Non-attendance in musculoskeletal outpatients: the good, the bad and the ugly

Abstract

Background: Non-attendance, i.e. the failure of patients to keep scheduled outpatient appointments, is well recognised. In England, of the 100.5 million outpatient appointments made between April 2013 and March 2014, 7.0 million (6.9%) were reportedly not attended. National non-attendance rates for physical therapy are unknown.

Non-attendance is claimed to increase health costs, lower productivity and disrupt patient flow, resulting in poor access to health care, longer waiting lists, delays in diagnosis and treatment, sub-optimal care and poor clinical outcomes. However, the empirical evidence for these claims is limited.

Understanding the causal chain to determine whether non-attendance is a voluntary behaviour, or whether there are underlying health system characteristics beyond the patient's control, is essential in designing interventions to reduce non-attendance rates.

Purpose: To identify why patients fail to complete physical therapy care episodes, using mixed methods, in multiple musculoskeletal outpatient settings.

Methods: An observational, longitudinal study was undertaken in one primary care musculoskeletal service, with 15 patients, purposively sampled and referred with low back pain. All physical therapy appointments were observed and audio-recorded. The clinicians and patients were interviewed about their physical therapy assessments and treatments, and a thematic analysis was undertaken, using a framework approach.

In addition, two postal surveys were undertaken, in physical therapy departments in a large teaching hospital and a small community hospital, using retrospective sampling. Patients who had attended the department at least once in the last 12 months and failed to complete their care were sent a 25-item checklist about the reasons for not finishing their physical therapy, with space for free text.

Results: In the observational study 8/15 patients did not complete their care. The interviews (in patients’ homes) revealed rich data about their decision to not attend, with some mismatches evident between patients’ and clinicians’ perceptions, in the multiple factors identified.

In the teaching hospital, 12/50 (24%) of the questionnaires were returned, with a mean of 1 factor cited for not attending (range 0–5). The top 3 reasons reported for non-attendance were: ‘my condition improved’ (17%); ‘no improvement with physiotherapy’ (17%); and ‘advised not to attend by another health care professional’ (17%).

There were 25 mailed and 5 telephone responses to the 77 questionnaires in the community hospital (39%), with a mean of 2.1 factors cited for not attending (range 1–6). The top 3 reasons for non-attendance were: ‘no improvement with physiotherapy’ (27%); ‘my condition improved’ (23%); and ‘other health issues took priority (23%).

Conclusion(s): The factors influencing non-attendance in three musculoskeletal outpatient services included voluntary behaviours by the patient, behaviours exhibited by other patients, service constraints, environmental factors and resolution of symptoms. A mixed methods approach to understand the reasons for non-attendance enabled depth of data through the qualitative interviews and breadth through the surveys. Systematic collection of non-attendance data is recommended using mixed methods, to identify the contributing factors from the patients’ perspective.

Implications: Identifying local reasons for non-attendance, directly from patients, could help in designing and implementing initiatives to reduce non-attendance in physical therapy services and enhance efficiency.

More information

Identifiers

ORCID for L. Roberts: orcid.org/0000-0003-2662-6696

Catalogue record

Export record

Altmetrics