February 5th, 2016

The next section of psychiatry to be reformulated as a spectrum: psychosis

http://www.bmj.com/content/352/bmj.i375

It's a great article, in part because it is so respectful of why we categorize things the way we do, and why that is a communication problem generally. This isn't someone saying WRONG WRONG WRONG must fix. This is someone saying, Okay, you can think of it one way or another way. I think this way of thinking about it is a lot more helpful, and here's why.

Lovely!

Snow day so wasting time; dealing with no-shows

Winter has returned, altho not with a vengeance. It's due to be above freezing for all of the upcoming week for at least part of each day. Kids have a snow day. Shops are sending out emails saying they are closed for the day. At some point, we will be going out to shovel, but probably not just yet.

In the meantime, health care and no-shows. What could they learn from airlines?

Here is what triggered this:

http://www.medpagetoday.com/PatientCenteredMedicalHome/PatientCenteredMedicalHome/56021

Like a dipshit airline from the 1990s, the thinking here is, hey, lost revenue! Lost opportunities to help!

Back in the 1990s, the no-show rate for airlines was about 20% Yes, you read that right. We know people who had a family member in an airline. The people we know _always_ flew standby, because their connection had the information to steer them to flights that were guaranteed to have space. How did they do this? Well, apparently, travel agents could (and maybe still can) book nonrefundable tickets without payment. Yeah, no-showing on that is no hardship. Must have been good for a few percentage points.

http://usatoday30.usatoday.com/money/biztravel/2005-12-19-bump-usat_x.htm

With a huge fraction of tickets booked online, that practice has dropped dramatically, and the industry no show rate is down closer to 12%.

https://operationsroom.wordpress.com/2014/02/10/an-airline-that-doesnt-overbook/

JetBlue doesn't publicize their We Don't Overbook Flights policy, but I was not too surprised to discover they had one. I'd never seen anyone get bumped voluntarily or otherwise, and it seemed like Back In the Day, every flight I was on left late as this complex negotiation wasted everyone's time. And generated MORE no-shows from missed connections.

JetBlue has a lower no-show rate, in part because most of us fly from our origin to our destination in a single leg. The opportunity for us to no-show on leg B, C, D, etc. is minimized when those legs don't exist. Even if our initial flight is hours late, it just uses up our theme park time; it doesn't cause us to miss a connection, at least not a JetBlue connection.

Returning to the original Pelzman article about medical no shows:

"It reminds me of smartphone apps where people can make reservations at restaurants, with very little sense of responsibility. Theoretically you could make 20 reservations for dinner Friday night, keep none of them, and it's no skin off your teeth. The restaurant wants you to make a reservation at their place, but they certainly don't want you not showing up.

In the olden days, you actually had to call the restaurant to make a reservation and speak to the maître d', and there was somehow some shame in not showing up for that reservation. In fact, many places would take a credit card and hold it for you, and use that to make sure you kept your reservation.

You feared not showing up and then dared try to make another reservation. Missed a dinner reservation last week? Table by the bathroom."

DisneyWorld has been through a lot of this. They now require credit cards to hold many reservations (at least one was requiring full pay up front, but it may be gone now since Flying Fish was under renovation last time I checked) and will charge $10 or more dollars per head if you no show. If nothing else, it motivated you to call and reduce the size of your party if you are wondering whether you are really going to get there, and some members definitely won't be there. But there were definitely years when I booked a nice table every night of our trip, and canceled half. I still do some of that, but instead of calling three hours before the reservation, I now make sure I call at least 24.

Strategically _overbooking_, however, does not seem like something that a person making doctors appointments is likely to do! I think the airline analogy might be a better one. In which case, thinking about what leads to no-shows might be worth contemplating. One thing I do sort of wonder about: how many no-shows are people who decide not to bother to come in because they knew how late the doctor was running, and just didn't show up for their scheduled appointment, because they would have waited, run out of time, and left? Are they counting no-shows as people who came, waiting for the time they had, and left, missing their appointment? Because that isn't THEIR fault!

For that matter, Pelzman's math is odd.

"If you think about it, that represents several practitioners sitting around essentially doing nothing for an entire year."

Whenever I've seen a no-show situation while I was in the waiting room, they just reduced how far behind they were. No-shows were sort of a win, basically. I suppose their may have been circumstances where there was no one waiting. Catch up on your charting? Eat lunch?

Pelzman is focused on repeat offenders, which makes sense. But his solution does not make sense. Send a warning letter? Come on! You have a patient portal. If you want to know _why_ they are missing appointments and you START with a warning letter, you aren't going to learn anything useful. They'll just get defensive. Communications 101. ASK! Find out why your 5,941 repeat offenders are not showing up. Are they missing one appointment, rebooking, missing that appointment, rebooking, etc.? In that case, something has gone haywire with their lives. Find out what it is! Are they missing every other appointment? Why do they have so many appointments in a year that there are 3-10 that they CAN miss? (And how on earth are they keeping a job/staying in school when they are having that many appointments?) I've canceled well baby appointments because the kid was too sick for a shot and I didn't want to have the argument about whether the kid was too sick for a shot (also, by and large, my providers trusted my judgment on this sort of thing anyway). Are these chronic disease monitoring appointments that a patient is skipping because they wound up in the ER somewhere else with something much more serious?

"The addition of a new telephone electronic reminder system seems to be chipping away a little bit at our no-show rate. The system calls patients (for whom we have an active telephone number) reminding them of their appointment 48 hours in advance, giving them the option to confirm that they are keeping the appointment, or selecting an option that allows them to tell the practice they will not be keeping it. This created availability has been extremely helpful in getting us a bunch of same-day or next-day appointments for patients who want to be seen urgently."

Wait, it's 2016 and that's a NEW system? What the ever living fuck is wrong with you people?

Doctors may think of patients booking appointments with them as going out for fine dining. But I never would. I think that people straight up forgot, and then were in tears when they didn't get the reminder call, and then rebooked. Lather rinse repeat. A lot of people don't maintain accurate calendars, and we shouldn't link health care provision to that level of personal organization (I completely forgot to put the kids' neurologist appointments on the calendar -- if I hadn't gotten the call, I would have missed them. Altho, in the event, the first call is the office rebooking because of a schedule change so, you know, whatever the fuck).

Pelzman is basically a tool and a fool. He's so focused on the wrong being done to his people, that he can't even think straight. Medical care is NOT like a dining reservation. If people are missing appointments, you _definitely_ should take a look first at your appointment reminder system, second at your wait time in the office, and third at accuracy and availability of directions to the office. I know a ton of people who missed a first appointment because they went to the wrong location, or it took much longer to get there and park than they had anticipated, and they gave up when they knew they were an hour late. That'll carve the no-shows down to a manageable level, and you can start to understand why people aren't showing up, categorize, and design solutions for the bigger chunks. I'm betting some of those repeat no-shows books first appointments with multiple providers, and never got around to canceling once they picked someone _because they assumed you would do that for them_. Honestly, if you have people booking first appointments with multiple providers and not showing up, _why_ did you even let them do that? Without so much as logging their explanation for non-appearance and an action plan to get them to the next one? How is this not worth charting?

"It does seem fair in the big picture, however, that if you've made multiple appointments to see one of our providers as a new patient, and just don't have the courtesy to call and cancel, you just don't show up"

The Lurie Center/LADDERS recognizes the new patient problem. There is a social worker assigned to shepherd you through the fill-out-the-paperwork process to get you actually in the door eventually. I'm not sure I would have made it through without that level of assistance. I sort of wonder if that's a common situation -- and I really, really despise this guy for being so unsympathetic that he can't even _imagine_ that there might be Best Practice out there to help.

More about no shows, because I cannot believe people are this silly

https://operationsroom.wordpress.com/2010/09/28/overbooking-should-doctors-act-like-airlines/

Look, someone _else_ made the airline/doctor comparison! Well, it's better than restaurants. I, of course, went straight to, don't overbook, you assholes. Also, I don't understand why no one appears to be factoring in how, if you overbook and have to bump, that tends to result in late flights and potentially cascading missed connections. Plus, all the administrative costs of calling and holding flights and so forth. Those are "free"! (<-- sarcasm)

In this one, someone actually modeled why people were skipping appointments.

"In this instance, a Northeastern engineering team used computer modeling to identify the types of patients most likely to skip their appointments, which here turned out to be those scheduled for an annual exam, and to figure out how much to overbook each day."

Well, hang on. Maybe you should just NOT FUCKING BOOK an annual exam. See current recommendations for pap smears, etc. If you've got a bunch of patients who book annuals but then show up every other year you should schedule every other year. If you've got a bunch of patients who you first notice that they moved when they no show at their annual and your reminder call went to a changed phone number, you should maybe send out reminder cards, rather than booking a year out. Etc. DO NOT ASSUME OVERBOOKING IS THE RIGHT SOLUTION.

"Overbooking now means scheduling more patients then you have capacity to handle in a time slot."

All doctors work this way anyway. I shudder to think what overbooking implies.

"There is a legitimate need to hedge against idle resources and if no shows are a fact of life, overbooking is pretty much the only available answer."

No. No it is not. I question your "legitimate need to hedge against idle resources". What, there's no backlog of stuff that needs to be done other than direct patient care? Because there are usually phone calls, patient portal messages, communication with support personnel, etc. to do. Why not do that during the no-shows exam period? Then maybe you could go home at the end of the day when you are supposed to.

Still More About No Shows, Because Morbid Fascination

Pun intended.

http://www.mgma.com/blog/30-ways-to-reduce-patient-no-shows

The usual behavior mod stuff, but then check this out:

"11. Limit appointments per patient to one per week."

W.T.F.?

Okay, to be clear. I AM NOT ADVOCATING FOR MORE THAN ONE APPOINTMENT PER WEEK FOR PATIENTS. I'm wondering how things got so weird that patients HAVE more than one appointment in a week.

ETA: Husband notes that PT would generate more than one appointment per week. I don't think that's what is going on here.

ETAYA:

https://www.webpt.com/blog/post/four-ways-reduce-patient-no-shows

This actually is about PT, in part.

"In a Practitioner's Journey article entitled “How to Reduce Cancellations, Reschedules and No-Shows: Our Strategy,” the first suggestion they offer is to make a reminder call: “Appointment cards are helpful, but in the end, a phone call is your best bet.” How much of a best bet? An article on American Medical Newsexplains that patients are significantly more likely to keep an appointment when they receive a phone call reminder, according to a study from the June American Journal of Medicine. Now, in a perfect world, you and your entire staff would have the time to personally call every one of your patients and remind them about their appointments. However, the same study explains that busy practices “frequently have a hard time fitting in these calls, which means that sometimes they don't happen at all.” Furthermore, the same study questioned the cost-effectiveness of personal phone calls."

I can't help but think that if you are arguing that your no shows left you with idle resources, you can't tell me you don't have time to make the phone calls for the next day appointments. And if you don't have time to make the phone calls for the next day appointments, well, your no-shows aren't leaving you with any idle resources. I don't need to tell you that that is NOT where the article went with this.

Ending on a Positive Note: a GOOD strategy for no-shows

https://www.stfm.org/fmhub/fm2013/October/Clark634.pdf

There is enough context to understand the practice (other articles were all over the place: PT, a chiropracter, primary care, etc.). They did lots of research to analyze the no-show prone cohort. They didn't just fine/warn them. They TALKED to them. They did a really creative pseudo-overbooking strategy AFTER explaining it. And they mostly focused on scheduling appointments in the next few days and wouldn't allow advanced booking unless people had shown they could show up for an appointment booked well in advance.

All in all, admirable and sensible.

Not a Book Review: _The First Year_, Gretchen Becker

This is NOT a book review. It is sort of notes along the way.

Probably NOT a good idea to assume that because I am reading a book about a medical condition, that I am reading it because I have or think I might have that medical condition.

At around 23%/loc 2000 or thereabouts, Becker discusses "tight" vs. "normal" control of blood sugar. She covers the 1993 Diabetes Control and Complications trial, T1D, 1441 participants, "relatively young". She summarizes this as "showed beyond a doubt that people with tight control of their BG levels had significantly fewer microvascular complications". She expends a single sentence on a Japanese study of 110 T2D people. Then 1998's UK Prospective Diabetes Study, T2D, microvascular complication rates decreased, and lowering blood pressure "to 144/82" also reduced both micro and macro complication rates.

Then a followup of participants in the DCCT (the 1993 T1D above) study called EDIC (Epidemiology of Diabetes Interventions) showed the "normal" group how to do with the "tight" group did and the A1c's of the two groups converged HOWEVER the earlier tight group had lower micro and lower macro BUT CV complications didn't appear because everyone was still too young.

And then, "if that doesn't convince you", general summary that since then blah blah blah.

But it's of course all bullshit, because (a) micro- and macro- effects are still a proxy for what we really care about and (b) how you get there matters (did you do it with diet and exercise, yay, but if you took a stack of drugs, the side effects overwhelm the benefits).

http://www.health.harvard.edu/diseases-and-conditions/controlling-blood-sugar-in-diabetes-how-low-should-you-go

For the most part, this DOES NOT MATTER, because Becker's book is focused on people who have just learned they have diabetes, and she is quite relentless in her focus on diet/exercise/lifestyle modifications, at least in the first quarter of the book. But it is worrisome. I'm reading the 3rd edition, dated 2015. This section should have been brought further up to date.

This is actually sort of a chronic issue with this book -- she wrote it during the early years of the consumer internet (that would be the mid 90s, for anyone who is wondering), and so a lot of her resource information is getting more and more dated. She's trying to bring it current, but that section is weak.