A Retrospective Analysis of Central Physician Appointment System Data in a Tertiary Health Center in Turkey

Abstract

Introduction:

Considerable advances have been made in hospital appointment systems in the past 60 years. In Turkey, the Central Physician Appointment System (CPAS) is used together with appointments made through direct presentations to the hospital. This study evaluated CPAS data.

Materials and Methods:

CPAS data for the previous 2 years (2015, Group 1; 2016, Group 2) were evaluated retrospectively. Department-based analysis was also performed. Total number of clinics, CPAS capacity, number of appointments through CPAS, and numbers of patients keeping appointments and “no shows” and ratios calculated from these were investigated.

Results:

Overall, 1,704,594 patients were examined in 20 departments during the 2-year period (January 1, 2015–December 31, 2016). Mean CPAS capacity per department was 12,831 ± 7,691 in Group 1 and 11,573 ± 6,849 in Group 2 (p = 0.588). Ratios of appointments made through CPAS to CPAS capacity were 0.7 in Group 1 and 0.84 in Group 2 (p = 0.009). The ratio of patients keeping appointments made through CPAS to the number of appointments made through CPAS was 0.772 in Group 1 and 0.775 in Group 2 (p = 0.831). The departments with the highest number of appointments made through CPAS to CPAS capacity were Neurosurgery in Group 1 (0.99) and Ophthalmology in Group 2 (0.99). The department with the lowest ratio was Infectious Disease and Clinical Microbiology in Group 1 (0.28) and Group 2 (0.45).

Conclusions:

The use of CPAS has increased. However, some CPAS vacancies remain unfilled, and some appointments are not kept. CPAS capacities must be adjusted in line with take-up rates through regular department-based analysis.

Introduction

The main aim of clinic appointment systems is to shorten wait time for patients and optimize physician time.^1,2 Various studies have been performed regarding appointment systems since the mid-20th century.^2,3 The Central Physician Appointment System (CPAS) has been actively used in Turkey since 2010, enabling patients to make appointments with hospitals and oral and dental health centers affiliated to the Turkish Ministry of Health. Patients can access the CPAS through the call center number 182, the Internet, or CPAS mobile apps.⁴ The most primitive clinic appointment system is one that is based on the order of arrival. In Turkey, this system is employed alongside the CPAS so that one part of the available appointments in hospitals is set aside for direct presentations, and another part is set aside for the CPAS. Patients make greater use of appointments made by direct presentation, which take place on the same day, whereas the individual can select a later date for appointments made through the CPAS.

The purpose of this study was to perform a retrospective evaluation of CPAS data from a tertiary hospital in Turkey.

Materials and Methods

Data for departments with which appointments can be made by using the CPAS (Neurosurgery, Pediatric Surgery, Pediatrics, Child and Adolescent Psychiatry, Dermatology, Internal Medicine, Infectious Disease and Clinical Microbiology, Physical Medicine and Rehabilitation, General Surgery, Pulmonology, Ophthalmology, Gynecology, Cardiac Surgery, Cardiology, Ear, Nose and Throat, Neurology, Orthopedic Surgery and Traumatology, Plastic Surgery, Psychiatry and Urology) at the Adıyaman University School of Medicine, Turkey, for 2015 and 2016 were examined retrospectively. Those departments that never employ the CPAS (Forensic Medicine, Emergency Medicine, Medical Pathology, Radiology, Medical Genetics, and Anesthesiology) were excluded from the study. Among the departments that do employ the CPAS, if it was not possible to make an appointment with a physician via the CPAS, that physician was also excluded (e.g., a pediatric cardiologist or an internal medicine nephrologist), although other physicians in that department were included. The year 2015 was defined as Group 1 and 2016 was defined as Group 2 to determine change over time. Legal permission for the study was obtained from the hospital administration (Document No. 53911808-929), the Turkish Ministry of Health (Document No. 66381196/619), and the local ethical committee (Document No. 2017/3-9).

The data obtained were analyzed on SPSS (IBM, version 21.0, Chicago, IL) software. Categorical data are expressed as number and percentage, and constant variables are expressed as mean and standard deviation. Student's t test was used to compare the two groups (Group 1 and Group 2). The two-rate test was also used for department-based evaluations. Statistical significance was set at p < 0.05.

Results

We determined that 1,704,594 patients were examined in the 20 departments investigated over the 2-year study period (January 1, 2015–December 31, 2016). A mean 41,211 examinations were performed per department in Group 1, and 44,018 examinations were performed in Group 2 (p = 0.747). The mean number of appointments allocated for the CPAS per department was 12,831 ± 7,691 in Group 1 and 11,573 ± 6,849 in Group 2 (p = 0.588). The mean number of appointments made by using the CPAS per department was 8,809 ± 5,184 in Group 1 and 9,804 ± 5,776 in Group 2 (p = 0.57). In addition, 6,799 ± 4,026 patients in Group 1 and 7,591 ± 4,486 in Group 2 kept appointments made through the CPAS and underwent examination (p = 0.56), whereas 2,009 ± 127 “no-show” patients (NSPs) were identified in Group 1 and 2,213 ± 1,342 were identified in Group 2 (p = 0.618). The ratio of appointments made through the CPAS to the total CPAS capacity was 0.7 in Group 1 and 0.84 in Group 2 (p = 0.009). The ratio of appointments made through the CPAS and actually kept to the total number of appointments made through the CPAS was 0.772 in Group 1 and 0.775 in Group 2 (p = 0.831). The proportion of NSPs making appointments through the CPAS to the total number of CPAS appointments was 0.227 in Group 1 and 0.224 in Group 2 (p = 0.831).

Department-based analysis revealed that the department performing the most clinical examinations in Group 1 and Group 2 was the Internal Diseases Department, which also has the highest CPAS capacity. Information regarding departments' polyclinic numbers, CPAS capacities, appointments made via the CPAS, patients making appointments through the CPAS, and keeping these and NSPs is given in Table 1. The department with the highest number of CPAS appointments to CPAS capacity was Neurosurgery in Group 1 (0.99) and Ophthalmology (0.99) in Group 2. Infectious Disease and Clinical Microbiology exhibited the lowest proportion in both Group 1 (0.28) and Group 2 (0.45) (Table 1). The departments with the highest number of appointments made through the CPAS and actually kept to number of appointments made through the CPAS were Infectious Diseases and Clinical Microbiology in Group 1 (0.83) and Physical Medicine and Rehabilitation (0.83) in Group 2. The proportions were lowest in General Surgery in Group 1 (0.66) and Cardiac Surgery (0.71) in Group 2 (Table 1).

Table 1.

The Central Physician Appointment System Data by Departments

DEPARTMENT	YEAR	TOTAL NUMBER OF PATIENTS EXAMINED	CPAS CAPACITY	NUMBER OF APPOINTMENTS MADE VIA CPAS			NUMBER OF PATIENTS MAKING APPOINTMENTS VIA CPAS AND ATTENDING THESE		NUMBER OF NSPs MAKING APPOINTMENTS VIA CPAS		NUMBER OF APPOINTMENTS MADE/CPAS CAPACITY	NUMBER OF PATIENTS ATTENDING EXAMINATION/NUMBER OF APPOINTMENTS MADE VIA CPAS	NUMBER OF NSPs/NUMBER OF APPOINTMENTS MADE VIA CPAS
Cardiac surgery	2015	12.150	6.696	<0.01	3.439	<0.01	2.501	<0.01	938	<0.01	0.51	0.73	0.27
	2016	12.775	5.256		3.850		2.741		1.109		0.73	0.71	0.29
Cardiology	2015	42.018	17.388	<0.01	12.673	<0.01	10.322	<0.01	2.351	0.02	0.73	0.81	0.19
	2016	47.062	18.090		13.835		11.236		2.599		0.76	0.81	0.19
Child and adolescent psychiatry	2015	4.136	1.872	0.45	1.559	<0.01	1.234	<0.01	325	<0.01	0.83	0.79	0.21
	2016	4.536	2.016		1.980		1.541		439		0.98	0.78	0.22
Dermatology	2015	51.658	14.904	<0.01	14.172	<0.01	10.692	0.46	3.480	<0.01	0.95	0.75	0.25
	2016	53.319	11.574		11.366		8.255		3.111		0.98	0.73	0.27
Ear, nose and throat	2015	61.205	14.436	<0.01	10.740	<0.01	8.194	<0.01	2.546	<0.01	0.74	0.76	0.24
	2016	59.484	11.232		10.919		8.129		2.790		0.97	0.74	0.26
General surgery	2015	29.226	13.572	<0.01	6.981	<0.01	4.628	<0.01	2.353	<0.01	0.51	0.66	0.34
	2016	36.150	11.070		8.857		6.524		2.333		0.8	0.74	0.26
Gynecology	2015	34.679	4.131	<0.01	3.977	<0.01	3.276	0.6	701	<0.01	0.96	0.82	0.18
	2016	45.534	4.917		4.830		3.877		953		0.98	0.8	0.2
Infectious diseases and clinical microbiology	2015	16.095	8.028	<0.01	2.209	<0.01	1.842	<0.01	367	<0.01	0.28	0.83	0.17
	2016	17.190	4.950		2.232		1.812		420		0.45	0.81	0.19
Internal medicine	2015	101.064	31.302	<0.01	17.416	<0.01	12.976	<0.01	4.440	<0.01	0.56	0.75	0.25
	2016	118.828	31.374		23.837		18.130		5.707		0.76	0.76	0.24
Neurology	2015	44.163	13.788	<0.01	9.627	<0.01	7.471	<0.01	2.156	<0.01	0.7	0.78	0.22
	2016	44.695	9.522		8.700		6.411		2.289		0.91	0.74	0.26
Neurosurgery	2015	38.357	8.766	<0.01	8.612	<0.01	6.489	<0.01	2.123	0.79	0.98	0.75	0.25
	2016	40.526	13.230		11.630		8.446		3.184		0.88	0.73	0.27
Ophthalmology	2015	77.880	21.348	<0.01	17.803	<0.01	14.186	<0.01	3.617	<0.01	0.83	0.8	0.2
	2016	90.893	18.486		18.316		14.370		3.946		0.99	0.78	0.22
Orthopedic surgery and traumatology	2015	43.027	8.658	<0.01	7.822	<0.01	5.841	<0.01	1.981	<0.01	0.9	0.75	0.25
	2016	59.759	14.616		14.389		11.301		3.088		0.98	0.79	0.21
Pediatrics	2015	93.565	26.082	<0.01	17.112	<0.01	13.173	<0.01	3.939	<0.01	0.66	0.77	0.23
	2016	74.434	17.946		16.271		13.010		3.261		0.91	0.8	0.2
Pediatric surgery	2015	10.317	4.374	<0.01	2.392	<0.01	1.800	<0.01	592	<0.01	0.55	0.75	0.25
	2016	8.236	3.186		2.753		2.186		567		0.86	0.79	0.21
Physical medicine and rehabilitation	2015	30.297	7.794	0.33	6.667	0.22	5.387	<0.01	1.280	<0.01	0.86	0.81	0.19
	2016	33.979	8.856		7.515		6.212		1.303		0.85	0.83	0.17
Plastic surgery	2015	12.450	5.364	<0.01	3.058	<0.01	2.347	<0.01	711	0.02	0.57	0.77	0.23
	2016	13.288	5.040		3.388		2.641		747		0.67	0.78	0.22
Psychiatry	2015	38.229	14.733	<0.01	9.512	<0.01	7.369	<0.01	2.143	<0.01	0.65	0.77	0.23
	2016	42.850	13.986		10.220		7.871		2.349		0.73	0.77	0.23
Pulmonology	2015	49.523	20.502	<0.01	11.398	<0.01	9.096	<0.01	2.302	<0.01	0.56	0.8	0.2
	2016	41.958	14.040		10.510		8.448		2.062		0.75	0.8	0.2
Urology	2015	34.194	12.888	<0.01	9.029	<0.01	7.175	<0.01	1.854	<0.01	0.7	0.79	0.21
	2016	34.865	12.078		10.700		8.694		2.006		0.89	0.81	0.19

Values show in bold signify p < 0.05.

CPAS; central physician appointment system; NSPs, no-show patients.

Discussion

Studies regarding appointment systems are based on shortening patient waiting times and regulating physician working times in a balanced manner.⁵ Various studies have been performed since the 1950s.^3,6
–8 However, studies in the literature have adopted time as the general criterion for appointment planning. Nonetheless, efficient functioning of the appointment system is more important than waiting times in many hospitals, in which the CPAS is actively used but where patients can also make appointments by presenting in person. In a study of the clinic appointment system, Vissers and Wijngaard.⁶ reported that the system was affected by departmental characteristics and recommended that departments' identification of their own variables (such as average examination and waiting times and physician “idle time”) be used in the establishment of the ideal appointment system. Bailey³ similarly determined that an average waiting time should be determined for each patient and that examination capacity should be established accordingly. As emphasized by Mardiah and Basri,⁹ the principal problem facing the health industry is to reduce costs while increasing patient satisfaction. They also emphasized that the ideal appointment system for hospitals should be calculated on the basis of such parameters as the time that physician examination commences, number of physicians, and waiting room capacity. The point requiring investigation is, therefore, whether the CPAS system is used efficiently. The main finding of our study is that some departments with a capacity set aside for the CPAS (such as Neurosurgery and Ophthalmology) exhibit a take-up of 99%, whereas in others only 50% of the capacity is used (such as Infectious Diseases and Clinical Microbiology). The capacity that is not taken up leads to productivity losses and increased costs, and also, it represents a problem for patients who are unable to make appointments. Our study proves that CPAS capacities need to be assessed at specific intervals in a department-based manner. On the other hand, the CPAS capacity that is not taken up can be transferred directly to the capacity for direct presentations to hospital through calculation on a daily basis. This will, in turn, lead to a significant increase in appointment capacities that are available through direct presentation.

Another important finding identified in this study is that patients do not always keep appointments made through the CPAS. A mean “no show” level of 23% for CPAS appointments was observed in Group 1 and Group 2. General surgery and cardiac surgery patients, making appointments through the CPAS, represent the group requiring the most urgent consideration, because these two departments were those in which “no shows” were most common (34% and 29%, respectively). Failing to attend an examination appointment causes time and productivity losses to the health system, delays in diagnosis and treatment and increases the risk that those patients' conditions will worsen. Patients unable to make appointments for departmental clinics may also present to emergency departments instead, leading to unnecessary overcrowding there. NSPs in Great Britain are reported to cause economic losses of 790 million sterling a year.¹⁰ The prevalence of appointment “no-shows” ranges between 9% and 20% in the literature.^11
–13 The prevalence of “no-shows” in Group 1 and Group 2 in our study was rather higher than that in the literature (22%). Financial penalties are imposed on “no-show” patients in some countries, but no such measure has been applied in Turkey.^14,15 We think that penalizing patients who request appointments from the CPAS but then fail to attend them will encourage patients to make appointments directly in Turkey, which wishes to see the CPAS use more actively. Unnecessary appointments can be prevented by means of family physicians referring those patients they consider appropriate to the CPAS for appointments, rather than patients making appointments to see a specialist when they so wish, but no such system exists in Turkey. Brief educational programs might be provided by producing informative brochures about the CPAS for patients presenting to hospital. Reminding patients of appointments via text message increases attendance rates.^{11
–13,16
–18} Reminders could also be sent to patients who make appointments through the CPAS, and patients might be asked to confirm whether or not they will attend an appointment made through the CPAS. Appointments made by patients who are unable to keep them can be canceled by adding a request along the lines of “If you are unable to keep your appointment, please reply saying “CANCEL” at the end of the reminder message.” Canceled appointments could then be added to those available for direct presentations. This will both confirm attendance at clinic appointments and increase the number of appointments available for patients presenting directly.

The proportion of appointments made through the CPAS to CPAS capacity was statistically significantly higher in Group 2 than in Group 1 (p = 0.009). This indicates increased patient CPAS use. Greater use of the 182 call center, the Internet, and CPAS mobile apps is a welcome development. However, the CPAS technology used must not be allowed to result in a vacant physician capacity or economic and productivity losses.

Conclusion

Our study shows that levels of making appointments through the CPAS are increasing. However, part of the CPAS capacity is not being used, and some patients are not keeping appointments made via the CPAS. CPAS capacities need to be evaluated at specific intervals on a departmental basis so that adjustments can be made in the time allocated for advance appointments and for same-day patient presentations. In addition, reminders and other measures must be adopted regarding patients making appointments through the CPAS and then not keeping them.

Footnotes

Acknowledgment

The authors are grateful to Associate Prof. Nazif Calıs for support with the statistical analysis.

Disclosure Statement

No competing financial interests exist.

References

Kaandorp

, Koole

. Optimal outpatient appointment scheduling. Health Care Manag Sci, 2007; 10:217–229.

Cayirli

, Veral

, Rosen

. Designing appointment scheduling systems for ambulatory care services. Health Care Manag Sci, 2006; 9:47–58.

Bailey

NTJ

. A study of queues and appointment systems in hospital out-patient departments, with special reference to waiting-times. J R Stat Soc Series B Stat Methodol, 1952; 14:185–199.

Turkish Republic, Ministry of Health. Central physician appointment system. www.mhrs.gov.tr/Vatandas/hakkimizda.xhtml (last accessed: March 14, 2017).

Vanden Bosch

, Dietz

. Minimizing expected waiting in a medical appointment system. IIE Trans, 2000; 32:841.

Vissers

, Wijngaard

. The outpatient appointment system: Design of a simulation study. Eur J Oper Res, 1979; 3:459–463.

Klassen

, Rohledern

. Scheduling outpatient appointments in a dynamic environment. J Oper Manag, 1996; 14:83–101.

Harper

, Gamlin

. Reduced outpatient waiting times with improved appointment scheduling: A simulation modelling approach. OR Spectrum, 2003; 25:207–222.

Mardiah

, Basri

. The analysis of appointment system to reduce outpatient waiting time at Indonesia's public hospital. HRM Res, 2013; 3:27–33.

10.

Boksmati

, Butler-Henderson

, Anderson

, Sahama

. The effectiveness of SMS reminders on appointment attendance: A meta-analysis. J Med Syst, 2016; 40:90.

11.

Reekie

, Devlin

. Preventing failed appointments in general dental practice: A comparison of reminder methods. Br Dent J, 1998; 185:472–474.

12.

Sawyer

, Zalan

, Bond

. Telephone reminders improve adolescent clinic attendance: A randomized controlled trial. J Paediatr Child Health, 2002; 38:79–83.

13.

Hashim

, Franks

, Fiscella

. Effectiveness of telephone reminders in improving rate of appointments kept at an outpatient clinic: A randomized controlled trial. J Am Board Fam Pract, 2001; 14:193–196.

14.

Buppert

. How to deal with missed appointments. Dermatol Nurs, 2009; 21:207–208.

15.

Fysh

. Missed outpatient appointments. J R Soc Med, 2002; 95:376–377.

16.

Gurol-Urganci

, de Jongh

, Vodopivec-Jamsek

, Atun

, Car

. Mobile phone messaging reminders for attendance at healthcare appointments. Cochrane Database Syst Rev, 2013; 12:CD007458.

17.

Lin

, Mistry

, Boneh

, Li

, Lazebnik

. Text message reminders increase appointment adherence in a pediatric clinic: A randomized controlled trial. Int J Pediatr, 2016; 2016:8487378.

18.

Guy

, Hocking

, Wand

, Stott

, Ali

, Kaldor

. How effective are short message service reminders at increasing clinic attendance? A meta-analysis and systematic review. Health Serv Res, 2012; 47:614–632.