(111) Using Real-Time Data to Improve Patient No-Shows and Late Cancellations

Background: The Cystic Fibrosis Foundation (CFF) advises that all persons with cystic fibrosis (PwCF) undergo visits to a cystic fibrosis (CF) care center every 3 months for evaluation, treatment, surveillance, counseling, and education [1]. In March 2020, our clinic went into modified operations in response to the COVID-19 pandemic, necessitating a temporary change in our ability to conduct routine face-to-face (F2F) visits. Within one month we operationalized virtual visits (VV) in addition to F2F. During the pandemic, staff noticed a drop in clinic attendance and we implemented a quality improvement (QI) plan in order to study and change this trend.

Methods: Our QI team is a multidisciplinary group that is a part of the Cystic Fibrosis Learning Network (CFLN). We defined the clinic fill rate (CFR) as the number of people seen over the number of available clinic slots. Each week we measured PwCF scheduled the following week and compared that number to no-shows and cancellations that occurred during that 7-day period. We also measured PwCF scheduled one month ahead as a comparison to weekly data. We utilized a Key Driver Diagram (KDD) to help focus our interventions (change ideas). Using run charts, we analyzed data each week to identify trends or variances. We used Plan-Do-Study-Act (PDSA) cycles and implemented initial interventions centered on publicizing CFF follow-up guidelines in town hall meetings, emails, and newsletters. We later identified PwCF who had a no-show history and prior to clinics, our social worker communicated with each family (telephone or text) to remind them of the upcoming visit as well identify any barriers to attending. During our study, Oregon experienced a surge in COVID-19 cases due to the Omicron variant and we overlaid our data with a graph of cases.

Results: Clinic Fill Rate was measured over 28 weeks with 598 encounters. CFR one month in advance was 79%. In the week prior to clinic, CFR was 84%. After the week, overall CFR dropped to 66% (68% for F2F visits and 58% for VV). Fifteen percent of our cancellations were COVID-related (this increased to 21% during surge), but CFR did not change during the surge. After our intervention, those contacted in advance came to clinic 93% of the time and our CFR improved to 74.8%.

Conclusions: An 84% Clinic Fill Rate, measured a week ahead of clinic, was dropping to an average of 66% due to late cancellations and no-shows, and widespread education about clinic attendance guidelines did not increase the rate. Having our social worker directly communicate with PwCF improved the overall CFR closer to our advance numbers, and the majority contacted came to clinic (93%). These communications also served as an additional patient interaction where other social work needs were identified. Overall reduced clinic attendance may be related to the indirect impact of the pandemic and benefits of modulator therapy. Going forward, we need more post-implementation data and to consider different approaches to partner with PwCF to achieve ideal follow up.

Acknowledgements:

References: [1] The Cystic Fibrosis Foundation Center Committee and Guidelines Subcommittee. Cystic Fibrosis Foundation guidelines for patient services, evaluation, and monitoring in cystic fibrosis centers. AJDC 1990; 144: 1311-2.