A qualitative study of staff perspectives of patient non-attendance in a regional primary healthcare setting

Understanding the causes of missingness in primary care: a realist review

BACKGROUND

Although missed appointments in healthcare have been an area of concern for policy, practice and research, the primary focus has been on reducing single 'situational' missed appointments to the benefit of services. Little attention has been paid to the causes and consequences of more 'enduring' multiple missed appointments in primary care and the role this has in producing health inequalities.

METHODS

We conducted a realist review of the literature on multiple missed appointments to identify the causes of 'missingness.' We searched multiple databases, carried out iterative citation-tracking on key papers on the topic of missed appointments and identified papers through searches of grey literature. We synthesised evidence from 197 papers, drawing on the theoretical frameworks of candidacy and fundamental causation.

RESULTS

Missingness is caused by an overlapping set of complex factors, including patients not identifying a need for an appointment or feeling it is 'for them'; appointments as sites of poor communication, power imbalance and relational threat; patients being exposed to competing demands, priorities and urgencies; issues of travel and mobility; and an absence of choice or flexibility in when, where and with whom appointments take place.

CONCLUSIONS

Interventions to address missingness at policy and practice levels should be theoretically informed, tailored to patients experiencing missingness and their identified needs and barriers; be cognisant of causal domains at multiple levels and address as many as practical; and be designed to increase safety for those seeking care.

Behaviourally informed, patient-led interventions to reduce missed appointments in general practice: a 12-month implementation study

BACKGROUND

Scalable, positive, behaviourally informed interventions may help people remember to attend their primary care appointment or cancel in good time, but have not yet been implemented long term.

AIM

To examine effects of social norms and making active commitments on missed and cancelled appointments in primary care over 12 months and explore implementation factors.

DESIGN AND SETTING

A mixed-methods design evaluation and implementation study led by a Patient Participation Group (PPG) member in a large GP practice in the West Midlands.

METHODS

Following a 6-month baseline, waiting room notices were redesigned to emphasise positive social norms for desired behaviours. When booking appointments, receptionists were trained to invite patients to (i) verbally actively commit to cancelling if needed; (ii) write down their own appointment details. Monthly missed appointments (MAs) and cancellations were statistically compared with baseline averages and seasonally equivalent months. To explore implementation, reception staff completed a knowledge, attitude, and behaviour questionnaire at 9 months, analysed descriptively. Study team field notes were thematically analysed.

RESULTS

Across 12 intervention months there was a mean of 37.67 fewer MAs per month (20% reduction) and 102.66 more cancellations (21.07% increase) compared with 6-month baseline means [MAs t(11) = -6.15, P < 0.001; cancellations t(11) = 3.637, P = 0.004] with statistically significant differences in seasonally equivalent months [MAs t(5) = -4.65, P = 0.006; cancellations t(5) = 3.263, P = 0.022]. Receptionists (n = 12) reported implementing the strategies except when facing pressures; knowledge and attitudes varied.

CONCLUSIONS

Behaviourally informed interventions reduced primary care MAs longer term; PPGs and practice teams can work together on quality improvement projects with support from leaders to prioritise and embed new practices.

Why do older people not use the public health services of the integrated aging program? A multidimensional approach in a qualitative study

OBJECTIVES

The world's population is aging rapidly and a huge amount of services are being provided to meet the needs of the older people. Identifying the factors affecting the non-attendance of the older people to health care centres is of particular importance. We focused on the reasons why older people do not use the services of the integrated aging program in Iran from the perspective of the older people, general practitioners, and primary health providers.

METHODS

A qualitative study in Ghaemshahr (IRAN) carried out during 2021. Data were collected through semi-structured interviews in two groups with the participation of 29 older adults and 18 employees of the health centres Purposeful sampling and sample size were determined based on data saturation. Data were analyzed manually using conventional content analysis.

RESULTS

Potential barriers to and challenges of older adults were generally categorized into four main themes including individual, systemic-structural, environmental, and social factors.

CONCLUSIONS

Both groups agreed on many aspects, including lack of education of the patients and lack of proper medical services. Existing problems in health care relate to both medical and non-medical factors. Improvement in health care delivery requires a deliberate focus on the patients' specific needs.

Causes, impacts and possible mitigation of non-attendance of appointments within the National Health Service: a literature review

PURPOSE

Missed appointments within the National Health Service (NHS) are a drain on resources, associated with not only considerable time and cost implications, but also sub-optimal health outcomes. This literature review aims to explore non-attendance within the NHS in relation to causes, impacts and possible mitigation of negative effects of missed appointments.

DESIGN/METHODOLOGY/APPROACH

MEDLINE, CINAHL Plus and PubMed were searched with a date range of 2016-2021. Databases were searched for peer-reviewed articles published in English addressing non-attendance of adults within the NHS. Studies were excluded if they were theoretical papers, dissertations or research concerning patients aged under 18. A total of 21 articles met the inclusion criteria and were selected for analysis.

FINDINGS

The results indicate a significant association of non-attendance and poor health outcomes. Patients from a lower socioeconomic status, adults aged over 85 and those with multiple co-morbidities are more likely to miss appointments. The most commonly reported patient-centred reasons for failing to attend were forgetfulness, transportation difficulties, and family commitments. Practice-specific reasons were cited as inefficiencies of the appointment booking system, failure of traditional reminders and inconvenient timings. Interventions included text reminder services, the inclusion of costs within reminders and enhanced patient involvement with the booking process.

ORIGINALITY/VALUE

Non-attendance is complex, and to secure maximum attendance, targeted interventions are required by healthcare facilities to ensure patient needs are met. The adaption of scheduling systems and healthcare services can assist in reducing DNA rates.

Factors Associated With Adherence to Outpatient Follow-Up in Patients With Idiopathic Intracranial Hypertension (IIH)

Idiopathic intracranial hypertension (IIH) is a chronic condition characterized by raised intracranial pressure of undetectable origin, that causes morbidity due to debilitating headaches and vision loss. Continuity of outpatient care is important to monitor for permanent vision loss, manage symptoms and limit emergency care. The purpose of this retrospective study was to identify factors associated with neuro-ophthalmology follow-up appointment completion among patients with IIH at a US academic medical center in order to establish evidence-based interventions to improve adherence patterns. Included are 111 completed or no-show neuro-ophthalmology return outpatient appointments by 23 subjects with IIH. Generalized estimating equation models were used to assess association between appointment completion status and factors previously shown to be associated with appointment adherence. Appointments were more likely to be completed during the summer (p=0.08) and by subjects with headache symptoms (p=0.06), however none of the patient factors reached statistical significance. Completed and no-show appointments did not differ by subject demographic or insurance factors. Further studies are needed to identify risk factors for lack of appointment adherence by patients with IIH, particularly those amenable to intervention, in order to improve continuity of care for IIH.

Increased non-attendance at epilepsy clinic in patients with neuropsychiatric comorbidities: A prospective study

BACKGROUND

In patients with epilepsy, regular follow-up is vital for adequate seizure control, antiseizure drugs' (ASDs) side effects, psychiatric comorbidities, and planning for epilepsy surgery. Non-attendance creates barriers to adequate patient care, inefficient allocation of resources, loss of income, and unnecessary emergency department visits due to lack of seizure control. This study aimed to determine the causes and sociodemographic characteristics of the non-attendant population at the Epilepsy Clinic.

METHODS

A prospective and observational study was carried out on patients treated at the Epilepsy Clinic of the National Institute of Neurology and Neurosurgery (NINN) in Mexico from August 2015 to June 2016. A phone interview was made with all those patients who did not attend the epilepsy consultation. This call incorporated ad hoc questions to meet the objectives of this study.

RESULTS

During the study period, 1299 patients had an appointment at the epilepsy clinic, where 233 (17.9%) patients missed their consultation, 123 (52.8%) were male, mean age was 35.9 ± 14.42 years. The most frequent cause of non-attendance was forgetfulness of the appointment in 62 patients (26.6%). Two patients died; no patient was reported to have experienced SUDEP. Non-attendant patients showed statistically significant overall prevalence of psychiatric comorbidities (41.6%), particularly depression, anxiety, and interictal psychosis.

CONCLUSION

Information on non-attendance at various specialist consultations is scarce, and to our knowledge, this is the first study to address non-attendance in patients with epilepsy in Latin America. Improving hospital protocols to reduce non-attendance can increase patient adherence to follow-up, ultimately improving the quality of care in the epilepsy clinic.

Assessment of diabetes knowledge, screening and uptake of community diabetes programs in a peri-urban region in Australia

AIMS

The Wollondilly Diabetes Program (WDP) is testing ways to improve uptake of diabetes prevention services. This project evaluated the reach of WDP in diabetes promotion while assessing diabetes knowledge and risk among residents.

METHODS

A WDP member travelled in the DW weekly to community events including outreach programs between October 2016 and June 2019. Data from diabetes knowledge questionnaire (DKQ), the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK), HbA1c and Random Blood Glucose (RBG) measurements obtained from participants who attended community events and road shows.

RESULTS

Over the 32 months period, WDP attended 32 community events reaching 1415 people (∼3% of the Wollondilly adult population). DKQ was completed by 154 people (52.9% females, 78% Australian born, median age 69 years), 39% had diabetes and their mean score (25.0 ± 3.1, maximum possible score = 31) was similar to those without diabetes (24.0 ± 4.6, p = 0.093). AUSDRISK assessment was completed by 166 people with 85% at intermediate or high risk of diabetes. There were 65% results above range for RBG (≥5.5 mmol/l) and/or HbA1c (≥5.7%,39 mmol/mol).

CONCLUSION

A community outreach team set up in partnership with local stakeholders that offers opportunistic diabetes screening, is an effective way of engaging with the community to increase diabetes awareness and knowledge.

Which patients miss appointments with general practice and the reasons why: a systematic review

Background

Missed GP appointments have considerable time and cost implications for healthcare services.

Aim

This systematic review aims to explore the rate of missed primary care appointments, what the reported reasons are for appointments being missed, and which patients are more likely to miss appointments.

Design and setting

This study reports the findings of a systematic review. The included studies report the rate or reasons of missed appointments in a primary care setting.

Method

Databases were searched using a pre-defined search strategy. Eligible studies were selected for inclusion based on detailed inclusion criteria through title, abstract, and full text screening. Quality was assessed on all included studies, and findings were synthesised to answer the research questions.

Results

A total of 26 studies met the inclusion criteria for the review. Of these, 19 reported a rate of missed appointments. The mean rate of missed appointments was 15.2%, with a median of 12.9%. Twelve studies reported a reason that appointments were missed, with work or family/childcare commitments, forgetting the appointment, and transportation difficulties most commonly reported. In all, 20 studies reported characteristics of people likely to miss appointments. Patients who were likely to miss appointments were those from minority ethnicity, low sociodemographic status, and younger patients (<21 years).

Conclusion

Findings from this review have potential implications for targeted interventions to address missed appointments in primary care. This is the first step for clinicians to be able to target interventions to reduce the rate of missed appointments.

Qualitative Analyses of the Reasons Why Patients Do Not Attend Scheduled Inpatient Appointments in a Hospital in Guangzhou, China

Purpose

Exploration of the reasons why people miss scheduled inpatient appointments from the perspectives of patients.

Methods

Semi-structured interviews via telephone were conducted with patients who missed their inpatient appointments. Data were analyzed based on Colaizzi’s seven-step method.

Results

Twenty-five patients and five dependents were enrolled. Three themes were identified: practical barriers, lack of knowledge about the disease, and negative emotional responses. Personal social obligations, state of illness, financial issues and long waiting times were the main practical barriers preventing patients from attending their inpatient appointment. Patients’ perceptions of feasible self-solving symptoms, readily believing people around them, and a blindly optimistic attitude towards disease contributed to their insufficient knowledge about the disease. Negative emotional responses (eg, sense of fear and lack of trust in physicians) had a detrimental effect on inpatient attendance.

Conclusion

Three main factors contributed to non-attendance of inpatient appointments: practical barriers, lack of knowledge about disease, and negative emotional response. Our study provides new, valuable evidence on non-attendance of inpatient appointments in China. Our findings could offer meaningful insights into developing effective strategies to reduce non-attendance of inpatient appointments in other countries.

Challenges to Introducing Integrated Diabetes Care to an Inner-Regional Area in South Western Sydney, Australia

Introduction

Diabetes care often requires collaboration between general practitioners, allied health professionals, nurses, and/or medical specialists. This study aimed to describe the establishment of an integrated diabetes prevention and care approach in an area with limited access to primary and secondary care, and the challenges faced in its initial development.

Description

A qualitative research approach to identify challenges was taken. Data included meeting minutes, observational data and reports involving local clinical and non-clinical stakeholders from June 2016- December 2018 and were thematically analysed.

Discussion

Key challenges were low patient attendance in general practice, healthcare professional time, low participation at health promotion activities/peer support groups and diabetes education reflecting a low priority among people with and at risk of diabetes. Coordination between services remained a challenge.

Conclusion

This study highlights the need to integrate new diabetes services with existing health activities in the community and the importance of allowing flexibility and regular contact with local healthcare professional and community to encourage their involvement. Regular meetings with the funders, internal and external stakeholders are key for sustainability and to adapt programmes to the local situation. Further work is needed to identify and implement strategies to overcome these challenges.

Service dissatisfaction and non-attendance in physiotherapy student-led clinics: a qualitative study

Background and Purpose: Student-led physiotherapy clinics are a valuable means for providing education opportunities and cost-effective services to the public. Service dissatisfaction is an important construct in understanding how student-led services can maximize patient care and minimize non-attendance while maintaining effective learning environments. Design: A qualitative interview design was used with semi-structured interviews. Results: Eighteen patients from three different university student-led physiotherapy clinics were interviewed. Five themes emerged that were associated with negative perceptions of service provision: (1) inadequate communication, (2) insufficient supervision, (3) loss of autonomy, (4) time commitment, and (5) continuity of care. Conclusion: The results of this study highlight factors that service providers should consider to mitigate negative patient experiences and relevant implications of dissatisfaction including non-attendance. Ensuring transparency of patient expectations of services and enhancing patient continuity of care between physiotherapists and students are important in minimizing the potentially negative factors associated with student-led health services.

When colocation is not enough: a case study of General Practitioner Super Clinics in Australia

Developed nations are implementing initiatives to transform the delivery of primary care. New models have been built around multidisciplinary teams, information technology and systematic approaches for chronic disease management (CDM). In Australia, the General Practice Super Clinic (GPSC) model was introduced in 2010. A case study approach was used to illustrate the development of inter-disciplinary CDM over 12 months in two new, outer urban GPSCs. A social scientist visited each practice for two 3-4-day periods. Data, including practice documents, observations and in-depth interviews (n=31) with patients, clinicians and staff, were analysed using the concept of organisational routines. Findings revealed slow, incremental evolution of inter-disciplinary care in both sites. Clinic managers found the facilitation of inter-disciplinary routines for CDM difficult in light of competing priorities within program objectives and the demands of clinic construction. Constraints inherent within the GPSC program, a lack of meaningful support for transformation of the model of care and the lack of effective incentives for collaborative care in fee-for-service billing arrangements, meant that program objectives for integrated multidisciplinary care were largely unattainable. Findings suggest that the GPSC initiative should be considered a program for infrastructure support rather than one of primary care transformation.

Western or Traditional Healers? Understanding Decision Making in the Hmong Population

Research has documented the influence of cultural values, beliefs, and traditional health practices on immigrants' health care utilization in their host countries. We describe our findings of how Hmong immigrants to the United States make decisions about whether and when to use traditional and/or Western health services. We conducted semi-structured interviews with 11 Hmong adults. We found their decisions depended on whether they classified the illness as spiritual or not and how they evaluated the effectiveness of different treatment options for their illness. Hmong participants' expectations for effective treatment in traditional or Western health care encounters combined with physical evidence of an illness influenced their decisions and often led them to shift from one type of care to the other. Understanding cultural differences in perceptions of the causes of illnesses and the link between perceived cause and treatment is important to improving care for the Hmong population.

A Mismatch Between Patient Education Materials About Sickle Cell Disease and the Literacy Level of Their Intended Audience

INTRODUCTION

Despite the first goal of the 2010 National Action Plan to Improve Health Literacy, the literacy demands of much health information exceeds the reading skills of most US adults. The objective of this study was to assess the health literacy level of publicly available patient education materials for people with sickle cell disease (SCD).

METHODS

We used 5 validated tools to evaluate 9 print and 4 online patient education materials: the simple measure of gobbledygook (SMOG) to assess reading grade level, the Peter Mosenthal and Irwin Kirsch readability formula (PMOSE/IKIRSCH) to assess structure and density, the Patient Education Materials Assessment Tool (PEMAT) to assess actionability (how well readers will know what to do after reading the material) and understandability, the Centers for Disease Control and Prevention's (CDC's) Clear Communication Index (Index) to obtain a comprehensive literacy demand score, and the Printed Cancer Education Materials for African Americans Cultural Sensitivity Assessment Tool.

RESULTS

Materials' scores reflected high reading levels ranging from 8th grade to 12th grade, appropriate (low) structural demand, and low actionability relative to understandability. CDC suggests that an appropriate Index score should fall in or above the 90th percentile. The scores yielded by materials evaluated in this assessment ranged from the 44th to the 76th percentiles. Eight of the 13 materials scored within the acceptable range for cultural sensitivity.

CONCLUSION

Reading levels of available patient education materials exceed the documented average literacy level of the US adult population. Health literacy demands should be a key consideration in the revision and development of patient education materials for people with SCD.

Factors associated with non-attendance in a general practice super clinic population in regional Australia: A retrospective cohort study

BACKGROUND

Non-attendance at medical appointments is associated with increased patient morbidity and is a significant drain on health service resources. Australian studies have focused on secondary healthcare settings, screening, and interventions to reduce non-attendance.

AIMS

To explore factors associated with non-attendance in a regional primary care setting.

METHOD

A retrospective cohort of all patients with a scheduled appointment between October 2011 and October 2013 at a regional, primary care clinic providing medical and allied health services in a region of New South Wales (NSW) serving a large Aboriginal population (10.7 per cent). Using multivariate logistic regression, non-attendance was regressed on a range of covariates, including number of appointments per person, gender and ethnicity, and day of the week.

RESULTS

The overall proportion of missed appointments was 7.6 per cent. Risk factors for non-attendance were day of the week [Mondays (8.1 per cent), Fridays (8.0 per cent), and Thursdays (7.9 per cent), (χ2(4)= 20.208, p<0.0005], having fewer scheduled appointments [≤5 appointments resulted in 19.1 per cent greater risk of failure to attend (FTA) (95% CI: 11-28%)]; Aboriginality (OR=4.022, 95% CI: 3.263, 4.956), and female gender (OR=1.077; 95% CI 1.024, 1.132). There was a trend toward an interaction between gender and Aboriginality, with Aboriginal females being the group most likely to miss appointments (OR=1.272, 95% CI: 0.949, 1.705).

CONCLUSION

This is the largest study of non-attendance in an Australian primary healthcare setting. While not a typical setting, the study had the advantage of a large, mixed population. The suggested high rates of non-attendance by Aboriginal females have potentially important policy implications.