ABSTRACT

Non-attendance to specialized healthcare appointments, diagnostic, and therapeutic procedures is a global problem in healthcare, leading to the wastage of resources both in the public and private sectors. This study aims to estimate financial wastage of resources linked to non-attendance to scheduled health specialist appointments and procedures in the metropolitan region of the Espírito Santo State (ES), Brazil, between 2014 and 2016. We studied 1.002.719 specialized healthcare procedures, being 666.182 appointments with specialized physicians and other healthcare professionals, and 336.537 specialized diagnostic and other therapeutic procedures. Non-attendance date were retrieved from the administrative procedure scheduling database (SisReg-ES) available in the ES Regulatory Agency and provided by the ES Health Office. Financial values used to estimate wastage were retrieved from the SUS and other standard tariff lists for medical procedures, and used according to the administrative regime of the three types of service providers. Non-attendance average rate for medical and health specialists’ appointments achieved 38.6%, or 257.025 missed appointments, equivalent to an estimated waste of resources of R$3.558.837,88. Non-attendance as for other specialized procedures reached 32.1%, or 108.103 missed procedures, equivalent to R$15.007.624,15. Total wasted resources reached significant values, evincing the ongoing challenge to managers seeking to attain SUStainable universal health care systems.

KEYWORDS
Absenteeism; Secondary care; Health management; Integrality in health

Introduction

Non-attendance of users is the act of missing consultations or scheduled procedures without any prior communication¹1 Santos JS. Absenteísmo dos usuários em consultas e procedimentos especializados agendados no SUS: um estudo em um município baiano. Vitória da Conquista. Dissertação [dissertação]. Salvador: Universidade Federal da Bahia; 2008; 33 p.. It is considered a global problem in health care both in the public and private sectors as per papers published in Brazil²2 Bender ADS, Molina LR, Mello ALSFD. Absenteísmo na atenção secundária e suas implicações na atenção básica. Espaç Saúde (Online). 2010; 11(2):56-65.^,33 Cavalcanti RP, Cavalcanti JCM, Serrano RMSM, et al. Absenteísmo de consultas especializadas nos sistemas de saúde público: relação entre causas e o processo de trabalho de equipes de saúde da família, João Pessoa - PB, Brasil. Rev Tempus Actas Saúde Col. 2013; 7(2):63-84. and worldwide⁴4 Ellis DA, Jenkins R. Weekday affects attendance rate for medical appointments: large-scale data analysis and implications. PLoS ONE. 2012; 7(12):e51365.

5 Giunta D, Briatore A, Baum A, et al. Factors associated with nonattendance at clinical medicine scheduled outpatient appointments in a university general hospital. Patient PreferAdherence. 2013; 7:1163-70.^-66 Jabalera Mesa ML, Morales Asencio JM, Rivas Ruiz F. Determinants and economic cost of patient absenteeism in outpatient departments of the Costa del Sol Health Agency. An Sist Sanit Navar. 2015; 38(2):235-45.. A systematic review on the subject revealed a 23% worldwide non-attendance average rate, being the highest rate found in Africa (43.0%), followed by South America (27.8%), Asia (25.1%), North America (23.5%), Europe (19.3%) and Oceania (13.2%)⁷7 Dantas LF, Fleck JL, Cyrino Oliveira FL, et al. No-shows in appointment scheduling: a systematic literature review. Health Policy. 2018; 122(4):412-21.. When the Unified Health System (SUS) is concerned, non-attendance to specialized healthcare appointments is accounted as a chronic problem since rates are close to or beyond 25%⁸8 Oleskovicz M, Oliva FL, Hildebrand e Grisi C, et al. Técnica de overbooking no atendimento público ambulatorial em uma unidade do Sistema Único de Saúde. Cad. Saúde Pública. 2014; 30(5):1009-17., reaching high percentages in various types of care and medical specialties⁹9 Bittar OJNV, Magalhães A, Martines CM, et al. Absenteísmo em atendimento ambulatorial de especialidades no estado de São Paulo. BEPA. 2016; 13(152):19-32..

Non-attendance to specialized healthcare appointment has been related to some causes, such as forgetfulness³3 Cavalcanti RP, Cavalcanti JCM, Serrano RMSM, et al. Absenteísmo de consultas especializadas nos sistemas de saúde público: relação entre causas e o processo de trabalho de equipes de saúde da família, João Pessoa - PB, Brasil. Rev Tempus Actas Saúde Col. 2013; 7(2):63-84.^,1010 Izecksohn MMV, Ferreira JT. Falta às consultas médicas agendadas: percepções dos usuários acompanhados pela Estratégia de Saúde da Família, Manguinhos, Rio de Janeiro. Rev Bras Med Fam Comunidade. 2014; 9(32):235-41. communication failures between the service and the user, reduction of illness symptoms¹¹11 Ferreira MB, Lopes AC, Lion MT, et al. Absenteísmo em consultas odontológicas programáticas na estratégia de saúde da família. Rev Univ Vale do Rio Verde. 2016; 14(1):411-9., scheduling at working hours²2 Bender ADS, Molina LR, Mello ALSFD. Absenteísmo na atenção secundária e suas implicações na atenção básica. Espaç Saúde (Online). 2010; 11(2):56-65.^,1010 Izecksohn MMV, Ferreira JT. Falta às consultas médicas agendadas: percepções dos usuários acompanhados pela Estratégia de Saúde da Família, Manguinhos, Rio de Janeiro. Rev Bras Med Fam Comunidade. 2014; 9(32):235-41.

11 Ferreira MB, Lopes AC, Lion MT, et al. Absenteísmo em consultas odontológicas programáticas na estratégia de saúde da família. Rev Univ Vale do Rio Verde. 2016; 14(1):411-9.^-1212 Gonçalves CÂ, Vazquez FL, Ambrosano GMB, et al. Estratégias para o enfrentamento do absenteísmo em consultas odontológicas nas Unidades de Saúde da Família de um município de grande porte: uma pesquisa-ação. Ciênc. Saúde Colet. 2015; 20(2):449-60., lack of transportation⁴4 Ellis DA, Jenkins R. Weekday affects attendance rate for medical appointments: large-scale data analysis and implications. PLoS ONE. 2012; 7(12):e51365.. Among the consequences, we highlight the increase in the waiting list and in urgencies²2 Bender ADS, Molina LR, Mello ALSFD. Absenteísmo na atenção secundária e suas implicações na atenção básica. Espaç Saúde (Online). 2010; 11(2):56-65.^,1212 Gonçalves CÂ, Vazquez FL, Ambrosano GMB, et al. Estratégias para o enfrentamento do absenteísmo em consultas odontológicas nas Unidades de Saúde da Família de um município de grande porte: uma pesquisa-ação. Ciênc. Saúde Colet. 2015; 20(2):449-60., the waste of public resources²2 Bender ADS, Molina LR, Mello ALSFD. Absenteísmo na atenção secundária e suas implicações na atenção básica. Espaç Saúde (Online). 2010; 11(2):56-65.^,44 Ellis DA, Jenkins R. Weekday affects attendance rate for medical appointments: large-scale data analysis and implications. PLoS ONE. 2012; 7(12):e51365.

5 Giunta D, Briatore A, Baum A, et al. Factors associated with nonattendance at clinical medicine scheduled outpatient appointments in a university general hospital. Patient PreferAdherence. 2013; 7:1163-70.^-66 Jabalera Mesa ML, Morales Asencio JM, Rivas Ruiz F. Determinants and economic cost of patient absenteeism in outpatient departments of the Costa del Sol Health Agency. An Sist Sanit Navar. 2015; 38(2):235-45.^,1313 Gurol-Urganci I, Jongh T, Vodopivec-Jamsek V, et al. Mobile phone messaging reminders for attendance at healthcare appointments. Cochrane Database Syst Rev. 2013; (12):CD007458., the reduction of productivity, and clinic and management loss of efficiency⁵5 Giunta D, Briatore A, Baum A, et al. Factors associated with nonattendance at clinical medicine scheduled outpatient appointments in a university general hospital. Patient PreferAdherence. 2013; 7:1163-70.. Those consequences hinder the access and lead to health care increasing costs²2 Bender ADS, Molina LR, Mello ALSFD. Absenteísmo na atenção secundária e suas implicações na atenção básica. Espaç Saúde (Online). 2010; 11(2):56-65.^,33 Cavalcanti RP, Cavalcanti JCM, Serrano RMSM, et al. Absenteísmo de consultas especializadas nos sistemas de saúde público: relação entre causas e o processo de trabalho de equipes de saúde da família, João Pessoa - PB, Brasil. Rev Tempus Actas Saúde Col. 2013; 7(2):63-84.^,1414 Stubbs ND, Geraci SA, Stephenson PL, et al. Methods to reduce outpatient non-attendance. Am J Med Sci. 2012; 344(3):211-9., which generates social costs¹⁵15 Bech M. The economy of non-attendance and the expected effect of collecting a fine from non-participants. Health Policy. 2005; 74(2):181-91., causes negative attitudes on the professional16 and delays the diagnosis and appropriate treatment¹³13 Gurol-Urganci I, Jongh T, Vodopivec-Jamsek V, et al. Mobile phone messaging reminders for attendance at healthcare appointments. Cochrane Database Syst Rev. 2013; (12):CD007458.. In summary, non-attendance is considered a multi-causal phenomenon, reflecting on every stakeholder, i.e., management, worker and user²2 Bender ADS, Molina LR, Mello ALSFD. Absenteísmo na atenção secundária e suas implicações na atenção básica. Espaç Saúde (Online). 2010; 11(2):56-65.^,33 Cavalcanti RP, Cavalcanti JCM, Serrano RMSM, et al. Absenteísmo de consultas especializadas nos sistemas de saúde público: relação entre causas e o processo de trabalho de equipes de saúde da família, João Pessoa - PB, Brasil. Rev Tempus Actas Saúde Col. 2013; 7(2):63-84..

Health care within SUS is divided into primary care, secondary care or medium complexity and tertiary care or high complexity¹⁷17 Mendes EV. As redes de atenção à saúde. 2. ed. Brasília, DF: OPAS; 2011.. The user gateway to the system is the primary care through also the Health Basic Units (UBS) as an Emergency Care Unit (UPA)¹⁷17 Mendes EV. As redes de atenção à saúde. 2. ed. Brasília, DF: OPAS; 2011.^,1818 Barreto ML, Teixeira MG, Bastos FI. Successes and failures in the control of infectious diseases in Brazil: social and environmental context, policies, interventions, and research needs. The Lancet. 2011; 377(9780):1877-89.. Primary care should solve more than 85% of the population's health problems, and the user should be addressed to specialized care whenever necessary¹⁹19 Mendes EV. As redes de atenção à saúde. Ciênc. Saúde Colet. 2010; 15(5):2297-305..

However, since SUS creation in 1988, the system has been facing numerous difficulties regarding the user access to resolving, appropriate, timely and effective health actions and services. The extent of benefits brought to the population throughout its existence is undeniable, but, in practice, it is still partial, facing numerous weaknesses and shortcomings²⁰20 Campos GWS. SUS: o que e como fazer? Ciênc. Saúde Colet. 2018; 23(6):1707-14.. SUS has been implemented but not consolidated²¹21 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Ciênc. Saúde Coletiva. 2018; 23(6):1723-8.. Access to specialized or medium complexity services has been stressed as one of the main obstacles to its consolidation²²22 Spedo SM, Pinto NRS, Tanaka OY. O difícil acesso a serviços de média complexidade do SUS: o caso da cidade de São Paulo, Brasil. Physis. 2010; 20(3):953-72..

Population aging has contributed to increase Chronic Non-Communicable Diseases (NCDs), the demands of specialized care, therefore imposing new challenges on the health system¹⁸18 Barreto ML, Teixeira MG, Bastos FI. Successes and failures in the control of infectious diseases in Brazil: social and environmental context, policies, interventions, and research needs. The Lancet. 2011; 377(9780):1877-89.. The increased prevalence of NCDs may also be explained by larger access to health services and to means of diagnosing those diseases²³23 Duncan BB, Chor D, Aquino EML, et al. Doenças crônicas não transmissíveis no Brasil: prioridade para enfrentamento e investigação. Rev Saúde Pública. 2012; 46(supl1):126-34.. Currently, the demand for diagnostic and therapeutic procedures due to NCDs is becoming a public health priority in Brazil²⁴24 Schmidt MI, Duncan BB, Azevedo e Silva G, et al. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet. 2011; 377(9781):1949-61..

So, service management needs to acknowledge in its planning the changes in the country's illness scenario in recent decades²⁵25 Souza MFM, Malta DC, França EB, et al. Transição da saúde e da doença no Brasil e nas Unidades Federadas durante os 30 anos do Sistema Único de Saúde. Ciênc. Saúde Colet. 2018; 23(6):1737-50.. Thus, to qualify the management of services in 2008, the Ministry of Health (MS) created the National Health Regulatory Police²⁶26 Brasil. Ministério da Saúde. Portaria nº 1.559, de 1º de agosto de 2008. Institui a Política Nacional de Regulação do Sistema Único de Saúde (SUS). Diário Oficial da União [internet]. 4 Ago 2008 [acesso em 2019 nov 4]. Disponível em: http://www.saude.mt.gov.br/upload/legislacao/1559-%5B2870-120110-SES-MT%5D.pdf.
http://www.saude.mt.gov.br/upload/legisl... . The regulation of access to health is applied by the state as an important tool of public management, still under improvement, with the aim to achieve efficiency, equity and balance between supply, demand and financing²⁷27 Vilarins GCM, Shimizu HE, Gutierrez MMU. A regulação em saúde: aspectos conceituais e operacionais. Saúde debate. 2012; 36(95):640-7.. The actual regulatory system (SisReg) is available online by means of SUS Computer Department (Datasus), MS, to manage the entire regulatory complex and run the Country’ regulatory centers. In this regard, the regulatory policy allows managers to know the size of waiting lists and non-attendance by means of the database it produces, guiding management in the search for solutions.

In the Metropolitan Health Region of Espírito Santo State (RSM-ES), non-attendance to specialized care service appointment is a frequent problem experienced by the Health State Department (Sesa-ES), which has caused losses to the population and to public budget due to the huge number of SUS users that do not cancel neither attend to scheduled consultations and tests. According to Sesa-ES data, in the first half of 2015, the non-attendance rate achieved 38% as per consultations and specialized tests scheduled by the Regulatory Center²⁸28 Ferreira B. Faltas em consultas médicas pelo SUS chegam a 46% no ES [internet]. 2015 set 14 [acesso em 2018 ago 8]. Disponível em: https://blog.atencaobasica.org.br/2015/09/14/faltas-em-consultas-medicas-pelo-sus-chegam-a-46-no-es/.
https://blog.atencaobasica.org.br/2015/0... .

Thus, non-attendance to specialized healthcare appointment has drawn the attention of SUS managers in Brazil, because it contributes to the waiting list increase, what, added to missing patients who tend to return to the waiting list, leads to a decrease in the supply rationalization, increasing the waiting time for a new consultation²2 Bender ADS, Molina LR, Mello ALSFD. Absenteísmo na atenção secundária e suas implicações na atenção básica. Espaç Saúde (Online). 2010; 11(2):56-65.. Currently, challenges regarding the provision of services by specialized care are numerous, and, possibly, will be aggravated by the Constitutional Amendment (EC) 95/2016, which limits public spending for 20 years and can hinder the increase of resources for health and other social policies, posing a major threat to these demands. Budget cuts could impact the population health indicators²⁹29 Garcia LP. A economia desumana: porque mata a austeridade. Cad. Saúde Pública. 2016; 32(11):e00151116.^,3030 Holst J, Giovanella L, Andrade GCL. Porque não instituir copagamento no Sistema Único de Saúde: efeitos nocivos para o acesso a serviços e a saúde dos cidadãos. Saúde debate. 2016; 40(esp):213-26..

In this sense, improving health management is necessary to fight against and to reduce expenditures so to increase efficiency by optimizing available financial resources. In 2010, World Health Organization (WHO) released the 'Universal Coverage Funding' report revealing that 20% to 40% of all health spending are wasted with inefficiency, resources that could be invested to attain universal coverage.

On the other hand, only scarce studies address non-attendance as a source of waste and apply economic evaluation as analytical methods of non-rendering services so to evince the waste caused by non-attendance⁴4 Ellis DA, Jenkins R. Weekday affects attendance rate for medical appointments: large-scale data analysis and implications. PLoS ONE. 2012; 7(12):e51365.. Most part of the publications addresses the causes and strategies for non-attendance reduction, being even emphatic in stating that they cause monetary loss, usually adopting approaches supported by empirical evidence⁵5 Giunta D, Briatore A, Baum A, et al. Factors associated with nonattendance at clinical medicine scheduled outpatient appointments in a university general hospital. Patient PreferAdherence. 2013; 7:1163-70.. Thus, it is increasingly necessary that the concepts of economic evaluation be part of the health systems and services routine³¹31 Silva EN, Silva MT, Pereira MG. Estudos de avaliação econômica em saúde: definição e aplicabilidade aos sistemas e serviços de saúde. Epidemiol Serv Saúde. 2016; 25(1):205-7..

Based on the considerations that identify non-attendance as a SUS growing problem, the aim of this study was to estimate the waste of monetary resources related to the non-attendance to SUS specialized procedures in RSM-ES between 2014 and 2016.

Methods

This is a descriptive study based on administrative records and carried out in RSM-ES, Southeast Region of Brazil. ES region is composed of the 20 municipalities that show the best Municipal Human Development Indices (HDI-M) of Espírito Santo State (0.68 to 0.856), and has a population of 1,935,393 inhabitants³²32 Instituto Brasileiro de Geografia e Estatística [internet]. Censo 2010 [acesso em 2018 ago 8]. Disponível em: https://censo2010.ibge.gov.br/.
https://censo2010.ibge.gov.br/... .

Data were gathered from 1,002,719 specialized consultations and tests scheduled for January 2014 to December 2016 in SisReg-ES, provided by Sesa-ES. The scheduled procedures refer to vacancies made available per specialties by the Integrated Agreed Schedule (PPI), and performed between the state and the municipalities of the region. We analyzed 666,182 specialized consultations and 336,537 specialized tests, in a total of 38 procedure premises, which included different scheduling specialties in public institutions of governmental management and in those contracted by SUS; in philanthropic institutions; and in public services managed by Social Organizations (OS).

The following variables were selected: years 2014, 2015 and 2016; scheduled procedure – codes for kinds of scheduled specialized consultation and test; confirmed procedure – performed in the presence of the patient; non-confirmed procedure – patient´s non-attendance; specialized consultations and tests – list of medium complexity care procedures; and place – premises where procedures were performed. Initially, data were classified per consultations and tests and year of scheduling.

Consultations recorded followed the several names applied by SisReg-ES, having been necessary to use the Brazilian Classification of Jobs (CBO) issued by the Ministry of Labor so to recodify medical specialties and those concerning the practitioner. The various names given to the same specialty were grouped into a single CBO classification for further coding and definition of correspondence (from-to) to the procedures of the Tables of values and prices applied.

Specialized tests encoded by the SisReg-ES table were also re-codified, following the procedure adopted for consultations. Tests were gathered into groups and subgroups, as stated by the classification issued by SUS Unified Table of Procedures, Medicines and Strategic Inputs (SUS Table), so to identify the number of scheduled tests, confirmed tests, non-attendance, and monetary amount. Group 02 was constituted of all subgroup procedures related to diagnostic purposes; group 03 formed by all subgroup procedures related to clinical procedures; and group 04 was made up of all subgroup procedures related to surgical procedures.

Values assigned to each procedure varied as for remunerations linked to procedure premises and their administrative natures. For procedures performed in federal and in state public institutions of governmental management and for those contracted from SUS (indirect management), the referencing values was SUS Table (Table SUS/2018). For philanthropic institutions, we added the values contained in the complementary tables issued in the 2018 additions provided by Sesa-ES and in those contained in Table SUS/2018. For public services under OS management, we adopted the table of estimated cost per procedure premise provided by Sesa, which adopts the tool called Key Performance Indicators for Health (KPIH) to carry out the cost management system. All values were updated for 2018.

Consultation and test procedures were grouped per specialty, totaling the scheduled value, the confirmed one, the non-attendance (non-confirmed procedures = scheduled-confirmed) and the annual monetary value per specialty attributed to non-attendance, following the tables organized by the administrative nature of the procedure premise. Subsequently, specialties were listed in ascending order per non-attendance rate and per monetary value generated in each specialty.

Annual non-attendance rates regarding specialized consultations and tests were calculated by dividing the total non-attended procedures by the total scheduled procedures as per each specialty. The result was multiplied by one hundred.

Monetary values of estimated waste were obtained by multiplying the total non-attended annual procedures per specialty by the values attributed to each procedure according to the administrative nature of the procedure premise.

The Microsoft Office Excel® program was applied in the analysis. The study was authorized by Sesa-ES by means of the Term of Consent dated September 26, 2017, file nº 79619819/2017, and approved by the Research Ethics Committee of the Federal University of Espírito Santo (Ufes) under the National Health Council resolution no 2,631,695, dated May 2, 2018.

Results

In the course of the study, 666,182 consultation procedures and 336,537 specialized tests were accounted, totaling 1,002,719 procedures, equivalent to R$18,566,462.03 wasted monetary value attributed to non-attendance. But these values need a careful consideration since the research faced limitations due to the weaknesses of SisReg-ES database and to the lack of economic analysis per procedure premise, therefore, not offering information on the actual procedure cost.

The specialized consultations scheduled for 34 specialties showed a 38.6% non-attendance average rate (257,025 consultations), equivalent to R$3,558,837.88 estimated waste. All clinical consultations added, the specialty that showed the lowest non-attendance monetary value during the three years of study was the clinical oncologist´s (R$880.00), while the one showing the highest value was the ophthalmologist´s (R$558,262,20). Non-attendance rates per specialized healthcare ranged from 0% (dentist for patients carrying special needs) to 75.9% (general physiotherapist). We note that scheduled consultations with dentist for patients carrying special needs were not offered in 2015 and 2016 (table 1).

Only the surgical cancerologist medical specialty (2.9%) showed a non-attendance rate smaller than 30% (26.4%), equivalent to R$900.00 non-attendance waste. Among the total, 19 specialties, equivalent to 55.9%, showed a non-attendance rate ranging between 30% and 40%. Consultations with oral and maxillofacial dentists (30.2%) showed the lowest group rate, while consultations with pulmonologists showed the highest one (39.4%), this latter totaling R$1,761,422.86 non-attendance estimated waste. Nine specialties (26.5%) showed a non-attendance rate ranging between 40% and 50%, the gastroenterologists and neurologists’ consultations achieving the lowest rate (40.1%), while geneticists exhibited the highest rate (47.4%). These specialties added amounted to a R$1,671,403.22 waste.

Two specialties (5.9%) showed non-attendance rates between 50% and 60% – pediatric surgeon (52.5%) and infectious diseases (58.3%) –, equivalent to R$62,831.80 estimated waste. Only physiotherapist consultations (2.9%) showed a non-attendance rate greater than 60% (68.4%), equivalent to R$45,630.00 estimated waste. General physiotherapist consultations (2.9%) showed the highest non-attendance rate (75.9%), equivalent to R$16,650.00 estimated waste.

Within the research period, the total number of scheduled specialized consultations grew from 200,831 in 2014 to 239,533 in 2016, in a 19.3% increase (graph 1), revealing an absolute growth stemming from orthopedic and ophthalmology specialties (table 1).

Non-attendance to specialized consultations increased by an average of 2.9% between 2014 and 2016. In 2014, scheduled specialized consultations totaled 200,831, while the non-attendance rate was equivalent to 36.9%, or 74,126 consultations. In 2015, scheduled specialized consultations totaled 225,818, while non-attendance rate was equivalent to 38.7%, or 87,492 consultations. In 2016, scheduled specialized consultations totaled 239,533, while non-attendance rate was equivalent to 39.8%, or 95,407 consultations. That means that the non-attendance average rate was 38.6%, equivalent to a total of 257,025 missed consultations (graph 1).

The non-attendance average rate regarding specialized tests was 32.1%, equivalent to 108,103 missed tests. Within the research period, 108,103 scheduled tests were missed, equivalent to R$15,007,624.15 estimated waste (table 2). As for specialized tests, non-attendance rate has decreased annually, at a rate of 34.3% in 2014, 32.7% in 2015 and 29.7% in 2016. In contrast, supply grew 9.7% from 2014 to 2015, and 13.1% from 2015 to 2016 (graph 1).

Within 2014 and 2016, 336,537 specialized tests were scheduled, while non-attendance rates related to extracorporeal lithotripsy tests ranged from 22.3% (CT diagnosis) to 100% (specialized therapies). Among diagnostic procedures (group 02), four tests showed non-attendance rates between 20.0% and 30.0%. The diagnosis by tomography of subgroup 02.06 showed the lowest non-attendance rate (22.3%), while examination by means of material collection of subgroup 02.01 presented the highest one (28.2%). Non-attendance rates regarding the other four specialized tests of this group ranged between 30.0% and 40.0%. Among them, endoscopic diagnosis of subgroup 02.09 revealed the lowest rate (30.4%), and radiology diagnosis of subgroup 02.04, the highest rate (39.1%). Group 02 tests amounted to R$13,774,088.92 estimated waste, equivalent to 91.8% of non-attendance total waste.

Procedures regarding group 04 – surgical procedures – showed non-attendance rates between 30.0% and 70.0%. Vision apparatus surgery (subgroup 04.05) revealed the lowest non-attendance rate (34.5%), while upper airway, head and neck surgery (subgroup 04.04) showed the highest one (66.7%). Groups 03 and 04 procedures totaled a waste of R$1,233,535.23, or 8.2% of the total monetary waste totaled by groups 02, 03 and 04 of specialized tests, as compiled in table 2.

Discussion

Both in Brazil and abroad, studies on non-attendance to specialized healthcare appointments are emphatic in stating that it causes monetary losses, although few contain a reasoned approach on economic evaluation and analytical methods of services to estimate the values involved⁴4 Ellis DA, Jenkins R. Weekday affects attendance rate for medical appointments: large-scale data analysis and implications. PLoS ONE. 2012; 7(12):e51365.. Therefore, this study pioneers in assigning monetary values to non-attendance of SUS users to scheduled procedures in the state of the ES.

Within the three years of the study, the estimated monetary waste accumulated in RSM-ES as a result of users’ non-attendance to consultations, tests and other specialized procedures achieved R$18,566,462.03, being table values updated for 2018. The results corroborate the existence of monetary losses as result of non-attendance, even if estimates are limited by the data available due to the existing administrative structures in the various management modalities, mainly as for public services, deeply restricting the analysis to just SUS Table.

Both the supply of consultations and tests and the non-attendance rate grew in the period, reinforcing the concern about the state management on the subject²⁸28 Ferreira B. Faltas em consultas médicas pelo SUS chegam a 46% no ES [internet]. 2015 set 14 [acesso em 2018 ago 8]. Disponível em: https://blog.atencaobasica.org.br/2015/09/14/faltas-em-consultas-medicas-pelo-sus-chegam-a-46-no-es/.
https://blog.atencaobasica.org.br/2015/0... . Results show that non-attendance rates regarding specialized consultations (38.6%) and tests (32.1%) in RSM-ES are high and consistent with other studies conducted in Brazil on specialized care. It confirms that non-attendance high rates are not only found in Espírito Santo State but also in São Paulo (34.4%)⁹9 Bittar OJNV, Magalhães A, Martines CM, et al. Absenteísmo em atendimento ambulatorial de especialidades no estado de São Paulo. BEPA. 2016; 13(152):19-32., Florianópolis (34,4%)²2 Bender ADS, Molina LR, Mello ALSFD. Absenteísmo na atenção secundária e suas implicações na atenção básica. Espaç Saúde (Online). 2010; 11(2):56-65. and João Pessoa (39,8%)³3 Cavalcanti RP, Cavalcanti JCM, Serrano RMSM, et al. Absenteísmo de consultas especializadas nos sistemas de saúde público: relação entre causas e o processo de trabalho de equipes de saúde da família, João Pessoa - PB, Brasil. Rev Tempus Actas Saúde Col. 2013; 7(2):63-84., worrying managers and evincing that joint efforts to expand the supply of consultations are not working.

Non-attendance rate in respect of dental specialty for patients with special needs was zero, which, according to the Regulatory Center management, can be justified by the fact that the specialty inception occurred only in 2014 and by the possibility that low supply of vacancies generates a great expectation by the family members. According to their impairments, special patients are not cared by dental primary care but referred to specialized care instead. The surgical cancer specialty showed the lowest non-attendance rate (26.4%), which can be justified by the severity of the pathology previously diagnosed and by the need for rapid intervention.

General physiotherapist consultation showed the highest rate (75.8%), corroborating Dantas et al. systematic review⁷7 Dantas LF, Fleck JL, Cyrino Oliveira FL, et al. No-shows in appointment scheduling: a systematic literature review. Health Policy. 2018; 122(4):412-21., who found the rate of 79.2%, the most frequent cause being locomotion limitations due to chronic pathologies inherent to those diseases. The understanding is also in tune with the Regulatory Center management report, according to which absences can be justified by failure in the attendance record, by the pathology worsening or, in some cases, by improvement of the symptoms.

Diagnostic procedures, such as tomography and magnetic resonance imaging (CT and MRI), showed the lowest non-attendance rates – 22.3% and 22.7%, respectively. The lowest non-attendance rate of the group can be explained by the fact that these tests involve greater technological complexity and are, in theory, requested in cases of more specific clinic, requiring sophisticated tests to assist in the diagnosis and conduct. Although being lower, these non-attendance rates are significant, and the waste estimated values are high due to being tests of high technology, resulting in R$2,652,279.49 waste, equivalent to 19.3% of group 02 total monetary waste. In the same group, it was observed that tests requiring lower technology, subgroup 04, the diagnosis by radiology, usually requested when clinic diagnosis is not well clear, are the ones showing the highest non-attendance rates (39.1%). High non-attendance rates can be explained by various reasons, among all we emphasize the long waiting list, causing the improvement or worsening of the symptoms, which makes the user look for emergency services or pay for the attendance in the private sector³3 Cavalcanti RP, Cavalcanti JCM, Serrano RMSM, et al. Absenteísmo de consultas especializadas nos sistemas de saúde público: relação entre causas e o processo de trabalho de equipes de saúde da família, João Pessoa - PB, Brasil. Rev Tempus Actas Saúde Col. 2013; 7(2):63-84.^,99 Bittar OJNV, Magalhães A, Martines CM, et al. Absenteísmo em atendimento ambulatorial de especialidades no estado de São Paulo. BEPA. 2016; 13(152):19-32..

During the study, consultation supply increasing among the RSM-ES 20 municipalities revealed management efforts to implement the Regional Intervention Plan (PIR), inspired in the 2011 Regionalization Director Plan (PDR) of ES State, dividing the state into four health regions. PIR was influenced by Federal Decree nº 7,508, dated June 28, 2011, which regulated Federal Law nº 8,080/90 and reassured the need to reorganize care networks within those health regions¹⁹19 Mendes EV. As redes de atenção à saúde. Ciênc. Saúde Colet. 2010; 15(5):2297-305.^,3333 Espírito Santo. Secretaria de Estado da Saúde [internet]. Plano Diretor de Regionalização (PDR) [acesso em 2018 ago 8]. Disponível em: https://saude.es.gov.br/Media/sesa/SISPACTO/PDR-Plano%20Diretor%20de%20Regionaliza%C3%A7%C3%A3o_ES_2011.pdf.
https://saude.es.gov.br/Media/sesa/SISPA... .

The split in regions, here understood as the organizational guideline of SUS, leading the decentralization process of health actions and services and the agreement between managers at the federal, state and municipal levels, aims to organize care networks that require different technological levels³⁴34 Lima LD, Viana ALÁ, Machado CV, et al. Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais. Ciênc. Saúde Colet. 2012; 17(11):2881-92.. It guided PPI implementation between the state and municipalities in the health region, absorbing the challenges regarding comprehensive care and responses to the population needs so to provide health services closer to the user, mainly for specialized care and high complexity³³33 Espírito Santo. Secretaria de Estado da Saúde [internet]. Plano Diretor de Regionalização (PDR) [acesso em 2018 ago 8]. Disponível em: https://saude.es.gov.br/Media/sesa/SISPACTO/PDR-Plano%20Diretor%20de%20Regionaliza%C3%A7%C3%A3o_ES_2011.pdf.
https://saude.es.gov.br/Media/sesa/SISPA... .

The concept of integrality here adopted is the one advocated by Giovanella et al.³⁵35 Giovanella L, Lobato LVC, Carvalho AI, et al. Sistemas Municipais de Saúde e a diretriz da integralidade da atenção: critérios para avaliação. Saúde debate. 2002; 26(60):37-61., i.e., the guarantee of care in the three governmental levels of health care and the coordination among promotion, prevention and recovery actions, following Pinheiro concept³⁶36 Pinheiro R, Guizardi FL. Cuidado e integralidade: por uma genealogia de saberes e práticas no cotidiano. In: Pinheiro R, Mattos RA, organizadores. Cuidado: as fronteiras da integralidade. São Paulo: Hucitec; 2003. p. 21-36.. As for the latter author, integrality is a collective construction that improves its form and expression by means of the meeting of the different subjects involved in the production of care and in the defense of life.

Specialized care is considered a shield for good performance and improvement in health system quality, and may become a critical node of highest complexity. Therefore, managers and researchers consider it a challenge to achieve integrality as a SUS guideline²³23 Duncan BB, Chor D, Aquino EML, et al. Doenças crônicas não transmissíveis no Brasil: prioridade para enfrentamento e investigação. Rev Saúde Pública. 2012; 46(supl1):126-34.^,3737 Göttems LBD, Pires MRGM. Para além da atenção básica: reorganização do SUS por meio da interseção do setor político com o econômico. Saúde Soc. 2009; 18(2):189-98.. As stated by Mendes³⁸38 Mendes EV. O acesso à atenção primária à saúde. Brasília, DF: Conass; 2016., in order to achieve integrality, it is need do link assistance and integration of services by means of regionalized and hierarchical health networks due to the difficulty in carrying all resources and competences for the solution of all health problems of a population. During the study period, ES networks were not yet defined. Its implementation began in September 2017 in the northern region of the state, being three networks implemented in 2018.

As a way to organize the flow among the three governmental levels of care, access regulation is considered a valuable management tool, because it creates a balance between demand, supply and financing²⁷27 Vilarins GCM, Shimizu HE, Gutierrez MMU. A regulação em saúde: aspectos conceituais e operacionais. Saúde debate. 2012; 36(95):640-7.. Increasing non-attendance rates in RSM-ES indicate that, despite the increase in the supply of controlled vacancies, non-attendance actually contributed to reduce access to specialized care, evincing missed assistance opportunities and contributing to increase the waiting list for procedures⁹9 Bittar OJNV, Magalhães A, Martines CM, et al. Absenteísmo em atendimento ambulatorial de especialidades no estado de São Paulo. BEPA. 2016; 13(152):19-32..

Access to medium complexity is understood here as the opportunity to seek and obtain adequate health services to the user needs³⁸38 Mendes EV. O acesso à atenção primária à saúde. Brasília, DF: Conass; 2016.. The expansion of access to actions and services is one of SUS great challenges and requires managers to organize and create mechanisms aimed at consolidating the system²³23 Duncan BB, Chor D, Aquino EML, et al. Doenças crônicas não transmissíveis no Brasil: prioridade para enfrentamento e investigação. Rev Saúde Pública. 2012; 46(supl1):126-34.. It is possible to understand that access goes beyond the use of the health system. It is a concept of multiple dimensions, composed of financial and non-financial factors, which can vary over time with the evolution and emergence of the society needs³⁹39 Sanchez RM, Ciconelli RM. Conceitos de acesso à saúde. Rev Panam Salud Pública. 2012; 31(3):260-8..

The challenges for offering specialized care in RSM-ES are great due to its characteristics. The reality of the 20 municipalities differs much. In eight of them, the population is around 15,000 inhabitants while in other four it exceeds 300,000 inhabitants, thus generating large differences in relation to investments in health care. Some municipalities have only basic services, evidencing the need to organize specialized care in health networks among municipal and state systems within the region³³33 Espírito Santo. Secretaria de Estado da Saúde [internet]. Plano Diretor de Regionalização (PDR) [acesso em 2018 ago 8]. Disponível em: https://saude.es.gov.br/Media/sesa/SISPACTO/PDR-Plano%20Diretor%20de%20Regionaliza%C3%A7%C3%A3o_ES_2011.pdf.
https://saude.es.gov.br/Media/sesa/SISPA... . Specialized care is strategic and necessary to yield effectiveness and continuity to primary care, also acting as a complement and providing specialized assistance to those who need the service⁴⁰40 Tesser CD, Poli Neto P. Atenção especializada ambulatorial no Sistema Único de Saúde: para superar um vazio. Ciênc. Saúde Colet. 2017; 22(3):941-51.. Thus, non-attendance in specialized care is a constant concern for managers both because of carelessness and wastefulness²2 Bender ADS, Molina LR, Mello ALSFD. Absenteísmo na atenção secundária e suas implicações na atenção básica. Espaç Saúde (Online). 2010; 11(2):56-65.^,99 Bittar OJNV, Magalhães A, Martines CM, et al. Absenteísmo em atendimento ambulatorial de especialidades no estado de São Paulo. BEPA. 2016; 13(152):19-32..

Specialized care costs are high and include procedures of higher technology, so-called specialized technologies⁴¹41 Solla J, Chioro A. Atenção ambulatorial especializada. In: Giovanella L, Escorel S, Lobato LVC, et al., organizadores. Políticas e sistemas de saúde no Brasil. 2. ed. Rio de Janeiro: Fiocruz; 2012. p. 547-76.. Among researches on the subject carrying stronger methodologies, from the standpoint of economic evaluation, we can detach a retrospective cohort in Texas, USA, from 1997 to 2008, whose analysis included direct and indirect costs for various health services. The average cost per non-attendance patient was $196.00 as per 2008⁴²42 Kheirkhah P, Feng Q, Travis ML, et al. Prevalence, predictors and economic consequences of no-shows. BMC Health Serv Res. 2016; 16:13.. In Brazil, scarce are the studies revealing non-attendance wasted values, but we can note a survey conducted in a public hospital in the city of Uberlândia, State of Minas Gerais, that, in 2011, identified a loss of R$1.1 million per year by accounting non-attending procedures as per SUS Table values⁴³43 Fernandes A. Uma em quatro pessoas não vai à consulta [internet]. [acesso em 2019 ago 8]. Disponível em: http://www.correiodeuberlandia.com.br/cidade-e-regiao/uma-a-cada-4-pessoasnao-vai-as-consultas/.
http://www.correiodeuberlandia.com.br/ci... .

It was only possible to take knowledge of the non-attendance data in the RSM-ES, made available by Sesa-ES, due to the existence of SisReg-ES. Data recording in the system is fault-prone, not allowing to identify whether non-attendance occurred only due to user-related problems or if it was also worsened by management reasons. Sesa-ES has already identified the overestimated data as a problem, because, in some procedure premises, the system does not receive any input informing that the procedure was performed, which jeopardizes the data since the system records as a non-attendance procedure³³33 Espírito Santo. Secretaria de Estado da Saúde [internet]. Plano Diretor de Regionalização (PDR) [acesso em 2018 ago 8]. Disponível em: https://saude.es.gov.br/Media/sesa/SISPACTO/PDR-Plano%20Diretor%20de%20Regionaliza%C3%A7%C3%A3o_ES_2011.pdf.
https://saude.es.gov.br/Media/sesa/SISPA... .

In view of repeated mistakes in the attendance system recording in the various procedure premises, including in its own services, Sesa-ES adopted administrative measures to meet the need for adequacy of the Record (scheduling key) as for all SUS users serviced via SisReg. Thus, on November 20, 2018, the Diário Oficial newspaper published Ordinance nº 084-R/2018 regulating the mandatory input in SisReg of the procedures performed, as well as its daily updating. The intention behind the measure is to obtain more accurate data on the user care.

Limitations of this study include the fragility of SisReg-ES database due to the non-input in the system of care performed, generating a higher rate of non-attendance. Another limitation was the lack of economic analysis per procedure premise hindering the actual data about cost per procedure. Available data does not allow to state that all the values are actually a waste, owing the peculiarities in monetary disbursement for services provided by RSM-ES’ different management modalities: federal and state public services, philanthropic services, private services and public services managed by OS. The cost calculated per procedure premise would enhance the study with a more accurate waste amount.

Causes of non-attendance are diverse and related to the management, the user and the worker. However, a study conducted on specialized care in Spain analyzed these issues and concluded that the percentage of preventable causes is 52,4%⁶6 Jabalera Mesa ML, Morales Asencio JM, Rivas Ruiz F. Determinants and economic cost of patient absenteeism in outpatient departments of the Costa del Sol Health Agency. An Sist Sanit Navar. 2015; 38(2):235-45.. That suggests that there is plenty of room for correction efforts. Therefore, a future individualized analysis of non-attendance behavior for each specialty may justified to support these efforts.

Conclusions

The non-attendance of users is a chronic problem also in the Brazilian health system as worldwide, what can hinder the SUStainability of the specialized service supply broadening. Specialized care non-attendance is increasing in RSM-ES, causing losses to public management and to users, mainly because of the social damage it entails. It is noteworthy that non-attendance rates and monetary values found by the research are significant data for the public health system.

It is suggested that the causes of non-attendance related to management and user particularities be sought so to propose viable reduction measures, such as strengthening of the primary care as the user's gateway; improvement of the regulatory system; implementation of regionalized and hierarchical health care networks; and others. The integrality of care is known as one of the hugest SUS challenges, demanding groundbreaking measures capable of promoting more and more not only a humanized care but also committed to life.

Cost-per-service data is an important information that helps manager decisions on investments and priorities, supporting the greater efficiency in health spending. Thus, it can be concluded that optimizing the available resources and fighting against the waste without jeopardizing the quality of care is and will be a constant challenge in the agenda of SUS managers today and in the coming years.

References

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