Analysis of erroneous appointments from the thoracic surgery outpatient clinic of a training hospital

Background: Applications of patients to the outpatient clinics of health institutions are not subject to any control and are left to the patient’s choice. System is confused by patients, especially in close specialties, and patients make appointments from the outpatient clinic, which is unrelated to their complaints. Likewise, a group of patients does not come to arbitrary appointments. Making an erroneous appointment or failing to attend an appointment causes a serious loss of time for physicians and other patients. Appointments from an outpatient clinic not related to the disease. In our study, the data of patients who made an incorrect appointment from our outpatient clinic in the last one year and did not come to their appointment were analyzed retrospectively. Materials and Methods: The data of patients who made an incorrect appointment from our outpatient clinic and did not come to their appointments within a year using central physician appointment system were analyzed retrospectively. Results: Of 1482 patients who made an appointment through the central physician appointment system, 278 (18.8%) did not come to their appointment. 128 (8.6%) patients had an incorrect appointment. Conclusions: Organizing outpatient clinic appointments through the central system aims to enable patients to reach the service more easily and to benefit from the outpatient clinic service at a time convenient for them. It is a common situation that patients do not come to their appointments or make an incorrect appointment, causing unnecessary loss of workforce and the inability of other patients who request outpatient services to get an appointment.


Introduction
Outpatient healthcare constitutes an integral part of diagnostic and therapeutic services provided to ambulatory patients, and the service procedures and principles for such units are specified in regulations [1][2][3]. In recent years, the central physician appointment system (CPAS; in Turkish: MHRS) has been (established and used to provide easier outpatient care access, prevent queues at the hospital, ensure better examinations, and other similar purposes [3]. Although this system has many advantages, it has also demonstrated various disadvantages, such as no-show to appointments or erroneous selection of appointments for clinics that are unrelated with the disease or complaint. Many of these disadvantages are clinicspecific. For instance, it is a known fact that patients with breast-related diseases make appointments with thoracic surgery clinics rather than general surgery clinics.
In our study, thoracic surgery outpatient clinic appointments were reviewed retrospectively. Patients who scheduled incorrect appointments, patients who missed their appointments, and the demographic data of these patients were examined. Our aim was to ascertain information about the possible causes of problems in the current appointment system and to procure solutions to these problems. In addition, we also discussed potential measures that could be taken to solve such problems.

Materials and Methods
Approval 2022 / 92 was obtained from our hospital ethics committee for the study. The data of patients who made an appointment with the thoracic surgery outpatient clinic through CPAS between January 1, 2021 and December 31, 2021 were analyzed retrospectively. Patients who applied to our outpatient clinic with a complaint related to a clinic than thoracic surgery were grouped as patients with incorrect appointments (PWIA). The study did not include follow-up appointments of patients who were previously evaluated, underwent surgery, or followed up by our clinic. Records of outpatient consultations, patients without an appointment, and patients scheduled for elective surgery were also not included. Demographic data such as age, sex, appointment time and the presenting complaints of the patients were recorded daily. At the end of each outpatient service day, all outpatient records were examined and recorded. Data were presented as percentages and mean.
It was determined that 128 (8.6%) of the patients applied to our outpatient clinic with a complaint concerning a clinic other than thoracic surgery. Of these patients, 91 (71.1%) were female and 37 (28.9%) were male, with a mean age of 41.4 ± 15.5 (range: 16-80) for females and 49.2 ± 19.5 (range: 23-84) for males. Seventy-seven of these patients (55.5%) reported that they had mistakenly made an appointment with the thoracic surgery outpatient clinic instead of the chest diseases outpatient clinic. Twenty-eight of these patients (36.4%) made appointments for asthma, 23 (29.8%) for coronavirus disease-2019, 10 (12.9%) for chronic obstructive pulmonary disease (COPD), and 4 (5.2%) for other reasons such as pre-employment examination.
Thirty-eight (29.7%) of the patients with incorrect appointments made an appointment with thoracic surgery instead of general surgery. Thirty-seven (97.4%) of these patients were female and the most common complaints were palpable breast mass in 10 (26.3%) patients and breast pain in 10 (26.3%) patients. Other female patients also presented with breast complaints such as discharge (6 patients, 15.8%). The complaint of the only male patient who mistakenly applied to our clinic instead of general surgery was inguinal hernia.
Thirteen (10.2%) of the PWIA patients also applied to our outpatient clinic with complaints that fell under the authority of different clinics. The most common complaint in these patients was aesthetic complaints about the breast (asymmetry in 2 patients, size in 1 patient, etc.). Other patients had atypical complaints such as allergic rhinitis (1 patient) and back pain associated with herpes zoster infection (1 patient).

Discussion
In this study, we found that 278 (18.8%) of the patients who had scheduled an appointment missed their appointment, 128 (8.6%) were in the PWIA group, and 406 (27.4%) of 1482 appointments caused unnecessary workload in the thoracic surgery outpatient clinic.
Outpatient clinics are the first units where patients apply for the outpatient examination, testing, diagnosis, and treatment services [1,2]. Efforts are being made to improve and increase the standards of outpatient care, which constitutes an important part of healthcare. The CPAS, which allows outpatient clinic appointments to be organized and controlled through a centralized system, is one aspect of these efforts. CPAS has many advantages for patients, such as easier access to outpatient clinics, benefiting from outpatient care at their convenience, and being able to undergo examinations without queues. However, it is common for patients to miss their appointments. This causes unnecessary workforce loss and other patients who need outpatient care cannot schedule appointments. In the 2017 CPAS services report of the Ministry of Health of Turkey, it was reported that appointment compliance rate was 74.6% in Ankara, 76.5% in Istanbul, 79.3% in İzmir, and 75.6% throughout Turkey [4]. This rate was relatively higher in our study (81.2%). From this point of view, it can be concluded that thoracic surgery patients appear to have greater adherence to their appointments than the general patient population. Although the 2017 CPAS report includes appointment compliance rates by provinces and health centers, there is no data based on clinics. For this reason, we did not have the opportunity to compare the data of our outpatient clinic with other outpatient clinics. However, similar problems were experienced in other clinics, leading to the development of the "backup appointment" application [5].
Another important piece of information acquired in our study is the high number of patients who made an appointment with the incorrect clinic, despite the fact that they showed up for their appointments. Although this is a frequently encountered problem, not enough studies have been carried out on this subject. To solve this problem, it was aimed to direct patients towards correct outpatient clinics with modules integrated into CPAS, such as the "What do I have?" module. Another characteristic of this problem is that it differs from clin-ic to clinic. It was not unexpected that the majority of patients who made an incorrect appointment with the thoracic surgery outpatient clinic were those who had to make an appointment with the chest diseases clinic. In addition, the fact that the clinics have similar names and that patients often have difficulty in acquiring appointments from the chest diseases outpatient clinic (due to the large number of patients seeking healthcare from this clinic) may also have played a role. More surprisingly, patients with breast-related complaints or diseases that are not closely related to the thoracic surgery clinic frequently scheduled appointments with the thoracic surgery clinic. In our study, the percentage of these patients was 2.5% in all patients with an appointment and 3.1% in patients who showed up for their appointments. Informing patients about this issue can prevent unnecessary appointments and patient grievance. Similar errors in appointment scheduling are also encountered in other outpatient clinics. For example, it is common in daily practice for patients to apply to Gynecology and Obstetrics clinics for breast-related complaints and to cardiovascular surgery clinics with cardiology-related complaints. Although the problem is frequently encountered, the literature on the subject is very limited and most of the studies in this field have focused on patient satisfaction rather than problems in outpatient care [6][7][8][9]. One of the rare studies addressing incorrect appointments was carried out by Akbaş et al [10], and the percentage of incorrect appointments was 3% in this study which enrolled 372 patients. This frequency was found to be much higher (8.6%) in our study. This difference can be explained by the high rate of admission of patients with breast-related complaints or disease. In a study by Kişioğlu et al [11], a much more striking result was obtained. It was found that 64.5% of the patients could have been treated in family medicine outpatient clinics and, in fact, they did not need to apply to any specialty outpatient clinic. In addition, the rate of scheduling an appointment from the specialty clinic was found to be 12.9%.
The limitations of our study are that it was a single-center study and contained data from only a 1-year period. Despite this limited study population, clear and remarkable results have been obtained. Although problems are frequently encountered in outpatient care, studies on this subject are insufficient and available in-formation is very limited. We think that our study can be pioneer in this respect for other clinics and may guide them in the analysis and comparison of their own outpatient services.