White R, Cangero T, Feustel PJ et al: Failure to attend urology appointments: a retrospective analysis of a single urban academic practice. Urol Pract 2021; 8: 487.

Nonattendance of outpatient urology appointments, defined as patients failing to attend without canceling in advance, is a serious problem.¹ Nonattendance of outpatient clinic visits occurs across all specialties with 23%–34% of outpatient appointments missed annually, although some studies have reported rates as high as 80%.^2,3 This leads to poor health outcomes for the patients as well as financial losses for the practice.² This is particularly relevant for urology patients: for example, those undergoing active surveillance for prostate cancer. Patients who do not routinely follow up on active surveillance protocols are at a higher risk of developing worsening disease.⁴ Because of this problem, we reviewed our experience with nonattendance in an academic urology practice.⁵

Our overall nonattendance rate was 7,592 out of 83,984 total appointments (9.0%) (see table). This is lower than what has been reported in the literature at some similar academic practices, which have reported rates as high as 18.2%–20.7%.^1,6 It is unclear why, but we suspect that our lower nonattendance rate is based on the patient population we serve, our practice model and the fact that our practice is highly subspecialized. Interestingly, we found a very low rate of missed appointments for oncology (4.5%) as compared with benign urology (9.6%) and pediatric urology (13.0%), which led us to suspect that those patients with a malignancy have a greater fear of their diagnosis vs those with a benign problem. Since some initially benign conditions such as hematuria or rising prostate specific antigen (PSA) may indicate a more serious diagnosis, increased patient education prior to an appointment may be trialed as a preventive strategy.

Having a previous missed appointment (in the past 12 months) was shown to be a strong predictor of nonattendance with the odds of missing an appointment increasing by 2.47 in our multivariable analysis (see table). Some studies have developed predictive models based on patient behaviors to decrease no show rates.⁷ Using previous missed appointments as a predictor would provide an opportunity to target those patients with additional reminders in order to prevent future medical problems for the patients and lost revenue for the practice. In particular, more aggressive use of new technology, such as online portals or text message reminders, might be a solution for these higher risk populations.

Interestingly, procedure visits had the lowest nonattendance rates (3.4%) as compared to new (11.4%) or followup (10.5%) visits (see table). The low nonattendance rate for procedures is likely due to increased patient education prior to the procedure, particularly since those patients almost always had an earlier office visit.

Most notably, we had a remarkably low rate of missed appointments for both telephone (2.9%) and video (2.8%). There is a quickly emerging consensus on the value of utilizing telemedicine and our data further support that by finding that patients are more likely to attend a telemedicine visit. For those patients who have the ability to use the technology, the low no-show rate is yet another advantage to using telemedicine. This may help to alleviate patient-specific factors that lead to nonattendance such as transportation issues or long travel distances.

Interestingly, our rate of nonattendance decreased over the course of the study. This could be due to better office systems, but was also helped by the improvement in nonattendance associated with telemedicine. We believe that targeting those patients who have repeatedly missed appointments will allow for interventions to decrease no-show rates and simultaneously improve patient health and improve the efficiency of the urological practice. Furthermore, with the evolving environment of the COVID-19 pandemic and the encouraging data on low no-show rates with telemedicine visits, we believe utilizing more telehealth when feasible is promising for outpatient urology practices.