Do ‘do not attends’ at a genitourinary medicine service matter?

INTRODUCTION

Patients who do not attend (DNA) clinic appointments are both problematic for service delivery – since clinic resources are wasted – and in the planning of future service delivery. In genitourinary (GU) medicine clinics, DNAs may also pose a potential public health risk through the onward transmission of any untreated sexually transmitted infections (STIs). ^1–3 In 2006, the UK Department of Health (DH) determined that all patients requesting a GU medicine appointment should be offered such an appointment within 48 hours, and 95% of all patients should be seen within this time. ^4,5 Nationally, GU medicine clinics are ‘open access’: booking is unrestricted, and ‘walk-in’ services are offered for those unable or unwilling to attend a clinic appointment. GU medicine clinics have also sought to extend clinic opening hours to the early mornings, evenings and weekends, and made use of outreach facilities intended to both reduce patient travelling times, and counter any barriers to attendance experienced by specific communities. ⁶ Thus, DNAs have also come to represent a marker for GU medicine clinic accessibility. Despite their significance to GU medicine services, however, there is little data published on DNAs. Specifically, it is unknown whether particular demographic groups DNA at a greater rate than the general clinic population; whether such groups represent a real risk of onwards STI transmission; and why patients DNA – and, therefore, whether non-attendance is, indeed, a valid indicator of clinic accessibility. This service evaluation: (1) assesses the demographics of DNAs at a GU medicine clinic; (2) assesses patient reasons for non-attendance; and (3) follows up data to determine the health outcomes of non-attendance.

METHODS

For the first part of the study, a retrospective analysis of the data of patients who DNA their appointment at the GU medicine clinic, Royal South Hants Hospital, Southampton, between January and April 2008 was untaken. The DNAs included both new patients and rebooked patients – those that had previously attended the clinic but were representing with a new complaint. This demonstrated that when patients DNA their first booked appointment, 30.6% (55/180) will self-reappoint or attend the open access ‘walk-in’ clinic. The majority of whom (89%, 41/55) do so within two weeks of their missed appointment. Patients who wait longer than this are very unlikely to make a further appointment.

In the second part of the study, telephone contact was attempted with the 383 patients who DNA their booked GU medicine appointment between October 2008 and March 2009. Using the findings from the initial part of the study to determine the most useful time for intervention DNAs were contacted two weeks after their missed appointment. DNA details, including ethnicity, age, sex, location and occupation was recorded, and compared with demographic data held on the clinic's general population. Consenting DNAs were interviewed and asked whether they had been symptomatic when booking their appointment; why they had missed their appointment; whether they had attended alternative medical services; and whether an SMS-based reminder service would be helpful in keeping future appointments. DNAs were also offered a new appointment, and informed of the open access ‘walk-in’ services. Up to six contact attempts were made for each DNA. If no contact was so made, and the facilities were available, an answer-phone message was left requesting that the patient contact the GU medicine clinic. The electronic patient records system was used to monitor subsequent attendances of all patients in the study, and all diagnoses made. Permission for this service evaluation was granted by Southampton City Primary Care Trust Clinical Audit Department.

RESULTS

The GU medicine clinic DNA rate between October 2008 and March 2009 was 6% (383/6961). Sixty-three percent (243/383) of DNAs were rebooked patients and 37% of DNAs were new patients. Patients were significantly more likely to DNA if unemployed (P < 0.001), resident within Southampton PCT (P < 0.001) or rebooked patients (P < 0.001), when compared with the general clinic population. Despite multiple attempts to contact all patients who DNA, only 48% (182/383) of DNAs were actually interviewed by telephone; 31% (118/383) of DNAs either did not provide a telephone number or provided an incorrect telephone number; 21% (81/383) were left answering-phone messages and did not respond; and <1% (2/383) did not consent to be interviewed.

When asked as to the reasons for their original non-attendance, 40% (73/182) reported that they had forgotten they held an appointment; 31% (57/182) reported personal reasons; 25% (16/182) reported that they were working and unable to attend; and 4% (6/182) reported that they were studying and unable to attend. Personal reasons cited by DNAs included childcare issues, carer responsibilities, menstruation and that an appointment was no longer felt necessary. No patients reported that clinic opening hours prevented their attendance. Eighty-four percent (152/182) of patients reported that they would find an SMS telephone reminder service, with details of appointment time and clinic number, useful in keeping appointments.

On interview, 76% (137/182) of DNAs stated that they were asymptomatic when booking their original appointment. When asked about continued need for GU medicine services, 38% (70/182) of DNAs stated that they had subsequently made a new appointment with a health-care provider: 61% (43/70) of these patients had made a second appointment or accessed the GU medicine ‘walk-in’ service; 4% (3/70) attended their general practitioner; 4% (3/70) attended a family planning clinic; and <1% (1/70) attended a private clinic. Twenty-four percent (17/70) of those attending alternative services were diagnosed with an STI: nine cases of chlamydia, four cases of non-specific urethritis (NSU) and four cases of anogenital warts were detected.

Forty-one percent (75/182) of DNAs accepted a new appointment at the GU medicine clinic during the telephone consultation, but of these 63% (43/75) went on to DNA this second appointment, although subsequently 9% (7/75) attended ‘walk-in’ services. Of the patients who finally attended the GU medicine clinic, 26% (9/35) were diagnosed with an STI: five cases of chlamydia, one case of NSU and three cases of anogenital warts were detected. Telephone contact thus increased GU medicine clinic attendance by 9% (35/383), but led to a greater incidence of DNAs.

DISCUSSION

Patients were significantly more likely to DNA if they are unemployed, resident within Southampton PCT and have previously accessed GU medicine services. That such patients are not limited in the time or date of any appointment by obligations to their employer, benefit from proximity to the GU medicine clinic, have previously made and kept GU medicine appointments and do not cite clinic opening hours, or similar, as contributing to their non-attendance, suggests that a clinic's DNA rate is not a reliable marker of clinic accessibility. Indeed, the inverse may be suggested: such patients appear capable of accessing GU medicine clinic services without difficulty, and may be prepared to miss appointments precisely because alternative access (whether through new appointments, or via ‘walk-in’ services) is known to be equally accessible. While some STIs are seen to be present in those patients that DNA GU medicine clinic services, many of these patients subsequently self-reappoint within two weeks.

This study demonstrated that telephone intervention increased DNA reattendance by only 9%. This may not represent a good use of clinic resources: the process is time-consuming, and significantly a high percentage (63%) of DNAs booked new appointments only to DNA once more. This intervention therefore would benefit few and may in turn increase the clinic DNA rate.

The majority of patients in this study stated that they simply forgot their appointment and said that an SMS telephone reminder would have been useful. Previous studies have demonstrated the value of this, ^7–10 but it should be noted that in this study approximately one-third of patients gave incorrect contact details when booking the appointment. A pragmatic approach might be to contact patients who DNA via an SMS message two weeks after their missed appointment and remind them of the walk-in service. This would allow testing and screening without compromising further clinic appointments.

In conclusion, the study shows that most patients who DNA their booked appointment at a GU medicine and who make no measures themselves to be seen within two weeks of their initial appointment are asymptomatic and have a lower STI rate than the general clinic population. As previous studies of access to GU medicine within 48 hours suggest, ^11,12 if the clinic accessibility is good then clinic opening hours were not cited by patients as the reason to DNA their appointment. Unexpectedly those patients who have previously used the service and who lived close by were significantly more likely to DNA than those patients who were new or had further to travel to clinic. Making use of SMS messaging services to remind patients of their appointment may be beneficial and a subsequent SMS message to patients who DNA notifying them of the time of walk-in services might be the most effective way of recapturing these patients without compromising future clinic appointment slots.