[Posted on 7 May, 2020 by Phil Wilson]
Most clinicians get mildly annoyed when a patient doesn’t turn up for their clinic, while a few might be secretly pleased to have some spare time to catch up on administrative tasks! Politicians and health service managers, on the other hand, often publicly blame people who don’t attend their appointments for wasting taxpayers’ money: recently NHS England calculated that the annual cost of missed appointments in general practice alone was over £200 million.
People miss appointments for lots of reasons: for example they may have cognitive impairment, a family emergency to deal with, a physical illness that makes them unfit to attend, transport problems, or their mental state may prevent attendance. As a GP, I have found that social anxiety, low cognitive capacity and attention difficulties are frequently factors underlying a pattern of missed appointments. ADHD, which is known to be associated with missed appointments1, is likely to be a factor in many cases.
It is easy to understand why researchers are unenthusiastic about studying missed appointments, and almost all the limited literature has used routine administrative data focussed on single missed appointments. Although a number of factors such as age and socio-economic status have been found to be associated with individual missed appointments, it remains possible that these findings overshadow a different set of problems experienced by people who miss appointments repeatedly.
People who miss multiple appointments are therefore an under-researched group who might have important unmet health needs: they certainly appear at least to have a dysfunctional relationship with health services. Individual-level patterns of missed appointments might therefore provide a risk marker for vulnerability and poor health outcomes.
A group of collaborators from the Universities of Glasgow, Lancaster and Aberdeen has been looking at factors associated with repeated missed appointments, and we obtained some striking results. We have used data from Scottish general practice: over 99% of the population are registered with a GP and general practice is the gateway to almost all UK secondary care services so we can build up a good profile of the health needs and demographic characteristics of patients according to their pattern of missed appointments. It is also cost-free for patients to use. GP appointment systems in Scotland are all integrated with the clinical records so it is possible, with the permission of practices, to extract data on which appointments were made and which were actually attended2. Furthermore, it is possible in Scotland to link the general practice dataset with other administrative data such as school attendance and attainment, hospital use and death records.
We first sought to ascertain the contributions of patient demographics and general practice-based factors to the likelihood of missing general practice appointments3. We extracted general practice data that were routinely collected across Scotland over a three-year period. We calculated the per-patient number of missed appointments and investigated the risk of missing an appointment, correcting for the number of appointments made. We then analysed the effect of patient-level factors (including age, sex, and socioeconomic status) and practice-level factors (including appointment availability and geographical location) on the risk of missing appointments.
The full dataset included information from over half a million patients: around one fifth of them missed more than two appointments in the 3-year study period. Those at highest risk of missing appointments repeatedly were aged 16–30 years or older than 90 years, and of low socioeconomic status. Practice factors also substantially affected attendance patterns, with urban practices in affluent areas that typically have appointment waiting times of 2–3 days the most likely to have patients who serially miss appointments. The combination of both patient and practice factors explained a very high proportion of repeated missed appointments.
Next, we looked at the association of missed appointments with patient health and mortality in a representative sample of over 800,000 people4. We linked the appointment information to both GP-held morbidity data and Scottish deaths records for patients who had died within a 16-month follow-up period.
Patients with a greater number of long-term conditions had an increased risk of missing general practice appointments despite controlling for number of appointments made, particularly among patients with mental health conditions. Patients who missed two appointments or more per year were at significantly greater risk of all-cause mortality (5% died within a year), and there was a dose-based response with increasing number of missed appointments. The most striking finding was that repeatedly missing patients was a strong independent risk factor for dying. The greatest increased risk was found in those with long-term mental health conditions: these patients who missed more than two appointments per year had a greater than 8-fold increase in risk of all-cause mortality compared with those who missed no appointments. They died prematurely (average age 49 years), most commonly from non-natural external factors such as suicide, violence or road traffic collisions and in many cases the cause of death could not be determined.
Missed appointments therefore represent a significant independent risk marker for all-cause mortality, particularly in patients with mental health conditions. Although the relationship is not necessarily causal, we can assume that existing primary healthcare appointment systems are ineffective for those who repeatedly miss them and this could well represent a risk to health. We could argue that the patients we most need to see are those who don’t turn up for their appointments!
My own view is that the relationship between repeatedly missing appointments and premature ‘unnatural’ mortality among those without major physical illness is likely to be explained at least in part by ADHD. These patients are known to miss psychiatric outpatient appointments1 and young adults with ADHD are known to be more likely to adopt risk behaviours such as problem drug and alcohol use, be involved in criminal activity5 and to die prematurely6.
Our research group plans to look for further evidence of an ADHD contribution to missing GP appointments in the near future, but in the meantime there seems to be a strong case for taking a pattern of missed appointments seriously, particularly among those with evidence of neurodevelopmental problems.