Effectiveness and cost-effectiveness of fining non-attendance at public hospitals: a randomised controlled trial from Danish outpatient clinics

OBJECTIVES: Fines have been proposed as means for reducing non-attendance in health care. The empirical evidence for 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 randomized controlled trial of appointments for an outpatient clinic, posted to Danish addresses, during 01.05.15–30.11.15. Only first appointment for users was included. Health-care professionals and investigators were masked. INTERVENTION: A fine of 250 DKK (34 EUR) 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 was analysed. Of the 3333 appointments randomized to the fine policy, 130 (5 %) of non-cancelled appointments were unattended and of the 3413 appointments randomized 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 DKK 47 (SE 4) in the no-fine group, leading to a non-statistically significant difference of DKK 10 (95 % CI –9; 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.