Sickest Patients 'Most Likely to Miss Doctor's Appointments'

Liam Davenport

January 11, 2019

Patients who repeatedly miss their primary care appointments appear to be those with the most long-term conditions (LTCs), potentially explaining why they have an increased all-cause mortality, the results of a large-scale Scottish study suggest.

Looking at data on almost 11.5 million appointments in over 820,000 patients, the team found that 40% of patients with at least four LTCs had missed at least two general practice appointments per year, versus 50% of those with up to three LTCs but only 10% of those with no LTCs.

The research, published online by BMC Medicine on January 10th, showed that, in particular, patients with at least four mental health-related LTCs were more than twice as likely to miss appointments as those with no LTCs, and were eight times more likely to die from all causes.

Patients with four or more physical LTCs had an approximately 40% increased risk of missing GP appointments and a three-fold increased risk of all-cause mortality versus those with no LTCs.

Sympathetic View

Lead author Ross McQueenie, PhD, a research associate in general practice and primary care at the University of Glasgow, told Medscape News UK that people who miss appointments are often seen as "lazy" or "can't be bothered" to attend.

"But we'd always argue that these people have unmet needs and nobody is making GP appointments for fun," he said, adding: "We should have a sympathetic view of people that miss appointments, rather than being particularly critical towards them for that."

McQueenie believes that the underlying issue might be that of the 'treatment burden' that patients experience as a consequence of having to manage their LTCs. He said: "That obviously, as you would imagine, escalates as you have more conditions.

"You may have asthma and COPD [chronic obstructive pulmonary disease] and you have your asthma appointment at one place and your COPD appointment at another place.

"You have to travel round, attend all your appointments, you have to take your medication, and all these sorts of things feed into what we call the burden of treatment."
 

Mental Health Conditions

For patients with mental health LTCs, McQueenie explained that they may "not feel like they're getting what they need out of the healthcare service and that leads to...a breakdown in the way that people interact with the healthcare system."

He believes that one way of tackling the issue of missed appointments is by having 'first point of contact' mental health specialists, allowing patients to be immediately triaged to mental health services on the same day as their GP appointment.

For physical LTCs, McQueenie and colleagues "always advocate what's called a holistic approach."

He said: "A lot of GPs are very overworked and very underfunded, and have very short appointments, but in the ideal situation you would treat the person as a whole, looking to all of their long-term conditions, rather than focusing on certain long-term conditions."
 

Careful About Conclusions

Dr Richard Vautrey, GP committee chair at the British Medical Association, told Medscape News UK that, while "we should be careful drawing any definitive conclusions from this study, it does reflect many of the experiences and challenges faced by some of our most vulnerable patients, and those suffering from multiple complex conditions."

He added: "Within this week's Long-Term Plan, NHS England highlighted the need for both mental health services to be prioritised and pledged extra investment in community health services.

"Only with these ambitions realised, which will require proper support and funding, will we see improved health outcomes for these groups of patients."

In a statement, Dr Helen Stokes-Lampard, chair of the Royal College of General Practitioners, said that patients with LTCs "need regular monitoring and treatment and advice tailored to their unique health needs, so missing appointments and not being able to access that support has the potential to have a devastating impact on their wellbeing."

She added: "People miss appointments for a range of reasons, but this study highlights why it's more important to show compassion to people who fail to attend, rather than punishing them; for some, life gets in the way and they forget, but others might not turn up precisely because of their health issue."

Underlying how difficult it can be for people with mental health conditions to ask for help, and the importance of GPs being aware of patients' needs, she called for more mental health therapists in primary care.

GP Forward View

"Ultimately, we need substantially more investment in general practice across the board," Dr Stokes-Lampard said.

"NHS England's GP Forward View promises an extra £2.5bn a year for general practice, and the NHS Long Term Plan announced this week guarantees that our profession will receive a significant share of the funding outlined for primary and community care.

"We need these pledges turned into a reality as a matter of urgency so that we have sufficient numbers of GPs and the wider practice team to give all our patients the care they need and deserve."

Scottish Data

The researchers point out that, while healthcare systems traditionally focus on the treatment of individual conditions, it is increasingly common for patients to have two or more LTCs.

Moreover, multiple LTCs are themselves associated with greater deprivation, older age, higher mortality, and depression, as well as greater treatment burden, with its requirement for more primary healthcare appointments.

Recent studies have looked at the underlying patient and primary care practice factors associated with missed appointments, but there has been less of a focus on the association with patient health and mortality.

The team therefore examined routinely collected general practice data from across Scotland for the period September 2013 to September 2016, yielding a cohort of 11,490,537 appointments for 824,374 patients at 136 practices.

The data, which equated to the appointment history of approximately 15% of the Scottish population, was linked to Scottish mortality records for patients who died over a 16-month follow-up period.

Overall, 41.1% of the patients had no LTCs, while 45.7% had one to three LTCs and 13.3% had at least four LTCs.

Categorising the number of missed appointments as zero, low (<1 per year), medium (1–2 per year) and high (>2 per year), the team found that, among patients with no LTCs, 51.5% had zero missed appointments and 9.8% had a high number of missed appointments.

Among patients with one to three LTCs, 41.6% had zero missed appointments, while 50.1% missed a high number of appointments.

When the researchers turned to patients with four or more LTCs, they found that only 7.0% had zero missed appointments, while 40.1% had missed a high number of appointments.

A high number of LTCs was also associated with increasing levels of deprivation, with 64.3% of those in the most deprived quintile having at least one LTC, compared with 51.1% of those in the most affluent quintile.

Controlling for patient and practice level factors, and number of appointments, the researchers calculated that having one to three LTCs increased the risk of missing appointments versus no LTCs by a relative risk ratio (RRR) of 1.29.

Patients with four or more LTCs had even greater risk of missing appointments versus those with no LTCs, at an RRR of 1.70.

Among patients with physical LTCs only, those with one to three LTCs had a RRR of missing appointments of 1.16, rising to 1.38 among those with four or more LTCs.

When it came to mental health-related LTCs, the team found that having one to three LTCs was associated with an RRR of missing appointments of 1.30, increasing to 2.05 in those with at least four mental health LTCs.

Patients with problem alcohol use and psychoactive substance misuse who missed at least two appointments were higher in proportion than those with other mental health LTCs, at 22.2% and 27.4%, respectively, versus 14.1%.
 

All-Cause Mortality

Missing appointments was associated with an increased risk of all-cause mortality.

Patients who missed a low number of appointments had a hazard ratio of all-cause mortality versus no missed appointments of 1.55.

This increased to a hazard ratio of 2.17 in those with a medium number of missed appointments, and 3.11 in patients who missed a high number of appointments.

Mortality rates associated with missed appointments in patients with physical LTCs alone were similar to those seen in the overall cohort, which the researchers say is "likely due to the increased predominance of physical over mental health-related LTCs."

Patients with mental health LTCs alone who missed appointments had a higher all-cause mortality rate, however.

Those with a low number of missed appointments had a hazard ratio of all-cause mortality versus no missed appointments of 2.10, increasing to 4.02 in those who missed a medium number of appointments and 8.37 in patients who missed a high number.

The primary causes of death in patients with physical LTCs alone were lung cancer and ischaemic heart disease, while dementia and ischaemic heart disease were the most common causes in those with both physical and mental health LTCs.

Among patients with mental health-related LTCs alone, the primary causes of death were self-harm by hanging, strangulation and suffocation, poisoning or overdoses, or by an ill-defined or unknown cause.

The average age at death was also lower with mental health LTCs, at 49–68 years of age versus 75–79 for those with physical alone, or both physical and mental health LTCs.
 

Next Steps

The team writes: "It is unlikely that the relationship between missed appointments and mortality is directly causal in most cases, particularly among those without pre-existing physical health LTCs.

"One possible mechanism involves conditions associated with cognitive difficulties such as dementia, attention-deficit/hyperactivity disorder, or problem drug or alcohol use, each of which is associated with an increased risk of missing appointments and with increased mortality."

Next, McQueenie would like to "try to flesh out a little bit more the type of person that is missing these appointments and their path through the healthcare system".

To do this, the team wants to look at service use.

"We want to see basically if the people that are missing the GP appointments are, for example, attending A&E appointments in place of the GP appointments," he said.

"A prevailing thought is that someone might be using the A&E service as a proxy for general practice appointments; so, rather than going to see your doctor you just turn up at an A&E and ask for an appointment for whatever condition you have there."

Furthermore, they would like to look at whether adverse experiences in childhood may also play a role in missing GP appointments.

McQueenie said: "So we want to see if people [who] have these adverse experiences are also the people who are likely to miss appointments."

This study was supported by a Scottish Government Chief Scientist Office research grant with Safe Haven and data linkage costs supported in lieu by the DSLS at Scottish Government.

No conflicts of interest declared.

BMC Medicine 2018 doi: 10.1186/s12916-018-1234-0 Abstract.

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