Family Practice Vol. 17, No. 3, 252-253
© Oxford University Press 2000
Defaulters in general practice: who are they and what can be done about them?
Centre for Innovation in Primary Care, Sheffield, UK.
John Waller, Centre for Innovation in Primary Care, Walsh Court, 10 Bells Square, Sheffield S1 2FY, UK.
Waller J and Hodgkin P. Defaulters in general practice: who are they and what can be done about them? Family Practice 2000; 17: 252–253.
Received 26 July 1999; Accepted 21 December 1999.
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Abstract |
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Background. The study of patients in primary care settings who default on their appointment has been based largely on short-term surveys in individual health centres.
Objective. As part of a wider research project into the potential of practice computer appointment systems as a data source, we wanted to explore the aggregate pattern of default.
Method. Comprehensive computer appointment data from nine general practices for 1 or 2 years were analysed to explore the pattern of defaulted appointments for doctors and practice nurses.
Results. Around 6.5% of all appointments ended in a default. Default rates were found to be highest amongst young adults and, at a practice level, to be highly correlated with deprivation level. About two-thirds of those who defaulted only did it once during the year. A small core of patients defaulted frequently, but only a quarter of these repeated their behaviour in the following year.
Conclusions. The discussion suggests that strategies based on educating or punishing defaulters in order to change their behaviour may be of limited effectiveness.
Keywords. Appointments, defaulters, general practice.
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Introduction |
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The study of patients in primary care settings who default on their appointment has been based largely on short-term surveys in individual health centres.1–4 As part of a wider research project into the potential of practice computer appointment systems as a data source, we explored the aggregate pattern of default in nine Sheffield general practices over 2 years.
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Method |
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For 1997, data were collected on 221 000 in-surgery appointments with a doctor or practice nurse, including 14 500 defaults, from the computer appointment systems of the nine practices (combined list ~50 000). Patients were only identified by the practice-specific patient number. Their gender, age in years, date of registration and (where relevant) removal were extracted from the clinical database. Six practices provided the equivalent data for 1996 and three for 1995.
The practices were a pragmatic selection from the small number in Sheffield that operate a computer appointment system for all surgery consultations including extras and drop-ins. Their age structures and deprivation levels broadly reflect the range within Sheffield practices.
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Results |
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Table 1
presents the percentage of consultations that ended in a default for various sub-groups within the population. The results for doctor consultations are in line with previous studies.1–4
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A total of 68% of defaults occurred with a doctor, but the average default rate was higher with practice nurses (9.8% compared with 5.7%). Nurse defaults also displayed a greater inter-practice variation. For doctors, the default rate was highest among young adults, particularly 20–24 year olds. For nurses, there were high default rates across the 0–34 years age range. Of all defaults, 60.7% were by women but, once the higher consultation rate of women was taken into account, there was little gender difference in default rates.
The combined doctor and nurse default rate showed a high correlation (Pearson's r = 0.72, P = 0.028) with each practice's score on the Townsend Index of Deprivation (attributed to practices according to the practice population in each enumeration district). For those practices with comparable 1996 data, the scale and pattern of defaults were broadly the same as in 1997.
Each year, ~17% of patients defaulted, but two-thirds defaulted once only. Of the once-only defaulters who remained on the practice list during the following year, 75% did not default again in that year.
A core of patients, 0.35% of the population, frequently defaulted (defined as 
5 times per year). In both years, these frequent defaulters were more likely to be women than men (60:40), with almost two-thirds aged 20–34 years. Of the 116 frequent defaulters in 1996 who remained on the practice list throughout 1997, only 29 (25%) were frequent defaulters in 1997. Patients who defaulted frequently also attended frequently: 60% of frequent defaulters successfully attended 10 or more appointments that year, and 90% were seen five or more times.
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Discussion |
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Defaults are a cause of concern in many practices, and some attempt educational or punitive strategies with patients to reduce default rates. Whilst a one-city study cannot be definitive, it raises questions about the likely effectiveness of such approaches.
Most defaulters in the study missed one appointment and did not default again. Perhaps patients hear the educational messages from the practice. Alternatively, for most patients, defaulting may be an exceptional occurrence which they are unlikely to repeat.5
A sizeable minority of defaults were caused by a small number of patients who both defaulted and attended frequently. Most ceased to be frequent defaulters in the following year. It seems reasonable to assume that many were experiencing a life crisis of some form, or living a chaotic phase of their lives. They will have more pressing problems to deal with than their tendency to default. Focusing on the clinical management of the underlying problems is likely to be more effective in reducing the number of defaults of such patients than the use of administrative procedures to try and change their behaviour.
Individual practices may have an underlying default rate, based on their age structure and deprivation levels, that they cannot change easily. Some commercial organizations welcome defaulters since they give the opportunity to sell the same ticket twice. General practice lacks this financial incentive, but practices with a default ‘problem’ might benefit from analysing their pattern of defaults3 to identify stable patterns, which they could then allow for by some selective overbooking of appointments.
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Acknowledgments |
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We thank the Sheffield general practices that provided us with these data. This study was funded by Trent NHS Executive.
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References |
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1 Deyo RA, Inui TS. Dropouts and broken appointments. A literature review and agenda for future research. Med Care 1980; 18: 1146–1157.[ISI][Medline]
2 Oppenheim GL, Bergman JJ, English EC. Failed appointments: a review. J Fam Pract 1979; 8: 789–796.[Medline]
3 Bickler CB. Defaulted appointments in general practice. J R Coll Gen Pract 1985; 35: 19–22.[Medline]
4 Smith CM, Yawn BP. Factors associated with appointment keeping in a family practice residency clinic. J Fam Pract 1994; 38: 25–29.[ISI][Medline]
5 Cosgrove M. Defaulters in general practice: reasons for default and patterns of attendance. Br J Gen Pract 1990; 40: 50–52.[ISI][Medline]
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