Non-attendance as a predictor of drop-out, relapse and readmission

An important question is how many of those who miss an appointment later reattend and resume treatment, and how many drop out of care permanently. Early non-attendance increases the risk of further non-attendance (Reference Carpenter, Morrow and Del GaudioCarpenter et al, 1981), but two prospective studies suggest that many patients who occasionally miss appointments subsequently reattend. Reference Sparr, Moffitt and WardSparr et al(1993) found that over a 3-month period 71.1% of missed appointments were rescheduled spontaneously by the patient (mostly within 2 weeks) and only about 25% resulted in disengagement from services. Reference Pang, Lum and UngvariPang et al(1996) traced 258 patients 6 months after their non-attendance at a follow-up clinic: 50% eventually returned but 50% dropped out of treatment. There is also good evidence that missed appointments, and unexpected disengagement in particular, can signal deteriorating mental health. In a prospective study of 365 out-patients receiving mental healthcare, Reference Killaspy, Banerjee and KingKillaspy et al(2000) found that follow-up patients who missed an appointment were more unwell and more functionally impaired than those who attended. In a comprehensive study, Reference Nelson, Maruish and AxlerNelson et al(2000) collected data on 3113 psychiatric admissions in eight south-eastern US states and calculated rehospitalisation rates after discharge. On the basis of the 365-day rehospitalisation rate, patients who kept a follow-up appointment had a 1 in 10 chance of being rehospitalised; for patients who did not keep (or were not offered) an appointment, the chances were 1 in 4. It is possible that the complications of non-attendance differ for new and ongoing patients. Reference Killaspy, Banerjee and KingKillaspy et al(2000) interviewed 57 new patients and 167 follow-up patients who did and did not attend general adult psychiatric out-patient clinic appointments over 12 months. Follow-up patients who did not attend had a 33% chance of being admitted in the next 12 months, compared with a 20% chance for the group that did attend. Also, the new patients who failed to attend were less likely to have agreed to the referral and less likely to have had it adequately explained to them.

A related concern is that attendance rates in those recently seen in emergency departments for self-harm who are offered follow-up are low (Reference Mitchell, Kingdon and CrossMitchell, et al, 2006). Indeed, the Confidential Inquiry into Homicides and Suicides by Mentally Ill People (Royal College of Psychiatrists, 1996) found that 28% of mentally ill suicide victims had lost contact with mental health services, 24% of suicides occurred within a month of discharge from hospital and most were before the first follow-up appointment had even taken place.

Attendance and medication adherence

Regular monitoring has been shown to lead to significant improvements in adherence to medication regimens (Fig. 2). When the US Federal Drug Administration decreased mandatory clozapine blood monitoring from weekly to every second week, there was a 10% rise in medication discontinuation (Reference Patel, Crismon and MillerPatel et al, 2005). As discontinuation of medication can lead to a significant deterioration in quality of life, it can be said that clinical contacts, medication use and quality of life are interrelated. Non-attendance is particularly closely linked with medication non-adherence (Reference Mitchell and SelmesMitchell & Selmes, 2007a ). Patients who discontinue medication of their own accord may be reluctant to disclose this to medical staff, and indeed cannot disclose it if not seen again. Conversely, patients who miss appointments will not receive the full benefit of medical advice and hence are less likely to make an informed choice about their care and are more likely to act autonomously in a self-directed manner (Reference MitchellMitchell, 2007).

Fig. 2 Illustration of the factors influencing adherence to medical advice.

Non-attendance and medical attitudes

Missed appointments may result in increased provider frustration (Reference Husain-Gambles, Neal and DempseyHusain-Gambles et al, 2004), decreased levels of provider empathy and lower quality patient–provider communication (Reference Pesata, Pallija and WebbPesata et al, 1999). In a primary care study, general practitioners (GPs) developed negative attitudes about patients who unexpectedly missed their appointments (Reference Husain-Gambles, Neal and DempseyHusain-Gambles et al, 2004). Not infrequently, favoured intervention strategies involve punishing the patient in some way for their ‘offence’ rather than discussing missed appointments with the patient (see also the section ‘Service responses to missed appointments’ below). Remarkably, despite the high risk of missed appointments in mental health services, a US survey showed that psychiatrists tended to be less active in trying to maintain contact with patients than non-physician therapists and junior doctors (Reference Smoller, McLean and OttoSmoller et al, 1998).

Environmental and demographic factors

A number of social and environmental factors have been linked to missed appointments in most medical specialties. Research indicates that patients who miss appointments tend to be younger and of lower socio-economic status (Reference Sharp and HamiltonSharp & Hamilton, 2001). Compared with attenders, such patients are more often in receipt of healthcare (incapacity) benefits and/or social benefits and are more likely to have psychosocial problems (Reference CosgroveCosgrove, 1990). In a comprehensive study of 221 000 primary care appointments in Sheffield, there was a strong correlation (r = 0.72) between non-attendance and the Townsend Deprivation Index Score for the patient's medical practice (Reference Waller and HodgkinWaller & Hodgkin, 2000). Reference Kruse, Rohland and WuKruse et al(2002) examined the medical records of 313 individuals with serious mental illness who were attending a US psychiatric out-patients clinic and found that 36% had missed their first appointment. The significant predictors were young age, Hispanic ethnicity, having a poor family support system, not having health insurance and also poor adherence to psychotropic medication (Reference Kruse, Rohland and WuKruse et al, 2002). In a study of 600 patients followed up after an emergency psychiatric assessment, Reference Dobscha, Delucchi and YoungDobscha et al(1999) found that homeless people were the least likely to attend, managing only a 34% follow-up rate. Although encouragement from family and friends is helpful, people who feel pressurised into attending by their family or doctor may be less likely to keep appointments.

A number of understandable accessibility issues are common to most studies of both help-seeking and attendance. Most frequently, transportation problems are cited (Reference Pesata, Pallija and WebbPesata et al, 1999), and distance travelled is another correlate (Reference Jackson, Booth and McguireJackson et al, 2006).

Patient factors

The most common single reason for non-attendance at follow-up appointments is forgetting the appointment, followed by being too psychiatrically unwell (Reference Killaspy, Banerjee and KingKillaspy et al, 2000). The proportion of psychiatric patients accidentally (unintentionally) missing an appointment appears to be higher than in other medical specialties. Reference Sparr, Moffitt and WardSparr et al(1993) examined reasons for non-attendance in 8.8% of 1620 contacts who missed scheduled appointments during a 3-month period. The most commonly stated reason for missing an appointment was patient error (forgetting, oversleeping or getting the date wrong). Reference Gudjonsson, Hannesdottir and AgustssonGudjonsson et al(2004) examined non-attendance in an alcohol clinic in Reykjavik. Of 313 patients asked to attend a follow-up appointment, only 27% did so. Predictors of non-attendance were younger age, high trait anxiety and lower social desirability scores. Psychoticism on the Eysenck Personality Questionnaire was the biggest single discriminator between those who attended. A study of the management of 3923 patients with diabetes in primary care found that those with secure attachment styles (as assessed by the Relationship Questionnaire) were significantly more likely to attend than those with dismissing attachment styles (Reference Ciechanowski, Russo and KatonCiechanowski et al, 2006). Reference Compton, Rudisch and CrawCompton et al(2006) collected data from team members and medical notes on 234 consecutively discharged patients from two in-patient units in a US urban county hospital. In a logistic regression model, the four characteristics that were significant predictors of missed first appointments were involuntary legal status at discharge or leaving against medical advice, not having an established out-patient clinician, an Axis IV problem relating to the patient's primary support group (for example, death of a family member or health problems in the family) and the number of days from discharge to the follow-up appointment.

Clinician and referrer factors

There is no doubt that the quality of service provided, as well as the rapport with the clinician, have a marked effect on attendance. Wilder et al(1997) suggest that ‘compliance’ is ‘as much a function of their [patients’] interactions with psychiatric personnel and of the suitability of the recommendations as it is of personal characteristics of the patients themselves’. In fact, this effect begins with the original referrer to secondary care.

Reminder and memory aids

The discovery that psychiatric patients are twice as likely to cite forgetting as the cause of non-attendance than those in other specialties (Reference Killaspy, Banerjee and KingKillaspy et al, 2000) might support interest in active reminder systems. Reference Boswell, Brauzer and PostlethwaiteBoswell et al(1983) was one of the first to use a telephone reminder before psychiatric clinic appointments for 184 patients compared with 185 treated as usual. There was a statistically significant improvement in attendance in this early randomised controlled trial. Similar positive results have since been reported for first attenders by Reference Burgoyne, Acosta and YamamotoBurgoyne et al(1983), Reference MacDonald, Brown and EllisMacDonald et al(2000) and Reference Conduit, Byrne and CourtConduit et al(2004), and for both first attenders and follow-up patients by Reference Shivack and SullivanShivack & Sullivan (1989) and for follow-up patients by Reference Bamford, Booth and McguireBamford et al(2004), the latter using both telephone and postal reminders with alcohol misusers. Telephone reminders seem to be particularly effective for elderly patients, especially those with dementia (Reference Dockery, Rajkumar and ChapmanDockery et al, 2001). Messages left on an answerphone can also be successful (Reference Conduit, Byrne and CourtConduit et al, 2004). Reference McFall, Malte and FontanaMcFall et al(2000) conducted a pilot outreach intervention for combat veterans receiving disability benefits for post-traumatic stress disorder but not receiving treatment. A letter inviting them to seek help followed by a telephone reminder led to a 23% attendance rate compared with 7% attendance for those who received just a letter. In one study of 103 new out-patients at a London psychiatric teaching hospital, patients were asked to confirm in writing or by telephone if they still required an appointment (Reference BaggaleyBaggaley, 1993). A number of automated methods of sending reminders to patients about scheduled appointments have been developed. For example, Reference Andrade, Mcgruder and WuAndrade et al(2005) measured the effect of a memory-prompting device (Disease Management Assistance System) on adherence to treatment in people with HIV. Interestingly, adherence improved only in those with diagnosed memory impairment. Unfortunately, the expense of these systems usually proves prohibitive for the majority of patients and healthcare providers.

Interpersonal and communication issues

Simple measures such as providing patients with sufficient information about the practical aspects of their appointment (where to park, directions, etc.) and even ‘orientation statements’ (explaining what to expect in the consultation) can lead to improvements in attendance (Reference Kluger and KarrasKluger & Karras, 1983). Reference Wenning and KingWenning & King (1995) offered the parents of children newly referred to child psychiatry an ‘orientation group meeting’, in which they were informed about the service provided. This reduced non-attendance at the first (but not subsequent) clinic appointments, and also allowed parents who were unlikely to attend to be identified in advance. Patients’ understanding can be increased with a simple discharge or exit interview explaining the need for follow-up and the rationale for medication. This approach appears to reduce subsequent non-attendance (Reference Guse, Richardson and CarleGuse et al, 2003). Given that one of the most important interpersonal variables in predicting attendance is the degree of helpfulness of the health professional (see above) we suggest that all clinicians check whether there is anything further that can be done to help at the close of all appointments and prior to hospital discharge. Even greater insight may be gained by routinely using an instrument to check the quality of their therapeutic relationships (Reference McGuire-Snieckus, McCabe and CattyMcGuire-Snieckus et al, 2007).

Service responses to missed appointments

All services must carefully consider their approach to those who miss one or more appointments (Reference Cruz, Cruz and McEldoonCruz et al, 2001). Clearly, many patients miss a single appointment by mistake (unintentionally) and we suggest that after one missed appointment a reminder is sent to the patient with another appointment date (or at least the offer of an appointment), possibly suggesting a home visit. After a second and third consecutive unexplained miss, there is a higher chance that the patient is unwilling or unable to attend. We suggest speaking directly to the patient, clarifying whether an appointment is still needed and, if so, finding a mutually agreed time. If a patient cannot be contacted an alternative is to ask the referrer to clarify whether the appointment is still wanted. Simply sending three written appointments for fixed out-patient slots may not be satisfactory as there is no allowance for administrative error or severe illness. An important question that arises when a patient is initially seen but then disengages is whether that service was truly meeting the individual's needs. It is not uncommon for patients to drop out of treatment because of a perceived lack of progress. For this reason we suggest attempting to ask all patients who disengage for feedback either verbally or in writing.

It is vital that services in all specialties review the ongoing needs of the patients they serve. For example, when staff at a paediatric clinic noted a particularly high non-attendance rate among Asian patients (50%) they found that common-sense steps, including avoiding appointments during Islamic religious festivals, reducing language barriers through the use of link workers, liaison with elders and education of staff, reduced this figure to 13.5% (Reference GatradGatrad, 2000). Surveys of non-attending patients (as described above) show that people often view services as inaccessible (and, to a lesser extent, inflexible). Although it is uncommon for patients to cite problems with the appointment time as a reason for non-attendance, significantly more patients will attend afternoon than morning appointments (Reference Weinerman, Glossop and WongWeinerman et al, 2003). In a study of 118 substance-misusing young people, a community-based treatment programme that was much easier to access than conventional care reduced disengagement from 22% to 2% (Reference Henggeler, Pickrel and BrondinoHenggeler et al, 1996). However, flexible but complex systems risk alienating those who cannot read English, or who have intellectual disabilities or significant psychiatric morbidity (Reference Sharp and HamiltonSharp & Hamilton, 2001).

The effectiveness of providing evening and weekend appointments has not been investigated in mental health settings, but providing hospital transport or taxis is beneficial (reducing non-attendance at prenatal appointments for low-income women by 22%) (Reference Melnikow, Paliescheskey and StewartMelnikow et al, 1997). The innovative but controversial method of rewarding those who attend clinic and/or punishing those who do not has been successfully piloted by more than one group (Reference Parrish, Charlop and FentonParrish et al, 1986; Reference BechBech, 2005). It may be more ethically acceptable to offer a nominal reward option alone (‘as a thank you for letting us know you could not attend’) (Reference Pollastri, Pokrywa and WalshPollastri et al, 2005).