Reducing DNAs in general practice: evaluating methods of change.

Problem

Non-attendance or Did Not Attend (DNA) is common UK in primary care, reducing clinical capacity. Nationally it is estimated that 5% of appointments in primary care are missed, of which 7.2 million are GP appointments, which equates to a waste of £216 million every year. Reducing DNAs is also important for effective primary care clinical delivery. Missed appointments may translate to patient presentations at less appropriate care settings with additional health and financial implications.The study aimed to:a) Evaluate the impact on practice DNA appointment rates of a system-wide quality improvement (QI) programme which included sharing data on appointment systems and DNA rates.b) Compare the effectiveness of different practice interventions to reduce DNA rates.

Approach

Based in a clinical commissioning group (CCG) in east London, with a mobile, ethnically diverse and socially deprived population; 25 of the 32 practices voluntarily engaged with the programme. Following the generic QI intervention,14 practices undertook further work on DNA reduction projects, supported by practice based coaching.CCG wide monthly appointment data was collected from the electronic health record (EHR) of each practice between April 2014 and June 2019. An interrupted time series analysis was used to compare DNA rates pre and post the generic intervention; and following specific project work on DNA reduction.

Findings

Appointment data from all 32 practices in the CCG were available for analysis, comprising more than 4 million booked appointments over the study period.Before the intervention (April 2017) the average DNA rate across the CCG was 7.6% with a practice range of 2-12%. Practice DNA rate was not associated with list size. For all practices combined 80% of DNAs were associated with a wait time of >2 days. Two years following the generic QI intervention the DNA rates for the 25 study practices fell to 5.2%. This equates to an absolute reduction of 4,031 DNAs among the study practices and a potential saving of £120,930. Trend in DNA rates: comparison of 25 Project practices* with 7 control practices 2014-2019 Monthly change in DNA rates p value for monthly changePROJECT practices (25) 0.990 (0.989 to 0.991) P<0.001(post intervention) Control practices (7) 0.996 (0.995 to 0.997) P<0.001 * Adjusted for the different intervention start date of each study practice. 13 practices which implemented patient behaviour change projects showed a modest additional drop in DNAs compared to the generic intervention. One practice introduced a system change to the appointment system, resulting in a sustained drop in DNAs.

Consequences

The number of days between booking a GP appointment and seeing the doctor is the best predictor of practice DNA rates. Sharing appointment data, combined with QI coaching, produced a significant reduction in missed appointments. Behaviour change interventions had a modest additional impact. In contrast introducing structural change to the appointment system effectively reduced DNA rates. To reduce non-attendance the appointment system needs to change – not the patient.