS ranges widely, from 15% to 75% (4,5). FTNS likely result from a complex interplay of demographic, clinical, and process variables (4), including patients’ resistance to seeing psychiatrists (6). Nonattendance has been shown to be reduced by telephone and written prompts and by 24-hour preappointment (7). A comprehensive review of 89 studies identified the following major predictors of nonattendance: wait time, previous therapy, presenting problem, socioeconomic factors, and referral source (2). A Singapore-based outpatient study reported that patients were more likely to miss afternoon appointments (8). A Spanish community mental health study reported that sex differences predicted no-shows, with men more likely to attend in the mornings and women, in the afternoon (5). The Urgent Short Term Assessment and Treatment Clinic (USTAT) is the primary mental health clinic servicing the urgent psychiatric outpatient needs of Greater Victoria, British Columbia (population 326 000). USTAT accepts patients with all adult psychiatric diagnoses, excluding schizophrenia and primary substance use disorder. We wanted to examine our FTNS rate, identify our profile, and see which process variables predicted FTNS. We included for examination the uncommon variable of time of day. MethodParticipants Procedure
To increase the sample size and modify the questionnaire, we undertook the second stage from February through May 2000. We removed questions requiring telephone contact that resulted in apparently inaccurate information and added a question on social support. This second-stage questionnaire was filled out by the investigators from the charts. Out of 321 referrals in stage 2, there were 24 FTNS (7.5%), giving a total of 60 FTNS for both stages. Only questions common to both stages were analyzed, except for the social-support question. Analysis ResultsOf all patients, 60% were female. FTNS were 50% female, and control subjects were 70% female. Most were unemployed, had social support (although we examined this only in the second subgroup), and were physician-referred. Most presented with depression or grief, or both. For FTNS, the significant presenting problems were depression, grief, and suicidal ideation (P = 0.03). Acuity level for FTNS was most frequently medium, whereas for control subjects, acuity level was high-medium to high. More FTNS had other treatment present, compared with control subjects and the referral group as a whole (P = 0.02). Most were contacted within 1 day of referral and had their first appointment within 15 days. For the total group and for FTNS, first appointments were most frequently scheduled between 8:30 AM and 10:00 AM (see Table 1). For control subjects, first appointments were most frequently scheduled between 1:00 PM and 2:30 PM (P = 0.02). Tested against a constant-only model, the logistic regression model with 10 predictors (3 with dummy variables) was statistically reliable (c2 = 50.05, df 17; n = 118; P < 0.001), indicating that the predictors reliably distinguished FTNS and control subjects. Only 3 variables significantly contributed to the analysis independently. These were presenting problem (P = 0.03), time of day of appointment (P = 0.02), and other treatment (P = 0.02). Although presenting problem and other treatment showed significance, the most novel and practical finding was the significant difference between FTNS and control subjects in time of day of first appointment. The odds ratio of patients attending an afternoon rather than a morning appointment was 3.6. ConclusionsFTNS rates in the literature range from 15% to 75% (4,5). Our rate was remarkably low at 7.7%. Guthrie cites waiting time as the variable most frequently associated with nonattendance (2). Our short waiting time (80% of our patients were seen within 15 days) may account for our overall low FTNS rate. As a set, 10 variables (that is, age, sex, referral source, presenting problem, patient acuity, time until first phone contact, time until first appointment, day of first appointment, time of day of first appointment, and presence of existing other treatment) influenced FTNS at 80% accuracy. However, a single multifaceted profile has limited practical value in reducing FTNS (4). Three individual variables had predictive significance in determining FTNS: presenting problem, time of day of first appointment, and concurrently available other treatment. Of these, time of day of first appointment is alone in its novel significance and easily lends itself to practical change. Patients are 3.6 times more likely to show up if their first appointments are scheduled in the afternoon. It is difficult to compare our findings with those reported from Singapore (8) and Spain (5), which have culturally and ethnically more homogeneous populations than Victoria. However, our findings may have greater relevance for urban heterogeneous communities, which now constitute the norm in Canada. Our study is limited owing to its post hoc nature. Additionally, we did not evaluate detailed socioeconomic or geographic status, which made it difficult to evaluate whether distance or lack of transportation was a problem contributing to FTNS. To our knowledge, our findings present the first North American evidence that simply making the first appointment in the afternoon could significantly decrease FTNS and thus ensure better use of scarce health care resources. References1. Blouin A, Perez E, Minoletti A. Compliance to referrals from psychiatric emergency room. Can J Psychiatry 1985;30:102–6. 2. Guthrie L. Non-attendance in psychotherapy: comparative study [MSW Thesis]. National Library of Canada; 1996. 3. Orme DR, Boswell D. Pre-intake drop-out at a community mental health center. Community Ment Health J 1991;27:375–9. 4. Rosenberg C, Raynes A. Keeping patients in psychiatric treatment. Cambridge (MA): Ballinger Publishing Co; 1976. 5. Livianos-Aldana L, Vila-Gomez M, Rogo-Moreno L, Luengo-Lopez M. Patients who miss initial appointments in community psychiatry? A Spanish community analysis. Int. J Soc Psychiatry 1999;45:198–206. 6. Gruenbaum M, Luber P, Callahan M, Leon AC, Olfson M, Portera L. Predictors of missed appointments for psychiatric consultations in a primary care clinic. Psychiatr Serv 1996;47:848–52. 7. Reda S, Makhoul S. Prompts to encourage appointment attendance for people with serious mental illness. Cochrane Database of Systematic Reviews 2001;2:CD002085. 8. Lim LE, Poo KP, Lein T, Chew CK. Why patients fail to attend psychiatric follow-up: a pilot study. Singapore Med J 1995;36:403–5. Author(s)Manuscript received June 2002, revised, and accepted January 2003. 1. Clinical Director, Urgent Short Term Assessment and Treatment Unit, Vancouver Island Health Authority South (VIHA), Victoria, British Columbia. 2. Therapist, Urgent Short Term Assessment and Treatment Unit, Vancouver Island Health Authority South, Victoria, British Columbia. 3. Psychologist, Urgent Short Term Assessment and Treatment Unit, Vancouver Island Health Authority South, Victoria, British Columbia. 4. Psychologist, Montreal, Quebec. 5. Psychiatrist, Urgent Short Term Assessment and Treatment Unit, Vancouver Island Health Authority South, Victoria, British Columbia. Address for correspondence: Dr R Weinerman, Clinical Director, VIHA, USTAT, 1119 Pembroke Street, Victoria, BC V8T 1J5
1 | 2
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||