In our clinic at St. Christopher's Hospital for Children, we attach a fluorescent golden, 8½-by-11-inch piece of paper to the top of the chart, with the omnipresent title "Missed Appointment" in large bold letters and the options of "send letter to have parent reschedule," "call parent to reschedule," or "doctor will arrange."
A colleague in a private suburban practice told me that she and her staff are surprised when a family doesn't show up for a well-visit appointment. Their anxiety escalates until they make sure the child and family are safe. No-show rates in her practice are in the single digits. By contrast, in larger, inner-city practices, the no-show rate ranges from 20 to 40 percent. In our practice, the no-show rate is close to 30 percent. That's 100 children every day. Almost 24,000 appointments missed yearly. All missed opportunities to discuss and promote health.
The adverse effects of no-shows are staggering. The missed visits put more work on staff who make the appointment, pull the chart, refile it (or record it in an electronic medical record), and reschedule the patient. The no-shows consume valuable slots that other families could use. They reduce a practice's revenue, which is extremely important to inner-city practices, whose payments are already low, due to Medicaid and the State Children's Insurance Program (SCHIP).
It is even more important to the child. Recently I saw a 2-year-old boy for what his parents thought was dandruff. When I told them he had ringworm of the scalp (the ubiquitous tinea capitis), his mother got defensive, insisting that he "doesn't play in dirt" (most ringworm is by direct contact with another child, not dirt).
Buried beneath the golden "no-show" sheets, I noticed that his last health maintenance visit was at 9 months of age. Although his weight was adequate, he was delayed in his vaccinations and development. He also had the start of early cavities. All of these would have been addressed and likely prevented at scheduled well visits. His lost opportunities for improved wellness can never be recovered. This type of interaction occurs at thousands of practices throughout the country, affecting tens of thousands of lost children.
The risk factors for "no-shows" have been well-documented and include: families living in poverty; households headed by a single parent and/or with less than a high school diploma; lack of a telephone; lack of transportation; having more than three children; inconvenient clinic hours; and long wait times between visits and in the clinic.
Missing visits can be an ominous sign that the child is at serious risk of neglect or intentional abuse. At a recent patient-safety conference, we discussed a 3-year-old who was taken to the emergency room with seizures. These were due to a large hematoma or bruise beneath the child's skull, a telltale sign of abuse. His records were riddled with "no-shows" and changes in health-care providers.
This is not unusual. A study in the United Kingdom showed that 52 percent of children who were abused had missed appointments.
There are some promising methods to ensure that families show up to their appointments. Open-access scheduling where families can get a visit within a few days shows some promise. Text messages, a few days before the visit along with reminder calls, have improved adherence in some offices. Some practices hire a care coordinator to help families who have missed appointments get transportation and decrease their stress load.
As caregivers in the epicenter of poverty in this city, our medical and social-work teams work closely to address such problems as food insecurity, developmental delays, dangerous living conditions, educational issues, and constant stress.
Our country spends more than $15 trillion in health care per year yet has higher rates of infant mortality than Cuba and Slovenia.
Each day as I leave my office, I glance over at the no-show pile of the day, topped with the ever-present yellow sheets of paper. Each yellow sheet has a child's name on it. A child unseen.
Daniel Taylor, a pediatrician
at St. Christopher's Hospital for Children, can be reached at Daniel.Taylor@DrexelMed.edu.