- Email: [email protected]
From telephone to office
Addictive Behaviors 27 (2002) 131 – 137
From telephone to office Intake attendance as a function of appointment delay David S. Festingera,*, R.J. Lambb, Douglas B. Marlowea, Kimberly C. Kirbya a
Treatment Research Institute at the University of Pennsylvania, 600 Public Ledger Building, 150 South Independence Mall West, Philadelphia, PA 19106-3475, USA b University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
Abstract In the present study, 116 clients calling an outpatient cocaine treatment clinic were randomly assigned to intake appointments scheduled either the same day, 1 day, 3 days, or 7 days later. Significantly more subjects scheduled 1 day later attended their intake appointments (72%), compared to those scheduled 3 days (41%) or 7 days (38%) later. Odds ratios indicate that subjects offered intake appointments approximately 24 h following their initial contact are more than four times as likely to attend their intakes as those scheduled later. This accelerated intake procedure allows clinics to reach more patients in need of services. D 2001 Elsevier Science Ltd. All rights reserved. Keywords: Treatment entry; Treatment initiation; Intake attendance; Appointment delay; Drug abuse
1. Introduction Over 50% of individuals who contact a clinic to schedule drug abuse treatment services do not follow through on their intake appointment (Fehr, Weinstein, Sterling, & Gottleib, 1990; Festinger, Lamb, Kountz, Kirby, & Marlowe, 1995; Stark, Campbell, & Brikerhoff, 1990). Gallant, Bishop, Stoy, Faulkner and Paternostro (1966), referring to these high rates of intake
* Corresponding author. Tel.: +1-215-399-0988 ext. 126; fax: +1-215-399-0987/0989. E-mail address: [email protected] (D.S. Festinger). 0306-4603/02/$ – see front matter D 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 4 6 0 3 ( 0 1 ) 0 0 1 7 2 - 1
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appointment failure, spoke of the paradox of having an overbooked, seemingly overburdened treatment facility, while counselors and other health professionals wait in their offices for clients who never arrive. In addition to the waste of clinic resources, these failed appointments may also represent lost opportunities to capitalize on potentially brief chances to engage recalcitrant individuals in treatment. Unlike individuals whom clinics attempt to bring into treatment with various outreach strategies (e.g., Iguchi et al., 1994), these individuals have already taken the first step by scheduling the initial appointment. Previous studies have indicated that even slight changes in clinic practices may significantly increase initial attendance. One such change has been the accelerated intake. Correlational investigations (Carpenter, Morrow, DelGaudio, & Ritzler, 1981; Festinger et al., 1995; Oppenheim, Bergman, & English, 1979; Orne & Boswell, 1991; Raynes & Warren, 1971) have revealed that the delay between initial contact and when a patient is scheduled for intake is inversely related to intake attendance. A small number of studies have experimentally investigated this appointment delay. BenjaminBauman, Reiss, and Bailey (1984) conducted the first true experimental investigation of appointment delay. In Part 1 of their study, 337 clients calling for gynecological appointments were randomly scheduled either 1 or 3 weeks following their initial contact. Results indicated that a significantly higher percentage of clients scheduled to the 1-week condition attended their appointments (75%) than those scheduled to the 3-week condition (57%). In Part 2, 192 clients were randomly scheduled either the next day or 1 week later. Again, clients scheduled to the earlier (next day) appointment attended at a higher rate (72%) than clients scheduled to the later (1 week) appointment (52%). To experimentally examine this relationship in a substance abuse population, Stark et al. (1990) randomly assigned patients calling for outpatient drug treatment to come in either ‘‘as soon as possible’’ (no appointment) or to an appointment scheduled an average of 9.7 days later. Again, the earlier appointments resulted in significantly greater rates of initial attendance (55%; 21/38) than the later appointments (41%; 9/22). These findings were replicated in an outpatient cocaine-dependent population. Festinger, Lamb, Kirby, and Marlowe (1996) randomly assigned 78 patients calling to schedule intake appointments to an accelerated appointment (the same day, or the next morning if the client called after 3:00 p.m.), or to a standard appointment (scheduled from 1 to 7 days later). Individuals offered the accelerated appointment attended at a significantly greater rate (59%) than those scheduled by the standard procedure (33%). Because these studies examined only two groups — one early and one later — it remains unclear what delay interval would be most effective at occasioning attendance. The current study examined four different appointment delay intervals in an effort to isolate the delay interval that occasions the greatest rates of initial attendance. We hypothesized that potential clients scheduled for an intake appointment the same day that they called would have the highest rates of attendance.
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2. Method 2.1. Setting The study was conducted in an outpatient cocaine clinic located in a poor, urban area in Southern New Jersey. The clinic offered a 12-week, 26-session, manual-driven, cognitive– behavioral treatment for cocaine dependence. Its operating hours were from 9:00 a.m. to 5:00 p.m., Monday through Friday. The clinic had a sliding fee for services. However, due to the low socioeconomic status of the surrounding population, most clients (98%), and all subjects included in this study, received their services pro bono. 2.2. Sample Subjects included all individuals between the ages of 18 and 65 who called the clinic to schedule an initial appointment, reported cocaine to be their primary drug of abuse, and reported having used cocaine or crack within the previous 3 days. Any clients currently in crisis were to be scheduled for an immediate appointment and excluded from the data analysis. However, this situation did not arise during the study. Utilizing a computergenerated random numbers table, clients were randomly assigned to four appointment delay conditions in equal proportions. This procedure assured equal group sizes, which improved the convenience of statistical analysis, and increased statistical conclusion validity (Kazdin, 1992). The four delay intervals were as follows: (1) offered same day appointment; (2) offered appointment 24 h later; (3) offered appointment 72 h later; (4) offered appointment 168 h later. 2.3. Procedure The study was approved by the Institutional Review Board of Allegheny University of the Health Sciences. Although the nature of the study precluded obtaining consent to participation, all of the delay intervals were well within current standards of practice. Predetermined assignments were recorded on a chart to ease the scheduling process. The chart enabled the receptionist or other staff answering the phone to immediately determine for each caller, based on their predetermined random assignment, and the time and day of their phone call, what time and day their appointment was to be scheduled. When individuals called the clinic, they were asked several inquiry questions designed to ensure that they satisfied inclusion criteria and to provide general demographic information. These questions included name, address, age, gender, marital status, referral source, primary and secondary drug of abuse, and time of last use. Qualified subjects were then offered their predetermined appointments in the following scripted manner: (a) ‘‘Our agency has predetermined appointment times. To provide for smooth entry into our program, we ask that you arrive on time for your scheduled appointment. Your appointment is scheduled for (predetermined time) on (predetermined day).’’ If the subject stated that he or she could not come in at that time, the receptionist was instructed to say the
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following: ‘‘It is important that your appointment be scheduled as close to (previous time and date) as possible, what time can you make it?’’ In addition to learning the standardized procedures, the receptionist and all nonclinical staff were instructed on how to handle irregular situations. All calls involving crises, emergencies, or problem situations, including patients who had special scheduling needs or circumstances, or specific concerns, were to be transferred to and handled by a clinician. Potential crises and emergencies, while not limited to, would have included instances of medical or psychiatric distress, and immediate danger to self or others. Such cases would then be excluded from the data analysis, and scheduled according to their clinical needs. No-shows were defined as clients who did not attend a scheduled intake appointment within 7 days of their scheduled appointment. While this may be seen as having allowed more time to show for those groups with longer delay intervals, such an operational definition increased the conservativeness of the test of our hypothesis that the same day group would have the highest rates of attendance.
3. Results One hundred and sixteen subjects were randomly assigned to the four groups, with 29 subjects per cell. No callers were excluded due to crisis, special needs, or failure to meet other inclusion criteria. The mean age of the sample was 32.8 years (S.D. = 7.2). The majority of the subjects were male (74.1%), and lived in the city in which the clinic was located (64.7%), with the balance residing from 3 to 8 miles away. Regarding marital status, 71.5% were single, 13.8% were married, and 14.7% were divorced or separated. While everyone in the sample reported abusing cocaine or crack, with a mean number of days since last use of 4 days (S.D. = 3.9), 25% also reported abusing alcohol, 13.8% reported abusing marijuana, and 6.9% reported abusing heroin. 3.1. Randomization check Randomization checks were conducted to assure that random assignment resulted in equal distribution of subject characteristics. ANOVA was used for the continuous variables: age and reported number of days since last use of cocaine. Chi-square was used for the categorical variables: gender, marital status, residence, and alcohol, marijuana, and heroin use. No significant between group differences were found for age, gender, city residence, marital status, marijuana use, or alcohol use. However, between group differences approached significance for reported number of days since last use of cocaine [ F(3,116) = 2.46, P < .10] (means and standard deviations for days since last cocaine use were: 6 ± 5.0, 3 ± 2.8, 4 ± 3.5, and 4 ± 3.9 for the same-, 1-, 3-, and 7-day groups, respectively), and were significant for reported use of heroin [c (3, N = 116) = P < .01] (percentages of clients reporting comorbid heroin use were: 1%, 1%, 6%, and 0% for the same-, 1-, 3-, and 7-day groups, respectively). To control for the possible influence of these two variables, they were entered as covariates in the main analysis of initial attendance.
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3.2. Integrity of assignment The same-, 1-, 3-, and 7-day groups had observed mean appointment delays of 12 h (range = 0.08 – 23.8), 25 h (range = 21.8 – 46.3), 70 h (range = 45.1 – 113.7), and 169 h (range = 75.33–240.24), respectively, and all were clearly similar to their intended length of delay. Paired-sample t tests, used to examine adherence to group assignment, revealed no significant differences between the observed and the planned appointment delays. Additionally, to check for possible overlap between group assignments, t tests were performed between the mean hours of delay of the three adjacent groups: same-day versus 1-day, 1-day versus 3-day, and 3-day versus 7-day. These all resulted in significant between group differences ( P < .001), indicating integrity and differentiation between the experimental conditions. 3.3. Attendance Of the total sample of 116 subjects, 60 (51.7%) showed for intake. As depicted in Fig. 1, a greater percentage (72%) of subjects scheduled 1 day later attended their intake appointment
Fig. 1. Percentage of subjects showing for their intake appointments across four appointment delay conditions: same-, 1-, 3-, and 7-day.
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than did those scheduled the same day (55%), 3 days later (41%), or 7 days later (38%). A chi-square analysis indicated an unequal distribution of attendance across the four conditions [c2(3, N = 116) = 8.56, P < .05]. To determine exactly where the significant differences were, we conducted post hoc comparisons. Using chi-square analyses, we examined all possible comparisons. These analyses identified significant differences in intake attendance between the 1-day and 3day groups [c2(1, N = 58) = 5.69, P < .05] and between the 1-day and 7-day groups [c2= (1, N = 58) = 6.97, P < .01]. Logistic regression indicated significant between-group differences on intake attendance (Wald = (3) 8.76, P < .05) regardless of the addition of the two covariates (days since last cocaine use or reported heroin use), both of which were not significant contributors to attendance. Examination of the odd ratios of the logistic regression indicated that subjects offered appointments scheduled for 1 day following their initial phone contact were 4.44 and 4.39 times as likely to attend their scheduled appointments as those scheduled to appointments 3 or 7 days later, respectively.
4. Discussion Results of this study confirm that clients scheduled for an intake appointment within 24 h of their initial phone contact are significantly more likely to attend. Furthermore, the design of the present study allowed us to establish that a 24-h delay resulted in significantly higher rates of attendance than either a 3-day or 7-day delay. Research suggests that clients scheduled for earlier appointments are significantly more likely to attend intakes than those scheduled to longer delays. However, due to the use of only two group designs, and the questionable integrity of the assignments, research to date has been unable to determine what is the most effective delay interval. The present study addressed these additional concerns. As discussed, the standardized scheduling procedures led to substantial congruence between the observed and planned scheduling delays. This integrity of assignment, coupled with the added delay intervals, allowed us for the first time to look at the functional relationship between appointment delay and intake attendance, finding that next day appointments resulted in the highest levels of attendance. It is important to note that scheduling intake sessions sooner resulted in greater attendance even when compared to 3- or 7-day delays, intervals that would be considered short in many substance abuse clinics. While the same- and 1-day conditions did not differ significantly on rates of attendance, individuals scheduled to the 1-day condition were significantly more likely than those scheduled to the 3- or 7-day delays to attend their appointments. This suggests that the 24 h appointment is the optimal scheduling procedure. This study provides the framework for an easy and cost-efficient method of increasing intake attendance. In these days of increasing needs and decreasing resources, it is particularly important to increase the efficiency of clinic procedures. Previous findings almost unanimously support the utility of reducing initial appointment delay. Results of this
D.S. Festinger et al. / Addictive Behaviors 27 (2002) 131–137
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multigroup study further validate, and operationalize the accelerated intake procedure, enhancing its applicability to substance abuse treatment services. Despite the accelerated intake’s apparent success, the goal of bringing more clients into treatment should not be confused with treatment efficacy. Efforts such as the accelerated intake offer clinics a way of reaching more individuals in need of treatment. Bringing more people to the clinic door, while critical, is only the first step. Once there, the service provider and the provider system must endeavor to keep them there and provide effective treatment during their tenure. Future research must now focus on methods of engaging clients during the orientation and early phases of treatment.
Acknowledgments This research was supported by Grant No. DA06986 from the National Institute on Drug Abuse. These data were presented as part of a symposium conducted at the 104th Annual Convention of the American Psychological Association, Toronto, Canada.
References Benjamin-Bauman, J., Reiss, M. L., & Bailey, J. S. (1984). Increasing appointment keeping by reducing the call – appointment interval. Journal of Applied Behavior Analysis, 17, 295 – 301. Carpenter, P. J., Morrow, G. R., DelGaudio, A. C., & Ritzler, B. A. (1981). Who keeps the first appointment? American Journal of Psychiatry, 138 (1), 102 – 105. Fehr, B. J., Weinstein, S. P., Sterling, S., & Gottleib, E. (1990). ‘‘As soon as possible:’’ an initial treatment engagement strategy. Substance Abuse, 3, 180 – 183. Festinger, D. S., Lamb, R. J., Kirby, K. C., & Marlowe, D. B. (1996). The accelerated intake: a method for increasing initial attendance to out patient treatment for cocaine addiction. Journal of Applied Behavior Analysis, 29 (3), 118 – 122. Festinger, D. S., Lamb, R. J., Kountz, M., Kirby, K. C., & Marlowe, D. B. (1995). Pre-treatment drop-out as a function of treatment delay and client variables. Addictive Behaviors, 20 (1), 111 – 115. Gallant, D. M., Bishop, M. P., Stoy, B., Faulkner, M. A., & Paternostro, L. (1966). The value of the ‘‘first contact’’ group intake session in an alcoholism outpatient clinic: statistical confirmation. Psychosomatics, 7, 349 – 352. Iguchi, M. Y., Bux, D. A., Lidz, V., Kushner, H., French, J. F., & Platt, J. J. (1994). Interpreting HIV seroprevalence data from a street-based outreach program. Journal of Acquired Immune Deficiency Syndromes, 7, 491 – 499. Kazdin, A. E. (1992). Research design in clinical psychology. Boston, MA: Allyn & Bacon. Oppenheim, G. L., Bergman, J. J., & English, E. C. (1979). Failed appointments: a review. Journal of Family Practice, 8 (4), 789 – 796. Orne, D. R., & Boswell, D. (1991). The pre-intake drop-out at a community mental health center. Community Mental Health Journal, 27, 375 – 379. Raynes, A. E., & Warren, G. (1971). Some characteristics of ‘‘dropouts’’ at first contact with a psychiatric clinic. Community Mental Health Journal, 7, 144 – 150. Stark, M. J., Campbell, B. K., & Brikerhoff, C. V. (1990). ‘‘Hello, may we help you?’’ A study of attrition prevention at the time of the first phone contact with substance-abusing clients. American Journal of Drug and Alcohol Abuse, 16 (1&2), 67 – 76.
From telephone to office Intake attendance as a function of appointment delay David S. Festingera,*, R.J. Lambb, Douglas B. Marlowea, Kimberly C. Kirbya a
Treatment Research Institute at the University of Pennsylvania, 600 Public Ledger Building, 150 South Independence Mall West, Philadelphia, PA 19106-3475, USA b University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
Abstract In the present study, 116 clients calling an outpatient cocaine treatment clinic were randomly assigned to intake appointments scheduled either the same day, 1 day, 3 days, or 7 days later. Significantly more subjects scheduled 1 day later attended their intake appointments (72%), compared to those scheduled 3 days (41%) or 7 days (38%) later. Odds ratios indicate that subjects offered intake appointments approximately 24 h following their initial contact are more than four times as likely to attend their intakes as those scheduled later. This accelerated intake procedure allows clinics to reach more patients in need of services. D 2001 Elsevier Science Ltd. All rights reserved. Keywords: Treatment entry; Treatment initiation; Intake attendance; Appointment delay; Drug abuse
1. Introduction Over 50% of individuals who contact a clinic to schedule drug abuse treatment services do not follow through on their intake appointment (Fehr, Weinstein, Sterling, & Gottleib, 1990; Festinger, Lamb, Kountz, Kirby, & Marlowe, 1995; Stark, Campbell, & Brikerhoff, 1990). Gallant, Bishop, Stoy, Faulkner and Paternostro (1966), referring to these high rates of intake
* Corresponding author. Tel.: +1-215-399-0988 ext. 126; fax: +1-215-399-0987/0989. E-mail address: [email protected] (D.S. Festinger). 0306-4603/02/$ – see front matter D 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 4 6 0 3 ( 0 1 ) 0 0 1 7 2 - 1
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appointment failure, spoke of the paradox of having an overbooked, seemingly overburdened treatment facility, while counselors and other health professionals wait in their offices for clients who never arrive. In addition to the waste of clinic resources, these failed appointments may also represent lost opportunities to capitalize on potentially brief chances to engage recalcitrant individuals in treatment. Unlike individuals whom clinics attempt to bring into treatment with various outreach strategies (e.g., Iguchi et al., 1994), these individuals have already taken the first step by scheduling the initial appointment. Previous studies have indicated that even slight changes in clinic practices may significantly increase initial attendance. One such change has been the accelerated intake. Correlational investigations (Carpenter, Morrow, DelGaudio, & Ritzler, 1981; Festinger et al., 1995; Oppenheim, Bergman, & English, 1979; Orne & Boswell, 1991; Raynes & Warren, 1971) have revealed that the delay between initial contact and when a patient is scheduled for intake is inversely related to intake attendance. A small number of studies have experimentally investigated this appointment delay. BenjaminBauman, Reiss, and Bailey (1984) conducted the first true experimental investigation of appointment delay. In Part 1 of their study, 337 clients calling for gynecological appointments were randomly scheduled either 1 or 3 weeks following their initial contact. Results indicated that a significantly higher percentage of clients scheduled to the 1-week condition attended their appointments (75%) than those scheduled to the 3-week condition (57%). In Part 2, 192 clients were randomly scheduled either the next day or 1 week later. Again, clients scheduled to the earlier (next day) appointment attended at a higher rate (72%) than clients scheduled to the later (1 week) appointment (52%). To experimentally examine this relationship in a substance abuse population, Stark et al. (1990) randomly assigned patients calling for outpatient drug treatment to come in either ‘‘as soon as possible’’ (no appointment) or to an appointment scheduled an average of 9.7 days later. Again, the earlier appointments resulted in significantly greater rates of initial attendance (55%; 21/38) than the later appointments (41%; 9/22). These findings were replicated in an outpatient cocaine-dependent population. Festinger, Lamb, Kirby, and Marlowe (1996) randomly assigned 78 patients calling to schedule intake appointments to an accelerated appointment (the same day, or the next morning if the client called after 3:00 p.m.), or to a standard appointment (scheduled from 1 to 7 days later). Individuals offered the accelerated appointment attended at a significantly greater rate (59%) than those scheduled by the standard procedure (33%). Because these studies examined only two groups — one early and one later — it remains unclear what delay interval would be most effective at occasioning attendance. The current study examined four different appointment delay intervals in an effort to isolate the delay interval that occasions the greatest rates of initial attendance. We hypothesized that potential clients scheduled for an intake appointment the same day that they called would have the highest rates of attendance.
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2. Method 2.1. Setting The study was conducted in an outpatient cocaine clinic located in a poor, urban area in Southern New Jersey. The clinic offered a 12-week, 26-session, manual-driven, cognitive– behavioral treatment for cocaine dependence. Its operating hours were from 9:00 a.m. to 5:00 p.m., Monday through Friday. The clinic had a sliding fee for services. However, due to the low socioeconomic status of the surrounding population, most clients (98%), and all subjects included in this study, received their services pro bono. 2.2. Sample Subjects included all individuals between the ages of 18 and 65 who called the clinic to schedule an initial appointment, reported cocaine to be their primary drug of abuse, and reported having used cocaine or crack within the previous 3 days. Any clients currently in crisis were to be scheduled for an immediate appointment and excluded from the data analysis. However, this situation did not arise during the study. Utilizing a computergenerated random numbers table, clients were randomly assigned to four appointment delay conditions in equal proportions. This procedure assured equal group sizes, which improved the convenience of statistical analysis, and increased statistical conclusion validity (Kazdin, 1992). The four delay intervals were as follows: (1) offered same day appointment; (2) offered appointment 24 h later; (3) offered appointment 72 h later; (4) offered appointment 168 h later. 2.3. Procedure The study was approved by the Institutional Review Board of Allegheny University of the Health Sciences. Although the nature of the study precluded obtaining consent to participation, all of the delay intervals were well within current standards of practice. Predetermined assignments were recorded on a chart to ease the scheduling process. The chart enabled the receptionist or other staff answering the phone to immediately determine for each caller, based on their predetermined random assignment, and the time and day of their phone call, what time and day their appointment was to be scheduled. When individuals called the clinic, they were asked several inquiry questions designed to ensure that they satisfied inclusion criteria and to provide general demographic information. These questions included name, address, age, gender, marital status, referral source, primary and secondary drug of abuse, and time of last use. Qualified subjects were then offered their predetermined appointments in the following scripted manner: (a) ‘‘Our agency has predetermined appointment times. To provide for smooth entry into our program, we ask that you arrive on time for your scheduled appointment. Your appointment is scheduled for (predetermined time) on (predetermined day).’’ If the subject stated that he or she could not come in at that time, the receptionist was instructed to say the
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D.S. Festinger et al. / Addictive Behaviors 27 (2002) 131–137
following: ‘‘It is important that your appointment be scheduled as close to (previous time and date) as possible, what time can you make it?’’ In addition to learning the standardized procedures, the receptionist and all nonclinical staff were instructed on how to handle irregular situations. All calls involving crises, emergencies, or problem situations, including patients who had special scheduling needs or circumstances, or specific concerns, were to be transferred to and handled by a clinician. Potential crises and emergencies, while not limited to, would have included instances of medical or psychiatric distress, and immediate danger to self or others. Such cases would then be excluded from the data analysis, and scheduled according to their clinical needs. No-shows were defined as clients who did not attend a scheduled intake appointment within 7 days of their scheduled appointment. While this may be seen as having allowed more time to show for those groups with longer delay intervals, such an operational definition increased the conservativeness of the test of our hypothesis that the same day group would have the highest rates of attendance.
3. Results One hundred and sixteen subjects were randomly assigned to the four groups, with 29 subjects per cell. No callers were excluded due to crisis, special needs, or failure to meet other inclusion criteria. The mean age of the sample was 32.8 years (S.D. = 7.2). The majority of the subjects were male (74.1%), and lived in the city in which the clinic was located (64.7%), with the balance residing from 3 to 8 miles away. Regarding marital status, 71.5% were single, 13.8% were married, and 14.7% were divorced or separated. While everyone in the sample reported abusing cocaine or crack, with a mean number of days since last use of 4 days (S.D. = 3.9), 25% also reported abusing alcohol, 13.8% reported abusing marijuana, and 6.9% reported abusing heroin. 3.1. Randomization check Randomization checks were conducted to assure that random assignment resulted in equal distribution of subject characteristics. ANOVA was used for the continuous variables: age and reported number of days since last use of cocaine. Chi-square was used for the categorical variables: gender, marital status, residence, and alcohol, marijuana, and heroin use. No significant between group differences were found for age, gender, city residence, marital status, marijuana use, or alcohol use. However, between group differences approached significance for reported number of days since last use of cocaine [ F(3,116) = 2.46, P < .10] (means and standard deviations for days since last cocaine use were: 6 ± 5.0, 3 ± 2.8, 4 ± 3.5, and 4 ± 3.9 for the same-, 1-, 3-, and 7-day groups, respectively), and were significant for reported use of heroin [c (3, N = 116) = P < .01] (percentages of clients reporting comorbid heroin use were: 1%, 1%, 6%, and 0% for the same-, 1-, 3-, and 7-day groups, respectively). To control for the possible influence of these two variables, they were entered as covariates in the main analysis of initial attendance.
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3.2. Integrity of assignment The same-, 1-, 3-, and 7-day groups had observed mean appointment delays of 12 h (range = 0.08 – 23.8), 25 h (range = 21.8 – 46.3), 70 h (range = 45.1 – 113.7), and 169 h (range = 75.33–240.24), respectively, and all were clearly similar to their intended length of delay. Paired-sample t tests, used to examine adherence to group assignment, revealed no significant differences between the observed and the planned appointment delays. Additionally, to check for possible overlap between group assignments, t tests were performed between the mean hours of delay of the three adjacent groups: same-day versus 1-day, 1-day versus 3-day, and 3-day versus 7-day. These all resulted in significant between group differences ( P < .001), indicating integrity and differentiation between the experimental conditions. 3.3. Attendance Of the total sample of 116 subjects, 60 (51.7%) showed for intake. As depicted in Fig. 1, a greater percentage (72%) of subjects scheduled 1 day later attended their intake appointment
Fig. 1. Percentage of subjects showing for their intake appointments across four appointment delay conditions: same-, 1-, 3-, and 7-day.
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than did those scheduled the same day (55%), 3 days later (41%), or 7 days later (38%). A chi-square analysis indicated an unequal distribution of attendance across the four conditions [c2(3, N = 116) = 8.56, P < .05]. To determine exactly where the significant differences were, we conducted post hoc comparisons. Using chi-square analyses, we examined all possible comparisons. These analyses identified significant differences in intake attendance between the 1-day and 3day groups [c2(1, N = 58) = 5.69, P < .05] and between the 1-day and 7-day groups [c2= (1, N = 58) = 6.97, P < .01]. Logistic regression indicated significant between-group differences on intake attendance (Wald = (3) 8.76, P < .05) regardless of the addition of the two covariates (days since last cocaine use or reported heroin use), both of which were not significant contributors to attendance. Examination of the odd ratios of the logistic regression indicated that subjects offered appointments scheduled for 1 day following their initial phone contact were 4.44 and 4.39 times as likely to attend their scheduled appointments as those scheduled to appointments 3 or 7 days later, respectively.
4. Discussion Results of this study confirm that clients scheduled for an intake appointment within 24 h of their initial phone contact are significantly more likely to attend. Furthermore, the design of the present study allowed us to establish that a 24-h delay resulted in significantly higher rates of attendance than either a 3-day or 7-day delay. Research suggests that clients scheduled for earlier appointments are significantly more likely to attend intakes than those scheduled to longer delays. However, due to the use of only two group designs, and the questionable integrity of the assignments, research to date has been unable to determine what is the most effective delay interval. The present study addressed these additional concerns. As discussed, the standardized scheduling procedures led to substantial congruence between the observed and planned scheduling delays. This integrity of assignment, coupled with the added delay intervals, allowed us for the first time to look at the functional relationship between appointment delay and intake attendance, finding that next day appointments resulted in the highest levels of attendance. It is important to note that scheduling intake sessions sooner resulted in greater attendance even when compared to 3- or 7-day delays, intervals that would be considered short in many substance abuse clinics. While the same- and 1-day conditions did not differ significantly on rates of attendance, individuals scheduled to the 1-day condition were significantly more likely than those scheduled to the 3- or 7-day delays to attend their appointments. This suggests that the 24 h appointment is the optimal scheduling procedure. This study provides the framework for an easy and cost-efficient method of increasing intake attendance. In these days of increasing needs and decreasing resources, it is particularly important to increase the efficiency of clinic procedures. Previous findings almost unanimously support the utility of reducing initial appointment delay. Results of this
D.S. Festinger et al. / Addictive Behaviors 27 (2002) 131–137
137
multigroup study further validate, and operationalize the accelerated intake procedure, enhancing its applicability to substance abuse treatment services. Despite the accelerated intake’s apparent success, the goal of bringing more clients into treatment should not be confused with treatment efficacy. Efforts such as the accelerated intake offer clinics a way of reaching more individuals in need of treatment. Bringing more people to the clinic door, while critical, is only the first step. Once there, the service provider and the provider system must endeavor to keep them there and provide effective treatment during their tenure. Future research must now focus on methods of engaging clients during the orientation and early phases of treatment.
Acknowledgments This research was supported by Grant No. DA06986 from the National Institute on Drug Abuse. These data were presented as part of a symposium conducted at the 104th Annual Convention of the American Psychological Association, Toronto, Canada.
References Benjamin-Bauman, J., Reiss, M. L., & Bailey, J. S. (1984). Increasing appointment keeping by reducing the call – appointment interval. Journal of Applied Behavior Analysis, 17, 295 – 301. Carpenter, P. J., Morrow, G. R., DelGaudio, A. C., & Ritzler, B. A. (1981). Who keeps the first appointment? American Journal of Psychiatry, 138 (1), 102 – 105. Fehr, B. J., Weinstein, S. P., Sterling, S., & Gottleib, E. (1990). ‘‘As soon as possible:’’ an initial treatment engagement strategy. Substance Abuse, 3, 180 – 183. Festinger, D. S., Lamb, R. J., Kirby, K. C., & Marlowe, D. B. (1996). The accelerated intake: a method for increasing initial attendance to out patient treatment for cocaine addiction. Journal of Applied Behavior Analysis, 29 (3), 118 – 122. Festinger, D. S., Lamb, R. J., Kountz, M., Kirby, K. C., & Marlowe, D. B. (1995). Pre-treatment drop-out as a function of treatment delay and client variables. Addictive Behaviors, 20 (1), 111 – 115. Gallant, D. M., Bishop, M. P., Stoy, B., Faulkner, M. A., & Paternostro, L. (1966). The value of the ‘‘first contact’’ group intake session in an alcoholism outpatient clinic: statistical confirmation. Psychosomatics, 7, 349 – 352. Iguchi, M. Y., Bux, D. A., Lidz, V., Kushner, H., French, J. F., & Platt, J. J. (1994). Interpreting HIV seroprevalence data from a street-based outreach program. Journal of Acquired Immune Deficiency Syndromes, 7, 491 – 499. Kazdin, A. E. (1992). Research design in clinical psychology. Boston, MA: Allyn & Bacon. Oppenheim, G. L., Bergman, J. J., & English, E. C. (1979). Failed appointments: a review. Journal of Family Practice, 8 (4), 789 – 796. Orne, D. R., & Boswell, D. (1991). The pre-intake drop-out at a community mental health center. Community Mental Health Journal, 27, 375 – 379. Raynes, A. E., & Warren, G. (1971). Some characteristics of ‘‘dropouts’’ at first contact with a psychiatric clinic. Community Mental Health Journal, 7, 144 – 150. Stark, M. J., Campbell, B. K., & Brikerhoff, C. V. (1990). ‘‘Hello, may we help you?’’ A study of attrition prevention at the time of the first phone contact with substance-abusing clients. American Journal of Drug and Alcohol Abuse, 16 (1&2), 67 – 76.