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Med Decis Making. 2013 Nov;33(8):976-85. doi: 10.1177/0272989X13478194. Epub 2013 Mar 20.

Estimating the cost of no-shows and evaluating the effects of mitigation strategies.

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  • 1Department of Systems Engineering & Operations Research, George Mason University, Fairfax, Virginia (BPB).



To measure the cost of nonattendance ("no-shows") and benefit of overbooking and interventions to reduce no-shows for an outpatient endoscopy suite.


We used a discrete-event simulation model to determine improved overbooking scheduling policies and examine the effect of no-shows on procedure utilization and expected net gain, defined as the difference in expected revenue based on Centers for Medicare & Medicaid Services reimbursement rates and variable costs based on the sum of patient waiting time and provider and staff overtime. No-show rates were estimated from historical attendance (18% on average, with a sensitivity range of 12%-24%). We then evaluated the effectiveness of scheduling additional patients and the effect of no-show reduction interventions on the expected net gain.


The base schedule booked 24 patients per day. The daily expected net gain with perfect attendance is $4433.32. The daily loss attributed to the base case no-show rate of 18% is $725.42 (16.4% of net gain), ranging from $472.14 to $1019.29 (10.7%-23.0% of net gain). Implementing no-show interventions reduced net loss by $166.61 to $463.09 (3.8%-10.5% of net gain). The overbooking policy of 9 additional patients per day resulted in no loss in expected net gain when compared with the reference scenario.


No-shows can significantly decrease the expected net gain of outpatient procedure centers. Overbooking can help mitigate the impact of no-shows on a suite's expected net gain and has a lower expected cost of implementation to the provider than intervention strategies.


colorectal cancer; discrete event simulation; efficiency; gastroenterology; operations research

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