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Figure.
Distribution of Dermatologic Spending Across Nonattendees
Distribution of Dermatologic Spending Across Nonattendees

Graphical representation of distribution of overall cost. The top 1%, 5%, 10%, and 25% of patients by total spending are responsible for, respectively, 31.8% ($133 000), 50.6% ($211 000), 60.9% ($254 000), and 81.6% ($340 000) of total health care costs.

Table.  
Variables Associated With High Rates of Use After Nonattendancea
Variables Associated With High Rates of Use After Nonattendancea
1.
Pehr  K.  No show: incidence of nonattendance at a dermatology practice in a single universal payer model.  J Cutan Med Surg. 2007;11(2):53-56.PubMedGoogle ScholarCrossref
2.
Waqar  S, Bullen  G, Chant  S, Salman  R, Vaidya  B, Ling  R.  Cost implications, deprivation and geodemographic segmentation analysis of non-attenders (DNA) in an established diabetic retinopathy screening programme.  Diabetes Metab Syndr. 2012;6(4):199-202.PubMedGoogle ScholarCrossref
3.
Centers for Medicare & Medicaid Services.  Physician fee schedule search.https://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Updated August 20, 2015. Accessed September 9, 2014.
4.
Machlin  S, Chowdhury  S.  Expenses and characteristics of physician visits in different ambulatory care settings, 2008. Agency for Healthcare Research and Quality statistical brief 318. http://meps.ahrq.gov/mepsweb/data_files/publications/st318/stat318.pdf. March 2011. Accessed September 9, 2014.
5.
Davis  K, Carper  K.  Use and expenses for office-based physician visits by specialty, 2009: estimates for the US civilian noninstitutionalized population. Agency for Healthcare Research and Quality statistical brief 381. http://meps.ahrq.gov/mepsweb/data_files/publications/st381/stat381.pdf. August 2012. Accessed September 9, 2014.
6.
Mirel  LB, Carper  K.  Expenses for hospital inpatient stays, 2010. Agency for Healthcare Research and Quality statistical brief 401. http://meps.ahrq.gov/mepsweb/data_files/publications/st401/stat401.pdf. February 2013. Accessed September 9, 2014.
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Research Letter
February 2016

Use of Health Care Resources and Costs After Patient Nonattendance in Dermatology

Author Affiliations
  • 1Department of Dermatology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
  • 2Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
  • 3Department of Biostatistics, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
JAMA Dermatol. 2016;152(2):220-221. doi:10.1001/jamadermatol.2015.4030

Patient nonattendance occurs when patients miss appointments without notifying their health care professionals in advance. In dermatology, nonattendance rates range from 7.8% to 31.0% of scheduled appointments.1 The consequences of nonattendance range from compromised care to wasted appointment slots, decreased efficiency, and diluted residency training.2 We seek to define the effect of nonattendance on subsequent use of health care resources and health care spending in dermatology.

Methods

The study included patients within the Partners Healthcare System who were seen at the dermatology office of Brigham and Women’s Hospital in Boston or in an associated suburban satellite clinic and who missed at least 1 dermatology appointment from February 1, 2009, through July 30, 2010. Of the 2289 patients who met these criteria, 250 randomly selected urban patients and all 237 suburban patients were included. Patients with a primary care physician outside Partners Healthcare System (128 patients) and those younger than 18 years at the time of the appointment (6 patients) were excluded, leaving 353 patients. This retrospective study was approved by the institutional review board of Partners Healthcare System, who waived the requirement for a patient to consent to receive treatment. Patient data were deidentified.

We reviewed each patient’s medical record to collect demographics, medical history, and dermatology-specific health care use in the 3 years after the missed appointment (final date of follow-up, July 30, 2013). We performed cost calculations using 2009-2010 figures from the Center for Medicare & Medicaid Services3 and 2011-2013 data from the Agency for Healthcare Research and Quality.4-6 The cost of a missed appointment, including a physician’s time and unused space, was defined as 50% of the cost of an attended appointment. Sensitivity analysis used to test costs from 25% to 75% of an attended appointment did not affect our conclusions.

The composite cost measure reflects missed and attended outpatient appointments, dermatology-related emergency department visits and inpatient stays, and biopsies. Surgical procedures, imaging, prescriptions, and other costs related to treatment were not included. Patients with high rates of use were defined as the top 10% of patients in relation to the cost measure. Changing this definition to those with values ranging from 5% to 15% did not affect the analysis.

Data were analyzed from February 1, 2009, through July 30, 2010. We performed a univariable analysis of all potential predictive variables and a multivariable analysis on all variables with P < .15.

Results

Overall, 47 of 353 patients (13.3%) failed to attend a dermatology appointment. Most of these patients (245 [69.4%]) had subsequent use of dermatology services after nonattendance. Costs were concentrated in a small proportion of these patients, with the top 10% (n=35) responsible for 60.9% of costs (Figure). The overall dermatologic spending was divided among inpatient costs (31.6%), emergency department costs (5.0%), attended outpatient appointments (51.0%), missed outpatient appointments (7.0%), and biopsies (4.4%). A multivariable analysis identified that missing a return visit (adjusted odds ratio, 3.69; 95% CI, 1.27-13.46) and having a history of nonmelanoma skin cancer (adjusted odds ratio, 3.97; 95% CI, 1.53-10.31) were associated with high rates of use (Table).

Discussion

This study of 353 outpatients demonstrates that most patients who miss a dermatology appointment continue to use dermatology services. Although dermatology is primarily an outpatient specialty, 36.6% of subsequent dermatology use came from hospitalizations and emergency department visits.

Health care cost after nonattendance is distributed unevenly, with 10% of patients accounting for 60.9% of spending in our cohort. We identified missing a return visit and a history of nonmelanoma skin cancer as independent predictors for high use of dermatologic care after nonattendance. Interventions aimed at individuals with these risk factors may improve health care quality while reducing overall cost.

Our study establishes that nonattendance of dermatology appointments has an impact beyond the immediate wasted resources. Limitations of this study include the lack of a comparison group without nonattendance. Furthermore, costs were not adjusted for inflation. Future research must evaluate whether educational initiatives, better access to care, or more aggressive outpatient follow-up may decrease cost and improve outcomes after a missed dermatology appointment.

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Article Information

Accepted for Publication: September 2, 2015.

Corresponding Author: Arash Mostaghimi, MD, MPA, Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, 15 Francis St, Peter Bent Brigham Building, Room 421, Boston, MA 02115 (amostaghimi@partners.org).

Published Online: November 11, 2015. doi:10.1001/jamadermatol.2015.4030.

Author Contributions: Drs Halim and Mostaghimi had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr Halim and Miss Weng contributed equally.

Study concept and design: Halim, Mostaghimi.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Halim, Weng, Joyce, Mostaghimi.

Critical revision of the manuscript for important intellectual content: Weng, Kuye, Joyce, Mostaghimi.

Statistical analysis: Halim, Kuye, Joyce, Mostaghimi.

Administrative, technical, or material support: Weng, Mostaghimi.

Study supervision: Mostaghimi.

Conflict of Interest Disclosure: None reported

References
1.
Pehr  K.  No show: incidence of nonattendance at a dermatology practice in a single universal payer model.  J Cutan Med Surg. 2007;11(2):53-56.PubMedGoogle ScholarCrossref
2.
Waqar  S, Bullen  G, Chant  S, Salman  R, Vaidya  B, Ling  R.  Cost implications, deprivation and geodemographic segmentation analysis of non-attenders (DNA) in an established diabetic retinopathy screening programme.  Diabetes Metab Syndr. 2012;6(4):199-202.PubMedGoogle ScholarCrossref
3.
Centers for Medicare & Medicaid Services.  Physician fee schedule search.https://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Updated August 20, 2015. Accessed September 9, 2014.
4.
Machlin  S, Chowdhury  S.  Expenses and characteristics of physician visits in different ambulatory care settings, 2008. Agency for Healthcare Research and Quality statistical brief 318. http://meps.ahrq.gov/mepsweb/data_files/publications/st318/stat318.pdf. March 2011. Accessed September 9, 2014.
5.
Davis  K, Carper  K.  Use and expenses for office-based physician visits by specialty, 2009: estimates for the US civilian noninstitutionalized population. Agency for Healthcare Research and Quality statistical brief 381. http://meps.ahrq.gov/mepsweb/data_files/publications/st381/stat381.pdf. August 2012. Accessed September 9, 2014.
6.
Mirel  LB, Carper  K.  Expenses for hospital inpatient stays, 2010. Agency for Healthcare Research and Quality statistical brief 401. http://meps.ahrq.gov/mepsweb/data_files/publications/st401/stat401.pdf. February 2013. Accessed September 9, 2014.
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