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Health economics
Research
Effectiveness and cost-effectiveness of fining non-attendance at public hospitals: a randomised controlled trial from Danish outpatient clinics
  1. Emely Ek Blæhr1,
  2. Ulla Væggemose1,
  3. Rikke Søgaard2,3
  1. 1 Central Denmark Region, DEFACTUM, Aarhus N, Denmark
  2. 2 Demartment of Public Health, Aarhus Universitet, Aarhus C, Denmark
  3. 3 Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
  1. Correspondence to Emely Ek Blæhr; emebla{at}rm.dk

Abstract

Objectives Fines have been proposed as means for reducing non-attendance in healthcare. The empirical evidence of the effect of fines is however limited. The objective of this study is to investigate the effectiveness and cost-effectiveness of fining non-attendance at outpatient clinics.

Design, participants and setting 1:1 randomised controlled trial of appointments for an outpatient clinic, posted to Danish addresses, between 1 May 2015 and 30 November 2015. Only first appointment for users was included. Healthcare professionals and investigators were masked.

Intervention A fine of DKK250 (€34) was issued for non-attendance. Users were informed about the fine in case of non-attendance by the appointment letter, and were able to reschedule or cancel until the appointment. A central administration office administered the fine system.

Main outcome measures The main outcome measures were non-attendance of non-cancelled appointments, fine policy administration costs, net of productivity consequences and probability of fining non-attendance being cost-effective over no fining for a range of hypothetical values of reduced non-attendance.

Results All of the 6746 appointments included were analysed. Of the 3333 appointments randomised to the fine policy, 130 (5%) of non-cancelled appointments were unattended, and of the 3413 appointments randomised to no-fine policy, 131 (5%) were unattended. The cost per appointment of non-attendance was estimated at DKK 56 (SE 5) in the fine group and DKK47 (SE 4) in the no-fine group, leading to a non-statistically significant difference of DKK10 (95% CI –9 to 22) per appointment attributable to the fine policy. The probability of cost-effectiveness remained around 50%, irrespective of increased values of reduced non-attendance or various alternative assumptions used for sensitivity analyses.

Conclusions At a baseline level of around 5%, fining non-attendance does not seem to further reduce non-attendance. Future studies should focus on other means for reduction of non-attendance such as nudging or negative reinforcement.

Trial registration number ISRCTN61925912.

  • non-attendance
  • randomized controlled trial
  • fines
  • fines for non-attendance

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2017-019969

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    Footnotes

    • Contributors All authors conceived and designed the study. EEB and UV managed the conduction of the trial and collected the data. RS supervised the analytical design and analysis which was conducted by EEB. The manuscript was drafted by EEB, and all authors contributed to critical revision and approved the final manuscript.

    • Funding This work was funded by Danish Regions, Ministry of Health and Prevention and Central Denmark Region.

    • Disclaimer The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

    • Competing interests None declared.

    • Ethics approval The local ethics committee reviewed the project and considered it to be a quality-improvement project outside of their responsibility (see the Committee Law, Section 2, No. 1). The Ministry of Health and Prevention approved the trial protocol (see the Health Legislation, Section 233, Subsections 1 and 3).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Data are owned by a third party and not available for public sharing.

    • Author note EEB (Msc) is Research Assistant at the Department of Health Economics at DEFACTUM, Central Denmark Region. UV (PhD) is Senior Researcher at the Department of Health Services Research at DEFACTUM, Central Denmark Region. RS (PhD) is Professor of Health Economics at the Department of Public Health and the Department of Clinical Medicine at Aarhus University.