Plain English Summary
Background and study aims
Non-attendance at scheduled appointments in public hospitals is a challenge to the best use of healthcare resources, which could ultimately affect patient health due to longer waiting times. It has been estimated that 7% of all scheduled outpatient appointments in the United Kingdom are not kept by patients. Different reminder systems have been shown to have a moderate effect on reducing the number of patient no-shows whereas the effect of fining people who do not show up for their appointment has not yet been tested in a clinical trial. Such use of financial incentives could however impact access to care differently across different socioeconomic groups (horizontal inequality). The aim of this study is to assess the effect of fines on hospital outpatient non-attendance.
Who can participate?
Patients that have made an appointment at the participating outpatient clinic.
What does the study involve?
All appointments made at the outpatient clinic are randomly assigned to one of two groups; an intervention group and a control group. Appointments assigned to the intervention group includes an attachment to the appointment letter explaining that a fine will be issued in case of non-attendance without giving notice. Appointments assigned the control arm follow usual practice (same system but no letter attachment). The study then compares the number of appointments for which the patients did not show up in each group, along with other analysis.
What are the possible benefits and risks of participating?
Not provided at time of registration
Where is the study run from?
The Department of Orthopaedic Surgery at Viborg Regional Hospital (Denmark)
When is the study starting and how long is it expected to run for?
March 2014 to June 2017
Who is funding the study?
The Danish Regions, Central Denmark Region and the Ministry of Health and Prevention (Denmark)
Who is the main contact?
1. Ms Emely Ek Blæhr
emebla@rm.dk
2. Dr Ulla Væggemose
Ulla.Vaeggemose@stab.rm.dk
Study website
Contact information
Type
Scientific
Contact name
Ms Emely Ek Blæhr
ORCID ID
Contact details
CFK Public Health and Quality
Region House Aarhus
Olof Palmes Allé 15
Aarhus N
8200
Denmark
+45 7841 4370
emebla@rm.dk
Type
Scientific
Contact name
Dr Ulla Væggemose
ORCID ID
Contact details
CFK Public Health and Quality
Region House Aarhus
Olof Palmes Allé 15
Aarhus N
8200
Denmark
+45 7841 4360
Ulla.Vaeggemose@stab.rm.dk
Additional identifiers
EudraCT/CTIS number
IRAS number
ClinicalTrials.gov number
Protocol/serial number
N/A
Study information
Scientific title
The effect of fines on non-attendance in public hospital outpatient clinics: a pragmatic, randomised controlled trial
Acronym
Study hypothesis
In Denmark, introduction of fines for non-attendance in hospital outpatient clinics have been debated over years. Already in 2005, a collaborative agreement between the Danish Regions and the Danish Medical Association opened the opportunity for privately practicing specialists to issue fines for non attendance of DKK 250 for consultations and DKK 500 for surgical procedures. The expected benefits were overall related to better use of resources whereas concerns were expressed about a detrimental effect on horizontal equity due to that fines could have the greatest impact on the most vulnerable individuals. Moreover, the use of fines was seen as a break with the fundamental value of free and equal access to health care as well as a potential threat to the patient-health professional relationship, which should ideally be independent of financial interests. Despite the fact that 10 years have passed since the regulatory context opened for use of fines in the Danish health care system for privately practicing specialists, no systematic evidence on the resulting practice, the efficacy or the effect appears to have been reported. It has therefore been decided by the Danish Regions that the effect of using fines to moderate non-attendance at somatic, hospital-based outpatient clinics in Denmark should be scientifically investigated. This trial is a result of that decision. In accordance, the objective is to investigate the effect of fines on hospital outpatient non-attendance with respect to attendance and efficiency as well as horizontal inequality.
Ethics approval(s)
The Ministry of Health and Prevention in Denmark, 28/11/2014, ref: 303/2014
Study design
Single-centre randomised controlled trial
Primary study design
Interventional
Secondary study design
Randomised controlled trial
Study setting(s)
Hospital
Study type
Other
Patient information sheet
Not available in web format, please use contact details to request a participant information sheet
Condition
The effect of fines on hospital outpatient non-attendance with respect to attendance and efficiency as well as horizontal inequality.
Intervention
All appointments will be made in accordance with usual practice except for two facts. First, the appointment letter will inform the individual (both intervention and control arms) about the trial. It is explained that the investigation has been initiated by the Danish Regions and approved by the Ministry of Health and that their appointment has been randomly assigned to be subject to a fine, in case of non-attendance without notice, if the appointment letter is attached to letter about the fine system. Second, for appointments randomised to the intervention group only, the letter specifying the conditions is attached to the appointment letter. In this letter it is made clear that a fine will be issued in case of non-attendance without giving notice, at any time, before the time of the appointment. It is also informed that the fine amounts to DKK 250 and that it will be issued by a central office under the local government administration (Corporate Finance, Central Denmark Region), which is open for e-mails and telephone calls during normal office hours in case of questions or complaints.
Intervention type
Behavioural
Primary outcome measure
Proportion of appointments who are attended: All types of appointments are registered in the clinic by the secretariat on a daily basis. All parameters except for sociodemographics are automatically extracted from the electronic patient journal system into a trial registry administrative registered in electronic trial registries. Sociodemographics are extracted from various, individual-level national registries administered by Statistics Denmark.
Secondary outcome measures
1. Proportions of appointments cancelled by the department
2. Proportion of appointments cancelled by the individual
3. Case-mix of individuals in terms of sociodemographics such as age, sex, income, education, distance to hospital, travel time and waiting times and in terms of health problem characteristics such as anatomy, type of appointment and treatment costs will be used as a secondary outcome
All types of appointments are registered in the clinic by the secretariat on a daily basis. All parameters except for sociodemographics are automatically extracted from the electronic patient journal system into a trial registry administrative registered in electronic trial registries. Sociodemographics are extracted from various, individual-level national registries administered by Statistics Denmark.
Overall study start date
18/03/2014
Overall study end date
30/06/2017
Reason abandoned (if study stopped)
Eligibility
Participant inclusion criteria
Inclusion criteria as of 28/06/2016:
1. Consecutive appointments for individuals scheduled for diagnostics, treatment or follow up in the outpatient clinic
2. Appointments for individuals who are booked via an appointment letter sent between 01/05/2015 and 01/12/2015
Original inclusion criteria:
1. Consecutive appointments for individuals scheduled for diagnostics, treatment or follow up in the outpatient clinic
2. Appointments for individuals who are booked via an appointment letter sent between 01/05/2015 and 30/04/2016
Participant type(s)
All
Age group
All
Sex
Both
Target number of participants
Around 6,500 appointments (based on department statistics).
Total final enrolment
6746
Participant exclusion criteria
Exclusion criteria as of 28/06/2016:
1. As a user may have more than one appointment, only the first appointment during the period was considered
2. Appointments for individuals who are booked without an appointment letter, e.g. via telephone or face-to-face
3. Appointments for individuals receiving physiotherapy or occupational therapy in the outpatient clinic (typically in a group-based setup also without appointment letters)
4. Appointments for individuals with residence in Greenland (requiring an overseas flight)
Original exclusion criteria:
1. Appointments for individuals who are booked without an appointment letter, e.g. via telephone or face-to-face
2. Appointments for individuals receiving physiotherapy or occupational therapy in the outpatient clinic (typically in a group-based setup also without appointment letters)
3. Appointments for individuals with residence in Greenland (requiring an overseas flight)
Recruitment start date
01/05/2015
Recruitment end date
01/12/2015
Locations
Countries of recruitment
Denmark
Study participating centre
The Department of Orthopaedic Surgery at Viborg Regional Hospital
Viborg Regional Hospital
Heibergs Allé 4
8800 Viborg
Viborg
8800
Denmark
Sponsor information
Organisation
DEFACTUM – Public Health & Health Services Research
Sponsor details
Olof Palmes Allé 15
Aarhus N
8200
Denmark
+45 (0)7841 4360
cfk@rm.dk
Sponsor type
Research organisation
Website
Funders
Funder type
Government
Funder name
Danish Regions
Alternative name(s)
Funding Body Type
Funding Body Subtype
Location
Funder name
The Ministry of Health and Prevention (Denmark)
Alternative name(s)
Funding Body Type
Funding Body Subtype
Location
Funder name
Central Denmark Region
Alternative name(s)
Funding Body Type
Funding Body Subtype
Location
Results and Publications
Publication and dissemination plan
All results from the trial will be published in the end of 2016 or beginning of 2017.
Intention to publish date
01/01/2017
Individual participant data (IPD) sharing plan
IPD sharing plan summary
Not expected to be made available
Study outputs
| Output type | Details | Date created | Date added | Peer reviewed? | Patient-facing? |
|---|---|---|---|---|---|
| Protocol article | protocol | 13/06/2016 | Yes | No | |
| Results article | results | 13/04/2018 | 19/02/2021 | Yes | No |