The Effect of Exit-Interview Patient Education
Background: Residency clinics with high no-show rates experience negative ramifications in patient health care, continuity, clinic productivity, and learning experiences for residents. This study tested patient education in the form of an exit interview to reduce no-show rates.
Methods: All eligible new patients at St. Mary's Family Practice Center between 1 February 1996 and 30 April 1997 were offered study enrollment. Patients with initial appointments during 5 of 9 clinic sessions were offered an exit interview with visit debriefing, written patient information where appropriate, and review of clinic policies. Missed patients or those with initial appointments during the remaining 4 sessions formed the control group. Interviewers were social work, medical, and nursing students. Insurance and subsequent appointment data were obtained from billing records. Median household income of ZIP codes in which patients resided was obtained from the 1990 Federal Census data. Data were analyzed using χ tests, Wilcoxon rank-sum tests, and logistic regression.
Results: One hundred forty-six patients were enrolled into the intervention and 297 into the control group. Simple logistic regression showed a significant reduction in the risk of no-shows in the intervention group (odds ratio = 0.71, P = .04).
Conclusions: The exit interview improved attendance at subsequent visits.

The effects of missed medical clinic appointments on patient health have not been studied extensively, and published studies are not comparable or definitive. It is reasonable to think that patients who miss appointments will also miss some opportunities for timely health care interventions. Andrews and colleagues concluded that 21 of 34 children in Great Britain whose parents did not bring them to follow-up appointments needed further medical attention and were therefore at risk for "avoidable ill health." Bigby's group, however, found no significant differences in development of new medical problems, exacerbation of old medical problems, or hospitalizations or death between 100 no-show and 100 control adult patients in a primary care center in Boston. This 1984 study also raised the question of whether follow-up appointments were being offered unnecessarily in some cases. Cummings group's study of 973 adults with hypertension used reminder cards and telephone calls to improve compliance with appointments and treatment in the study group, who also showed some improvements (not statistically significant) in blood pressure control over the control group.

However, although the medical importance of keeping clinic appointments remains to be elucidated, reducing no-show rates is important for other reasons. Missed appointments adversely affect clinic productivity. At our institution and other residency training clinics, no-show rates are believed to significantly reduce resident learning opportunities. Weingarten and colleagues found a significant difference in missed appointment rates by training level of the physician, with medical students and first-year residents having the highest rate of missed appointments.

Keeping appointments for medical services has been evaluated in a variety of different settings, from outpatient mental health facilities to primary care clinics. Attempts have been made to identify common patient factors associated with failure to keep appointments or to elicit reasons for missing appointments. Although individual studies have found a correlation between appointment keeping and certain characteristics such as age, race, insurance status, and time of day, other studies show no correlation. It is likely that the reasons patients fail to keep appointments are multiple and complex and that attempts to characterize such patients will serve no useful purpose.

Many studies have been geared toward interventions that may decrease no-show rates. Letters, postcards, telephone calls, pamphlets, orientation videos, monetary incentives, and patient education have all been evaluated in a variety of settings. Although many of these methods have been shown to be useful in decreasing no-show rates, interventions clearly need to be tailored to the population of interest. For example, telephone calls would be ineffective in a population with no or intermittent telephone service, and letters or postcards may not be helpful for a population with a low literacy level or frequent changes of address.

St. Mary's Family Practice Center in Milwaukee, Wisconsin, serves a population composed largely of low income and ethnic minority inner-city residents and averages a no-show rate between 22% and 25%. Prior attempts to decrease no-show rates with phone calls the day before the patient's appointment and phone calls to patients by their physicians after a missed appointment failed to make an impact. A clinic policy discharging patients from the clinic after 3 no-shows in a year also failed to appreciably affect the kept appointment rate.

According to Barron, "...a breakdown of communications is at the heart of higher failure rates often described in low income and ethnic minority patients." Hertz and Stamps attributed a rise in broken appointments to a breakdown in communication on the part of the health center under study. Several studies have looked at the effect of face-to-face patient education in reducing the no-show rate, but face-to-face patient interventions aimed specifically at addressing the no-show problem in a general patient population have not been studied.

We undertook this prospective study to determine whether a one-time, face-to-face patient interview intervention (visit debriefing, review of clinic procedures, and written health information where appropriate) during the first clinic visit decreases no-show rates in new patients at an inner-city family practice residency clinic.