“Did Not Attend” (DNA) has impact on resources and outcomes . Unfortunately, DNA remains a global issue . The financial cost of annual DNAs in NHS England is equivalent to staggeringly high 257,000 hip replacements or 990,000 cataract operations .
Incidence of breast cancer in the UK is approximately 55,200 per annum, and is projected to rise by 2% between 2014 and 2035 . Cancer Waiting Times standards monitor the length of time that patients with cancer or suspected cancer wait to be seen and treated in England . These were first introduced through the NHS Cancer Plan (September 2000). The current measures and the operational standards include:
- Two weeks from urgent GP referral for suspected cancer to first outpatient attendance (93% target)
- Two weeks from referral with breast symptoms (where cancer is not suspected) to first hospital assessment (93% target).
All new breast referrals are seen at the rapid access breast clinic, which allows triple assessment in a single visit, hence the clinic is also known as one-stop breast clinic. Triple assessment includes clinical assessment, radiological evaluation (mammogram and/or ultrasound scan) and/or tissue sampling (biopsy or cytology). Needless to say, triple assessment involves in-depth multidisciplinary inputs and is time-consuming. Patients are made aware in advance of the waiting time for triple assessment, which can sometimes take up to 4 hours. Given the nature of the assessment, only a limited number of patients can be seen in a rapid assessment new patient breast clinic. In our set-up, the clinic template provides slots for ten new patients per clinician per session. Clinics are held usually within routine working hours and weekdays. Depending on the workload, sometimes clinics are held on weekends and evenings as well. Waiting times are under constant scrutiny and NHS Foundation Trusts are held accountable through Monitor via the NHS Foundation Trust (NHSFT) Compliance Framework . Any DNA, therefore, can lead to an increase in the waiting time, be costly, and reduce productivity . It is expected that organisations should be monitoring DNA data and making a decision locally on what is an acceptable DNA rate for the organisation .
During first phase of our study, we initially assessed the DNA rate over a 12-months period (2018/2019) in retrospect (Cycle 1), which was found to be 8.2%. The Trust all-specialty DNA rate for the same period was 8.8%. Our findings are in accordance with annual average 2018/2019 DNA rates of 8.6% and 7.8% noted across the NHS in England and Northern Ireland respectively [12.27]. There is no NHS data available for comparison of DNA in the breast clinic. NHS Northern Ireland data provides an insight into DNA rates of different specialties. For example, the highest DNA rate in Northern Ireland during 2018/19 was Urology, with a rate of 14.6%, followed by Dermatology (9.3%), Cardiology (9.2%), Trauma and Orthopaedic Surgery (8.7%), ENT (8.3%) and Ophthalmology (5.1%). Most of the DNAs in our study took place during weekdays and specifically on Mondays. Least DNAs were noted in the evening clinics. These might reflect rigid commitments at work or home.
In some cases, DNAs may be associated with clinical risk or less favourable outcomes, for which hospitals may face financial and regulatory penalties . Providers should therefore ensure there are local policies in place to deal with DNAs and clinic cancellations by the patients (CNAs), which reflect the spirit of cancer access guidance . NHS Scotland has issued guidelines about managing DNAs . NHS Improvement has provided tools for reducing DNAs . Many Trusts have adopted guidelines and put local DNA policies in place [28, 30]. Communication failure, short notification, timing or day of appointment, age and sex, have all been cited as important reasons for DNA . We therefore considered these factors in our study.
Changes were implemented during second phase of the study in order to address potential causes of DNA. Hospitals, as per the Department of Health (DoH) guidelines, aim to give appointments to rapid access new patient breast clinics within 2 weeks of referral to maintain a minimum target of 93%. Therefore, quite often, patients are offered appointments at a short notice. It is a traditional practice to send the clinic appointment letters by post. Unfortunately, letters do not always get delivered on time. Also, the appointment date and time may not always be suitable to the patients. Therefore, a dedicated breast appointment team was designated to work beyond routine hours and make contacts with patients by phone prior to offering appointments. This served two purposes, namely it mitigated uncertainty over postal delay and patients could opt for the days and times most convenient to them. Subsequently, appointment letters were also sent by mail. To be sure, a SMS reminder was sent close to the clinic date as well. These steps helped address potential underlying causes of DNA, such as poor communication, short notification, and inconvenient timing or day of appointment . Prior to embarking on data collection (cycle 2), we allowed a period of 6 months for implementing the changes. The six months period was deemed necessary and adequate to sort out any teething issues encountered during the process. The change in practice continued through the whole of cycle 2 as well.
Third phase of the study, which involved assessment of DNA following implementation of changes, showed a DNA rate of 4.1% (Cycle 2), a significant improvement by 50%, compared to Cycle 1. This is not surprising as patients found it convenient to be contacted beforehand and they could made necessary changes at work and/or home. It is worth emphasizing that the reduction in DNA rate was achieved despite raised DNAs that took place at the end of March 2020 due to COVID-19 pandemic, which affected almost every aspect of the National Health Service. Some studies have shown a reduction in missed clinic appointments, to a varied degree, following interventions [6, 13, 15]. However, no study has been performed involving direct patient contact prior to appointment and SMS alert nearer the time in regards to breast clinics. There is still a paucity of well-conducted SMS alert-based studies in reducing DNA . Unfortunately, in some cases in our study, it was not possible to contact patients or send text messages, particularly if they were away or simply not contactable by phone, or did not have mobile phones. SMS alerts rely on mobile phone technology. It’s true that not growing up with technology from a young age can put older generations at a disadvantage to start learning, and that age-related health issues can make navigating a smartphone much trickier . We therefore looked at age distribution of those who did not attend.
The median ages of patients who did not attend appointments following intervention were almost 9 years older, compared to the pre-intervention group. One explanation for this may be that by providing a mobile phone-based reminder service we are catering more for the younger population and this may not be suitable to reduce the number of DNA of the older population, who are more likely to be reluctant in using mobile phone technology. One corollary that consequently follows is that breast cancer, which predominantly affects the older population, may potential be missed as a result .
An analysis of outpatient appointment DNA data in NHS Highland found the risk of DNA to be higher for men than women . Hence, we explored the possibility that sex could be a risk factor and hypothesised male sex as a potential for higher DNA. However, the odds ratio (1.12) ruled out any such association between sex and breast clinic attendance.
Some have compared DNA with the ‘No Show’ encountered in the airline practice, which involves intentional overbooking of seats in anticipation of no-shows . A similar action entailing overbooked clinics has been tried. But unlike airlines, clinics cannot refuse (or ‘bump’ as colloquially known in the airline practice) patients from being seen, Unsafe practice may ensue and serious capacity issue can occur, if all patients turn up on the day . Therefore, blind overbooking of clinics simply is not a solution . Instead, the underlying booking processes should be optimized. This would explain, rather than overbooking the clinics, why we endeavored to make changes in our booking process to address the issue with DNA,
Sometimes patients cancel in advance (CNA), even at a short notice, which changes official DNA rate . Due to late cancellation of clinics, the vacant slots may not always be taken by other patients . We therefore assessed CNA rate as well, which were 0.9% and 1.1% in Cycle 1 and Cycle 2, respectively. There was no statistically significant difference in the occurrences of CNA between Cycle 1 and Cycle 2. Lack of any significant change between pre- and post- intervention CNA rates could be explained by the fact that the occurrence of CNA was very low (0.9%) to start with. A larger study over a longer period would be warranted to assess whether, despite a low baseline rate, it is possible to reduce CNA rate significantly by pre-emptive actions. Out of four countries in the UK, NHS Northern Ireland is the only NHS body that has published data on CNA. Indeed, the CNA figures in our study were all along better than the available data from the NHS Northern Ireland that showed a CNA rate of 11.3% for 2018/2019, which remained mostly unchanged compared to preceding years . The specialty with the highest CNA rate in Northern Ireland was Chemical Pathology (20.4%). Once again, like DNA, no data was available on CNA for breast clinics. However, a relatively low CNA rate, as noted in our study, is a welcoming finding. Interestingly, we also noted that most of the cancellations of clinics took place on Mondays and in the afternoon. This may perhaps reflect unexpected changes or situations that patients occasionally face, which are unavoidable and can’t be swayed by SMS alerts. Awareness of higher chance of clinic cancellation on Mondays or of afternoon sessions helped our appointment team to stay alert, so that vacant slots could be offered to other patients. NHS Scotland has issued guideline as how to define and manage CNAs, assuming a reasonable offer of appointment has been made . Late cancellation of clinics can interfere with the ability to utilize clinic capacity fully and some Trusts feel that insufficient notice of cancellation of the clinic by the patient should be classed as DNA rather than a CNA. Such a premise may potentially introduce a subjective element to the criteria of ‘insufficient’ timescales deemed appropriate by different Trusts. Hence, as per NHS Scotland, the current definition of CNA stands unchanged . However, NHS Wales guidance states that ‘When a patient contacts the Trust to cancel a second appointment, the Trust may treat the cancellation as a DNA and not make an appointment’ .
DNA rates have been noted to decline monotonically over the week, as found by Ellis et al. . We therefore assessed the association between DNA and days of the week. Highest occurrence of DNAs took place on Mondays. Least DNAs were noted in evening clinics, which was not significantly affected by the intervention. The reasons for this may be because evening (being after office hours) is the most accessible time for the majority of the working population, requiring minimum adjustments at work place. Evening clinics also allow flexibility in terms of working partners of patients being free to cater for the child-care. Hence, evening clinics can be considered as a model for those set-ups with a high DNA rate. By virtue of being aware of the distribution of DNA amongst weekdays and sessions, it is possible to reduce DNA rates by modifying appointment allocation strategy .
Cost of each DNA in NHS England in 2017/2018 was assessed at £120 . Our study showed that even prior to the intervention, the breast unit was performing slightly better than national average in terms of clinic DNA rates [8, 9]. With the application of our intervention, we were able to reduce 73 projected DNAs over six months. The latter equated to a projected £17,520 annual savings due to missed rapid access new patient breast clinic appointments, not considering the potential penalties for unachieved targets as well as extra health and financial implications of possible missed cancers through DNAs. The actual financial saving would be more than the above figure as the cost of referral to one-stop (rapid access) new patient breast clinic is significantly higher than general clinic in view of the extra time and resources required for triple assessment. However, our Trust currently holds a block contract for the breast services with the Clinical Commissioning Group (CCG) and therefore, we could not confirm the individual cost for the breast clinic referral on its own. The annual efficiency saving would help fund the appointment team working beyond core hours and could potentially make the project self-sustainable.
In summary, it is possible to significantly reduce DNAs in new patient rapid access breast clinics by introducing changes such as contacting patients prior to giving appointments and sending SMS alerts. One has to be mindful of the limitation of mobile phone technology that can potentially disadvantage the older age group. The study also showed a very low CNA rate, and that patient’s sex was not a risk factor for DNA in breast clinic. Evening sessions encountered least DNAs and opens the possibility of holding evening sessions as an option to reduce DNAs. Therefore, it would be worth a consideration whether such changes in practice (namely, contacting patients in extended hours prior to offering appointments and sending SMS alerts close to clinic dates) could be implemented across the board in order to attempt to reduce DNA rates.
Limitations of our study include a relatively smaller number of male patients, shorter period of study in the post-intervention period and the focus on a speciality clinic. General clinics may have different set-ups and our experience may not necessarily be transferrable to all set-ups. Nevertheless, the changes introduced in our study are essentially a reflection of good practice and can still be used as a model for introducing changes. Moreover, this is the first study on DNA involving a speciality breast clinic and our findings will add to the existing literature in addressing reduction of DNAs.