Included under terms of UK Non-commercial Government License.
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
McLean S, Gee M, Booth A, et al. Targeting the Use of Reminders and Notifications for Uptake by Populations (TURNUP): a systematic review and evidence synthesis. Southampton (UK): NIHR Journals Library; 2014 Oct. (Health Services and Delivery Research, No. 2.34.)
![Cover of Targeting the Use of Reminders and Notifications for Uptake by Populations (TURNUP): a systematic review and evidence synthesis](/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-ukhsdr0234-lrg.png)
Targeting the Use of Reminders and Notifications for Uptake by Populations (TURNUP): a systematic review and evidence synthesis.
Show detailsHaving synthesised the evidence relating to reminder systems in the preceding chapters, we turn to provide a narrative overview of literature generated by our review on attendance behaviour more generally (review 3; see Figure 1 and Chapter 3, Review questions). Given that our review has identified significant gaps in current understanding regarding how reminder systems operate in different service settings and for different population subgroups, there is value in exploring the identified literature from this wider perspective. Specifically, looking beyond the evidence directly related to reminder systems to examine what is known about patterns and influences on attendance behaviour more generally may:
- prompt ideas for how attendance/reminder interventions should be designed in future (for instance, in terms of particular barriers to attendance that they might seek to overcome or enablers they might seek to enhance)
- provide insight into the reasons why reminders have greater/lesser impact in particular patient groups or in particular services settings
- highlight aspects of the wider health-care setting that require particular attention if the impact of reminder/attendance interventions is to be maximise
- suggest issues to consider, or areas where caution may be warranted, in introducing reminder interventions in relation to potential differential impacts of reminder interventions across patient subgroups
- flag up specific areas requiring further research in relation to reminders.
It is important to highlight, however, that our project did not set out to provide a comprehensive review of the literature on patterns and determinants of health-care appointment attendance. The information presented here is necessarily limited. We have drawn primarily on sources generated from our review and, when possible, supplemented these with highly cited papers that provide further information in support of the key issues and themes that emerge. We also signpost additional literature, outside the scope of our review, that may usefully inform future work on reminder systems and associated interventions aimed at improving attendance levels.
Appointment attendance behaviour has been investigated extensively in both the UK and other contexts, with a wide variety of putative factors – relating to the health-care setting, the nature of the appointment, the characteristics of the individual patient and the wider social setting – having been explored through both qualitative and quantitative research methodologies. Although some studies simply report on the reasons that patients cite for not attending appointments, others have involved comparative analyses between different subgroups of patients and/or more detailed investigation of the processes that support or hinder appointment attendance. Some consistent findings emerge, but the relationships between many of these factors and attendance behaviour are inconsistent across studies, suggesting that context is important in moderating their influence.
In keeping with the conceptual framework presented in Chapter 4, we organise the material into the following subsections:
- reported reasons for non-attendance
- factors linked to the health-care setting (conceptual framework domain C)
- factors linked to the wider social system (conceptual framework domain D)
- distal/proxy patient attributes (conceptual framework domain F).
Reported reasons for non-attendance
Given that simple reminders are effective across a wide range of settings, it is not surprising that many studies identified ‘forgetfulness’ as the most common reason given by patients for not attending a health-care appointment.20,111–114 Studies also suggest that health-care professionals perceive forgetfulness to be one of the most important reasons for non-attendance.104 However, the evidence from multiple studies indicates that forgetting to attend accounted for between 8%112 and 45% of the patients who did not attend their appointments,74 suggesting that other factors are also in operation in many settings. Furthermore, other reasons for non-attendance cited by patients across a range of studies include:
- timing and (in)compatibility issues: having several appointments in various hospitals,20,72 effort (distance, transportation, parking),113,115,118 presence of a sick child or relative113 (as cited by Horstmann et al.116), lack of child care113 (as cited by Horstmann et al.116), conflicts with work schedules115 (as cited by Horstmann et al.116), other commitments,69,84 overslept113 and having ‘lot on their mind’104
- financial reasons113
These numerous reported reasons for not attending appointments suggest that non-attendance at appointments is a highly complex and multifactorial problem. The following sections throw further light on the processes operating to shape attendance behaviour.
Factors linked to the health-care setting
Perhaps unsurprisingly, a wealth of research suggests that attendance behaviour is linked to various aspects of the health-care setting. A variety of factors have been explored and yet many of these have received little attention within research focused on reminder interventions as reviewed in the preceding sections. For convenience, we organise this material under three broad themes: characteristics of the appointment system, patient–provider ‘alliance’ and ‘engagement’, and other features of the service/care. It is important, however, to recognise that these different arenas are not distinct but inter-relate, each being elements of the fundamental interplay between the patient and the health care on offer.
Characteristics of appointment systems
Our review examined six characteristics of appointment systems that appear important in relation to attendance behaviour: administrative (in)accuracy [a significant problem in some contexts, already discussed above – see Chapter 4, Evidence statement (B.1): there is strong consistent evidence that the reminder may not be received by the patient (evidence category Ia)], source of the appointment, timing of the appointment, time to wait for the appointment, patient involvement in appointment initiation and/or scheduling and whether the appointment is a first or follow-up.
The source of the original appointment
Only two studies25,80 were identified that explored the differential impact of reminders delivered by different sources and these produced equivocal findings. In addition, limited and inconsistent evidence was yielded on the effect of source of appointment on attendance behaviour. Just two UK papers89,121 reviewed included quantitative analyses addressing this hypothesised relationship and these related to contrasting settings and employed inconsistent categorisation of sources.
A UK-based study in a gynaecology clinic121 compared 105 non-attenders with 105 attenders at the same index clinics and concluded that referrals from primary care were more likely to be missed than interspecialty or referrals from the accident and emergency (A&E) department. In contrast, a study of attendance at a specialist alcohol treatment centre in the UK89 undertook multivariate analysis of patient characteristics of non-repliers (n = 100), non-attenders (n = 100) and attenders (n = 100) and found no statistically significant association between source of referral and attendance. A study in a paediatric dermatology clinic in Hong Kong122 found that non-attendance was significantly higher among referrals from the emergency department than among referrals by private practitioners (p = 0.05).
A qualitative study exploring attendance for breast screening by women in Turkey123 provided some support for the hypothesis that invitations/recommendations for screening received from family doctors might be important in encouraging attendance. Respondents in the study reported ‘if we face a genial approach, we wouldn’t hesitate going to a doctor, even if it is a male doctor’, ‘we might be ignorant, but our doctor should enlighten us in detail, we need information’.123
Despite the limited information in the review, a scan of the wider literature (including citations in our reviewed papers) indicates that the hypothesis that the source of the appointment/invitation can influence attendance has received some attention in both research and practice, particularly in relation to screening interventions. A key contrast of interest has been between GP/primary care referral and referral from a hospital clinic or central administrative unit. For instance, in relation to attendance for breast screening, some UK interventions have involved letters of endorsement or telephone calls from the woman’s local GP practice in addition to standard screening invitations and leaflets, but the reported impact on uptake has been disappointing.124,125
Explanations and implications for reminders
Several potential mechanisms might explain variations in levels of attendance by source of original appointment. First, the identity of the person/department/service that initiates the making of an appointment (invites the patient to the appointment) may influence patient perceptions that attendance at the appointment will positively contribute to well-being and/or that non-attendance will result in negative consequences. It may also be hypothesised that the source of the original appointment could influence patient perceptions that attendance is the morally ‘right thing’ to do, for instance if the appointment invitation comes from a health-care professional with whom the patient has a pre-existing relationship.
In addition, however, associations between the source of a referral/original appointment and attendance may relate to differences in the knowledge level of the practitioner about how likely a patient is to attend, perhaps related to knowledge of personal circumstances and/or readiness to engage with the particular treatment/care on offer. For example, Booth and Bennett89 in their study of a specialist alcohol treatment centre in the UK suggest that ‘it is possible that since GPs tend to have a longer-standing professional relationship with their clients than other referral sources, they may be better placed to assess patient readiness to seek help for an alcohol problem’. In this way, some practitioners may act as gate-keepers/demand managers by not offering referrals to patients they believe will not turn up anyway.
Differential attendance rates by source of referral may also reflect a higher degree of involvement of the patient in the decision to seek the appointment and the scheduling of that appointment. For instance, hospital referrals made by a GP are likely to result from a consultation initiated by a patient in response to some perceived need and may also allow for involvement of the patient in the scheduling of the appointment, whereas referrals between departments may not involve the patient to the same degree.
In addition, higher attendance rates associated with appointment invitations emanating from general practices may reflect more up-to-date and far-reaching patient contacts, so that the appointment information may simply be received by more patients when it comes from some sources rather than others.
The available evidence does not allow a detailed exploration of these various potential mechanisms and does not provide consistent evidence to inform decisions regarding the source of reminders that are likely to be most effective.
Timing of the appointment
The review identified several studies that had explored patterns of attendance by appointment timing, looking at both the day of the week and time of day. Explanation for higher non-attendance at particular times or on particular days has centred on the incompatibility of the appointment with employment commitments, with some discussion of caring commitments also.
Time of day
Three studies, all with reasonable designs and sample sizes – a RCT including 3899 patients, a prospective study and a case–control design – reported no evidence that the time of day of the original appointment has an effect on attendance.
A RCT in Portugal63 included 3899 patients of various ages across various outpatient clinics and found that looking at the overall attendance data (for reminder and control groups) the time of day (morning or afternoon) was not a statistically significant variable with respect to non-attendance (p > 0.05). A UK study based in a specialist alcohol treatment centre89 undertook multivariate analysis of patient characteristics of non-repliers (n = 100), non-attenders (n = 100) and attenders (n = 100), and also included a trial element that examined the effect of a telephone reminder. The authors found that the time of the appointment (morning or afternoon) was not an independent predictor variable associated with attendance and was the last to emerge from the logistic regression equation. In addition, it was not significant over and above age and distance. The authors were somewhat surprised by this finding and speculated that there may have been a chance combination of older patients with shorter distances to travel to morning appointments. A UK study121 exploring attendance behaviour at a gynaecology clinic with an ethnically diverse and deprived patient population employed a case–control design to explore the association of morning compared with afternoon clinic attendance (compared characteristics of 105 attenders with 105 non-attenders) and did not find evidence of a statistically significant difference (p > 0.05).
In contrast, one study112 – a prospective study of non-attendance in a physiotherapy outpatient department in Ireland – reported a statistically significant association between time of day of the appointment and did-not-attend rate. This study categorised attendance into three time periods – morning, early afternoon and late afternoon – in contrast to the studies above that simply used ‘morning compared with afternoon’. Late afternoon appointments produced a non-attendance rate of 6%, compared with 10% and 13% in the morning and early afternoon, respectively. A study126 in the USA reported that morning appointments were significantly more likely to be kept (72.1%) than afternoon appointments (65.8%).
It may be that the cruder classification employed by the first three studies reported above – grouping early and later afternoon appointments – failed to identify time of day that is associated with higher attendance. If the main obstacle to attendance is conflicting work commitments, then it would seem likely that late afternoon (or evening, if offered) appointments would be more likely to be attended.
Day of the week
The available studies identified in our review produced equivocal evidence regarding the link between day of the week and appointment attendance. One UK study based in a specialist alcohol treatment centre reported no evidence of a relationship between day of appointment and attendance. Authors undertook multivariate analysis of patient characteristics of non-repliers (n = 100), non-attenders (n = 100) and attenders (n = 100) and found day of appointment (Monday to Thursday; clinics did not run on Friday) did not have any significant bearing on patient attendance in response to referrals.89 Similarly, a study126 in the USA reported no association between attendance level at a family practice residency clinic and day of the week (65.8%).
However, three studies (two RCTs63,85 and a case–control analysis121) reported a statistically significant association between day of appointment and attendance rates, but the findings were inconsistent in terms of which days produced the best level of attendance.
A RCT in Portugal63 included 3899 patients of various ages across various outpatient clinics and found that looking at the overall attendance data (for reminder and control groups) patients were more likely to not attend in the middle of the week (Wednesday). In fact, the non-attendance rate increased from Monday to Wednesday and decreased from Wednesday to Friday. The authors suggest that this pattern can be explained by the fact that people going to appointments on Monday or Friday can skip their jobs and have an extended weekend.
A UK study121 exploring attendance behaviour at a gynaecology clinic, with an ethnically diverse and deprived patient population, employed a prospective case–control design to explore the association of day of appointment with attendance (105 attenders compared with 105 non-attenders). In contrast to the Portuguese study, the non-attendance rate was significantly higher on Mondays and Fridays than on other days (non-attendance rates on Monday and Friday were 17.6% compared with 15.1% on the other three days; p = 0.009).
Similarly, a RCT85 involving 679 patients invited for an appointment at two physical therapy outpatient departments in metropolitan acute public hospitals in Australia found higher non-attendance on Mondays and Fridays. The non-attendance rate on Mondays was 16% and on Fridays was 24%, compared with 10–13% on other days of the week. They also found that younger patients were more likely to not attend and speculated that this may be to do with difficulty attending during normal working hours.
Subsequently, a large-scale UK data analysis has produced some noteworthy results. Ellis and Jenkins127 conducted two related studies. In the first they examined attendance records for 4,538,294 outpatient hospital appointments across Scotland between 1 January 2008 and 31 December 2010. The did-not-attend rate was highest on Mondays (11%), lowest on Fridays (9.7%) and decreased monotonically over the week. In their second study, they analysed attendance records for 10,895 appointments at a single GP clinic in Glasgow, Scotland. Here again, did-not-attend rate was highest on Mondays (6.2%), lowest on Fridays (4.2%) and decreased monotonically over the week. A further observation was that this weekly decline was found in male and female patient groups of all ages, but was steeper for younger age groups. They conclude that the did-not-attend rate could be significantly reduced by preferentially loading appointments onto high-attendance days.
In addition to these studies that employed quantitative analyses to compare attenders and non-attenders, several descriptive qualitative and quantitative studies report, perhaps not surprisingly, the importance of appointments being compatible with other commitments. Again, employment commitments featured prominently.
A qualitative study in the UK115 exploring attendance behaviour among asthma patients reported that the inability to schedule appointments at a convenient time was considered a barrier to attendance. In another UK study,128 the authors reported that they had previously shown that 63% of patients attending the cardiorespiratory outpatient clinics would like out-of-hours clinics, largely because they are in employment during the day. A discrete choice experiment among 1200 patients presented respondents with trade-offs between two hypothetical, yet realistic, health conditions: an acute, low-worry condition and an ongoing, high-worry condition. For both conditions, one of the four valued components of appointment systems was a convenient time of day.
Explanations and implications for reminders
Higher levels of non-attendance at particular times and on particular days may primarily be explained by incompatibility with other commitments, particularly employment.
Several qualitative and descriptive quantitative studies identify incompatibility with other commitments as a reason for non-attendance. For example, in a qualitative study investigating the perspectives of young adults attending diabetes outpatient clinics in the UK,101 some respondents reported that the available hours at the clinic were not compatible with unsympathetic employers’ demands and that time booked off work for an appointment could sometimes be cancelled at very short notice. Addressing this aspect of non-attendance would clearly require attention to the appointment systems and clinic opening hours, rather than to reminder interventions.101
Addressing this aspect of non-attendance would clearly require attention to the appointment systems and clinic opening hours, rather than to reminder interventions.
However, available evidence suggests that the proportion of patients who actually miss appointments because they are unable to secure appointment times that are convenient varies considerably between settings. For example, in a UK study129 based in a genitourinary clinic, no patients reported that clinic opening hours prevented their attendance. Wilkinson and Daly130 report a small retrospective and prospective audit of 142 patients who did not attend their appointment at Care Plus and diabetes clinics in a large general practice in New Zealand, finding that work commitments or being unable to take time off work were cited by only four participants (although they identified the patient population as being predominantly > 65 years and highly deprived; therefore, potentially high numbers were unemployed). A descriptive US study of pregnant women (from a deprived and ethnically diverse patient population) found that 12% of no-show patients who were surveyed said that their reason for non-attendance was that their appointment was at an inconvenient day or time. Casey et al.131 conducted a small (n = 76) telephone survey over a 1-month time frame to determine reasons for non-attendance in patients who had missed their urology outpatient appointment and found that approximately 10% were unable to attend because of work commitments.
Thus, although it seems reasonable to assume that having an appointment time that is compatible with other commitments is important for all patients (albeit that some patients will consider that they have more competing commitments than others), available evidence does not suggest that large proportions of patients in different settings are unable to ensure such compatibility when the original appointment is made. The extent to which this is an important contributory factor to non-attendance will clearly relate to the appointment system and patient involvement in identifying the timing of the initial appointment (see Time to wait to the appointment).
Furthermore, incompatibility of appointment timing will translate into consistent patterns of higher non-attendance at certain times of day or on certain days of the week only if a significant proportion of people have commitments that are hard to shift on those particular times/days and are nevertheless offered appointments at those times. Again, it seems likely that this will be a more significant issue when appointments are allocated rather than booked in conjunction with the patient. It is also likely that any such patterns would be context specific, as daily and weekly work patterns vary between settings, thus reducing the transferability of findings across settings and highlighting that clinic managers and practitioners need to be aware of local schedules.
Aside from incompatibility issues, some studies have suggested that at least part of the explanation for higher non-attendance on certain days may be greater forgetfulness. For instance, a UK study121 exploring attendance behaviour at a gynaecology clinic found that a majority of patients cited ‘forgetting’ and family and work commitments as reasons for FTA and the authors postulated that patients are more likely to default on days falling after and before the weekend, as their daily routine is less regular. The authors also reported that these reasons might also be partly explained by the fact that the defaulters are, on average, 8 years younger than those who are compliant (38.93 vs. 46.44 years; p = 0.002) and, thus, may have school-aged children.
If people do indeed forget their appointments more when they coincide with certain days, then clearly reminders would be particularly important for patients with appointments on those days.
Time to wait to the appointment
The review generated strong consistent evidence that a longer time between the date of the appointment being made and the date of the appointment taking place is associated with higher non-attendance. Multiple primary quantitative comparative studies (across a range of contexts and patient groups) found a statistically significant association between time between appointment scheduling and appointment date and non-attendance. No studies were found that reported a lack of association between the time between booking and appointment and attendance behaviour.
In a UK RCT study based in a respiratory clinic,82 authors employed linear regression to explore predictors of non-attendance. They demonstrated that each increase in wait time for initial patient visits of 30 days resulted in a 25% increase in the no-show rate. Similarly, a study in a UK eating disorders clinic serving young adults and adults132 reported that the adjusted OR of attending an appointment was 2.4 times greater for those with short waiting times (≤ 4 weeks) than for those with long waiting times (≥ 5 weeks). A logistic regression model in which waiting time (in weeks) was entered as a continuous variable suggested that the odds of attendance at an appointment falls by 15% per week (OR 0.85, 95% CI 0.770 to 0.945; p = 0.002). A UK study121 in a gynaecology clinic serving an ethnically diverse and relatively deprived population also reported that the longer the interval between hospital appointment letter and the actual appointment date, the more likely patients were to default on their appointments (p = 0.001). Another UK study,89 based in a specialist alcohol treatment centre, also found that attendance was less likely with longer delays between referral and an appointment invitation being sent by the clinic. However, in this context the authors also noted that delays could result from both patient- and agency-originated factors contributing to the total waiting time and that patient delays might indicate greater ambivalence about their alcohol problem.
A review paper133 employing hand searches and forward citation searching focused on mental health services in the UK and also reported that waiting time to appointments was a factor that is consistently linked to higher non-attendance.
In addition to the UK studies, numerous studies from other settings report a negative relationship between attendance and time to wait for the appointment. A US study based at a veterans outpatient clinic134 found that missed appointments increased with time between scheduling and appointment up to 13 days, with the rate of missed appointments being between 10% and 20% when the interval was 1 day and between 16% and 25% for an interval of 13 days; however, they found no further rise thereafter. In contrast, for cancellations, the authors found that the rate continues to rise with time interval up to and beyond 1 month. A study of adult primary care in Geneva79 reported that having a follow-up appointment of more than 1 year was significantly associated with missed appointments. Similarly, an Australian study in a general hospital setting93 reported that those with a waiting time of more than 21 days until their appointment were significantly less likely to attend than those with a shorter waiting time (OR 2.8; p = 0.002).
Explanations and implications for reminders
Several papers identified through the review provided some insight into the reasons why a longer delay to appointment is associated with lower attendance.
First, unsurprisingly, forgetfulness is implicated as the cause of the association in several studies. For instance, in a study of adolescent outpatients in Switzerland,135 the authors reported that forgetting the appointment was a common cause and suggested that the higher non-attendance for appointments with a long delay probably reflects the greater risk of forgetting the appointment. Similarly, a study in a dermatology clinic in Italy136 concluded that as long delays to appointments were common; this explains why the most frequent reason given for non-attendance is forgetting the appointment.
However, other factors are also identified as potentially contributing to lower attendance when appointments are scheduled further in advance. First, it has been suggested that other issues are more likely to arise that mean the appointment timing becomes incompatible.135
It has also been suggested that when appointments are scheduled a long time in advance, patient symptoms may be resolved, either because they resolve themselves or because the patient (or referring health-care professional) opts to seek alternative care. For instance, an Irish study that examined appointments in a general surgical outpatients department20 revealed that resolution of symptoms accounted for almost one-third of missed appointments. The authors suggested that this finding questions the appropriateness of some referrals and suggests that many patients might be managed in the primary care setting. They suggest that in the absence of a quick referral, GPs may be forced to institute treatment measures as intermediate solutions and that these may often these prove sufficient to alleviate symptoms. In the Italian study,136 the authors also reported that a common reason for non-attendance was that the patient had been able to consult a private dermatologist in a shorter time.
However, some authors suggested that under particular circumstances, a long delay could result in reduced motivation on the part of the patient despite continued need. In the context of an eating disorders clinic, Bell and Newns132 noted that their clients ‘. . . may be at a motivational juncture and delaying their appointment on a treatment programme may mean that by the time their appointment is due, they are less ready to address change . . . All patients waiting for mental health care are potentially at risk of failing to engage’. Similarly, this association, also found in a study by Booth and Bennett89 in a specialist alcohol treatment centre in the UK, seems unlikely to be explained by patient symptoms/need having been resolved and more likely by a loss of motivation, which raises concerns about long appointment waits contributing to poor health. It may be that scheduling an appointment a long time in advance can convey the impression to the patient that the appointment is unimportant.
One study suggested an alternative explanation for the association between time to appointment and non-attendance. The authors of a study in a US veteran’s clinic134 speculated ‘it is known that clinicians vary widely in their selection of return visit interval, it is possible that characteristics of clinicians who choose shorter intervals affect these rates [of non-attendance and cancellation] rather than the interval itself’. However, the consistency of this relationship across contexts suggests that this mechanism, even if present, is unlikely to explain the observed patterns in their entirety.
It seems likely that the association between time to appointment and attendance rates will also depend on the nature of the appointment, in particular whether it is a one-off (or first) appointment or rather a regular (repeat) appointment that is scheduled at regular (familiar) intervals of some considerable duration. However, the available evidence did not provide any such exploration.
Keeping waiting times down remains a government priority with patient rights to receive non-emergency treatment within a maximum waiting time being enshrined in the NHS constitution.137 A short waiting time is also shown to be an important criterion for patients seeking care in many contexts. For instance, a discrete choice experiment128 among 1200 patients in which respondents were presented with making trade-offs between different levels of attributes for two hypothetical, yet realistic, health conditions: an acute, low-worry and an on-going, high-worry condition found that for both conditions one of the four key components of appointment systems that were of value was an appointment sooner rather than later (fourth out of four – behind choice of doctor, a convenient time of day and a doctor rather than a nurse).
Nevertheless, some appointments will necessarily be scheduled at longer intervals than others either because of constraints in appointment slots or because the patient’s treatment demands such an interval. The available evidence suggests some issues for consideration in relation to reminder systems:
- Reminders will be particularly important when appointments are scheduled well in advance.
- It may be useful to explain to patients why they are having to wait and why the appointment is, nevertheless, important.
- It is particularly important to provide easy ways to cancel when appointments are scheduled long in advance given that a proportion of patients will no longer need the appointment or no longer be able to attend.
- Keeping waiting times to a minimum is important (as already recognised) in clinics that deal with patients with serious conditions that are unlikely to resolve themselves, particularly mental health conditions that result in the patient’s readiness to engage with services fluctuating over time.
Patient involvement in the initiation and scheduling of the appointment
Several studies support the hypothesis that when patients make their own choice of appointment time and date, attendance is better. A US-based study of elderly patients attending a veterans clinic138 explored the effects of advanced clinic access on patient appointments. Patients were sent a letter advising them to call and make an appointment a month before their next anticipated visit. Advanced clinic access (or open-access scheduling system) worked for elderly veteran patients and indicated that they would prefer to schedule their next appointment than to use the previous system. A UK study in a paediatric hospital108 discusses ‘partial booking’, whereby patients are sent a letter inviting them to call and make an appointment. The authors report that the rate of non-attendance for first appointments was significantly lower for those who experienced partial booking than those who did not regardless of whether or not a reminder was sent (5.2% vs. 15.3% among those with no SMS reminder and 3.4% vs. 9.8% among those who did receive SMS). Murdoch et al.12 refer to an earlier study139 in which they achieved a reduction in non-attendance by asking patients to make their own appointments and confirm their intention to attend.
Closely linked to the above discussion is the issue of whether the appointment is patient or provider initiated. Service-initiated appointments will often be screening-type appointments for which most patients will not recognise any current symptoms or prompts. However, service-initiated appointments may also be referrals between departments. In both these cases, some studies suggest lower levels of attendance than when patients initiate the appointment themselves in response to some perceived need (see First versus follow-up appointments for a discussion of evidence on this).
Explanations and implications for reminder/attendance interventions
Better attendance rates when patients are engaged in initiating and scheduling their own appointment may reflect numerous different mechanisms. First, and perhaps most obviously, the timing is more likely to be convenient for the patient. Second, patients may be less likely to forget if they have made the booking themselves (and perhaps entered a note of it into a diary at the same time). Third, patients may be more likely to feel obliged to attend if they have booked it themselves (and may, therefore, take steps to overcome obstacles to attendance that arise, etc.). There is some evidence that asking patients to enter into an agreement by sending back a confirmation of attendance or contracting to attend may act to compel patients to attend their appointment.56,140,141 A more recent study142 adopted three specific mechanisms aimed at increasing attendance at primary care appointments, two of which can been seen to relate to engaging the patient more closely in the scheduling process with a view to reducing the likelihood of forgetting and increasing the feeling of obligation to attend: patients calling for an appointment were asked to repeat back the time and date of their appointment before the call ended and when booking follow-up appointments; patients were asked to write down the time and date on an appointment reminder card rather than health-care or reception staff doing it for them.
If patient involvement in appointment booking has an effect on causal pathways that a reminder intervention is also intended to address (e.g. prompting a forgetful patient, appealing to moral obligation) then, ceteris paribus, we would expect to find the baseline level of attendance to be higher and the reminder effect size to be lower in contexts in which patients are engaged in original booking than when they are not (because there would be fewer patients within the patient population who experienced the obstacle to attendance that the reminder seeks to overcome). The UK-based study by Milne et al.108 did indeed find a smaller absolute reduction in non-attendance, from 5.2% to 3.8% (i.e. a difference of 1.4%) among those who experienced partial booking, than among those who did not, for whom non-attendance fell from 15.3% to 9.8% (i.e. a difference of 5.5%).
A shortcoming of some of the studies of the effectiveness of reminder interventions is that the pre-existing appointment system into which the reminder intervention is introduced is not always adequately described nor taken into consideration as a factor that might influence the effectiveness of the reminder in the current or other contexts.
Greater involvement of patients in the scheduling of their appointments appears to be beneficial in increasing attendance rates. However, it is worth noting a recent evaluation141 of the UK ‘Choose and Book’ initiative aiming to involve patients in the scheduling of their hospital care has reported that patients did not, in practice, experience the degree of choice over date, time and location that Choose and Book was designed to deliver.
If appointments are necessarily service initiated rather than patient initiated, efforts will often be needed to increase patient perception that attendance at the appointment will positively contribute to their health/well-being and will not imply any significant risks, downsides or inconvenience. Reminder systems in relation to such appointments will likely also need to address these issues rather than simply serve as a prompt for the date and time of the appointment.
First compared with follow-up appointments
As discussed above, a small number of studies48,89 have examined whether reminder effectiveness varies according to whether or not an appointment is a first or a follow-up, but findings are rather inconsistent. The review also identified several studies that explored attendance behaviour more generally in relation to first compared with follow-ups and, again, the findings were equivocal.
Five quantitative papers74,98,108,121,135 reported higher no-show rates for follow-up appointments in comparison with initial appointments, with most speculating that this is because initial appointments are more likely to be prompted by the patient rather than the provider (see Patient involvement in the initiation and scheduling of the appointment).
However, four quantitative comparative studies59,82,84,85 reported higher no-show rates for initial rather than for follow-up appointments. Suggested explanations related to patient–provider relationships and perceived value of the appointment (see Patient–provider ‘alliance’, communication and ‘engagement’). A UK study based in a respiratory clinic82 found that the overall no-show rate was significantly higher for new patients than for established patients. A study of a general adolescent clinic in New Zealand84 reported that 22% of new appointments were not attended compared with 9.5% of review appointments (OR 2.7, 95% CI 1.1 to 6.8; p = 0.034), although this no longer reached significance in a multivariate analysis.
Furthermore, some studies63,112 report no significant differences between first and follow-ups in non-attendance.
Explanations and implications for reminders
Clearly, the results of studies comparing first and follow-up appointment attendance are equivocal. It seems likely that more sophisticated study designs are needed to fully understand the processes that are in operation. Indeed, explanations for the results presented have largely been speculative in studies reported to date.
Foley and O’Neill,98 in their study of a UK dental clinic, reported that there was a significant cohort of patients who attend as casual patients with dental pain or facial swelling and who, having received symptomatic relief of their symptoms, do not attend for further appointments that are often booked with the non-specialist dentists. Similarly, in their study of antenatal care among a deprived US population, Maxwell et al.74 speculate that higher no-show rates for follow-up visits relate to the ‘crisis-oriented health care-seeking behaviours’ of the patient population and the fact it is often the patient who identifies the need for an initial visit, while the provider often identifies the need for follow-up care. Therefore, follow-up visits may not be as highly valued by the patient.
In contrast, Roberts et al.82 suggest that higher attendance among established patients compared with new patients is explained by established patients feeling a connection with their provider and, therefore, being more likely to attend the appointment to maintain the relationship and continuity of care. Similarly, in their study of physiotherapy in New Zealand, Taylor et al.85 speculate that higher attendance for review appointments may be because of ‘developing an understanding of benefits of attending and establishment of a relationship with the treating therapist’.
The above findings suggest that reminder interventions are appropriate for both first and follow-up appointments, but that the distribution of reasons for non-attendance among those who do not attend may differ between these two scenarios as well as across service contexts and may therefore warrant different types of reminder input.
Patient–provider ‘alliance’, communication and ‘engagement’
The review yielded some evidence on the issue of whether or not the degree of provider–patient ‘alliance’ or patient ‘engagement’ with the treatment process affects levels of appointment attendance. Five descriptive qualitative studies from contrasting UK service settings provided evidence that the relationship between the patient and the service can impact on attendance behaviour.
A study143 employing focus group discussions and interviews with 43 drug users identified various barriers to treatment uptake, including perceptions of long waiting times, stigma and a perceived lack of understanding among providers. A qualitative study115 involving 50 patients with asthma illustrates how the patient’s perception of his or her relationship with the doctor and the treatment received was an important factor shaping attendance. In this study, patients reported that a desire not to jeopardise what was seen as an important relationship with their doctor was a factor that could influence their attendance behaviour. In contrast, an existing poor relationship with the doctor would deter some patients from attending an appointment with that doctor.
Similarly, a qualitative study101 explored the reasons for attendance behaviour from the patient viewpoint at a UK young adult diabetes outpatient clinic. Semistructured interviews were conducted with a purposive sample of 17 patients. An important theme linked to attendance was the behaviour of health-care professionals. The authors noted that, while previous studies of non-attendance assume a causal connection between missed appointments and associated higher HbA1c, results from this study indicated that fear of being ‘told off‘ for failing to reach biomedical targets was an important factor in the decision not to attend. In other words, health professionals’ negative reactions to patients exhibiting poor control of glucose levels encouraged non-attendance. The respondents valued friendly, positive behaviour among both reception and clinical staff.
In another qualitative study144 investigating the perspectives of 12 long-term non-attending adults with diabetes, several respondents reported feeling fearful and anxious about attending the diabetes clinic and identified the counterproductive use of ‘fear arousal tactics’ employed by some health professionals.
. . . I can honestly say that there’s a type of depression when I go out there [the diabetic clinic]. Every time I go in . . . all I hear is . . . ‘You’re gonna go blind, you’re gonna have your legs amputated, your arteries are gonna clog up’ . . .
Patient called Liam144
Lawson et al.144 also identified that the main differences between groups of patients who seek structured care and those who do not is that those who seek structured care appear to need the support and reassurance that can be offered by health-care professionals.
In another UK study,145 focus groups and semistructured interviews were used to explore communication experiences of 30 pregnant women from diverse social and ethnic backgrounds affiliated to a large London hospital. The authors concluded that poor communication and lack of empathy among providers could act to discourage patients from attending appointments. They further noted that constructive communication styles, characterised by empathy, openness, time to talk through problems and proactive contact such as reminders or text messages, were more likely to reassure patients, facilitate information exchange, foster tolerance in stressful situations and improve attendance at appointments. They identified features of poor communication as including insufficient discussion and discourteous styles of interaction. The authors also concluded that providers require communications training to encourage empathic interactions that promote constructive provider–user relationships and better use of technologies to improve communication with patients.
The review also identified a qualitative study123 employing focus group discussions with 43 women in Turkey exploring attendance for breast screening that reported similar findings. Authors reported that women demanded a friendly and tolerant approach from health personnel who were making recommendations for screening programmes. One of the women participating in the study suggested that she would not hesitate to attend an appointment with a male doctor provided the interaction was genial and enlightening.
As well as supportive and respectful behaviour, ‘navigational support’ – which provides information and guidance regarding how the health system works and what to expect from treatment/care – has also been suggested as important.145
Thus, several studies identified through the review concluded that a supportive, non-judgemental attitude of the health-care professional and a responsive service more generally is considered important by patients who are considering attending their clinic appointments. These review findings echo those reported in the much wider body of research literature that explores issues related to the relationship between patients and the service on offer, employing such concepts as ‘therapeutic alliance’, ‘(dis)engagement’ and ‘trust’.146,147
In addition to the research literature, the importance of developing a close service–patient relationship has been recognised in several practice settings, particularly those dealing with long-term conditions and more vulnerable patients. For instance, Comfort et al.61 highlight the many strategies that have been tried out in substance abuse treatment settings to improve patient engagement and patient–service alliance, although they note that few have been carefully evaluated.
Explanations and implications for reminders
The studies highlighted above suggest that, when there is a poor relationship between the patient and the service (or particular providers within the service), the patient will tend to perceive the likely costs of attending an appointment to outweigh any anticipated benefits, for instance because interactions with staff will be unpleasant or stressful or because the care/treatment on offer is perceived to be inappropriate, unhelpful or even risky/harmful.
These findings suggest several implications for reminder systems and wider intervention to support attendance. There may be some, relatively simple, measures that can be taken to ensure that reminder systems do not have a negative effect on patient engagement and patient–provider relationships, for instance ensuring that patients receive reminders in the format of their preference and do not receive reminders that they find irritating or stressful.55 It is worth noting that several of the reviewed studies highlighted the fact that many patients view regular communication from their health professional positively, so that reminders may actually contribute to a more positive patient–service relationship.
High levels of non-attendance are likely to reflect obstacles to attendance over and above forgetfulness and may be reflective of poor patient experiences and low levels of therapeutic alliance, such that reminder systems alone are unlikely to be sufficient to achieve high levels of attendance.
Although many patients indicate that they are happy to receive a reminder (see Chapter 6, Other reminder characteristics), there is a risk of antipathy from a sizeable percentage of patients who feel negative or very negative about reminders. Those who were disturbed by the reminder gave the following reasons: telephone call too early in the morning, they were waiting for other important results, they were contacted at work, felt that were being treated as senile or felt that the reminder was unnecessary.79
Service features
In addition to the engagement/alliance issues discussed above, the review highlighted two other service-related features that have been explored in relation to attendance behaviour: service location and related transportation/access issues, and seniority/identity of the health-care practitioner providing the appointment.
Service location and transport difficulties
The review indicated that service location and transport difficulties have been implicated in non-attendance in both research and practice interventions across a variety of settings. However, the available evidence regarding the impact of service location on attendance levels appears somewhat limited and equivocal, suggesting that the importance of transportation issues is likely to vary importantly between service settings and patient groups.
Several descriptive studies identified transport difficulties as a reason given for non-attendance in diverse settings. For example, a US study118 reported that the main reasons associated with missed appointments in paediatric clinics were effort (waiting time, distance, transportation, parking), communication (misunderstanding about appointment time and date) and forgetting. Hamilton and Gourlay148 conducted 120 face-to-face survey interviews with women who had missed maternity appointments in the London Boroughs of Richmond and Newham. Almost 70% considered transport the main reason for their missing an appointment and more than half the women had dependent children and reported difficulties travelling with their children to hospital, especially where this travelling was on public transport. In a qualitative Turkish study123 focused on breast screening attendance, respondents noted that receiving the screening procedures in a familiar institution would be more convenient. Those women who discussed transportation facilities as something they were concerned about shared lower socioeconomic status.
However, in contrast, one descriptive study130 of diabetes patients in New Zealand (n = 142) reported that transport difficulties/location issues affect only a small proportion of patients and are not a major reason for non-attendance, with just 2 out of 142 patients giving this as the reason for missing their appointment. Furthermore, the available quantitative studies in the review produced equivocal evidence on the relationship between travel distance and appointment attendance.
Three quantitative studies explored the association between travel distance and attendance. One quantitative study89 indicated that location of the clinic may affect attendance, but only for patients who live very close to the clinic. This UK study based in a specialist alcohol treatment centre undertook multivariate analysis of patient characteristics of non-repliers (n = 100), non-attenders (n = 100) and attenders (n = 100) and found that patients who had a very short distance to travel were more likely to attend their appointment. The distance variable was calculated from patient postcodes. These were divided into four bands on the basis of distance from the clinic (with band 1 being the immediate surrounding area). Patients living in distance band 1 were more likely to attend than patients living at all other distances [OR vs. distances 2, 3 and 4: 4.41 (p < 0.001), 3.12 (p < 0.01) and 3.32 respectively (p < 0.05)]. Further from the clinics, there was no difference between attenders and non-attenders and there was also no effect of distance on the likelihood of replying to the appointment invitation. The authors speculated that, although the clinics were easily accessible by public transport, the cost of travelling probably reduced attendance by some patients. They cited previous observations, from a US treatment manual,149 that problems arising from lower socioeconomic status, including lack of transportation and a telephone (which would, in addition, make it unlikely that patients would cancel their appointments), may lead to decreased chances of attendance specifically for treatment of alcohol problems. Other research150 had previously demonstrated that distance travelled is also correlated with non-attendance at a specialist alcohol clinic.
One small RCT in the USA,61 that sought to explore whether or not a series of interventional supports could improve attendance levels among substance abuse patients, found no significant effect overall, but reported that van transportation was the most frequently used element of the package of support that was on offer. However, two quantitative comparative studies60,82 concluded that service location is not related to attendance; and one study113 suggested that patients living closer to the clinic were more likely not to attend.
A US study60 of attendance at a paediatric dental clinic serving a deprived population reported that 85% or more of patients travelled < 1 hour to the appointment and that only 3 of the 28 long-distance patients (> 1 hour) failed to show up for their scheduled appointment. The authors also reported that the long-distance patient group demonstrated better punctuality than the study group as a whole. They speculated that this may reflect the greater degree of planning required for the long-distance drive or the practice of co-ordinating multiple health care. Similarly, a UK study82 of respiratory outpatients, employing a randomised controlled design and involving 504 patients, reported that travel distance was not associated with attendance.
Interestingly, findings from a UK service evaluation113 of a genitourinary clinic involving telephone interviews with 182 non-attenders contradict the hypothesis that easier/closer appointments are more likely to be attended. Patients were significantly more likely not to attend if they were unemployed, resident within the local catchment population area (i.e. Southampton Primary Care Trust area) and had previously accessed genitourinary medicine (GUM) services. The authors speculate that as such patients do not have competing employment demands, live close to the clinic, have previously made and kept GUM appointments and do not cite clinic opening hours, or similar, as a reason for not attending, their non-attendance does not reflect problems of accessibility.
A brief scan of the wider literature also suggests some varying degrees of success for interventions that have sought to overcome transport difficulties and, thereby, improve attendance at appointments. For example, Ogilvie and Mayhew151 report on a carefully conducted audit in the UK and conclude that holding appointments for school-aged children at schools rather than clinics was an effective way to increase attendance by parents and children. In contrast, Bell et al.125 evaluated an intervention through which private transport was provided to minority ethnic women, but found no increased uptake of breast screening appointments.
Explanations and implications for reminder/attendance interventions
The variable findings across different studies examining the association between travel distance/accessibility and attendance highlight several complexities and considerations.
First, varied measurement approaches between studies can compromise their comparability; for instance, while some studies use travel time, others use travel distance. Furthermore, the qualitative studies indicate that clinic accessibility is composed of multiple components not simply being a function of distance or travel time. Potentially, these include travel costs, ease/difficulty of parking and public transport availability on the route. It is possible that such dimensions vary between patients who are grouped according to travel distance or travel time and also between clinic contexts that appear to have similar patient profiles in terms of travel times/distances. For example, the ability to park near to the facility may be more of an issue for parents bringing small children to an appointment than for young adults, who may be more likely to travel by public transport. These factors do not seem to have been tested rigorously in the current research base.
Second, it seems likely that transport issues (however measured) are more significant for some groups of patients than for others. The literature suggests that patients who are more socioeconomically deprived may experience transport-related obstacles to attendance more often than more advantaged patient populations, for instance because travel costs are more prohibitive or because they are more reliant on public transport (see Deprivation). Transport issues may also be more relevant to patients with young children and the elderly.
Third, Swarbrick et al.129 suggest that more readily accessible clinics can actually encourage non-attendance, noting of non-attenders that ‘such patients appear capable of accessing GUM clinic services without difficulty, and may be prepared to miss appointments precisely because alternative access (whether through new appointments, or via “walk-in” services) is known to be equally accessible’. This suggestion alerts us to the fact that travel distances/durations and other aspects of physical accessibility may also inter-relate with appointment availability and booking systems, as well as patient motivations, to influence attendance behaviour.
It seems clear that further research is needed to fully understand the relationships between clinic location/transport issues and appointment attendance, but in relation to reminder/attendance interventions, the following implications can be drawn from the existing evidence base.
- Services should consider whether or not they can include within any reminder useful information that could aid patients’ journey to their appointment.
- Different groups of patients will experience the same journey differently.
- For some groups of patients in some settings, reminders will be insufficient to prompt attendance because transport difficulties over-ride the incentives to attend.
Seniority/identity of the health-care provider
Findings from the review were equivocal in relation to the effect of health-care provider identity/seniority on attendance. Three descriptive quantitative studies with adequate sample sizes reported a positive association between seniority/qualification level of the provider and attendance rate.
A UK study based in a dentistry clinic98 reported that significantly more patients failed to attend their appointment with non-specialist dentists and a similar pattern was observed at clinic level, with the non-attendance being low at specialist staff clinics but high at non-specialist staff clinics, although the difference did not attain statistical significance. Similarly, a study135 in Switzerland of adolescent attendance at outpatient clinics explored the characteristics of non-attenders (n = 2193, women = 1873) and found that the intended provider being a member of the paramedical staff (vs. a physician) significantly increased the risk of missing appointment for females with a somatic diagnosis but not for those in the psychiatric model. The risk of missing an appointment was also increased among those who had consulted a paramedical provider at the last appointment. The most prominent factor predicting non-attendance was the intended provider, with a non-weighted probability of non-attendance of 6% for physician appointments compared with 17% for paramedics. In another Swiss study,79 the authors examined attendance at a primary care and ambulatory HIV clinic in a deprived Genevan population and studied the characteristics of 2123 patients included in a RCT and found that being cared for by a junior doctor rather than a senior doctor was significantly associated with missed appointments. Analysis of predictors of non-attendance showed an OR of 0.5 (senior vs. junior; 95% CI 0.27 to 0.93).
In addition to these primary studies, the review identified a study by Magnes97 that included a limited review of earlier work on psychiatry outpatient attendance. This study identified a paper by McIvor et al.152 in which non-attendance rates were examined by cross-sectional survey of 482 patients seen by psychiatrists of different grades and a consultant clinical psychologist over a 21-month period. The clinical psychologist’s patients had the lowest rate of non-attendance (7.8%), followed in turn by those of consultant psychiatrists (18.6%), specialist registrars (34%) and senior house officers (37.5%).
However, in contrast to the findings reported above, a study of physiotherapy in Ireland112 reported higher non-attendance for appointments with senior grade staff and suggested various reasons why this might be the case. This prospective study found that non-attendance rates were significantly higher for senior grade (12.7%) than staff grade (8.9%) physiotherapists. A survey by Murdock et al.12 found that fear of being seen by a junior doctor rated fifth on a list of reasons for non-attendance alongside more common explanations.
Explanations and implications for reminders
Several mechanisms are suggested for differences in attendance behaviour by type of provider to be seen. Differential attendance may relate to patient perceptions of the importance of attending the appointment and/or to the quality of care they expect to be received.
A study128 using a discrete choice experiment among 1200 patients in which respondents were presented with trade-offs between two hypothetical, yet realistic, health conditions – an acute, low-worry condition and an on-going, high-worry condition – found that, for both conditions, the two of the four key components of appointment systems that were of value were being offered a choice of doctor and a doctor rather than a nurse.
Magnes97 suggested that factors such as continuity of care, perceived clinical competence and the provision of non-medical interventions might have an impact on attendance rates.
Chariatte et al.135 observed that the risk of missing an appointment was also increased among those who had consulted a paramedical provider at the last appointment, suggesting that expectations for a subsequent appointment may well be shaped and modified by past experience. However, differential allocation of more serious cases to higher-grade staff could also affect the rates of attendance. This could be because less serious cases may resolve themselves before the appointment or patients with less serious cases may be more likely to forget their appointment or to prioritise other commitments over appointment attendance. In a mental health context, there is specific concern that more serious cases are more likely to be those that do not attend.
French et al.112 cite an earlier study by Brookes153 that reported a perceived increase in the rate of non-attendance for the senior therapist as a result of such factors as leave and transfer of patients from other staff. However, these anecdotal reasons lacked detailed analysis. In this study, it was noted that one senior therapist who was specialised in one particular area with a complex group of patients had a did-not-attend rate of 45%.
It is unclear what implications can be drawn from these findings in terms of reminder systems. It could be argued that reminders should not indicate which health-care professional will be seen; for instance, the practice in some clinics is always make the appointment under the name of the senior provider, even if the practitioner to be seen will be another member of staff. However, this could potentially be counterproductive for those patients who have established a positive relationship with a practitioner whom they would like to see again.
More generally, it would seem important to monitor attendance patterns by individual members of staff as well as grades of staff in order to identify any patterns indicative of issues to be addressed, such as poorer engagement/alliance achieved by particular staff, while recognising that attendance levels will be influenced by such factors as the types of cases referred to different providers within a team.
Wider social system (conceptual framework domain D)
Our conceptual framework hypothesised that factors operating at the level of the wider social system including norms of behaviour, values, attitudes and prevailing understandings, as well as structural factors, could act as enablers or obstacles to attendance and might, therefore, be of relevance to how reminder interventions operate in different contexts or for different population subgroups. In general, however, our review did not generate very much information on this area. This reflects the fact that most reminder-related research has taken a rather narrow focus. Nevertheless, we highlight key themes flagged up by our review for which there are wider bodies of research evidence that warrant consideration by those seeking to enhance attendance levels.
Norms, attitudes and understandings regarding the (dis)benefits of health care on offer
The prevailing norms, attitudes and understandings within a ‘community’ might be hypothesised to shape attendance behaviour because they could influence patient perceptions that attendance at the appointment will positively or negatively contribute to his/her well-being. However, while our review yielded evidence to suggest that how an individual rates the health care on offer is a factor that influences attendance (see Seniority/identity of the health-care provider), we did not identify evidence that related to factors operating at the level of the wider social setting or ‘community’.
Nevertheless, it is important to note that prior literature covering a range of care settings has identified the relevance of shared norms, values and meaning systems within ‘communities’ in shaping individual health-care behaviour, including appointment attendance, particularly for marginalised groups of patients. For example, the meta-synthesis of qualitative work by Downe et al.154 on antenatal care uptake identified several shared perceptions among marginalised groups relating to quality of care, the trustworthiness and cultural sensitivity of staff and feelings of mutual respect that shaped attendance. Similarly, Manderson and Allotey155 report of the ‘story-telling’ about health services that takes place within immigrant communities in Australia and shapes their uptake of health care.
Indeed, evidence that patient behaviour is influenced by the values and attitudes of their immediate peers has underpinned various recent interventional approaches aimed at enhancing health-care engagement, including appointment attendance. For example, Turner et al.156 compared the effectiveness of a telephone call by a peer coach compared with an informational brochure in increasing attendance for colonoscopy among 275 patients who had a poor attendance record in primary care and found that the peer coach had a greater impact. Greenhalgh et al.157 have developed interventional approaches using story-telling techniques that are grounded in the finding that patients from some minority ethnic and cultural backgrounds often learn about health and the health system through informal interactions with other members of their communities through which shared meanings and norms are established.
Norms, attitudes and understandings regarding condition/symptoms
In our conceptual framework we also hypothesised that norms, attitudes and understandings relating to particular conditions or symptoms might also shape attendance behaviour.
One study143 found that the behaviours and attitudes of the wider population (significant others) around certain health conditions may influence patient attendance at health-care appointments. In this qualitative study of ‘hard-to-reach’ heroin users who were not currently in structured treatment, subjects reported that the experience of stigma within individual relationships (e.g. GP, family or friends) and social groups impacted on either their intention to attend or actual attendance at appointments related to their substance abuse.
Furthermore, Ambrose and Beech17 observe that primary care psychiatric nurses have tended to schedule client appointments in the community setting, usually in GP surgeries or health centres, with the intention of minimising stigma and easing accessibility, a factor with a positive impact on attendance. A further study158 observing attendance behaviour among patients attending a Spanish allergy clinic, 3 years after setting up and launching telephone reminders for patients’ first appointments, suggested that one possible reason for continued non-attendance could be related to cultural factors related to certain pathologies.
Clearly, these findings from the review were rather limited and it would of interest to explore the wider literature on stigma and how this relates to appointment attendance (see, for example, Scambler159).
Norms, attitudes and understandings regarding whether or not attendance is the morally right thing to do
We hypothesised that prevailing norms and attitudes might influence attendance through the way they construct attendance as (in)appropriate or (il)legitimate or indeed the morally right or wrong thing to do. However, none of the included studies generated information on this aspect.
However, wider literature does relate to these issues. So, for example, there is work that shows that non-attendance at health-care appointments can, in some cases, be explained by patients (usually women) prioritising the care of their children or husbands over their own health because they perceive this to be what is expected of them by significant others and to behave otherwise might bring condemnation.160 There is also past work on patterns of screening uptake that has linked attendance to patient perceptions of moral obligation to perform this health behaviour.161
A recent study focused on non-attendance has sought to use social influence to reduce no-shows at primary care appointments in the UK. As well as other interventions, Martin et al.142 replaced signs in the clinics that had communicated the number of patients who did not attend appointments in previous months with signs that conveyed the much larger number of patients who do turn up.
Explanations and implications for reminders
Whether and how societal/community-level norms, attitudes and understandings shape attendance behaviours among different groups of patients deserves greater investigation and there is greater scope to consider how these factors might be relevant to the design of reminder interventions.
Structural factors
As discussed above, the review generated quite a large amount of evidence to indicate that structural factors can influence whether or not reminders are accessible to particular groups of patients (see Chapter 4, Proposition B: reminder accessibility). In addition, several studies highlighted the ways in which structural factors affecting particular communities can result in higher levels of non-attendance. We discuss these factors under Patient characteristics as they relate to groups of patients with particular characteristics.
Patient characteristics
Our review indicated that various studies have explored whether or not levels of attendance vary between groups of patients identified by particular individual characteristics, but that findings are inconsistent. These studies have not always been designed to support such comparative analyses and sampling design and sample sizes may, therefore, compromise the results in some cases and provide partial explanation for the inconsistency in findings across studies. Nevertheless, the inconsistent findings are also suggestive of the importance of factors, perhaps related to the practice setting, nature of the appointment or wider social setting, that moderate the associations between patient characteristics and attendance. This is, of course, not surprising as each of these distal factors must operate through some more proximate mechanisms which, as discussed in the sections above, are sensitive to a range of factors. Here we provide an overview of the findings that emerged from our review organising the materials into three main sections: demographic and socioeconomic characteristics (age, gender, ethnicity and deprivation), health- and well-being-related patient characteristics (substance misuse, mental health, co-morbidity and severity of illness) and past attendance behaviour. While not completely exhaustive, we felt that these patient characteristics are those that are most likely to have potential utility in identifying categories of patients or constructing patient population profiles that might inform clinic managers or clinicians designing interventional approaches to improving attendance levels.
Demographic and socioeconomic characteristics
Age
Our review indicated that age has been found to be associated with attendance behaviour in a large number of studies across varied geographical and clinic settings. Despite the fact that differences in the categorisation of age groups complicates comparisons across studies, a largely consistent pattern is reported among adult patient populations of higher levels of non-attendance among younger patients than older patients.
Sharp and Hamilton162 provide an informal review of the evidence on non-attendance and report that youth is frequently found to be associated with hospital non-attendance. Parikh et al.,77 in their study of outpatients from 10 clinics in the USA, used linear regression modelling to demonstrate that, for every 1-year increase in age, the absolute no-show rate decreased by 2.4% (p < 0.0001). Similarly, Costa et al.63 found a decreasing level of non-attendance rate with increasing age in their study of outpatient attendance at a district hospital in Portugal. In their study in primary care of patients receiving lipid-lowering therapy in the Republic of Korea, Cho et al.59 noted age differences in attendance, with older adults being more likely to attend than younger adults. In a study of primary care attendance in urban Geneva,79 missed appointments were significantly associated with younger age. Similarly, Booth and Bennett89 found that older patients were more likely than younger patients to attend their assessment appointments at an alcohol treatment clinic. Waller and Hodgkin163 examined attendance patterns across nine general practice clinics in the UK and reported that non-attendance rates were highest among young adults. The investigation by Moore et al.126 of over 4000 appointments at a family practice centre in the USA found that older patients were less likely to fail to show than younger patients and that appointment keeping increased with age. Thus, an older person was 1.18 times more likely to keep an appointment than a person 10 years younger (OR 1.18, 95% CI 1.13 to 1.23). Neal et al.108 also report higher non-attendance rates at clinical services among younger patients in the UK general practice context.
Patterns of attendance for children across ages or in comparison with adults are less clear and, as in the UK context they are often attending specialist paediatric clinics, it is difficult to draw direct comparisons. In their study of appointment attendance in a Scottish general dental clinic, Patel et al.164 reported the highest rate of non-attendance among the 21–30 year age group, followed by 31–40 years and then 11–20 years. Clearly, this study focused on younger patients and grouped children with young adults, which may explain why the observed pattern was not similar to the patterns presented in previous studies. Bos et al.55 examined attendance at an orthodontic clinic in the Netherlands and found similar levels of non-attendance in patients aged under 12 years and 12–18 years (around 3.4%) but higher non-attendance in those aged greater than 18 years (8.1%), although numbers included in the study were small.
Explanations and implications for reminders
Numerous explanations have been advanced for the positive association between patient age and attendance. First, it is postulated that older people may have fewer competing commitments than younger people77 and that children in particular may have high rates of non-show because of their dependence on other people (usually working-age adults) to accompany them to an appointment.63 No studies were identified that explored the age group of parents/carers in relation to children’s attendance at appointments.
A second line of argument, however, is that older patients may be more likely to attend scheduled appointments because of the nature of their health condition and being more likely than younger patients to have multiple conditions necessitating appointment attendance77 or less likely to have symptoms that resolve themselves before the appointment date.89 Parikh et al.77 also speculated that older patients may be more cognisant of their own health care.
To date, there has been little detailed exploration of these alternative potential explanations. Nevertheless, as discussed in Chapter 4, Evidence statement (F.1): there is sufficient weak equivocal evidence to suggest that age does not have a differential effect, over and above pre-existing appointment behaviour, on reminder effectiveness (in terms of attendance, cancellations or rebooking) (evidence category IVa), there is good evidence that reminders are effective at improving attendance among all age groups. Furthermore, although rates of non-attendance are higher among younger patients, it is older patients who make up the majority of appointments, often at outpatient clinics where non-attendance costs the UK NHS an estimated £790M per year.165 Therefore, the findings reported provide no support for the suggestion that the use of reminder systems should be restricted to certain patient age groups. Furthermore, the findings here confirm the importance of reminder systems enabling patients to cancel and, if necessary, rebook their appointment with ease. However, as discussed above, there are important considerations to be made in relation to the type of reminder technology that may be most appropriate for different age groups (e.g. mobile phones remain less commonly used by older populations108).
Gender
Our review indicated that there is inconsistent evidence regarding differential attendance behaviour between male and female patients, but that researchers often confidently state that male patients are more likely than female patients to default on appointments.
Several studies reported higher levels of non-attendance among male patients than females. Sharp and Hamilton162 provide an informal review of the evidence on non-attendance and report that being male is one of the main associations with hospital non-attendance. Moore et al.126 investigated over 4000 appointments at a family practice centre in the USA and found that females tended to be less likely to miss appointments than males, although the effect was of borderline statistical significance in a multivariate analysis (OR 0.8, 95% CI 0.7 to 1.0; p = 0.06). Hon et al.122 report on a study of non-attendance at a paediatric dermatology clinic in Hong Kong and found that 67% of non-attenders were male and that males were more than twice as likely as females to fail to attend clinic (p = 0.010).
However, in contrast, Sims et al.96 found that gender was not a significant predictor of attendance at four adult community mental health outpatient clinics in London. Similarly, Bos et al.,55 in their study of attendance at an orthodontic clinic in the Netherlands, including both adult and child patients, reported no significant difference between males (n = 109) and females (n = 153). Meanwhile, Can et al.56 reported that females were twice as likely as males to not attend their appointment in their study of 232 new patients referred to an orthodontic clinic in England. Furthermore, Waller and Hodgkin163 examined attendance patterns across nine general practice clinics in the UK and reported that women were disproportionately represented among the group of patients who were frequent defaulters (defined as missing an appointment five or more times per year).
Explanations and implications for reminders
Given that the reasons behind any observed gender differential in attendance behaviour are likely to be shaped by gender-related factors, it is unsurprising that contrasting results are reported across geographical and cultural contexts. In general, however, the available studies that reported on attendance patterns did not explore in any detail the reasons behind any observed gender differentials.
Instead, authors have speculated about the underlying causes of observed gender differences in attendance. For example, when it was found that females were less likely to attend a dental appointment than males, Can et al.56 suggested ‘. . . that dentists may be more willing to refer a girl when the malocclusion is mild and following the referral the patients then change their mind about attending. This, however, is purely conjecture.’.
Some authors have suggested that differentials could arise because of different patterns of disease and symptomology between male and female patients. For example, Hon et al.122 were unable identify the exact reasons for higher non-attendance among male patients in their paediatric dermatology clinic in Hong Kong, but speculated that female referrals may involve more serious dermatological conditions. However, as noted above (see Sex), it is also recognised that differential patterns of referral for male and female patients, as well as differential responses by patients (and their carers/parents in the case of children), could also contribute to the patterns of attendance observed.
In relation to reminders, the available evidence on attendance rates does not suggest that reminder systems should be differentially employed for male and female patients, but clearly this is an area that warrants further investigation.
Deprivation
Our review indicates that there is weak but consistent evidence to suggest that deprivation status is a factor in attendance. Although the use of a variety of measures of deprivation or low socioeconomic status makes aggregation of evidence across studies difficult, as does variation in the economic context across geographical settings, there is nevertheless evidence from a range of studies that patients with higher levels of deprivation are more likely to miss appointments than those who are more affluent/advantaged.
Several studies employing individual measures have reported a negative association between deprivation or low socioeconomic status and the likelihood of appointment attendance. Sharp and Hamilton162 provide an informal review of the evidence on non-attendance. They report that deprivation is one factor that is commonly associated with hospital non-attendance. Ramm et al.166 compared attenders and non-attenders at a cardiac rehabilitation programme in New Zealand using simple univariate statistics and found lower levels of attendance among patients categorised as having a low socioeconomic status on the basis of their occupational grouping. In a study of colposcopy attendance in Cornwall, Oladipo et al.76 reported that younger, unmarried women of lower socioeconomic status were less likely to attend than more affluent patients. Another colposcopy clinic study,86 in Manchester, reported a similar association with deprivation. In their study of 232 new patients referred to an orthodontic clinic in England, Can et al.56 reported that patients living in an area of high social deprivation were 2.7 times more likely to fail to attend an appointment than people who were resident in more affluent areas (95% CI 1.1 to 6.5). A study167 (as cited by Dixon-Woods et al.168) of management of women with cancer found that significantly more patients from deprived areas failed to attend hospital appointments, although the difference was small.
A study that employed analysis at the aggregate clinic level also documented this association. Waller and Hodgkin’s UK study,163 in 2000, found that levels of non-attendance at general practice level showed a high correlation (Pearson’s r = 0.72; p = 0.028) with the score at each practice on the Townsend Index of Deprivation (attributed to practices according to the practice population in each enumeration district).
In contrast, a smaller number of studies report no difference in attendance levels between patients categorised by measures of deprivation or socioeconomic status, for example a study by Conduit et al.169 of attendance at a university-based psychology clinic in Australia. However, when no difference was reported, the results are often compromised by small sample sizes, questionable measures of socioeconomic status or low levels of socioeconomic diversity within the patient population.
Explanations and implications for reminders
A range of explanations have been advanced for why non-attendance is often higher among the more deprived sections of patient populations, as well as at clinic level for those clinics serving deprived areas. However, there has been little detailed exploration of these causal pathways in the literature that has focused on appointment attendance behaviour.
Several authors draw attention to the potential influence of structural factors, such as poor transport options,89,123,148,166 low ownership of landline telephones,89 low levels of social support and difficulties in arranging child care.86 A systematic review by George and Rubin18 identifies that the appointment systems themselves can prove a barrier to care. They may be particularly challenging to use for members of communities in areas of social deprivation, because such systems require resources and competences that are not readily available. People in these groups may have less predictable, chaotic lives that are not consistent with structured systems. They conclude that non-attendance can be viewed as the manifestation of a critical level of unsuitability in the agreed arrangements for an access episode. This perspective that problematises the rigid system rather than a perceived ‘difficult’ population is to be welcomed.168 As Dixon-Woods et al.168 point out, services that use appointments systems rely on people being able to read and require people to present themselves in particular places at particular times. Such services include immunisation and screening programmes, outpatient clinics and elective procedures, and these encounter very high rates of ‘default’ by more deprived people.
Higher levels of non-attendance may also in part be explained by the mobility of people in deprived populations. People who are in rented accommodation rather than owner occupation may change address much more frequently, and this puts them at risk of not receiving invitations (or reminders).103,168 The Fourth National Survey of Morbidity in General Practice170 found that 8% of people registered with practices were not at their stated addresses and were not contactable. At the more extreme end, people who are homeless or who live in travelling communities may not be sent or receive invitations to appointments at all171 while asylum seekers may face similar obstacles to receiving appointments and navigating the health-care system, resulting in high levels of non-attendance.78
Heath172 argues that all barriers to consultation should be examined to ensure that those on low incomes are not disadvantaged, giving the highly pertinent example of those without a telephone, who may be easily disadvantaged if appointment systems are rigidly enforced and largely organised by telephone, or if there is increased use of e-mail. Another concern regarding text messaging reminders is their possible impact on health inequalities, as people in higher socioeconomic groups, who are more likely to own a mobile phone, will be less likely to miss appointments.173 However, this concern may not be realised given mobile phone ownership statistics and other unpublished studies regarding mobile phone use and socioeconomic status.174,175 The availability of same-day compared with advance appointments and the potential for such appointment mixes to affect different groups of patients differentially has also been raised.176–178 It has been suggested that patients in deprived areas are more likely to use same-day appointments.177 A recent study found that patients receiving same-day care were likely to be in work and have a higher educational status.176 Sampson177 found differential levels of satisfaction with appointment mixes by age and by deprivation of practice population and concluded that it is important to accommodate the requirements of different patient groups by allowing both pre-bookable and same-day appointments; Sampson’s conclusions echo those of earlier studies.176,178
A further line of explanation for lower levels of attendance among deprived patient groups relates closely to the issues of patient–provider communication, therapeutic alliance and engagement discussed in section Patient–provider ‘alliance’, communication and ‘engagement’. One study103 has suggested the possibility that deprived groups are more likely than the better-off to hold a negative perception of health services on offer. Hussain-Gambles et al.104 report on the attitudes of health-care providers who perceived patients living in more deprived areas as lacking responsibility and missing more appointments, and suggests that these negative attitudes may not be beneficial to improving attendance. Patel et al.164 suggest that single parents and low-wage earners find dental treatment a low priority.
Associations between employment status and appointment attendance are also important to consider, since the most common reasons cited for missing an appointment, after forgetting it, are family and work commitments. However, the findings across studies are inconsistent and difficult to interpret because of the complex of causal pathways that may be in operation. First, as discussed above under Reported reasons for non-attendance, incompatibility of appointment timing with work commitments is commonly cited as a reason for appointment non-attendance. For instance, Roberts and Partridge179 had previously shown that 63% of patients attending their cardiorespiratory outpatient clinics would like out-of-hours clinics, largely because they are in employment during the day. However, the degree to which employment status presents a barrier to appointment attendance is likely to depend on both the type of employment and the appointment system on offer. It is suggested that people in lower occupational groups may have less flexibility at work and, therefore, face greater problems in negotiating time off work for health-care appointment attendance.168 However, people who are unemployed have been found in some cases to have higher rates of non-attendance than those who are employed (see, for instance, Patel et al.164) and they may face a different set of obstacles to appointment attendance that are linked to lack of income and structural factors.
The available literature tends to suggest that deprived populations face multiple obstacles to health-care appointment attendance. Thus, while simple reminders may be effective at prompting attendance among those who are at risk of forgetting their appointment, it seems likely that more sophisticated attendance interventions will be needed to achieve high levels of attendance. Clinics that achieve high levels of attendance despite serving patient populations with high levels of socioeconomic deprivation would warrant close investigation, as they may have introduced ways of working that could be transferable to other settings. Furthermore, as discussed above, reminder systems are very dependent on accurate and stable data from patients and so deprived populations with unstable contact details (either address or telephones) may mean these patients are disadvantaged.103
Ethnicity
Race and ethnicity are complex, contingent and contested biosocial concepts that have been operationalised in diverse ways in health-related research, making any attempt to compare and synthesise findings across studies fraught with difficulties.180 It is not, therefore, surprising to find that our review yielded rather inconsistent evidence on the association between (minority) ethnicity and attendance behaviour. Furthermore, compared with measures of deprivation, race/ethnicity appears to have been less often considered in attendance research, particularly outside the USA.
Patel et al.164 explored attendance at dental clinics in the UK and reported that Asian patients had higher non-attendance rates than English patients in an outpatient setting. In a study130 of non-attendance at Care Plus and diabetes clinics in New Zealand, the ethnic breakdown showed that New Zealand European people were under-represented as non-attendees in proportion to the enrolled population, while Pacific people were over-represented, accounting for 13% of non-attendances while constituting 3% of the enrolled population. Maori non-attendance (13%) was slightly higher than the enrolled population of 11%. An audit study181 of paediatric outpatients in a hospital in the West Midlands of England found differences in the appointment-keeping behaviour of patients by ethnicity. An original 1995 study had shown that non-attendance for clinic visits was around 33% for Europeans compared with 50% for Asian patients.182 A subsequent follow-up study in 1998, following interventions, showed a fall to 12.0% and 13.5%, respectively, with an overall rate of 12.3%.183
There is a much wider body of evidence that reports on the health-care experiences of minority ethnic patients in different settings, often highlighting issues of cultural (in)competence, lack of trust and in some cases inappropriate or abusive treatment. Some of this work has made direct connections to low levels of attendance and poor uptake of health-care interventions among minority ethnic groups as compared with majority populations (see, for example, Greer184).
Explanations and implications for reminders
Ethnic (and racial) categories are proxy markers for a host of inter-related factors that may affect attendance behaviours. In particular, the interplay of minority ethnic status and socioeconomic deprivation requires careful consideration. However, studies of attendance behaviour have largely failed to unpack ethnicity to examine causal pathways in any detail. Nevertheless, various potential explanations for lower levels of attendance among minority ethnic (or racial) groups have been suggested.
First, several studies identify language difficulties as contributing to lower attendance among some minority ethnic patients. For example, Maxwell et al.74 found, in a US multiethnic population, that reasons for non-attendance included a lack of understanding of the purpose of the appointment related to language difficulties. Similarly, a study in inner London148 suggested that language difficulties may result in problems in accessing available facilitators for attendance, specifically hospital transport. It is worth noting that one study reported no differences in attendance levels by language competency and has drawn attention to the fact that availability of translator services and advocacy for immigrant communities can help to ensure that there is no disparity in the delivery of services in this respect.121
Second, higher levels of mistrust and lower degrees of therapeutic alliance or engagement with services have been noted for minority ethnic patients across several studies (see, for example, Mir and Sheikh185).
Third, as minority ethnic populations often experience high levels of individual and neighbourhood deprivation, the structural factors identified above – such as transport difficulties, high levels of residential mobility and low access to telephones – frequently apply to these groups of patients. Interestingly, however, US observers have remarked that cellular phones are the first technology with a documented trend towards more use by other ethnicities than Caucasians. African Americans and English-speaking Latinos were identified among the most active users of cell phones.186,187 According to the Pew Report,186 more African Americans and Latinos than Caucasians own a cell phone (87% vs. 80%) and minority cell phone owners use a greater range of the features on their phones. Denizard-Thompson et al.187 found, in their study of low-income patients in an adult medicine clinic, that SMS messaging was more common among African Americans than Caucasians, and was more common among females and patients aged < 50 years. Although we must be cautious in translating such trends to a UK population, it is important to consider that the overall effect of mobile phone access may be to ‘leapfrog’ other technologies such as landlines, thereby widening access to services. Clearly, wireless mobile technology holds significant potential to improve communication regarding appointments and reminders and increase utilisation in certain underserved populations provided that patients have a mobile phone, can afford a mobile tariff and are able to utilise the full range of features available on their mobile phone. However, caution should be exhibited in recognition that Denizard-Thompson et al.187 observe that clinicians typically overestimated the usage of mobile phone technologies by their population.
Fourth, some studies have recognised that cultural factors may influence attendance behaviour for particular groups of patients in particular contexts. For example, in the study by Gatrad,181 various cultural practices found among the local Asian Muslim population were identified as potentially affecting attendance patterns and, therefore, requiring accommodation within the appointment-making system, such as lunchtime Friday prayers.
Patient indicators of health and well-being
Substance abuse
Our review yielded indicative evidence to suggest that substance abuse can be a factor in non-attendance. A study188 of patients with schizophrenia found that those who missed 20% or more of their appointments were more likely to abuse drugs and alcohol and manifested lower levels of community functioning. Clearly, the proportion of a patient population who are substance abusers will vary greatly between service contexts and geographical areas, with mental health services being the most likely to have large numbers of patients with this characteristic.
Mental health
Our review yielded indicative evidence to suggest that mental health status can be a factor in attendance. One study188 showed that patients who missed more than 20% of appointments in mental health clinics were more likely to abuse drugs and alcohol and exhibited lower levels of community functioning. Sims et al.96 reported percentages of missed appointments of 36% (in 2008), 26% (in 2009) and 27% (in 2010). The reduction in RR of failed attendance following a text message intervention was 28% between the 2008 and 2009 samples and 25% between the 2008 and 2010 samples.
Donaldson and Tayar189 conducted a feasibility study of use of SMS messages in mental health outpatients. They encountered some unexpected difficulties, for example, despite mobile phone ownership matching that expected for the national average (76%), only 74% of these could remember their telephone number and only 53% were agreeable to being contacted by text message. The authors concluded that although SMS appointment reminders appear to be a potentially useful and cost-effective method of improving psychiatric outpatient clinic attendance rates, it is ‘unlikely that psychiatric clinics would provide as impressive results as those reported in other settings’.189
Pennington and Hodgson190 conducted a non-randomised study of non-attendance to assessment for clients referred for psychological therapy in relation to invitation type. The study concluded that telephone invitations followed by a telephone prompting reminder significantly reduced non-attendance to initial assessment appointments. Limitations of the study included key variables being omitted or not being controlled which may have biased the findings, together with the small effect size.
Physical illness/comorbidity
Our review yielded evidence to suggest that poor health status or perceived poor health status can be a factor in attendance.
Roberts et al.111 used a questionnaire-based study to explore reasons for non-attendance among 204 outpatients at neurology clinics in Ireland and found that, after simply ‘forgetting’, being ‘too ill’ to attend was one of the most frequent explanations for missed appointments.
Killaspy et al.191 is one of several studies8,192,193 that demonstrates that non-attendance at psychiatric services is related to increased pathology and greater need, and serves as a corrective to suggestions that non-attenders may self-select because they do not need to be seen.
Alexandre et al.8 conducted an exploratory prospective cohort study in New Yorkers with low back pain. Part of their study investigated predictors of attending. Following multivariate analysis, the authors identified that the presence of other comorbidities, such as diabetes and hypertension, was associated with poor attendance at scheduled physical therapy sessions. As part of their RCT, Resnick et al.192 evaluated attendance at treatment visits among older women post hip fracture. At 6- and 12-month follow-ups, physical health (measured by evidence of comorbidities or overall physical health status) and mental health (measured by evidence of depressive symptoms or mental health status) directly influences attendance at treatment visits. Whitmarsh et al.193 investigated psychological variables predicting poor attendance or non-attendance at cardiac rehabilitation. Using multivariate analysis they found that poor/non-attenders at cardiac rehabilitation were distinguished by illness representations, distress and usage of coping strategies.
Explanations and implications for reminders
Although low levels of attendance among patients experiencing the above health and well-being-related characteristics, i.e. substance misuse, poor mental or physical health, and/or low levels of social support, may in part be explained by forgetfulness, it seems likely that other factors are also in operation that are unlikely to be overcome by simple reminder systems.
These characteristics are likely to be clustered within particular clinic populations, particularly clinics serving those with mental illnesses and elderly populations. Such clinics will need to consider more sophisticated interventions to support attendance. In addition, however, within any clinic setting, managers should be alert to the fact that patients exhibiting these characteristics may be particularly vulnerable to non-attendance and that simple reminder systems may further disadvantage them when compared with the general patient population.
Symptomatology and severity
In contrast to the tendency for some patients to be ‘too ill’ to attend their appointment, the review highlights the fact that attendance at appointments may also be less likely when patients do not recognise symptoms that warrant the appointment on offer. Several studies suggest, perhaps not surprisingly, that patients are less likely to attend when asymptomatic (for instance, when being called for a screening check) or when the symptoms they have are perceived to be minor or unconcerning.
Oladipo et al.76 report that patients referred to colposcopy are mainly symptom free and, therefore, exhibit some inertia to keep their appointments. Booth and Bennett89 similarly observed that patient contact with the referrer may be initiated after concerns about physical symptomatology or other crises, specifically within the context of alcohol disorders. Roberts et al.111 reported that when patients were ‘happy’ with their neurological symptoms they were more likely to be non-attenders. In her study of respiratory outpatient clinics in the UK, Roberts et al.82 cited Grufydd-Jones et al.,194 who showed that the main reason for non-attendance in an asthma clinic in primary care was low perception of severity. Parikh et al.77 report, within the context of the US health system, that if a patient thought an appointment was unnecessary (either the condition had resolved or the patient was able to self-manage the symptoms), he/she was less likely to show. As discussed above under Time to wait to the appointment, the higher levels of non-attendance with longer wait to appointment have been explained in part by the resolution of symptoms in the interim period. A study20 in a general surgical clinic in Ireland revealed resolution of symptoms to account for almost one-third of missed appointments. The authors questioned the appropriateness of referral, suggesting that many patients might be managed in the primary care setting. It may also be a function of delays in obtaining a specialist opinion. GPs may be forced to institute treatment measures as intermediate solutions, and often these prove sufficient to alleviate symptoms. This could be viewed as a successful outcome provided that the patients (or GP) contact the hospital to let them know of the resolution of symptoms in sufficient time to reallocate the appointment slot.
However, as Martin et al.142 observe, ‘one cannot assume that a did not attend is a medical condition resolved’. They further point out that ‘patients still present, but at less convenient times, in less appropriate care settings, with the additional health and financial implications that frequently accompany a worsened condition’. Being too ill to attend was discussed in the previous section (see Physical illness/comorbidity).
Explanations and implications for reminders
When patients do not recognise the need to attend an appointment, or see little value/benefit in attending, simple reminders are unlikely to encourage attendance, although they could be useful in encouraging people to cancel. Non-attendance in this context could be seen as a positive sign of resolution of symptoms without clinical intervention, a marker of inappropriate referral as judged by the patient or a warning sign of unacceptable delays in receiving an appointment. Clearly, when attendance is important, even for those who are asymptomatic or experiencing only minor symptoms, attendance interventions will need to enhance patients’ perception that attendance at the appointment will contribute positively to their health and well-being. There are, for example, studies focused on screening appointments that have evaluated the impact of different approaches to increasing patient perception of the importance of attendance that could provide useful insights for other health-care contexts for which low attendance is a problem, such as ‘stepped reminders’46,195 and patient navigators.196,197
Previous patterns of non-attendance
Our review indicated that whether non-attendance at health-care appointments can be predicted on the basis of past attendance patterns has been the subject of some interest in past research. For instance, several studies categorise patients into ‘high non-attenders’ or ‘frequent defaulters’ and try to isolate the characteristics of these patients. However, several studies suggest that patterns of attendance behaviour are unpredictable and that patients do not necessarily display consistent patterns of poor or good attendance over time.
Snow and Fulop101 reported that diabetic patients in their study could not be divided into ‘attenders’ and ‘non-attenders’ as many showed a complex record of attendance, non-attendance and cancellations. Non-attendance can thus be viewed as ‘the manifestation of a critical level of unsuitability in the agreed arrangements for an access episode, either from the outset or as a result of change in circumstances’.101 Within the study sample, participants could be grouped into those who made a cost–benefit analysis of the obstacles and benefits of going to clinic and those who did not think about it at all. However, some patients moved from one group to another over time. Waller and Hodgkin163 similarly concluded that it was difficult to predict non-attendance on the basis of past behaviour. They noted that most people who defaulted missed one appointment and did not default again. In addition, they found that, among those categorised as ‘frequent defaulters’ (missing five or more appointments in 1 year), most ceased to be frequent defaulters in the following year. The authors suggest that many of these patients may be ‘experiencing a life crisis of some form, or living a chaotic phase of their lives. They will have more pressing problems to deal with than their tendency to default.’163 They further suggest that prioritising the clinical management of the underlying health problem may be more effective in reducing non-attendance than the application of administrative processes to attempt and alter their behaviour.
However, Chariatte et al.135 found that in an adolescent outpatient clinic, the probability of missing an appointment was explained in their statistical models in part by having missed or cancelled the next to last appointment and having missed the antepenultimate appointment. Having missed the next to last appointment was found to be the most important of these factors, providing 39% of the total explanation.
At least two of the RCTs64,83 examined in review 2 were targeted at defaulters rather than at a general clinic population. The study by Rutland et al.83 included all patients aged from 16 to 30 years who did not attend a booked GUM appointment during a 6-month study period. In the study by Fairhurst and Sheikh,64 only patients who failed to attend two or more appointments in preceding 12 months were included. Rutland et al.83 recorded a reduction in non-reattendance of 3.7%, while Fairhurst and Sheikh64 demonstrated a reduction in the non-attendance rate of 5.3%. These rates appear fairly modest compared with some of those achieved in the general clinic population. This may suggest that, for this particular group, it is factors other than ‘forgetting’ that have acted as barriers to attendance.
Explanations and implications for reminders
Included studies were ambivalent with regard to whether or not previous non-attendance may predict future non-attendance. It seems largely intuitive that most people can find themselves in circumstances which mean that they may not be able to attend an appointment from time to time and that they may need to cancel an appointment;101 therefore, at a general level, it would seem sensible to send all patients a reminder which includes a message about cancelling an unwanted appointment and rescheduling for a future appointment if treatment is still required. For health services that do find that in their population there is a clear relationship between previous non-attendance and future non-attendance, and that there is a relatively high rate of ‘frequent defaulters’, more intensive reminder strategies such as the sequential reminder intervention described by Perron78 could be initiated. First, a telephone call to either landline or mobile; second, a SMS if participants do not answer the telephone after three attempts and have a mobile phone and, finally, a postal reminder if participants did not answer the telephone, had no mobile phone for SMS, or had no phone at all. Such a design, although labour intensive, would reach the maximum number of participants and may increase attendance rates while still being cost-effective.
- Patterns and influences on health-care attendance behaviour: a narrative overvie...Patterns and influences on health-care attendance behaviour: a narrative overview of key themes and issues - Targeting the Use of Reminders and Notifications for Uptake by Populations (TURNUP): a systematic review and evidence synthesis
Your browsing activity is empty.
Activity recording is turned off.
See more...