Ask your doctor's office about their pet peeves, and likely as not, patient no-shows will rank at the top of the list.

Recent research suggests many missed appointments aren't due to flaky patients but to scheduling errors or a doctor's failure to consider transportation and other logistical challenges for the most at-risk patients. These findings are leading some practices to rethink the way they handle referrals, from low-tech methods such as reminder calls to utilizing the latest health-information technology.

When researchers at the Indiana University School of Medicine and the Regenstrief Institute tracked nearly 7,000 primary-care patients age 65 or older at an Indianapolis geriatric clinic who were referred to a specialist, they were dismayed to discover that only 71% were ever scheduled for a needed follow-up appointment.

Of those, 70% were actually seen at the specialist's office, meaning that just 50% received the treatment that their primary-care doctor intended them to have, according to the study, published in the February 2010 issue of the Journal of Evaluation in Clinical Practice.

Because of the high percentage, researchers called missed specialist referrals the most frequent error in medicine. The adverse consequences can be significant, whether resulting in a worsened medical condition or higher costs, said Michael Weiner, associate professor of medicine at Indiana University and director of the Regenstrief Institute's Health Services Research Program.

"The most obvious one is the immediate care that would be provided is delayed, " he said. "Rescheduling could take several months if it's a busy clinic or specialist."

Some unscheduled appointments and no-shows could be attributed to patient forgetfulness or anxiety about disability, transportation or the time and effort it would take to attend an appointment, issues which might apply disproportionately to seniors, he added.

But just as important was lack of a system to track whether specialist appointments were made and to avoid breaks in communication between the primary- care physician and specialist offices, Weiner said. The chain can break down because of such mundane things as the specialist never receiving the referral because a fax machine ran out of paper.

Now a new computer-based scheduling system generates automated reminders to primary-care physicians if specialist scheduling doesn't happen in a timely manner. The tool also facilitates communication between the two to ensure the specialist understands the reason for referral and the primary-care doctor receives a report on the results.

Since instituting the system, the clinic has reduced its lack of completion rate to less than 20%.

Reducing No-Shows

The problem of missed appointments is hardly limited to seniors. The Sibley Heart Center at Children's Healthcare of Atlanta, which handles 30,000 outpatient appointments at 18 facilities annually, rolled out a new initiative two months ago to reduce a 16.7% same-day cancellation and no-show rate.

The types of patients who were least likely to show often came from low-income families either on government coverage such as Medicaid or who were uninsured and self-pay, said Dr. Patrick Frias, a pediatric cardiologist and director of outpatient operations at the center.

"We hear it all," he said. "'We couldn't find the place. The directions were bad.' Some people didn't have a ride and didn't realize that Medicaid rides are available. Other patients say they forgot or they didn't like the parking."

Every patient's family routinely receives an automated reminder call 48 hours before the appointment. But for the five historically worst clinics for attendance, staff members now make a personal call five to seven days in advance to families from the two main no-show categories and anyone else who has missed an appointment previously, Frias said. The caller not only provides a reminder but also checks to see if directions are needed and the child has a ride, he added.

The program is in too early a stage for any comprehensive data to be available, but no-shows appear to be declining, he added.

Medicaid patients were most likely not to show up at an outpatient psychiatry clinic that reported a 19% to 22% no-show rate among 11,000 scheduled appointments in a 2009 University of Missouri study. Logistical issues, such as when the appointment was scheduled, were also significant predictors.

Medicaid patients never showed up for an appointment after 3 p.m. when local public transportation stopped for the day, and patients coming from a long distance rarely arrived for early morning appointments.

Schedulers with the least no-shows directly asked patients: "When would you like to come in?"

Staying On Top Of Appointments

The most important thing you can do to ensure you or a family member don't miss out on an important specialist referral is not to leave everything up to your doctor, said Sheryl Kurland, vice president of Patient Advocates of Orlando, Fla.

She often hears her clients complain about feeling overwhelmed with the " medical maze" or agonizing about long wait times to see their doctor, things that could tempt one to not call a doctor's office or to stay home, she added.

Kurland advises patients to prioritize their health appointments the same way they do for activities critical to protecting their business interests. "[You] certainly wouldn't miss an important business meeting," she said. "It would cost [you] dearly."

If you're concerned you may forget to set up your specialist appointment, ask your primary-care doctor's staff if they will make the appointment before you leave the office. That lessens the chance that you or the medical practice will forget to follow through, Weiner said.

If you leave scheduling up to your primary-care doctor's office and don't receive a date and time by two weeks after the referral, you should call the office, he said.

Another good idea, especially for older patients and anyone with hearing loss, is to bring someone else along with you to your appointments to help you keep track of any physician instructions, including referrals, Kurland said.

If you are juggling lots of appointments or family members live far away, a patient advocate can serve that purpose. If you can't afford one, nonprofit organizations such as the American Heart Association or the American Cancer Society may have volunteers who can offer assistance, she added.

Don't be afraid to ask for directions, express your concern about ability to pay for the visit or say when you can't make it due to work or transportation limitations, Frias said. The Sibley Heart Center employs a social worker specifically to help uninsured families obtain coverage, he added.

And if you have to miss an appointment, don't just not show up, said Kenneth T. Hertz, a principal in the HealthCare Consulting Group of the Medical Group Management Association, a trade association for practice administrators.

Instead, call the doctor's office as soon as you know you won't be able to make it, apologize and ask to reschedule, he said. That courtesy allows another patient to be fit into your empty slot.

Most medical practices don't charge for missed appointments, although it's likely that your dentist will, Hertz said.

Most employers don't help workers remember their specialist appointments, said Helen Darling, president of the National Business Group on Health, a nonprofit whose membership includes many of the country's largest employers.

"Most employers pay so much for specialty care that they don't feel there's underuse of specialty care," she said. Indeed, 24% of employers perceive that their employees overuse services by seeking inappropriate care, according to 2009 results of an annual survey conducted by the National Business Group on Health and Towers Watson.

However, some employers may provide general reminders for preventive screenings or give financial incentives to employees who engage in a disease- prevention program, which could include specialty services, Darling said.

Finally, in certain specialized situations, such as treatment related to an automobile accident or a worker's compensation claim, a pattern of missed appointments may cause a claims adjuster to question the validity of the injury for which treatment is being compensated, said Chris Davis, a principal in the Seattle-based Davis Law Group, PS.

In that case, you should definitely call the doctor's office to explain why you missed the appointment, but keep in mind that the reason you give will likely be noted in your medical record, he added.

"If you say it's because you're going on vacation, that could be a problem," Davis said.

(Anya Martin is a freelancer for MarketWatch. Anya can be reached at 415-439- 6400 or via email at AskNewswires@dowjones.com.)

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