by Caroline Helwick
Washington—The strategy of “ predictive overbooking” can optimize endoscopy scheduling and negate the effect of no-show patients, according to researchers who used it to streamline their clinic’s operation at a Veterans Affairs (VA) health care system in Los Angeles.
“Predictive overbooking may be a useful tool for improving patient throughput in gastrointestinal endoscopy units,” said Brennan Spiegel, MD, director of the Cedars-Sinai Center for Outcomes Research and Education and a gastroenterologist at the VA Greater Los Angeles Healthcare System. “We improved our productivity substantially and our staff were very enthusiastic about this.”
Absenteeism for scheduled outpatient visits and procedures occurs frequently in health care systems. No-show patients delay their own treatment and that of other patients, lead to poor use of clinic resources and increase the cost of health care. No-shows are particularly common for endoscopic procedures, with rates reported as 5% to 35%, depending on site and patient demographics, the researchers noted.
The VA researchers developed a plan for predicting what proportion of scheduled patients would not show up each day, and they offered these slots to patients desiring an appointment. They were able to maximize scheduling without denying service to any patients.
Dr. Spiegel described the approach at the 2015 Digestive Disease Week (abstract 495). He said appointment reminders, such as calls, mailings and text messages, and even the use of patient navigators, have shown inconsistent benefits and generally minimal returns. “No matter how rigorous you are with patient follow-up, there are patients who won’t show up,” Dr. Spiegel said.
One proposed solution is overbooking by a fixed percentage, which he called the “airline model,” but under this system patients can be denied service. “It understandably upsets patients,” he said, “and this may actually increase the risk of subsequent no-shows.”
Dr. Spiegel and his colleagues modified the overbooking concept into a “variable-percentage overbooking” model that used electronic health records (EHRs) to predict the likelihood that a given patient would fail to appear for his or her appointment.
“The idea is that each individual has his or her own unique problems for not coming. We could use the information already available to us to predict who won’t come,” he explained.
The researchers collected performance data from a large VA outpatient GI clinic, including number of available appointments, number of procedures completed and length of clinic workday. Using the EHR-based no-show prediction model, they assigned each patient a no-show risk score.
The factors that predicted a no-show included previous attendance and cancellation records, demographics, medical comorbidities, and a history of mood disorder or substance abuse.
“By far, the single most important predictor of no-show was the proportion of previously scheduled visits that were canceled or were no-shows,” he said. The model that contained these variables had an overall accuracy of 85% in predicting no-shows in a pilot study of 1,397 patients.
In a follow-up to the pilot study, the researchers prospectively applied this no-show prediction model to measure the impact of the scheduling program (“fast-track”) on clinic utilization rates and staff workflow at the West Los Angeles VA Medical Center for all patients scheduled for outpatient GI endoscopy. Clinic utilization rates were determined by dividing the number of appointments attended by the number available.
During randomly selected experimental weeks, appointment slots for patients whose no-show risk scores exceeded a cutoff value were made available to other patients on short notice. Patients were actively recruited from a weekly outpatient clinic to fill these projected openings. Physicians could request a fast-track endoscopy for a given patient, enabling the patient to be seen within two weeks of the visit, versus the typical 30-day wait for an appointment at the facility.
Fast-track patients had to agree to several conditions: They might have to wait to be seen on the day of their appointment; the procedure might be canceled, but only if they had not done a bowel prep and the examination was not urgent; and if the endoscopy could not be performed, the patient would be scheduled for the next available time slot.
During control weeks, patients were not actively recruited and the operation of the clinic was not altered.
New Strategy Fills Vacated Slots
Of 1,559 patients, 111 accepted fast-track booking and all kept to their scheduled appointment. Compared with the typical “one patient, one slot” scheduling during 22 control weeks, predictive overbooking during 17 experimental weeks resulted in nearly all endoscopy appointment slots being filled: 2.91 slots versus 0.28 slots available per day (P<0.0001).
“We were able to fill more slots during the weeks using overbooking scheduling,” Dr. Spiegel said.
Clinic utilization rates increased from 86.5% during control weeks to 99.5% during experimental weeks, allowing more than 100 additional patients to undergo procedures, according to the researchers.
“We occasionally overshot or undershot in the intervention period,” Dr. Spiegel added, “but most of the time it was by only one slot.” No patients were denied service, he said.
However, physician and ancillary staff overages were more common during experimental weeks, when the average workday was a half-hour longer (7.8 vs. 8.3 hours for conventional scheduling; P=0.02), according to the researchers. “We were careful to have backup plans, and if we overshot, they called me, the PI [principal investigator], to come in. So yes, there is some uncertainty,” Dr. Spiegel said.
John Inadomi, MD, the Cyrus E. Rubin Endowed Chair in Medicine and head of gastroenterology at the University of Washington, in Seattle, called the project “a very good effort” toward maximizing clinic resources, especially in facilities that tend to be “resource-challenged. These are precious slots, and we lose money when the patient doesn’t show up,” he told Gastroenterology & Endoscopy News.
However, he said, the concept may not work as well in private practice, where the patient population tends to be different and the reasons underlying no-shows are probably different.
The challenge for practices, Dr. Inadomi said, will be achieving the right balance. “You don’t want to get to the point where you are like the airlines, with overbookings and discontented customers,” he said. “The big question is what level of overbooking or discontent will you accept? How bad of a day do you have to have, to say this approach is not working? We can’t tell from this report, but if it happens consistently, we can’t do it. It’s a matter of tailoring the algorithm so you minimize the number of ‘very bad’ days.”