Longer Appointment Duration Reduces Future Missed Appointments in Safety-Net Clinics

ABSTRACT

Objective: To determine whether longer prior appointment durations are associated with reduced missed appointment rates.

Study Design: Retrospective cohort study at a large Texas federally qualified health center network.

Methods: The dependent variable was missed appointments, and the primary independent variable was prior appointment duration. Other independent variables included sociodemographic (age, sex, race/ethnicity, insurance status), geographic (distance to the clinic, residence in a medically underserved area [MUA]), and clinical (visit history, visit type, visit dates, days between visits) factors. We used mixed-effects logistic regression to examine the relationship between prior appointment duration and missed appointments.

Results: The study sample included 28,090 unique patients who had 56,180 appointments. The regression model demonstrated that longer prior appointment duration was associated with a lower likelihood of a missed appointment (OR, 0.90; 95% CI, 0.88-0.92). Being Hispanic or non-Hispanic Black (Hispanic: OR, 1.08; 95% CI, 1.03-1.15; Black: OR, 1.49; 95% CI, 1.38-1.61), lacking insurance (OR, 1.47; 95% CI, 1.38-1.57), and living 40 or more miles from the clinic (OR, 1.21; 95% CI, 1.08-1.36) were associated with higher odds of missing appointments. In contrast, living in an MUA (OR, 0.92; 95% CI, 0.82-0.96), having 3 or more previous visits (3-4 visits: OR, 0.87; 95% CI, 0.82-0.93), having more days between visits (91-180 days between visits: OR, 0.54; 95% CI, 0.50-0.59), and scheduling visits with physicians (OR, 0.90; 95% CI, 0.86-0.95) were associated with lower odds of missing appointments.

Conclusions: Duration of past appointments is inversely correlated with future missed appointment rates. Efforts to lengthen appointment times may have important effects on quality and health outcomes.

Am J Manag Care. 2025;31(2):In Press

Takeaway Points

• Duration of past appointments inversely correlated with future missed appointments, indicating that longer appointments potentially improve patient adherence.
• Patient demographics such as age, race/ethnicity, insurance status, and proximity to the clinic significantly influenced the likelihood of missing appointments.
• Factors including residence in a medically underserved area, frequency of visits, type of health care provider, and experience level of the clinical provider also impacted future missed appointment rates.

Federally qualified health centers (FQHCs) have long stood as pillars of community health for underserved populations, serving 29.8 million low-income patients across the US.¹ These settings are a critical component of the health care safety net and serve as a major source of care for 1 in 11 Americans.² Importantly, they provide affordable access to comprehensive primary care, regardless of the patient’s ability to pay. However, compared with other primary care clinics, FQHCs often face additional operational challenges. For example, many patients who receive care in these settings frequently present with multiple medical and social needs.³ Good care often means additional time spent coordinating with other providers to address multiple health issues⁴ and nonmedical drivers of health,⁵ such as housing and food insecurity.⁶ Many FQHCs also face financial challenges, including higher rates of missed appointments,^7,8 that impair operations and often result in lost revenue.⁹

Earlier studies on missed appointments in primary care settings have reported missed appointment rates ranging between 21% and 80%.^8,10,11 Others have focused on the impact of missed appointments, including how they reduce the likelihood of receiving preventive care and result in poorer chronic disease control, increased emergency department^12,13 and hospital visits,¹⁴ and higher mortality rates.¹⁵ In their work on factors associated with missed appointments, Odonkor and colleagues identified demographic and environmental factors associated with a higher likelihood of missed appointments.¹⁰ Boshers et al noted that patients typically missed appointments due to personal issues and societal barriers.⁷ Although these study findings provide a springboard to understanding missed appointments, many of the factors identified are beyond the locus of control for clinic administrators. However, one modifiable factor is prior appointment duration. Multiple competing demands may shorten standard prior appointment duration,¹⁶ making it difficult for providers to adequately address patient priorities.¹⁷

Prior work suggests that various factors can play a role in the ultimate experience of a patient¹⁸ and that prior appointment duration may contribute to care continuity patterns in primary care settings.¹⁹ Prior appointment duration refers to the amount of time that a patient spends with the clinician and constitutes a part of the office visit cycle time—a separate measure that captures the amount of time in minutes that a patient spends from arrival to leaving the clinic.^1,20 Earlier reports suggest that physicians spend on average 15 to 18 minutes with patients^21,22 and that female physicians spend more time with patients.²³ Overhage and colleagues further broke down the amount of time clinicians spend with patients, noting that chart reviews (33%), documentation (24%), and writing orders (17%) accounted for most of their time.²⁴

Yet several anecdotal reports suggest that physicians spend even less time with patients,²⁵ citing ever-growing time pressure.²⁶ Physicians have also reported feelings of discontent with the amount of time spent with patients; more than 80% of physicians report that the duration of their face-to-face interactions is often too short to provide all the needed care,²⁷ contributing in part to clinician burnout.²⁸ Several researchers have voiced concerns about prior appointment duration, raising the possibility of misdiagnosis. However, despite its importance, the role of prior appointment duration and its implications for care continuity have received little attention. Much research in this area has focused on factors influencing appointment lengths rather than the impact of prior appointment duration on continuity, which is especially important because missed appointments can create a critical gap in care continuity. We hypothesize that longer appointment duration provides adequate time for patients to discuss their health concerns with their providers, which results in better perceived care quality and contributes to a greater desire to follow up with their next appointment.

Because many patients served in safety-net clinics are often underserved, examining the relationship between prior appointment duration and the likelihood of future missed appointments can shed light on the care provided to some of the nation’s most vulnerable populations. Given the significant association between prior appointment duration and patient satisfaction^29,30 and earlier work suggesting that missed appointments are heavily influenced by factors such as patient satisfaction and the perceived quality of the patient-physician relationship,^31,32 it is important to investigate whether prior appointment duration can contribute to reducing the likelihood of missed appointments.

Using data from a large FQHC network with 14 family practice locations, we examined prior appointment duration and its influence on future missed appointment rates. Studies of this nature are important to physicians, patients, health care payers, and populations because they offer additional insights into how prior appointment duration may affect care continuity, an essential element of good care.

METHODS

Data

The study’s primary data source consisted of electronic health record data obtained from community-based family practice clinics within a large FQHC network serving rural and urban areas across Texas. The family practice clinics span 14 locations across Texas. To allow for an examination of prior appointment duration and future missed appointment status, the data pull focused on patients with 2 or more appointments over 16 months from November 1, 2018, to March 1, 2020. We further limited the analytic sample to the 2 most recent consecutive appointments during the study period. Data included patient demographic information, encounter-level information, patient residence geographic characteristics, and provider characteristics.

Measurement

The outcome of interest was having a missed appointment (no [0], yes [1]) after a scheduled and confirmed medical appointment. Missed appointment was defined by the FQHC clinical operations team as a patient who did not appear for the appointment or a patient who canceled or rescheduled the appointment less than 2 hours before the appointment time. The independent variable of interest was prior appointment duration, defined as the total amount of time (in minutes) scheduled for the most recent prior patient visit. We created a lag variable capturing the previous appointment duration’s effect on missing a future appointment. To improve the readability and interpretation of our estimates, we standardized the measure of prior appointment duration to be in SD units (1 SD = approximately 15 minutes).

Other independent variables included patient sociodemographic variables (age, sex, race/ethnicity, insurance coverage type), patient geographic classifications (distance in miles to the clinic, residence in a medically underserved area [MUA] as defined by the Health Resources and Services Administration), and medical appointment information (lagged visit type [acute vs nonacute], dates of clinic visit, number of days between visits). Because the data provided did not include patient symptoms and/or medical diagnoses (factors that may affect the need for more frequent primary care checkups), the research team used past-visit volume over the preceding 15 months as a proxy measure for health. Using this analogy, patients with 1 or 2 visits in the 15 months before March 1, 2020, were considered relatively healthy; those with 3 or 4 visits were considered to probably have acute exacerbations and/or chronic conditions necessitating follow-up; and those with 5 or more visits were considered to likely have chronic conditions for which they frequently visit a clinic. Provider characteristics included provider identity (physician vs nonphysician [nurse practitioner or physician assistant]) and years in practice.

Analysis

The descriptive analyses performed included frequencies, proportions, means, and SDs of variables used to describe patient demographic characteristics. The research team used χ² tests to assess the strength of the relationship between each independent variable and missed appointments. To account for repeated appointments within each patient, a mixed-effects logistic regression model assessed the relationship between missed appointments and prior appointment duration, adjusting for patient sociodemographic characteristics, geographic classification, medical appointment information, and provider characteristics. An independent institutional review board approved this study in October 2020. All data management and analyses were performed using Stata 16 (StataCorp LLC). Findings were considered statistically significant at a P value less than .05.

RESULTS

The study sample contained 56,180 appointments for 28,090 unique patients (Table 1). Most patients were female (64%), and 87% of patients in these community-based family practice clinics were aged 18 to 64 years. Approximately 57% of the sample identified as Hispanic, 29% were non-Hispanic White, and 14% represented other racial/ethnic minorities. These subgroups included non-Hispanic Black or African American (10%), Asian (3%), and mixed race (1%). Regarding insurance coverage, approximately 19% of the sample had private insurance, 9% had Medicare, 15% had Medicaid, and 58% were uninsured. Approximately 28% of the sample resided less than 5 miles from the clinic, 25% between 5 and 9 miles, 28% between 10 and 19 miles, 15% between 20 and 39 miles, and 4% resided 40 miles or farther from the clinic. Approximately 32% of the sample had 1 or 2 visits prior, 35% had 3 or 4 visits prior, and 34% had 5 or more visits prior to the preceding 15-month period.

Unadjusted Results

Table 2 displays bivariate associations of baseline characteristics by missed appointment status. Those who missed their appointment had a shorter mean prior appointment duration than those who did not miss their appointment (13.5 vs 14.9 minutes; P < .001). Compared with the overall study population, Hispanic (58%) and Black patients (13%) were overrepresented among those with missed appointments (P < .001). Missed appointments also varied by age; 90% of patients who missed appointments were aged 18 to 64 years compared with 6% who were adults 65 years and older and 5% who were children/adolescents younger than 18 years (P < .001). Of those who missed appointments, 61% were uninsured compared with 14% who were privately insured, 7% who had Medicare, and 18% who were insured through Medicaid. More than half of those who missed appointments resided outside MUAs compared with those who lived in MUAs (59% vs 41%) (P < .001). Increasing number of days between visits was strongly associated with a reduced likelihood of future missed appointments (1-14 days: 28.0%; 15-30 days: 23.0%; 31-90 days: 28.5%; 91-180 days: 12.5%; >180 days: 8.0%). Patients who had follow-up visits with a physician made up a lower percentage of those who missed appointments compared with patients who had follow-up visits with a nonphysician health care provider (41% vs 59%; P < .001). Patients who had follow-up visits with providers who had 0 to 5 or more than 20 years of experience made up a lower proportion of those with missed appointments (17% and 16%, respectively) compared with those who had follow-up visits with providers who had 6 to 10 or 11 to 20 years of experience (37% and 30%, respectively).

Adjusted Results

Results from the mixed-effects regression model appear in Table 3, with 1 SD unit for an additional 15 minutes. As the prior appointment duration increased, patients had a statistically significantly lower likelihood of a future missed appointment (OR, 0.90; 95% CI, 0.88-0.92). In other words, physicians spending 1 SD more time with patients on average (15 minutes) was associated with a 10% reduction in the odds of missing the next appointment. Compared with adults 18 to 64 years, children and adolescents were less likely to miss appointments (OR, 0.84; 95% CI, 0.75-0.95), as were older adults (OR, 0.74; 95% CI, 0.67-0.83). Missed appointment status varied by patient race/ethnicity. Compared with non-Hispanic White patients, Hispanic and non-Hispanic Black patients had significantly higher odds of missed appointments (Hispanic: OR, 1.08; 95% CI, 1.03-1.15; Black: OR, 1.49; 95% CI, 1.38-1.61), and Asian patients were less likely to miss appointments (OR, 0.76; 95% CI, 0.65-0.89).

The odds of having a missed appointment were 18% greater for those enrolled in Medicare (OR, 1.18; 95% CI, 1.05-1.32), 47% greater for uninsured patients (OR, 1.47; 95% CI, 1.38-1.57), and 66% greater for those enrolled in Medicaid (OR, 1.66; 95% CI, 1.52-1.81) compared with patients with private insurance. Those who resided more than 40 miles from the clinic were significantly more likely to have a missed appointment (OR, 1.21; 95% CI, 1.08-1.36) than those who resided less than 5 miles from the clinic. The odds of missing an appointment were lower for those with 3 or 4 prior visits (OR, 0.87; 95% CI, 0.82-0.93) and with 5 or more prior visits (OR, 0.92; 95% CI, 0.87-0.99) compared with patients with only 1 or 2 visits in the preceding 15 months.

Residence in an MUA was associated with a lower likelihood of missed appointments (OR, 0.92; 95% CI, 0.82-0.96). Moreover, as the number of days between visits increased, the odds of missing an appointment significantly decreased compared with a span of 1 to 14 days (31-90 days: OR, 0.82; 95% CI, 0.77-0.87; 91-180 days: OR, 0.54; 95% CI, 0.50-0.59; >180 days: OR, 0.60; 95% CI, 0.55-0.66). Appointments with physicians vs nonphysicians also were associated with a lesser likelihood of missed appointments (OR, 0.90; 95% CI, 0.86-0.95). Compared with physicians who had been in practice for 5 years or less, those in practice for 6 to 10 years were more likely to have patients miss their appointments (OR, 1.13; 95% CI, 1.05-1.21).

DISCUSSION

In this large cohort study examining correlates of missed appointments in safety-net clinics, our results highlight a significant association between increasing prior appointment duration and a lower likelihood of missing a future appointment. Much of the previous research regarding missed appointments has focused on the implications for the clinics and system-level approaches to address the issue. For example, Kheirkhah et al estimated missed appointment rates and their associated costs to primary care clinics using an administrative database.³³ Their findings indicate that missed appointments pose a large financial burden on health care systems and that patient reminder systems only modestly reduce missed appointments.³³ Parikh et al studied the effect of 2 different patient appointment reminder systems and the effect on missed appointments.³⁴ They found that reminders by clinic staff were more effective than automated reminders at reducing missed appointments.³⁴ Another study implemented a clinical trial that evaluated offering rideshare transportation services to help patients attend primary care appointments, which resulted in modest gains in mitigating missed appointments.³⁵

Our study offers initial evidence of how actions by clinical practitioners can reduce missed appointments in safety-net settings. These findings are consistent with a recent study in a primary care setting that showed patient time spent with a physician was the strongest predictor of patient satisfaction.³⁶ Our results demonstrate physicians spending 1 SD more time with patients on average (15 minutes) is associated with a 10% reduction in the odds of missing the next appointment. Although many factors in our analysis affecting both patient prior appointment duration and future missed appointments are immutable from a clinical perspective, our notable finding highlights the direct action that clinics and providers can take to improve the quality of care for patients.

Although it is crucial to consider how longer appointments might impact patient volume and overall clinic efficiency, the implications are much broader, touching upon key policy debates that affect the entire health care system. One of the most significant concerns is the financial viability of such changes. Increasing appointment durations could potentially reduce the number of patients seen each day, which in turn might impact the clinic’s revenue stream. For many health care providers, especially those operating in underserved or resource-limited settings, maintaining a high patient volume is essential to cover operational costs. Without careful planning, the reduction in patient throughput could lead to financial strain, limiting access to care and potentially exacerbating health inequities.

Although the impact of physician time with patients is important and significantly affects the odds of a future missed appointment, the magnitude of this effect is small relative to the effects of patient race and ethnic category as well as patient insurance type. Our study showed that Black patients have the highest relative odds of a future missed appointment. This finding is similar to that of Samuels et al, who noted a larger composition of African American patients in the patient group with high missed appointment rates in an urban primary care clinic setting.³⁷ Potential mechanisms were identified, including transportation problems and trouble taking time off work as significant factors hindering patients from attending appointments.³⁷ Our finding also aligns with earlier work on missed appointments in safety-net clinics during the COVID-19 pandemic, in which the authors noted that minority racial/ethnic group populations had higher odds of missed appointments,³⁸ evidenced by higher medical mistrust among minority patient populations, especially African American patients in the Southern US.³⁹

Regarding the effect of the type of health insurance used by patients, privately insured patients had lower odds of missing appointments than those with any other type of insurance or no insurance at all. A large 2014 study of 9 suburban private practice clinics investigated missed appointment rates and similarly found higher missed appointment rates for uninsured and Medicaid patients but a lower missed appointment rate for Medicare patients.⁴⁰ The rate of missed appointments by non–privately insured patients might have potential determinants similar to those driving the association with race, such as logistic and transportation barriers or income insecurity.

Study findings linking increased distance from a clinic to missed appointments have been consistent across multiple health care settings.^41-44 For example, work by MacLeod et al on nonemergency appointments among Medicaid patients found that patients living more than 30 miles from the clinic were 31% more likely to have missed their appointments compared with those living less than 30 miles away.⁴⁵ This aligns with our findings on increased odds of missing an appointment among patients residing 40 or more miles from the FQHC clinics. We also observed that residence in an MUA is associated with a lower likelihood of missed appointments. We posit that this may be due to the strategic positioning of FQHC clinics in designated MUAs to increase the geographic proximity to the populations they serve. This is consistent with work conducted by Gresenz et al, in which geographic proximity to FQHCs was associated with an increased likelihood of physician visits.⁴⁶ Although the literature on the direct correlation between distance and missed appointments is limited in MUA settings, the strategic location of FQHC clinics in MUAs suggests greater care adherence and fewer missed appointments when resources are first and foremost accessible.

Clinic-level factors also played a role in influencing missed appointments. Notably, a greater number of days between visits was associated with a reduced likelihood of missed appointments. This finding aligns with existing research indicating that Americans average approximately 1.5 visits to primary care each year.⁴⁷ Given the financial challenges many individuals face, particularly within FQHC populations,⁴⁸ more frequent clinic visits may impose a financial strain that patients cannot sustain, irrespective of their insurance coverage or status. This financial burden could contribute to higher rates of missed appointments.

Provider type also influenced the rate of missed appointments. Much has been written about patient preferences for and satisfaction with different types of providers, but ours is one of the first studies to document that patients have lower missed appointment rates when the visits are scheduled with physicians rather than physician assistants or advanced practice nurses.^49,50 The reasons underlying this relationship are unclear, although we hypothesize that it may stem from medical complexity and the urgency with which patients need to be evaluated.⁵¹ A report focusing on associations with primary care appointment lengths revealed that longer appointments were more frequent among trainee physicians, patients with limited English proficiency, and patients with more comorbidities.⁵²

Limitations

This research, like all other research, does have limitations. The setting is a single, large safety-net provider with multiple clinics that provide services to individuals in South and Central Texas; hence, findings may not be generalizable to non–safety-net clinics or clinics in other geographic regions. Although the populations served in other safety-net settings are relatively similar to the population investigated in this study, the analysis of missed appointments in different settings or environments or clinics of a different size may differ from our results. Also, this research would have benefited from including patient comorbidities, which were not included in the data provided. Although we provide a surrogate for the seriousness of a patient’s conditions, the effects of the length of previous visits and the training of the provider may differ by the patient’s diagnosis and should be examined in future research. Finally, prior appointment duration in this study represents the amount of time that was scheduled and may not represent the total amount of time spent with a patient—this is a major limitation. Although actual visit time would provide a more precise measure of patients’ experiences, we relied on scheduled visit time due to the constraints of the available data. We acknowledge that there is a potential disconnect between scheduled and actual visit durations, which could influence patients’ decision-making and perceptions. In our analysis, scheduled visit time served as a consistent and standardized measure across all patients, which allowed us to control for variability in appointment types and provider schedules. To support the use of scheduled visit time, we reference previous studies^52-54 that have used scheduled visit duration as a reasonable proxy when actual visit time data were unavailable. Although imperfect, these studies suggest that scheduled visit time can still provide valuable insights into patient behavior, particularly in large-scale analyses where detailed time tracking is impractical.

Additionally, although we discuss the practical implications of adjusting scheduled appointment times, implementing these findings is complicated by broader systemic factors, such as clinic workflows and reimbursement frameworks, which extend beyond individual practices.

CONCLUSIONS

As previous research indicates, the dynamics that affect the likelihood of missed appointments are quite complex. Patients’ demographics, clinic characteristics, and environmental factors all play a role in whether a patient misses an appointment. Unlike much other research, this study contributes to the literature on the correlates of missed appointments by focusing on the patient’s experience with the provider—how much time a physician spends with a patient. Using this information in planning care for those most likely to miss appointments may reduce missed appointment rates to benefit both the clinic and its patients.

Author Affiliations: Department of Health Systems and Population Health Sciences, Tilman J. Fertitta Family College of Medicine, University of Houston (OEA, WL, CDP), Houston, TX; Humana Integrated Health System Sciences Institute, University of Houston (OEA), Houston, TX.

Source of Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (OEA); acquisition of data (OEA); analysis and interpretation of data (OEA, WL, CDP); drafting of the manuscript (OEA, WL); critical revision of the manuscript for important intellectual content (WL, CDP); statistical analysis (OEA, CDP); administrative, technical, or logistic support (OEA); and supervision (WL, CDP).

Address Correspondence to: Omolola E. Adepoju, PhD, MPH, University of Houston, 5055 Medical Circle, Houston, TX 77204. Email: oadepoju@central.uh.edu.

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