Blæhr Emely Ek, Væggemose Ulla, Søgaard Rikke
Central Denmark Region, DEFACTUM, Aarhus N, Denmark.
Demartment of Public Health, Aarhus Universitet, Aarhus C, Denmark.
BMJ Open. 2018 Apr 13;8(4):e019969. doi: 10.1136/bmjopen-2017-019969.
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.
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.
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.
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.
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.
ISRCTN61925912.
罚款已被提议作为减少医疗保健中患者未就诊情况的手段。然而，关于罚款效果的实证证据有限。本研究的目的是调查对门诊未就诊情况进行罚款的有效性和成本效益。
设计、参与者与设置：2015年5月1日至2015年11月30日期间，对寄往丹麦地址的门诊预约进行1:1随机对照试验。仅纳入用户的首次预约。医疗专业人员和研究人员均不知情。
对未就诊情况处以250丹麦克朗（34欧元）的罚款。若未就诊，用户会在预约信中被告知罚款事宜，并且在预约前能够重新安排或取消预约。由一个中央管理办公室负责管理罚款系统。
主要结局指标为未取消预约的未就诊情况、罚款政策管理成本、扣除生产力影响后的净值，以及在一系列假设的减少未就诊值情况下，罚款未就诊情况比不罚款更具成本效益的概率。
对纳入的6746次预约全部进行了分析。在随机分配到罚款政策的3333次预约中，130次（5%）未取消预约未就诊；在随机分配到无罚款政策的3413次预约中，131次（5%）未取消预约未就诊。罚款组未就诊每次预约的成本估计为56丹麦克朗（标准误5），无罚款组为47丹麦克朗（标准误4），因罚款政策导致每次预约的差异为10丹麦克朗（95%置信区间 -9至22），无统计学意义。无论减少未就诊值增加或用于敏感性分析的各种替代假设如何，成本效益概率均保持在50%左右。
在基线水平约为5%时，对未就诊情况进行罚款似乎并不会进一步减少未就诊情况。未来的研究应侧重于其他减少未就诊情况的手段，如助推或负强化。
ISRCTN61925912
