Why do Patients Miss Appointments?

This the first of three posts based on a presentation I did for noon Oncology Rounds.

1) The Background Article:  Why do Patients Miss Appointments?
2) The Practical Article:  15 Ways to Reduce Missed Appointments.
3) Advise from our Lawyers: implement a color coded system to track missed appointments

SERIES SUMMARY:  Patients who miss appointments have worse outcomes.  Missed appointments can be predicted and reduced with deliberate interventions.

I)  Appointments

What is an Appointment?

Appointments are a heterogenous entity that include:

  • Clinical assessment: first consultation, follow up
  • Investigative: imaging, laboratory, mammogram, colonoscopy
  • Interventional: surgical
  • Therapeutic: chemotherapy, radiation, IV antibiotics

Multiple 'agendas' may be present at an appointment. Patients are more interested in attending appointments that help them understand why they feel unwell and in which they receive treatments.  Not infrequently the appointment is predominately for the 'doctors agenda'.  Physicians may book appointments to follow up and confirm a patient is doing well; patients are not keen to attend when they feel well. Appointments may be scheduled to review the patient's chart and follow up on the test results - essentially a paid way to do office work.

Appointments may have limits, such as the number of questions a patient may ask. The stated reason for this is to help "keep the appointment on schedule". But another motivating factor in Canada's fee-for-service system is the only way to bill for a longer appointment that solves multiple issues is to have the patient come back on multiple occasions.  (I realize there are a few exceptions to this, such as billing in psychiatry by time increments.)

Why do patients miss appointments?

Consider why you have miss appointments. Do you always take your care in precisely when called for its oil change? Have you ever canceled seeing your physiotherapist or trainer? I've assembled trends from the literature of why people miss medical appointments.

1.  The appointment didn't make its way onto the patient's schedule: there are multiple reasons for this, but it essentially breaks down to ineffective communication and misunderstanding between the hospital/clinic and the patient.

2.  Socio-Economic: this is a huge category. It includes everything from difficulty finding someone to take them to the clinic, inability to pay for transportation, or obligations at home to care for others.

3. Difference in perceived importance:  between the clinic and the patient. If the patient 'feels well', it is more difficult to ask them to attend cancer surveillance follow ups. If they opt for another treatment (such as naturopathic) they may not attend.

4.  Too sick to attend: these are patients who may want to attend, but are too sick; or are ill and but don't have the insight to realize they should attend. 

5.  Avoidance of discomfort: men will put off an appointment knowing there is a rectal exam. Chemotherapy treatments may cause discouraging side effects.

II) Literature Search

Literature Search: Missed Appointments

A PubMed search for variations of 'missed appointments', 'no shows', and 'failed appointments" finds around 1200 results. When these are filtered exclusively for Oncology papers - at times avoiding the papers on increasing cancer screening - there are about 30 results.

Limitations of the Literature

Incomplete Survey Data

Unsurprisingly, patients who miss appointments may not return surveys. Survey based research often failed to capture a quarter of patients with missed appointments. Do the people who fail to respond to surveys have different reasons for missing than those who do? Its hard to say.

Biased Results

When people complete surveys they are more inclined to select answers that are socially acceptable.  I wouldn't tell my clinic on the phone I missed their appointment because "I didn't care", but instead that "I was was too busy".

III) Consequences of Missed Appointments

Missed appointments are generally associated with more advanced pathology, higher ER visits, increased admissions, decreased medication adherence, increased morbidity and mortality.  Each subpopulation of patients, such as heart failure or HIV, have studies demonstrating the effects of missed appointments on outcomes. In oncology the same trends hold true.

Indicator of Sick Patients

One of the most interesting studies in this area was on 1352 sequential patients with advanced cancer. These patients were referred to a supportive care consultation at the University of Texas Medical Centre. The no-show rate was 16% for the initial visit.  At the 2 week mark patients who had not shown were four times more likely to have been seen in the ER.  Most significantly, the median survival of the group that missed the first appointment was 177 days (127-215). Whereas, the group that kept the first appointment had a median survival of 253 days (192-347).  Of those patients who did not attend the appointment, 46% of them were seeing another doctor, in the ER, admitted, or dead. (Delgado Guay et al. Characteristics and outcomes of advanced cancer patients who miss outpatient supportive care consult appointments. Supportive Care in Cancer. 2014)

Oncology Outcomes & Socio-Economic Status (SES)

It is known that patients with lower socio-economic status have worse outcomes, and cancer is no exception.  Part of the hypothesis is that missed appointments may be partially responsible for worse outcomes.  A study of 1227 patients in an urban academic setting with 21.7% non-compliant (missed 2 or more scheduled appointments) suggested that:

RT noncompliance is associated with inferior outcomes across many disease sites, even after adjusting for confounders such as comorbidity index and SES, suggests to us that noncompliance may serve as a behavioral biomarker for other risk factors that contribute to poor outcomes. These may include noncompliance with other important clinician visits and procedures, lack of social support, and mood disorders. (Ohri 2016)

(Ohri, N et al. Radiation Therapy Noncompliance and Clinical Outcomes in an Urban Academic Cancer Center. International Journal of Radiation Oncology, Biology, Physics. 2016)

15 Ways to Reduce Missed Appointments

Increasing Patient Involvement in Referrals to Specalists

Increasing Patient Involvement in Referrals to Specalists