Journal of Cleaner Production 269 (2020) 122318

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Journal of Cleaner Production

journal homepage: www.elsevier.com/locate/jclepro

Managing patients’ no-show behaviour to improve the sustainability

of hospital appointment systems: Exploring the conscious and
unconscious determinants of no-show behaviour
Miao Hu a, *, Xiaoyan Xu a, Xiaodong Li b, Tong Che c
a
School of Management, Zhejiang University, Hangzhou, Zhejiang, China
b
School of Management and Engineering, Anhui Polytechnic University, Wuhu, Anhui, China
c
Dongwu Business School, Soochow University, Soochow, Jiangsu, China

a r t i c l e i n f o a b s t r a c t

Article history: A hospital appointment system promotes information exchange between hospitals and patients. Because
Received 29 November 2019 patients’ no-show behaviour wastes medical resources and compromises the sustainability of medical
Received in revised form services, it is of utmost importance to expound no-show behaviour and its determinants. From a multi-
5 May 2020
stage perspective, we identify channel convenience, waiting time, and expected technical quality as
Accepted 15 May 2020
Available online 21 May 2020
conscious determinants and no-show habit as an unconscious determinant and propose a model for
analysing patients’ no-show behaviour. The proposed hypotheses are examined with data collected from
^ as de
Handling editor: Cecilia Maria Villas Bo a Chinese tertiary care public hospital’s appointment system by binary logistic regression. The results
Almeida show that channel convenience and expected technical quality are negatively related to no-show
behaviour whereas the effects of waiting time and no-show habit on no-show behaviour are signifi-
Keywords: cantly positive. Meanwhile, the relationship between no-show habit and no-show behaviour is stronger
No-show behaviour for shorter waiting time or higher levels of channel convenience and expected technical quality. Our
Hospital appointment system findings have implications for managing patients’ no-show behaviour, improving hospital appointment
Sustainability
system management, and providing sustainable medical services.
Multi-stage
© 2020 Elsevier Ltd. All rights reserved.

1. Introduction patients’ waiting time for registration at a Chinese hospital has

A hospital appointment system is a typical application of health
information systems (HIS). In serving as a platform, such a system
promotes the exchange of information between hospitals and pa-
tients by providing real-time information to allow patients to
schedule appointments with their preferred doctors at a conve-
nient time (Xie et al., 2020). Through this efficient approach, hos-
pitals’ medical service capabilities match patients’ healthcare needs
and medical service quality and patient satisfaction are further
improved. Meanwhile, from an operations management perspec-
tive, the hospital appointment system advances hospital operation
efficiency and outcomes, e.g., by shortening patient waiting time,
reducing medical staff workloads, and increasing hospital revenues
(Zhao et al., 2017). For example, Cao et al. (2011) found that
* Corresponding author.
E-mail addresses: humiao0723@163.com (M. Hu), xyxu@zju.edu.cn (X. Xu),
lixiaodong@ahpu.edu.cn (X. Li), chetong@suda.edu.cn (T. Che).
been reduced from 98 min to 7 min since implementing a hospital
appointment system. Since these benefits, hospital appointment
system management has received considerable attention among
management scholars and hospital managers.
Patients’ no-show behaviour is a prevalent issue and challenges
hospital appointment system management. Medical appointments
prevent other patients from using scheduled medical resources
(e.g., a doctor’s attention). When no-show behaviour happens and
then the medical appointments fail to be rescheduled in the short
term, medical resources are wasted and service delivery is inter-
rupted (Davies et al., 2016). Hence, from perspectives of sustainable
medical services and operational efficiencies, managing patients’
no-show behaviour is essential. In practice, hospitals have tried to
implement several interventions (e.g., overbooking, telephone re-
minders), yet no-show problems persist and substantial benefits
are not yielded. For example, overbooking does not reduce the
number of no-show behaviour and may result in scheduling colli-
sion, longer patients’ waiting time and doctors’ working time
(Zacharias and Pinedo, 2014). Thus, identifying the determinants of

https://doi.org/10.1016/j.jclepro.2020.122318
0959-6526/© 2020 Elsevier Ltd. All rights reserved.
2 M. Hu et al. / Journal of Cleaner Production 269 (2020) 122318
patients’ no-show behaviour could increase the accuracy of pre-
dicting no-show behaviour and provide explicit references for
designing interventions.
Prior studies on HIS and healthcare management have generally
reached the consensus that patients’ no-show behaviour does not
happen arbitrarily and have explored its determinants as related to
gender, age, referrals, appointment time, transportation services,
and weather conditions (Lapidos et al., 2017; Lee et al., 2018). Such
studies are helpful in identifying the characteristics of patients’ no-
show behaviour. Nevertheless, they fail to identify determinants of
no-show behaviour from a multi-stage perspective. Patients must
go through several stages (e.g., choosing an appointment channel,
waiting a few days, and expecting service outcomes) in a serial
manner for appointment services to be delivered (Soteriou and
Hadjinicola, 1999; Devasahay et al., 2017). In other words, pa-
tients’ no-show behaviour is an outcome of a multi-stage service
that relies on a hospital appointment system. Applying a multi-
stage perspective can reveal problems that occur in a single stage
(Sulek et al., 2006). In turn, hospital managers may apply different
efforts according to different problems encountered in each
appointment stage to enhance the efficacy of their efforts. In
addition to patients’ perceptions and evaluations of each stage, no-
show behaviour may be influenced by unconscious determinants,
which have been disregarded by prior studies. Incorporating un-
conscious determinants into the analysis of no-show behaviour
may have complementary effects on conscious determinants and
reveal new means of managing no-shows (Sheeran et al., 2013).
Motivated by a multi-stage perspective and conscious and un-
conscious determinants, this study develops a theoretical model to
explore the determinants of no-show behaviour under a reflective-
impulsive model. Specifically, channel convenience, waiting time,
and expected technical quality are identified as conscious de-
terminants, and no-show habit is operationalized as an uncon-
scious determinant. The moderating effects of these conscious
determinants on the relationship between no-show habit and no-
show behaviour are also examined. We tested the proposed hy-
potheses by collecting data on the hospital appointment system of
a large Chinese tertiary care public hospital with 13,618 patients.
Our study makes two contributions to the emerging literature on
no-show behaviour. First, it identifies determinants of no-show
behaviour from a multi-stage perspective, which focuses on the
determinants in each appointment stage and can help capture the
main issues encountered in a certain appointment stage resulting
in no-show behaviour. Second, our study emphasizes that no-show
habit plays a direct and crucial role in determining no-show
behaviour, and its influences are moderated by the identified
conscious determinants. Integrating no-show habit our study en-
riches our theoretical understanding of no-show behaviour and
provides new insights into managing no-show behaviour and
hospital appointment systems and providing sustainable medical
services.
In the next section, we introduce our conceptual framework and
research hypotheses. We then report our research methodology
and empirical results, after which we have discussion and
conclusion.
2. Theoretical background and hypotheses
2.1. No-show behaviour and its determinants
No-show behaviour occurs when a patient is not able to keep his
or her scheduled appointment and fails to inform the respective
hospital before the time of his or her appointment (Perez et al.,
2014). Prior studies have explored determinants of no-show
behaviour. For example, Torres et al. (2015) found that prior no-
show appointments, waiting time, seasons, days of the week, pro-
vider types, age, gender, and language proficiency are associated
with a missed appointment in an urban, academic, underserved
outpatient internal medicine clinic. Moreover, AlRowaili et al.
(2016) reported that higher no-show rates for MRI (Magnetic
Resonance Imaging) appointments are observed among females,
those with less formal education, those not given procedure in-
structions, and those experiencing barriers to transportation.
Likewise, Mohammadi et al. (2018) found that lead time, past
missed appointments, cell phone ownership, tobacco use, and the
number of days since a patient’s last appointment serve as impor-
tant indicators of no-show behaviour among community health
centres. Lee et al. (2018) demonstrated the associations between
no-show behaviour and characteristics of patients with cancer (e.g.,
age, gender, region, insurance types, appointment types, time of
visit, and days of week) in a tertiary hospital. In a recent review of
the literature on this topic, Dantas et al. (2018) claimed that de-
terminants of no-show behaviour can be categorized into three
groups: patient demographics, appointment characteristics, and
other factors. Patient demographics refer to gender, age, race,
marital status, and level of education (Davies et al., 2016; Li et al.,
2019; Ahmad et al., 2019). Appointment characteristics refer to
lead time, appointment times, types of visits, and sources of re-
ferrals (Norris et al., 2014; Mohammadi et al., 2018; Liu et al., 2019).
Other factors such as weather conditions, transportation, and sea-
sons have also been analysed (Peng et al., 2016; Lapidos et al., 2017).
Despite the merits of prior studies in examining patients’ no-
show behaviour, two limitations remain. First, prior studies have
defined no-show behaviour as a single-stage behaviour while
ignoring the fact that appointment services are delivered over
multiple stages. Patients perceive and evaluate each appointment
stage and decide to attend or not attend their appointments. In this
case, determinants of a certain appointment stage may be not de-
terminants of other appointment stages. Second, prior studies have
found that cognitive factors affect no-show behaviour, e.g., the
perceived need for treatment (Lee et al., 2017) and depression
(Miller-Matero et al., 2016). However, to our knowledge, none of
the related literature has empirically investigated the influences of
unconscious determinants on no-show behaviour.
2.2. The reflective-impulsive model
The reflective-impulsive model (RIM) is an extended dual-
process model that claims that individual behaviour is a function
of reflective and impulsive determinants (or conscious and un-
conscious determinants) (Strack and Deutsch, 2004; Hofmann
et al., 2008; Hagger, 2016). Conscious determinants influence
conscious processes that elicit behaviours, which are consequences
of logical and rational consideration. Unconscious determinants
influence unconscious processes to spur certain behaviours, which
are activated automatically and unintentionally.
Our study applies RIM as a theoretical basis for two reasons.
First, conscious and unconscious determinants of no-show behav-
iour can be analysed simultaneously with the model. From a multi-
stage perspective, when patients go through an appointment stage,
they weight costs against benefits. That is, patients’ perceptions
and evaluations in each stage will shape their show/no-show
behaviour, which is logical and rational. Determinants influencing
patients’ cost-benefit analyses are referred to as conscious de-
terminants. However, prior studies have found that individual
behaviour is not always rational and argue that unconscious de-
terminants could be salient to behavioural analyses (Hagger, 2016;
Houlihan, 2018). Accordingly, unconscious determinants exist in
appointment stages and may activate no-show behaviour auto-
matically and unintentionally. On this basis, we suggest that
 M. Hu et al. / Journal of Cleaner Production 269 (2020) 122318
conscious and unconscious determinants influence each appoint-
ment stage simultaneously and trigger no-show behaviour.
Second, RIM can help us focus on the simple outcomes of
scheduled appointments, i.e., show or no-show behaviour
(Yonelinas and Jacoby, 2012), considering that generated mecha-
nisms of no-show behaviour are so complex that it is difficult to
categorize no-show behaviour as a purely “conscious” or “uncon-
scious” behaviour. Many prior studies have also proven that RIM is
effective to explain several complex social and health-related be-
haviours, e.g., older adults’ sedentary behaviours (Maher and
Conroy, 2016) and product attitude formation (Bettiga et al., 2017).
2.2.1. Conscious determinants
Convenience is related to the nonmonetary costs (e.g., time and
effort) that individuals must bear to receive a service (Berry et al.,
2002). In a hospital appointment system, convenience typically
involves an appointment requiring less time and effort (Batbaatar
et al., 2016) and is closely related to the appointment channels
selected by patients. Modified from Miquel-Romero et al. (2020),
channel convenience is defined as the practicality of the appoint-
ment channel or as the perceived ease and speed with which a
patient can gather appointment information and receive an
appointment through the hospital appointment system. Prior
studies have found that channel convenience has positive effects on
individuals’ perceived levels of behavioural control and can reduce
their perceived risks (Xu and Jackson, 2019). Therefore, it is
reasonable to consider channel convenience as a determinant of
patients’ no-show behaviour.
Waiting time is time costs that always appear in service delivery
and are intrinsic (Djelassi et al., 2018). The time from which a pa-
tient is ready to receive a medical service to the time at which the
service commences is defined as the waiting time according to
Casado Díaz and Ma s Ruíz (2002). The need to wait triggers nega-
tive emotions, e.g., anger, irritation, and frustration, and eventually
results in behavioural responses, e.g., abandonment (Djelassi et al.,
2018). The influence of waiting is stronger especially when it is
costly and limits an individual’s ability to engage in other activities.
Therefore, it is postulated that waiting time affects no-show
behaviour.
Expected service quality is defined as the outcome of compari-
sons between patients’ expectations and the medical services they
perceive to have received (Gro € nroos, 1984). Expected technical
quality is an important dimension of service quality that focuses on
the results (or benefits) of service provisions (Kang, 2006). Prior
studies have found that expected service quality affects patient-
hospital relationships, patient satisfaction and a patient’s loyalty
to a hospital (Andrade et al., 2013; Yang et al., 2015; Meesala and
Paul, 2018). In our context, after waiting for a few days, a patient
must consider the outcomes of all appointment stages (whether
there has been an opportunity to receive desired medical services)
and decide to attend or not attend his or her appointment. There-
fore, incorporating expected technical quality into a theoretical
model is essential.
2.2.2. Unconscious determinants
Habit is an unconscious determinant of health-related behav-
iours and means a form of automaticity (Orbell and Verplanken,
2010; Gardner, 2015). When a new behaviour is executed, a
mental association between the corresponding situation and action
is created in one’s memory, and alternative behaviours are less
accessible in that situation. Then, a response is automatically trig-
gered when the associated context cue is encountered. Hence, this
automaticity is context dependent (Gardner, 2012). Best and Papies
(2017) demonstrated that context cues can include sounds, tex-
tures, tastes, objects, times of day, affective or bodily states,
3
previous actions performed in a sequence, or other people present.
Some studies have also confirmed the importance of contexts in
habit, e.g., Wood et al. (2005); Neal et al. (2012). When contextual
cues are rarely encountered, responses may continue to be auto-
mated by cue-response mechanisms. For example, the habit of
saying ‘amen’ at the end of a public prayer is performed weekly
among those attending church every week but annually for those
who attend church only on Christmas Day (Gardner, 2012). Such
behaviour may be automatic under these two circumstances, which
involve significantly different frequencies. Following Limayem et al.
(2007), no-show habit in our context is defined as the degree to
which no-show behaviour for scheduled appointments becomes
automatic after learning from sequences of no-show behaviour.
Importantly, this automaticity may persist in all appointment
stages. Thus, incorporating no-show habit as an unconscious
determinant can provide more insight into no-show behaviour.
2.3. Hypotheses
We build a theoretical model to capture the determinants of
patients’ no-show behaviour (Fig. 1). Conscious determinants are
operationalized as channel convenience, waiting time, and ex-
pected technical quality. An unconscious determinant is oper-
ationalized as no-show habit. The influences of these determinants
on no-show behaviour and particularly the moderating effects of
conscious determinants on the relationship between no-show
habit and no-show behaviour are further investigated below.
2.3.1. Channel convenience
Channel convenience in hospital appointment systems contains
four aspects, i.e., the technology interface, the location of the
appointment channel, the social environment surrounding the
appointment channel, and the accessibility of the appointment
channel (Collier and Kimes, 2013). It is intuitive that a lower level of
channel convenience involves more effort and time costs that pa-
tients must bear when using the selected appointment channel and
less perceived value. Prior studies have found that channel conve-
nience is a component of perceived channel value with positive
effects on channel satisfaction and loyalty intentions (Carlson et al.,
2015; Venkatesh et al., 2016). In our context, patients must usually
choose one channel (e.g., online or offline appointment channels)
to initialize their appointments. A convenient channel can provide
location and time flexibility and satisfy patients’ needs for acces-
sibility (Ming-Hsiung, 2018). In this case, patients’ intentions to
receive treatment at a hospital are increased. Therefore, we hy-
pothesize the following:
H1. Channel convenience is negatively related to patients’ no-
show behaviour.
2.3.2. Waiting time
After using appointment channels, patients usually need to wait
a few days before going to the hospital. Long waiting time means a
higher probability of unexpected incidents, which prevents pa-
tients from receiving medical services. In this case, uncertainties
surrounding receiving medical services in time become more pro-
nounced, which has two consequences. First, uncertainty affects
patients’ evaluations of service reliability, which negatively affects
medical service quality evaluations (Luo et al., 2012). Second, as
levels of uncertainty increase, capacities to plan decrease while
perceived losses of power increase (Taylor, 1994). Consequently,
patients’ intentions to receive treatment at a hospital are reduced.
Prior studies have also found waiting time to be positively associ-
ated with no-show behaviour, e.g., Rodríguez-García et al. (2016);
Drewek et al. (2017). Therefore, we propose the following:
4 M. Hu et al. / Journal of Cleaner Production 269 (2020) 122318
Fig. 1. Research model.
H2. Waiting time is positively related to patients’ no-show
behaviour.
2.3.3. Expected technical quality
At the final appointment stage, patients determine whether
their medical needs can be satisfied at a hospital. The primary goal
of most patients seeking medical services is to relieve pain and
anxiety and recover quickly, and making an appointment with a
doctor is the first step involves in receiving medical services. On
this basis, consistent with Gro € nroos (1984), expected technical
quality in our context means that patients can see their preferred
doctors at a convenient time. Prior studies have emphasized that
technical quality is related to the accuracy of diagnoses and the
effectiveness medical services and treatments, e.g., Venkatesh et al.
(2011); Tam (2012). A higher level of expected technical quality
increases patients’ perceived value and their intentions receive
treatment at a hospital. Therefore, we propose the following:
H3. Expected technical quality is negatively related to patients’
no-show behaviour.
2.3.4. No-show habit
No-show habit is the context-dependent automaticity in our
context. Patients’ mental associations between situations and no-
show behaviour have been encoded into their memory. When
these patients wish to make appointments again, similar associated
context cues of no-show behaviour emerge and automatic re-
sponses are activated. According to Best and Papies (2017), context
cues in patients’ no-show behaviour can include appointment
channels, appointment stages, health statuses, doctors, appoint-
ment times, and primary purposes for seeing a doctor. It is
important to note that a single context cue can trigger behaviour
automaticity (Best and Papies, 2017). A higher level of no-show
habit means that higher probabilities of no-show behaviour for
future scheduled appointments consequently result. On this basis,
we propose the following:
H4. No-show habit is positively related to patients’ no-show
behaviour.
2.3.5. Moderating effects of three conscious determinants
Conscious determinants can moderate the relationship between
habit and behaviour by using deliberate cognition to change the
context of automaticity. That is, the context of habit is not stable or
consistent, and the activation of a learned response pattern is
fundamentally interrupted (Wood et al., 2005). The strength of the
automaticity of habit is then reduced, reducing the influence of
unconscious determinants on behaviour. In other words, it is
possible to make conscious determinants more salient and influ-
ential, which may lead to new choices and decisions being made.
This line of reasoning is referred as the habit discontinuity hy-
pothesis (Verplanken et al., 2008; Haggar et al., 2019). Some prior
studies on breaking habits and designing interventions have
described this moderating effect, e.g., Verplanken and Roy (2016);
Best and Papies (2017).
In our context, when patients perceive levels of channel con-
venience to be low, they dedicate considerable effort and time to
making new appointments, e.g., driving to the hospital and
spending time searching for a doctor. These inputs produce new
experiences, which are viewed as new context cues for patients and
which are stored in their memories. Because the effects of no-show
habit on no-show behaviour should be observed within a stable
and consistent context, these new context cues change the current
context and fundamental requirements are not satisfied. Conse-
quently, the effects no-show habit on no-show behaviour are
weakened. Therefore, we propose the following:
H5. Channel convenience will moderate the relationship between
no-show habit and no-show behaviour, and this relationship will
be stronger when levels of channel convenience are high.
When patients wait for a longer time before receiving treatment
at a hospital, they must manage unexpected issues, e.g., scheduling
conflicts and emotional reactions. Patients must dedicate efforts to
manage these problems to improve their current conditions.
Consistent with the hypothesis of channel convenience, these un-
expected issues or inputs also appear as new context cues stored in
patients’ memories and disturb the stable and consistent contexts
of no-show habit. As a result, the effects of no-show habit are
weakened and behaviour is less likely to be activated by no-show
habit. Hence, we hypothesize the following:
H6. Waiting time will moderate the relationship between no-
show habit and no-show behaviour, and this relationship will be
stronger when waiting time is short.
When expected levels of technical quality are high, patients’
needs are satisfied, and they do not wish to make changes until
they receive treatment at a hospital. Hence, no new context cues
are involved, and the context of no-show habit is stable and
consistent. No-show behaviour is easily activated by no-show habit.
 M. Hu et al. / Journal of Cleaner Production 269 (2020) 122318 5

By contrast, low levels of expected technical quality result in pa- et al., 2014). After filtrating, a total of 13,618 patients and their
tients not making appointments with their preferred doctors or at most recent scheduled appointment records were used for this
an inconvenient time. The need to see different doctors at incon- study. Distributions of the samples are presented in Table 1.
venient times produces new context cues for patients and changes
the consistency of the context. Then, no-show behaviour is less 3.2. Measures
likely to be activated by no-show habit. Therefore, we hypothesize
the following: Table 2 shows the measures of each construct. Following Norris
et al. (2014), the result of the most recent appointment (i.e., arrival
H7. Expected technical quality will moderate the relationship
or no-show) was used to measure no-show behaviour. The indictor
between no-show habit and no-show behaviour, and this rela-
was treated as a dichotomous variable, i.e., with a value of one
tionship will be stronger when expected levels of technical quality
denoting a no-show and a value of zero denoting a completed
are high.
appointment. Inspired by the convenience value of online channels
used by Carlson et al. (2015), we recorded channel types to measure
channel convenience. According to Wirtz et al. (2014), to match the
3. Methodology dependent variable (no-show behaviour), which is a categorical
variable, this indicator was also coded as a categorical variable, i.e.,
3.1. Data collection with a value of one assigned for online channels and a value of zero
for offline channels. Waiting time was determined from the cor-
We chose a large Chinese tertiary care public hospital’s responding lead time, which was defined as the number of days
appointment system as our research setting for two main reasons. from the date of using the hospital’s appointment system to the
First, this hospital is located in the city of Hangzhou and is one of date of a hospital appointment (Drewek et al., 2017). Expected
the largest general hospitals in China. The hospital has ten affiliated technical quality was measured from registration fees, which esti-
hospitals and collaborates with over 100 healthcare institutions mate quality in a relatively straightforward manner and are
and 31 community clinics across China, thus covering enough consistent over time and contexts. Higher amounts of money
samples. Second, the hospital’s well-developed appointment sys- denote more promising access to higher quality services (Mogilner
tem allows patients to access a wide range of online and offline and Aaker, 2009).
appointment channels. We used patients’ past no-show rates, which were calculated as
We obtained a total of 285,605 and 163,309 original appoint- the number of past no-show records divided by the total number of
ment records for 2015 and 2016, respectively. The system data past appointments, to measure patients’ no-show habit. We
include detailed demographic and appointment information for all measured this value instead of the absolute value for two reasons.
patients registered at the hospital (i.e., ID numbers, gender, age, First, as shown in Table 1, the absolute frequency of patients’ no-
appointment channels, scheduled appointment dates, login times, show behaviour is low and difficult to compare. Second, stronger
types of doctors seen, and departments). Our sample includes or weaker no-show habit should be compared on the same basis.
154,838 newly registered patients and 90,323 returning patients. Repeating a behaviour in the presence of consistent cues has been
The returning patients account for 294,076 appointment records shown to encourage behaviour to become more automatic (Lally
and each has made three appointments on average. We selected and Gardner, 2013), and Limayem et al. (2007) showed that
patients with at least one no-show record in the observed period behaviour performed weekly usually gives rise to weaker habit
according to the definition for no-show habit. Cancellation data than behaviour performed daily. There is an underlying assumption
were also excluded. We used the last visit made by each patient to that the same number of behaviours are performed on a weekly and
test the model rather than considering multiple visits per patient. daily basis. Because the number of total past appointments differs
While this reduced the size of our dataset, in considering only the across patients, the absolute number of past no-show behaviour
last visit made by each patient we avoided potentially generating cannot be compared directly. Thus, the no-show rate is more
biased results from studying by multiple visits per patient (Norris reasonable to study.
To further ensure the reliability of our indicators, a group of
hospital professionals and managers were invited to evaluate them.
Table 1
The results of their assessments show that the selected indicators
Distributions of the samples.
are reasonable. We also controlled for gender and age, as de-
Indicator Frequency(n) % mographic variables might impact no-show behaviour (Dantas
Gender Male 5337 39.19% et al., 2018). In measuring gender, a value of 1 was assigned for
Female 8281 60.81% males and a value of 0 was assigned for females. Age was measured
Age 1e20 582 4.27%
in years. Table 3 shows differences found between the “no-show”
21e40 6729 49.41%
41e60 3828 28.11% and the “show” groups, and Table 4 provides a correlation analysis.
>60 2479 18.20%
Behaviour Show 5466 40.14% 3.3. Model development
No-show 8152 59.86%
Appointment channels Online 9076 66.65%
Offline 4542 33.35%
To evaluate the proposed model and hypothesized relationships
Lead time (Days) 1e3 6849 50.29% among the studied constructs, we built three models for hierar-
4e7 6769 49.71% chical regression analysis and used binary logistic regression in
Types of doctors seen Expert 7636 56.07% Stata 14. In Model 1, two control variables (gender and age) were
Common 5982 43.93%
included. In Model 2, channel convenience, waiting time, expected
Previous no-show records At least 1 11311 83.06%
More than 1 2307 16.94% technical quality, and no-show habit were included. Finally, inter-
Previous appointment records 1e2 7593 55.76% action terms (no-show habit
channel convenience, no-show
3e4 3095 22.73% habit
waiting time, and no-show habit
expected technical
>4 2930 21.52% quality) were included in Model 3. The regression models were
Total 13618 100.00%
established as follows:
6 M. Hu et al. / Journal of Cleaner Production 269 (2020) 122318

Table 2
Measures of each construct.

Variables Measures References

Dependent variable
No-show behaviour
Control variables
Gender
Age
Independent variables
Channel convenience
Waiting time
Expected technical quality
No-show habit
No-show behaviour was measured from the result of the most recent appointment. 1 ¼ No-show, 0 ¼ Show. Norris et al. (2014)
1 ¼ Male, 0 ¼ Female. Dantas et al. (2018)
The true age of the patient (Years).
Channel convenience was measured from channel types. 1 ¼ Online channel, 0 ¼ offline channel. Carlson et al. (2015)
Waiting time was determined from lead time (in days). Drewek et al. (2017)
Expected technical quality was measured from registration fees in RMB. Mogilner and Aaker (2009)
No-show habit was measured by patients’ past no-show rates. Gardner (2015)

Table 3 4. Results
Differences between “no-show” and “show”.

No-show Show t-Test 4.1. Main effects

(n ¼ 5466) (n ¼ 8152)

Mean SD Mean SD
The regression results are shown in Table 5. The results of Model
1 show that gender and age have no significant effects on no-show
‘Gender 0.40 0.490 0.38 0.486 1.835
behaviour. The variance explained by the control variables was
Age 42.75 17.292 42.95 17.790 0.683
Channel convenience 0.62 0.485 0.73 0.442 14.192*** found to be only 0.02%. For Model 2, channel convenience
Waiting time 3.80 2.170 3.79 2.217 0.210 (b ¼ 0.437, p < 0.001) and expected technical quality (b ¼ 0.004,
Expected technical quality 41.40 49.517 42.83 48.844 1.669 p < 0.001) have significantly negative effects on no-show behav-
No-show habit 0.78 0.295 0.33 0.153 118.034*** iour, supporting H1 and H3, respectively. As expected, no-show
Note: ***, ** and * denotes significance at 0.1%, 1%, and 5% respectively. behaviour is positively influenced by waiting time (b ¼ 0.063,
p < 0.001) and no-show habit (b ¼ 6.553, p < 0.001), supporting H2
and H4, respectively.
Model 1:

4.2. Moderating effects examination

logitðBehaviourÞ ¼ b0 þ b1 Gender þ b2 Age þ ε
Table 5 shows that the moderating effects of channel conve-
nience (b ¼ 0.507, p < 0.05), waiting time (b ¼ 0.112, p < 0.05) and
Model 2: expected technical quality (b ¼ 0.010, p < 0.001) on the relationship
between no-show habit and no-show behaviour are significant. To
further illustrate these moderating effects, simple slopes were
plotted. Three regression lines for effects of the independent vari-
logitðBehaviourÞ ¼ b0 þ b1 Gender þ b2 Age þ b3 CC þ b4 WT
able on the dependent variable were plotted when the moderating
þ b5 ETQ þ b6 NSH þ ε variable was high and low (Dawson, 2014). As Fig. 2(a) shows, ef-
fects of no-show habit on no-show behaviour are weaker under
lower levels of channel convenience. As shown in Fig. 2(b), when
Model 3: waiting time is longer, no-show habit has a weaker effect on no-
show behaviour. Fig. 2(c) depicts the moderating effect of ex-
pected technical quality and suggests that expected technical
logitðBehaviourÞ ¼ b0 þ b1 Gender þ b2 Age þ b3 CC quality enhances the positive influence of no-show habit on no-
þ b4 WT þ b5 ETQ þ b6 NSH show behaviour, supporting H5 - H7.
þb7 CC
NSH þ b8 WT
NSH þ b9 ETQ

NSH þ ε 5. Discussion and conclusion

where CC, WT, ETQ, and NSH represent channel convenience, Our findings show that a multi-stage perspective and conscious
waiting time, expected technical quality, and no-show habit, and an unconscious determinant can be integrated in analysing
respectively. patients’ no-show behaviour in the studied research context. Our

Table 4
Correlation analysis.

Mean SD 1 2 3 4 5 6 7

1. No-show behaviour 0.60 0.490 1.000

2. Gender 0.39 0.488 0.016 1.000
3. Age 42.83 17.092 0.006 0.061*** 1.000
4. Channel convenience 0.67 0.471 0.119*** 0.008 0.139*** 1.000
5. Waiting time 3.80 2.189 0.002 0.024** 0.026** 0.108*** 1.000
6. Expected technical quality 41.97 49.251 0.014 0.043*** 0.106*** 0.009 0.262*** 1.000
7. No-show habit 0.60 0.334 0.670*** 0.047*** 0.001 0.104*** 0.021* 0.045*** 1.000

Note: ***, ** and * denotes significance at 0.1%, 1%, and 5% respectively.

 M. Hu et al. / Journal of Cleaner Production 269 (2020) 122318 7

Table 5
Logistic regression results.

Model 1 Model 2 Model 3

B SE B SE B SE

(Constant) 0.408*** 0.049 2.155*** 0.108 1.643*** 0.173

Gender 0.675 0.036 0.100* 0.050 0.095 0.050
Age 0.001 0.001 0.001 0.001 0.001 0.001
Channel convenience 0.437*** 0.052 0.655*** 0.117
Waiting time 0.063*** 0.011 0.110*** 0.025
Expected technical quality 0.004*** 0.001 0.009*** 0.001
No-show habit 6.553*** 0.114 5.353*** 0.400
Channel convenience
No-show habit 0.507* 0.239
Waiting time
No-show habit 0.112* 0.054
Expected technical quality
No-show habit 0.010*** 0.003
Pseudo R2 0.02% 41.15% 41.26%

Note: ***, ** and * denotes significance at 0.1%, 1%, and 5% respectively.

Fig. 2. Slopes for the relationship between no-show habit and no-show behaviour across levels of (a) channel convenience; (b) waiting time; and (c) expected technical quality.

study identifies three conscious determinants of no-show behav-
iour from a multi-stage perspective, i.e., channel convenience,
waiting time, and expected technical quality. We found that
channel convenience negatively affects no-show behaviour. Prior
studies have revealed that different channels are characterized by
different no-show rates (Giunta et al., 2013). Differently, we ana-
lysed the effects of appointment channels on no-show behaviour
with a focus on convenience and found results consistent with the
convenience literature in showing a direct positive impact of con-
venience on customer satisfaction and loyalty (Roy et al., 2018). It
8 M. Hu et al. / Journal of Cleaner Production 269 (2020) 122318

can therefore be deduced that patients often highly value conve- increase patient satisfaction.
nient hospital appointment systems, which when present improve Some study limitations and avenues for future research should
their evaluations of appointment stages. In accordance with prior be noted. First, our work was conducted in China. Because context
studies finding longer waiting time to have a negative effect on idiosyncrasies are likely to evolve distinct tactical and strategic
satisfaction and intentions (Djelassi et al., 2018; Garaus and responses, future research could add some cultural factors and
Wagner, 2019), our findings confirm that waiting time is posi- extent our findings and implications to other contexts. Second,
tively related to no-show behaviour. When waiting time is viewed empirical data in our study was collected from a hospital
as a time cost of medical service delivery, it worsens patients’ appointment system. To improve the validity of our findings, a
evaluations of medical services. In our context, waiting time is survey-based approach is needed that could directly reflect pa-
closely related to unexpected incidents and uncertainty and further tients’ perceptions and evaluations of hospital appointment sys-
reduce patients’ intentions to seek treatment at a hospital. There- tems, e.g., self-reported habit indexes. Third, this study is limited to
fore, it is confirmed that waiting time indeed have a strong effect on several determinants. Future research could identify other
patients’ no-show behaviour. In line with previous research, e.g., Li conscious and unconscious determinants of no-show behaviour,
et al. (2018), we found expected technical quality to have negative e.g., health belief.
effects on patients’ no-show behaviour. As the benefit that patients
expect to receive, expected technical quality reflects the accuracy of Declaration of competing interest
diagnoses made and the effectiveness of treatments given and can
thus enhance patients’ intentions to seek treatment at a hospital. The authors declare that they have no known competing
Thus, we can conclude that whether an appointment service is financial interests or personal relationships that could have
perceived to provide high or low levels of expected technical appeared to influence the work reported in this paper.
quality shapes patients’ no-show behaviour.
To comprehensively analyse patients’ no-show behaviour, we CRediT authorship contribution statement
have added no-show habit as an unconscious determinant in the
research model. Our empirical results have shown that no-show Miao Hu: Writing - original draft, Conceptualization, Method-
habit has a positive influence on no-show behaviour. No-show ology, Formal analysis. Xiaoyan Xu: Supervision, Writing - review
habit in our context is characterized by automaticity and is & editing, Conceptualization. Xiaodong Li: Writing - review &
context-dependent. Our results confirm previous findings showing editing, Methodology. Tong Che: Writing - review & editing, Formal
that habit directly influences future behaviour and has supple- analysis.
mentary effects on conscious decision-making, e.g., Maher and
Conroy (2016). We also tested the potential nonlinear relation-
Acknowledgments
ship between no-show habit and no-show behaviour. However, we
cannot confirm that this nonlinear relationship exists in our study
This work was supported by National Natural Science Founda-
because the empirical data did not pass a robustness check (see
tion of China [No. 71601137, 71701002]; and the Philosophy and
Appendix A).
Social Science Research in Colleges and University of Jiangsu
We further reveal that the relationship between no-show habit
Province [No. 2017SJB1325]. We thank Niels Noorderhaven for his
and no-show behaviour is moderated by the identified conscious
helpful comments on an earlier draft.
determinants. Consistent with prior studies, e.g., Wood and Neal
(2009), conscious determinants can change the contexts of no-
show habit and reduce the automaticity of behaviour. Specifically, Appendix A
according to our empirical results, the strength of the relationship
between no-show habit and no-show behaviour will be stronger as We have conducted Lind and Muhlum (2010) procedure to test
levels of channel convenience and expected technical quality in- the U-shaped relationship between no-show habit and no-show
crease. By contrast, the strength of this relationship is reduced behaviour. This procedure contains three steps. The results of the
when waiting time increases. first step are shown in Table 1. The coefficients of no-show habit
Our research suggests that it is important for hospital managers and its square term are significantly negative and positive,
to manage no-show behaviour and provide sustainable medical respectively.
services with a focus on three aspects, i.e., hospital appointment
systems, medical services, and patients. First, multiple communi- Table 1
cation functions could be incorporated into hospital appointment Logistic regression results
systems to enable patients to engage in more flexible interactions
Behaviour B SE
with hospitals and doctors and improve the perceived ease of
(Constant) 0.929*** 0.133
system usage. It is helpful for hospitals to understand the medical
Gender 0.083 0.050
needs of their patients and assign appropriate doctors to patients in Age 0.003 0.001
advance. Second, we recommend that hospitals remove check-in Channel convenience 0.442*** 0.052
procedures to simplify appointment stages, shorten patients’ Waiting time 0.054*** 0.011
waiting time and improve hospital operation efficiencies. In addi- Expected technical quality 0.004*** 0.001
No-show habit 1.456* 0.446
tion to satisfying basic requirements of fundamental medical ser-
(No-show habit)2 8.039*** 0.493
vices, hospitals can provide other supportive services, e.g., more Pseudo R2 43.18%
comfortable waiting rooms and personalized accompanying ser-
Note: ***, ** and * denotes significance at 0.1%, 1%, and 5% respectively.
vices for patients. Finally, while most patients do not frequently
exhibit no-show behaviour, hospital managers must still treat this
issue seriously and design effective interventions for managing
patients’ no-show behaviour. Employing specific interventions for In the second step, we tested the slopes at the lower and upper
different groups could not only reduce operational costs but also bounds of no-show habit (in Table 2). The slope at the lower bound
decrease the frequency of no-show-related disturbances and of no-show habit is negative and significant (Slopelower ¼ 1.119, p-
 M. Hu et al. / Journal of Cleaner Production 269 (2020) 122318
value ¼ 0.004), and the slop at the upper bound of no-show habit is
positive and significant (Slopeupper ¼ 14.623, p-value ¼ 0.000). In
the third step, the turning point (0.091) is located well within the
data range. Therefore, the U-shaped relationship between no-show
habit and no-show behaviour is significant with our empirical data
(p-value ¼ 0.004).
Table 2
Slopes at the lower and upper bounds
Lower bound Upper bound
Interval 0.21 1 and functional quality. Manag. Serv. Qual.: Int. J. 16, 37e50.
Slope 1.119** 14.623***
t-value 2.625 25.107
Note: ***, ** and * denotes significance at 0.1%, 1%, and 5% respectively.
We have also conducted a robustness check. Following Haans
et al. (2016), the slopes of two linear regressions with no-show
habit below and above the turning point are all positive and sig-
nificant (Slopebelow ¼ 45.906, p-value ¼ 0.018; Slopeabove ¼ 6.583,
p-value ¼ 0.000), and are not consistent with the U-shaped curve.
Therefore, the U-shaped relationship is not robust.
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