Patient absenteeism in outpatient consultations: an integrative literature review

O absenteísmo dos pacientes em consultas ambulatoriais: revisão integrativa da literatura

El absentismo de los pacientes en citas médicas ambulatorias: revisión integrativa de la literatura

ABSTRACT

Objective:

To identify and analyze the production of knowledge in national and international literature on patient absenteeism in scheduled medical consultations.

Method:

This is an integrative literature review in the databases PubMed, Embase, Scopus, Web of Science, CINAHL, Medline, LILACS, Virtual Health Library of the São Paulo State Department of Health and Spanish Bibliographic Index in Health Sciences, accessed through the Virtual Health Library Portal, based on the guiding question.

Results:

A total of 767 articles was found and nine were selected. Forgetfulness predominated among the reasons for absence. Other findings regarding the cost to the health service and strategies for solving the problem are highlighted.

Conclusion:

As the focus of the studies, the concern with the quality of care, increased treatment queues and high demand, as well as the cost of absent patients, are evident. Despite the relevance of the theme for the health services organization, the literature is still scarce.

DESCRIPTORS
Patients; Absenteeism; Ambulatory Care; Health Resources; Nursing Administration Research; Review

RESUMEN

Objetivo:

identificar y analizar la producción de conocimiento en la literatura nacional e internacional sobre el absentismo de los pacientes en las citas médicas programadas.

Método:

Revisión Integrativa de la literatura en las bases de datos PubMed, Embase, Scopus, Web of Science, CINAHL, Medline, LILACS, Biblioteca Virtual en Salud de la Secretaría de la Salud de la provincia de São Paulo e Índice Bibliográfico Español en Ciencias de la Salud, accedidas por la Portada de la Biblioteca Virtual de Salud, basada en la cuestión norteadora.

Resultados:

Fueron encontrados 767 artículos y seleccionados nueve. El olvido predominó entre los motivos de ausencia. Otros hallazgos en relación al costo para el servicio de salud y estrategias para resolución del problema son destacados.

Conclusión:

Se evidencian, como enfoque de los estudios, la preocupación con la calidad del atendimiento, aumento de las colas y alta demanda, además del costo de los pacientes ausentes. A pesar de la relevancia del tema para organización de los servicios de salud, la literatura todavía es escasa.

DESCRITORES
Pacientes; Absentismo; Atención Ambulatoria; Recursos en Salud; Investigación en Información de Enfermería; Revisión

RESUMO

Objetivo:

Identificar e analisar a produção de conhecimento na literatura nacional e internacional sobre o absenteísmo dos pacientes nas consultas médicas agendadas.

Método:

Revisão Integrativa da literatura nas bases de dados PubMed, Embase, Scopus, Web of Science, CINAHL, Medline, LILACS, Biblioteca Virtual em Saúde da Secretaria de Estado da Saúde de São Paulo e Índice Bibliográfico Espanhol em Ciências da Saúde, acessadas pelo Portal da Biblioteca Virtual de Saúde, com base na questão norteadora.

Resultados:

Foram encontrados 767 artigos e selecionados nove. O esquecimento predominou entre os motivos de ausência. Outros achados em relação ao custo para o serviço de saúde e estratégias para resolução do problema são apontados.

Conclusão:

Evidenciam-se, como focos dos estudos, a preocupação com a qualidade do atendimento, aumento das filas e alta demanda, bem como o custo dos pacientes ausentes. Apesar da relevância do tema para organização dos serviços de saúde, a literatura ainda é escassa.

DESCRITORES
Pacientes; Absenteísmo; Assistência Ambulatorial; Recursos em Saúde; Pesquisa em Administração de Enfermagem; Revisão

INTRODUCTION

The Brazilian 1988 Federal Constitution defines “Health as a right of everyone and the State’s obligation”. The Brazilian Public Health System (SUS) is based on comprehensive health care, with universal, equal, and free access to health in the country(¹), and the opportunity to access the service is a preponderant factor in achieving comprehensiveness in order to promote, protect and restore health(²).

To improve the health system, the organization of the Health Care Network (RAS) is recommended, aiming to promote the integration of services at the different levels of care and to offer quality care, which includes comprehensiveness and humanized actions, with equality and clinical and economic efficacy(³).

The health system organization, as well as the articulation in the RAS, are challenges for Collective Health(¹). For a better understanding of this organization, it is necessary to know absenteeism in services of different complexities, considering that the articulation of the levels of care begins with the entry into the Public Health Service, according to Ordinance 2436. Entry takes place through Primary Health Care, either through the Basic Health Unit (UBS) or through the Family Strategy Unit (USF)(⁴). The provision of health services shall meet the needs of the population, and the systems shall be designed to optimize material and human resources, aiming at quality, economy, and problem solving(³). Preservation and guarantee of SUS’s principles are the responsibility of its managers, in the different spheres of government – municipal, state or federal(²).

A study observed that the Brazilian health system, although being free for the population, when compared to countries such as Germany, Australia, Austria, Belgium, Canada, Korea, Denmark, Slovakia, Spain, United States, Finland, France, Greece, Netherlands, Hungary, Iceland, Ireland, Italy, Japan, Luxembourg, Mexico, New Zealand, Norway, Poland, Portugal, United Kingdom, Czech Republic, Sweden, Switzerland, Turkey, still has some unfavorable health indicators, such as infant mortality and low income per capita(⁵).

Ordinance no. 1631/2015, which “approves criteria and parameters for the planning and programming of health actions and services within the scope of SUS”, establishes a proportion of 62.7% for medical consultations in primary care, of 22, 3% for specialty care, and 15% for emergency services(⁶).

The challenges for the health organization, based on SUS’s principles, are extended to professionals working in the area(⁷) and have an impact on the quality of care levels(⁸). Despite the efforts to integrate health levels and the commitment of managers, there are flaws in the logistics of the service to the system’s user. The inappropriate use of resources is present, for example, in the absence to scheduled medical appointments, which cause losses to the services, both financially and individually, leading to the increase in waiting lines and time for rescheduling appointments. It directly affects health planning that optimizes resources for patient care. This is related to the increase in the number of visits to emergency units and failure to address the health problem.

Absenteeism in consultations influences the results of patient care(⁹), affecting the demands for care, which are high in relation to what the service has to offer.

The managers’ concern about absenteeism in medical appointments is evident. In the Metropolitan Health Region of the state of Espírito Santo, absenteeism in scheduled medical appointments was 38.6%, leading to losses to the individual and the service administration(¹⁰). In a public university hospital in Argentina, the absenteeism rate reaches 21.3%(¹¹). The World Health Organization mentions, in the World Health Report “Health Systems Financing, The Path to Universal Coverage”, the difficulty of countries, regardless of their wealth, to meet the population’s universal health needs, as well as the waste of health resources around 20 to 40%, hindering the improvement of the quality of services provided(¹²).

Due to the importance of planning and organizing health resources, the objective of the study was to identify and analyze the production of knowledge in national and international literature on patient absenteeism at medical appointments scheduled in outpatient clinics.

METHOD

Design of Study

This is an integrative literature review(¹³), which is a research method that synthesizes knowledge in the study area to be applied to practice. Considering the phenomenon of interest, the population and the context, the question outlining the study was: What is the proportion and how is absenteeism characterized in scheduled medical appointments of adult patients in the outpatient setting?

The following methodological steps were developed: identification of the problem and elaboration of the guiding question; searching for literature in the databases; data evaluation; definition of information to be extracted from the studies; critical analysis and synthesis of data and final presentation of the review; discussion of data and presentation of the review(¹⁴).

For the integration of the data found, the principles of SUS were considered, especially the concept of comprehensive health care in meeting the needs of users served in the Public Health Sector(¹).

It was based on the understanding that absenteeism interferes with the use of outpatient resources, which, in its turn, affects the continuity of care and the comprehensiveness of care.

The inclusion criteria were being published and indexed in the referred databases and highlighting the absenteeism of adult patients in medical consultations scheduled in an outpatient clinic; being written in English, Portuguese and Spanish; and no restriction on the date of publication. The exclusion criterion was to be related to Primary Health Care, regarding the cost of the disease.

The sample was selected through access to the databases, via the Regional Portal of the Virtual Health Library (VHL), where articles were obtained from the following databases: Latin American and Caribbean Literature on Health Science (LILACS); Medline, Spanish Bibliographic Index in Health Sciences (IBECS), and Virtual Health Library if the State Health Department of São Paulo. The following databases were also accessed: Web of Science; National Library of Medicine (PubMed), Scopus; Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase, with descriptors searched in the Health Sciences Descriptors (DECS) and in the Medical Subject Headings Section (MESH), as shown in Chart 1. The search was carried out in July 2020 and updated in October of the same year, with the search strategy being guided by a specialized librarian, who guided the choice of Boolean terms and operators.

Chart 1
Search strategies according to the database/data portal – 2020.

Data Analysis and Treatment

To select the studies, the analyses of the titles and abstracts were carried out; when they were not enough, the articles were read in full.

Study selections were made by two authors, one of whom being a Nursing PhD and the other a doctoral student of the doctoral program in nursing.

In the third phase, after reading the 11 articles selected in full, two articles were excluded because they did not meet the research guiding question, as shown in Chart 2.

Chart 2
References excluded and reasons for exclusion – 2020.

The sample included 9 articles for the corpus of analysis, as they referred to the absenteeism of adult patients in medical consultations scheduled in an outpatient clinic, responding to the research objectives and guiding question. Following data analysis, the results were organized into thematic categories.

The articles selected for the study were evaluated according to the level of scientific evidence(¹⁵), which establishes Level I of evidence for systematic reviews and meta-analyses, Level II for randomized clinical studies, Level III for non-randomized clinical studies, Level IV for cohort studies and well-designed control cases, Level V for systematic reviews of descriptive and qualitative studies, Level VI for qualitative or descriptive studies, and Level VII for opinions or consensus.

RESULTS

From the search in the databases, 767 articles were obtained. Ninety-three were duplicated and were excluded, with 674 articles remaining. The studies were initially identified by a thorough reading analysis of the title and abstract, with 663 articles being excluded because they did not meet the inclusion criteria, and 11 articles remained.

At the end of the analysis process, nine articles were selected that met the inclusion criteria and constituted the final sample. The analysis of the date of publication showed that the studies were published as of 2008, and with 88.9% as of 2010.

Figure 1 below shows the flowchart for the selection, inclusion, and exclusion of articles.

Figure 1
Flowchart of selection of articles for the integrative review.

For the collection, selection, and analysis of the data from the articles used, characterizations were done according to Chart 1 and the items represented in it. Respecting the methodological rigor and the research question, the elements of analysis were: title and authors, year/country, design, outcomes, database where the article was found, and level of scientific evidence(¹⁵), as shown in Chart 3.

Chart 3
Characterization of the 9 articles included in the study: title, database, country of origin, design, database, and levels of scientific evidence – 2020.

There was a greater presence of international articles in the sample of nine articles included in this review.

As for the methodological approach of the studies, the quantitative character prevailed.

Regarding the level of evidence of the articles, Level VI predominated (six articles), and three articles presented Level IV. The predominant level of evidence was moderate to weak; however, it has been described so as the more robust evidence could be known. Hence, the other articles with moderate and weak evidence were included, since in the integrative review all levels are considered. Thus, it was decided that all levels of evidence of the articles that were related to the objectives of the study would be included. Although there was an intention to separately analyze the levels of evidence from I to III and from IV to VII, as articles of groups I, II and III were not identified in the corpus of analysis, the analysis was integrated, considering the groups from IV to VII, due to the scarcity of studies. Studies with lower evidence may lead to the scientific production of new studies with better findings, in order to improve the quality of the evidence.

Despite the small number of studies, there is a concern in the management area about absenteeism at scheduled appointments, indicating that it is a topic involving managers, professionals, socioeconomic and behavioral issues. Issues related to time, distance, and communications are relevant and will be further developed in the thematic categories, together with the discussion.

DISCUSSION

Of the seven international studies, two were carried out in Spain, one in the United States, one in Africa, one in China, one in Argentina, and one in Ireland. There was a predominance of articles in English, in a total of five; two were in Portuguese and two in Spanish.

From the corpus of analysis, three thematic categories emerged: the expense of absenteeism to consultations for the Health Service, Reasons for absences, and Strategies to prevent absences.

Expenses on Absenteeism to Consultations for the Health Service

Absenteeism in consultations usually leads to losses for patients, such as the increase in waiting lines and idleness in the use of resources previously organized to meet the demand of people scheduled and who do not go to the consultation. In addition, rescheduling appointments tends to generate costs for the organization.

A study carried out in Spain(¹⁷) shows that health expenditure represents 5.9% of the Gross Domestic Product (GDP), while in Brazil around 8% of its GDP is used(²⁵).

In Spain(¹⁷), a study analyzed the cost of patients who missed outpatient visits through a case-control study at the Costa del Sol Health Agency (ASCS), which includes Hospital Costa Del Sol, Centro de Alta Resolution de Especialidades (CARE) of Mijas and the High Resolution Hospital of Benalmádena. The groups of patients who were absent were compared to those who were not absent, as well as the cost of appointments.

The same study(¹⁷) showed an absenteeism rate of 13.8%, with a cost of three million Euros. The cost of the first consultation and exams for each ASCS specialty was analyzed. The specialties of gastroenterology, internal medicine, and rehabilitation appear with higher costs. In Spain, the National Health System has as its principle the universality of care, ensuring all care regardless of the amount paid for taxes; it is regionalized and decentralized(²⁶) and resembles the Brazilian system(²⁷).

The cost of human and material resources used in quality care becomes a concern for the services and, consequently, for the nurse who assumes the managerial function.

Reasons for Absences

In the state of São Paulo(¹⁶), a study was carried out to analyze the causes of absenteeism and primary data were used from seven units of the State Department of Health, in the period from 2011 to 2015. It was observed that, in some units, there was a decrease in the rate of absenteeism when guidance techniques for health users were used at work. The main reasons for patients missing appointments were: 29% due to lack of transportation, followed by 23.5% due to forgetting the date of the consultation, and 16.3% due to financial difficulties.

As for the type of consultation(¹⁶), there was a higher percentage of absences in the first consultations when compared to follow-up visits.

In Los Angeles(¹⁹), a study with 1,392 patients identified as factors for absences: patients who had previously missed appointments, comorbidity, and patients with psychological problems, including the use of chemical substances.

In Africa, in a rural area of Uganda(¹⁸), a study shows that the absenteeism of HIV patients, measured by GPS, is related to the distance from the clinic. Users report the high cost of transportation.

In Spain(²¹), forgetting the consultation prevailed in 29.6% and problems in communication in 16%.

A study in Taiwan, China(²²), shows that there are factors that influence the absence of patients, such as waiting time for the appointment, the characteristics of the scheduled appointments (such as period of the day, day of the week, time), and weather factors (such as rains).

In view of the problem that absenteeism represents to the health services, it is essential to create strategies to reduce these rates. In most of the selected studies(¹⁶–²⁰), the need for intervention by those responsible for health is emphasized, but for this, it is necessary to know the reasons for the users’ absences.

There are major differences in health systems; however, absenteeism in medical consultations is present in these countries studied. In the United States, private insurance is seen as a health model(²⁸). In China, health has progressed to bring equality and accessible values to the population, with government incentives in public health, especially in regions with low income and with voluntary health insurance(²⁹).

Strategies to Prevent Absences

In order to avoid patients’ absences from health services, which can lead to losses in treatment, misuse of resources and equipment, and significant financial losses, it is important to apply methods and strategies for monitoring and evaluating services.

In the United States(¹⁹), a model has been developed to detect which patients are at high risk of not attending or of canceling scheduled medical appointments and to analyze the impact in 15 digestive endoscopy clinics, where many resources are used. An algorithm was developed, based on retrospective data from the patient’s electronic medical record for a period of eight months and a prospective period of four months, to calculate the probability of the patient not attending the consultation.

In a study(¹⁹) with a sample of patients who were war veterans in the United States, the average rate of overbooking was observed at 0.51 consultations that were not used per day versus 6.18 for scheduled capacity. With the monitoring of this process, the service could have increased its use from 62 to 97% of capacity.

The same study(¹⁹) showed the benefit of predictive overbooking, as it is based on the patient’s next data, while permanent overbooking is only based on historical averages and can increase or decrease the use of consultations.

Another overbooking study was carried out in Brazil(²⁰), with patients from the public health service at Specialties Clinic in the neighborhood Jardim Peri, in the western region of São Paulo, managed by the School of Medicine of Universidade de São Paulo. Some data were collected from the Integrated Health Care Management System. The study showed that benefits in the efficiency of the service are visible and showed an increase in the number of visits, since, with the inversion of the period of consultations available in orthopedics and ophthalmology, an increase in the expected rate of use of 3.2% was observed.

A study(¹⁶) carried out in the state of São Paulo indicated measures that have been carried out to reduce absenteeism, such as: hiring employees to perform the call center service (reminder for the scheduled medical appointment); work of the scheduling employee in the queue control (the patient leaves the consultation with the follow-up visit date). Such measures promoted a reduction in the number of absentees from 2,815 to 313 in six months. Additionally, investment was made in updating records and a rule was established to the persons missing an appointment: with the first absence, the appointment is rescheduled, but in a second absence, the patient returns to the municipality of origin, restarting the referral process.

A study developed in Argentina(²³) highlights that knowing the patients’ absences allows intervening in the quality of health by associating the data of the absentees with the demand for care in the Emergency Department, and with the mortality due to the illnesses of the patients included in the high-complexity university hospital integrated with two hospitals and 20 health centers in Buenos Aires, through integrated electronic medical records in these units. Absence to medical specialties consultations was observed, during the period of one year, with more than five appointments scheduled, of patients with an average age of 63 years, 29.9% of whom were male. Non-attendance was of 20%, of which 10% were associated with emergency room care and mortality.

These data are in line with the literature that shows absenteeism increasing urgent and emergency care and causing discontinuity of care(³⁰).

Absenteeism may have been influenced by the low equity of the health service and also by being segmented and fragmented, despite the prioritization of some medication and maternal and child health policies in the public service(³¹).

In a study in Ireland(²⁴), in a psychiatric outpatient clinic, an audit was carried out with the purpose of checking the demand that was attended. Absenteeism was observed in 13.9% of those scheduled, as well as a high demand from unscheduled patients who sought care (30.1%), and of inappropriate care (20.4%). Also, 2.2% did not belong to the area covered. With the creation of Attendance Protocols, after three months and with a new audit, it was observed that the scheduled appointments and the number of unscheduled patients decreased, but not the absenteeism rate. In Ireland, there is a large investment in outpatient areas, with a reduction in hospital beds and investment in health aimed at prevention for the community. No other study was found with emphasis on the intervention process through protocols and audits to compare with the findings of this study. The health system in Ireland is similar, in some points, to the Brazilian Public Health System, having as doctrine universality, equity and comprehensiveness, with financing through tax collection and growth of private participation in health; however, it has been impacted by the global crisis and expenditure restraint(³²). These factors can interfere with patients’ absenteeism.

There is a limitation in the study due to the little research found in various databases, which reinforces the need and motivation to carry out research in this area. The methodological limitation of the review may be associated with studies found with moderate to weak levels of evidence, requiring well-controlled intervention studies to minimize the problem studied.

The search for research methodologies to improve quality care for the patient becomes extremely important(³³).

The findings bring, as an implication for the practice, the need to organize public health services to improve the quality of the service provided, thinking about individual and collective needs, thus reducing waiting lines and demands for care at the Emergency Department and, consequently, guaranteeing the continuity of patient care.

The implications for the research are linked to the need for further studies to adapt the services, changing directions for health intervention, with the need to search for alternatives to reduce health expenses and strategies to solve the problems faced both in Brazil and abroad.

CONCLUSION

The integrative literature review allowed knowing issues related to absenteeism in outpatient consultations, such as costs, reasons, and percentages of patient absences to scheduled medical appointments and strategies to solve the problem, highlighting the need to recognize this management problem and propose solutions.

It is observed that the concern with the quality of care, the increase in queues, and the high demand, as well as with the cost of idle vacancies for patients who are not seen, is the central focus for the management team, and that management and communication measures can minimize the problem.

Despite the importance of the topic, the literature is scarce. Health services cannot ignore the situation, and future studies are of paramount importance to expand the knowledge of teams and managers about absenteeism, to promote quality assistance, with continuity of care, reduction of waiting lines and of absence cost, thus seeking the optimization and adequate use of the available resources.

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Financial Support

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Publication Dates

• Publication in this collection
  20 Aug 2021
• Date of issue
  2021

History

• Received
  24 Aug 2020
• Accepted
  23 Mar 2021