Increasing patient compliance appointment keeping

with

Alan M. Gross, Ph.D., F. Watt Bishop, D.D.S., M.S., Dawn Reese, B.A., Teresa Lollis, B.A., Cindy Janke, M.S., Cindy Hedden, M.S., and Steve Smith, B.A. Universi~ and Oxford, Miss.

P a t i e n t noncompliance with orthodontic health care regimens is a pervasive problem, l Noncom- pliance encompasses a variety of topics. Although it is most commonly considered as instances in which pa- tients fail to wear orthodontic appliances (for example, headgear, retainers, intraoral elastics) or do not follow instructions concerning oral hygiene, noncompliance also involves failure to meet scheduled treatment visits. Irresponsible behavior concerning scheduled appoint- ments may result in less effective treatment or unne- cessarily extended treatment periods because of dis- continuous care. When patients fail to appear for a scheduled visit or arrive late for an appointment, it results in staff frustration and a waste of valuable re- sources. This may be the case especially in orthodontic practice when patients agree to pay a specific fee for treatment regardless of the number of visits required to achieve the dentofacial correction.

The purpose of the present study was to evaluate the effectiveness of a behavioral program designed to reduce attendance problems at an orthodontic clinic. The clinic was open 3 days a week. The subjects of the study were patients with scheduled appointments. They ranged in age from 8 to 46 years, with a mean age of 12 years. Patients were undergoing treatment for a wide variety of dentofacial disorders.

The attendance measures involved (1) monitoring the number of patients who failed to appear for a sched- uled appointment (no shows), (2) recording the fre- quency of last-minute cancellations (patients who failed to provide 24-hour notice when they were unable to keep an appointment), and (3) recording the instances in which patients arrived for appointments on time (pa- tients were considered late if they arrived 1 minute after the scheduled time).

From the Department of Psychology, University of Mississippi. This research was supported by National Institutes of Health Grant DEO7978.

The procedures were evaluated by use of a reversal design. 2

During baseline a digital clock was placed on the desk where patients were required to sign in when they arrived for an appointment; they were asked to record their exact arrival time. On occasions when a patient called to cancel an appointment, the receptionist noted on the sign-in sheet the time the call was received. The sign-in sheet was examined daily to determine whether a patient had arrived late or was a no-show or last- minute cancellation. This phase was in effect lbr 33 days (11 clinic weeks).

With the implementation of the lottery program, a large poster was placed in the office waiting area an- nouncing an attendance lottery. It stated that patients who kept their appointments and arrived on time would be entered in the lottery. A large gift-wrapped box was placed along side the receptionist's desk. When a pa- tient arrived on time, their appointment card was marked by the receptionist and the patient was in- structed to place it in the box. The poster also noted that the winner of the lottery would receive a $15 gift certificate to the local shopping mall, and that winners would be determined monthly. This condition was in effect for 33 days (11 weeks).

After treatment, baseline conditions were reinstated for 16 days (5 weeks).

Reliability checks were conducted during all stages of the study to determine whether patients accurately reported arrival times. Observers, posing as patients, sat in the waiting room daily and recorded patient arrival times. If patient-recorded and observer-recorded arrival times differed by greater than _+ 1 minute, they were considered disagreements. Reliability was computed by dividing the number of agreements by the number of agreements plus disagreements and multiplying the quotient by 100. Reliability averaged 86%.

An examination of the results showed that during baseline procedures, 69% of the patients arrived on time

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260 Gross et al. Am. J. Ortt~od. Dentofac, Orrhop, March 1988

for their appointments. With the implementation of the lottery, this increased to 79%. This performance was maintained (78%) during the second baseline phase. This represents an overall improvement in patients' on-time behavior of t5%. Last-minute cancellations decreased from an average daily rate of 7% during baseline procedures to 4% during the lottery phase. With the reinstatement of baseline procedures, last- minute cancellations increased to 6%. No-shows oc- curred at an average daily rate of 4% during baseline conditions, 1% during the lottery condition, and 0.5% during the second phase of baseline conditions. This is an overall decrease in no-shows of 75%.

The results of the present study indicate that an attendance lottery is an effective method to improve patient compliance with scheduled treatment visits. With the implementation of the lottery, there was a 15% increase in on-time behavior, a 57% reduction in last- minute cancellations, and a 75% reduction in no-shows. In general, these improvements were maintained when the lottery was discontinued.

The maintenance of increased patient compliance after the discontinuation of the lottery was not expected and may have been a result of the relatively short du- ration of the second baseline condition. This phase was in effect for 5 weeks. Since the majority of patients in an orthodontic practice visit the office for treatment on a monthly basis, it is likely that the relatively short duration of this phase made it difficult for the subjects to discriminate the change in reinforcement contingen- cies. Continued operation of the lottery would most likely be required to sustain improved compliance with appointment keeping.

As a method to improve patient compliance in keep- ing scheduled appointments, the lottery offers a number of advantages. Methods such as mailing appointment reminders or phoning patients to call their attention to a scheduled appointment involve a large commitment of staff time and expense. The lottery System involves minimal staff time. Moreover, in the present study the staff reported that they enjoyed conducting the~lottery.

The lottery program described requires minimal ex- pense. A $15 gift certificate was used tO reinforce on- time behavior. Although it is difficult to make general Statements concerning the average cost per hour for an orthodontist to maintain a practice, there is no doubt that operating expenses (for example, staff saiaries, available treatment contact time, office utilities) easily involve amounts exceeding $100 to $200 per hour. Even with this conservative figure, it appears that the cost/benefit ratio associated with this procedurejustifies its use if it saves as little as 1 hour per week of staff time.

REFERENCES 1. Gross AM, Samson G, Dierkes M. Patient cooperation m treat-

ment with removable appliances: a model of patient noncompli-: ance with treatment implications. AM J ORTI-IOD 1985;87:392-7.

2. Hersen M, Barlow DH. Single case experimental designs. New York: Pergamom Press, t976.

Reprint requests to: Dr. Alan M. Gross University of Mississippi Department of Psychology College of Liberal Arts University, MS 38677