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Waiting Time, Doctor Shopping, and Nonattendance at Specialist Outpatient Clinics: Case-Control Study of 6495 Individuals in Hong Kong

Leung, Gabriel M. MD, MPH*†; Castan-Cameo, Susana MBBS*; McGhee, Sarah M. PhD*†; Wong, Irene O. L. MPhil*†; Johnston, Janice M. PhD*

Original Articles

Objective. Nonattendance is a major health services research and management issue that has received little attention or systematic study in Asia. We examined the independent associations between waiting time, doctor shopping, and nonattendance in specialist outpatient clinics of 4 large public hospitals in Hong Kong.

Research Design. Case-control study.

Setting and Participants. A total of 6495 attenders and nonattenders enrolled from July 2000 through October 2001.

Pain Outcome Measures. Odds ratios (ORs) and associated 95% confidence intervals (CI) for nonattendance.

Results. Longer waiting times (adjusted OR2nd quartile, 1.67; 95% CI, 1.38–2.03; adjusted OR3rd quartile, 1.90; 95% CI, 1.56–2.30; adjusted OR4th quartile, 2.30; 95% CI, 1.91-2.78) and doctor-shopping behavior (adjusted OR, 2.91; 95% CI, 2.51–3.38) were independent risk factors for nonattendance. These effects were robust after multivariate adjustment and testing for effect modification. They also appeared to persist uniformly across hospitals and specialties. There was no demonstrable relationship between waiting time and doctor shopping.

Conclusions. This is the largest study of nonattendance at outpatient clinics and the first such study carried out in Asia. Targeted strategies should be implemented and evaluated using these results to reduce waiting time, doctor shopping, and ultimately nonattendance.

Nonattendance is a major health services research and management issue. 1 For patients, nonattendance can lead to delayed and suboptimal care either for themselves or others who are in the waiting line, especially in a national health service-type setting like that found in the United Kingdom. 2 For providers, particularly those who reimburse physicians on a non-fee-for-service basis, it represents inefficient use of resources that manifests as higher costs and lower productivity. 3,4

There have been many patient, provider, and social factors proposed to explain nonattendance behavior. 5,6 However, little has been reported outside the United States and United Kingdom despite a substantial pattern of nonattendance, for example, in Asia. 7

Hong Kong has a mixed medical economy where the public sector is responsible for 94% of total inpatient bed-days and 15% of ambulatory visits. Care has been criticized as fragmented, and there is as yet no organized primary care network or referral system. 8 This has led to the common practice of “doctor shopping,” defined as the changing of doctors without professional referral in a single illness episode. 9

Long waiting times have often been implicated in nonattendance. 5,10 In Hong Kong, there is anecdotal evidence suggesting that a long waiting time for specialist appointments might also contribute to doctor shopping, which in turn results in nonattendance.

We therefore investigated the associations between waiting time, doctor shopping, and nonattendance and hypothesized that waiting time independently contributed to both doctor shopping and nonattendance, and that doctor shopping also influenced nonattendance.

From the *Department of Community Medicine, The University of Hong Kong.

From the †Medical and Health Research Network, The University of Hong Kong

SCC has since left the department.

SCC, SMMcG, and JMJ designed the study and obtained funding for the project. GML, IOLW, and JMJ were responsible for carrying out the study, collected and collated the data. GML and IOLW analyzed the data. GML wrote the first draft of the paper and all authors contributed to the revision of subsequent drafts and approved the final version. JMJ is the guarantor for the study.

This study was funded by the Health Services Research Committee, Hong Kong (grant no. 921029)

Address correspondence and reprint requests to: Janice M. Johnston, PhD, Department of Community Medicine, The University of Hong Kong, Faculty of Medicine Building, 21 Sassoon Road, Pokfulam, Hong Kong. E-mail:

© 2003 Lippincott Williams & Wilkins, Inc.