Non-attendance at a difficult-asthma clinic
Patients may miss difficult-asthma clinic appointments for several reasons; a study examined whether telephoning those who did not turn up improved future attendance
In this article…
- Possible reasons why appointments might be missed
- The usefulness of follow-up phone calls
- Suggestions for improving attendance
Beverley McDonough is asthma specialist nurse; Susan Mault is asthma specialist nurse; both at Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool.
McDonough B, Mault S (2013) Non-attendance at a difficult-asthma clinic. Nursing Times; 109: 16, 12-14.
Increasing demand for our weekly difficult-asthma clinic means routine appointments are at a premium. This led us to explore the reasons why patients failed to attend for appointments and whether contacting them by telephone within a week of their missed scheduled appointment increased attendance. Memory lapses were the most common reason for non-attendance. Telephoning non-attenders led to a two-fold increase in attendance at subsequent clinics. Non-attendance may be a reflection of poor concordance, which, in itself, may contribute to a patient’s difficult asthma.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
5 key points
- Missed appointments cost NHS hospitals an estimated £600m a year
- Asthma clinics have a higher than average number of missed appointments
- Missing appointments may have a detrimental effect on patients’ asthma
- Telephoning patients who missed appointments can improve their future attendance
- All health professionals and patients should ensure contact details are up to date
Almost one in 10 NHS patients fails to attend scheduled appointments, costing NHS hospitals an estimated £600m per year (Department of Health, 2012). It is therefore no surprise that reducing “did not attend” (DNA) rates is a key objective for the NHS Institute for Innovation and Improvement (2008).
Studies have identified no single reason for non-attendance. A qualitative study by van Baar et al (2006) that explored reasons for non-attendance specifically at a hospital asthma clinic offered three main explanations for missed appointments:
- Memory lapses;
- Feeling ”too well” or ”too ill” to attend;
- Disillusionment with care.
To overcome the issue of forgetfulness, telephone reminders are now used by many hospitals and GP surgeries. Roberts et al (2007) demonstrated a 15% improvement in attendance at a respiratory out-patient clinic when patients were successfully contacted beforehand. However, despite the practice of sending reminders of forthcoming appointments being used in our trust for at least two years, DNAs at our difficult-asthma clinic remained consistently high compared with the general respiratory clinic led by the same consultant (32.6% against 23.7%).
At the Royal Liverpool and Broadgreen University Hospitals Trust, we hold nine consultant-led respiratory clinics, one of which is dedicated to difficult asthma. This clinic runs weekly and is staffed by a consultant respiratory physician specialising in the management of difficult asthma, specialist respiratory registrars, two asthma specialist nurses (ASNs) and qualified outpatient staff.
As the majority of our patients have complex health needs that are known to be a risk for developing fatal or near-fatal asthma attacks, we feel that discharging many non-attenders would not be in their best clinical interest. Our practice, therefore, in addition to reminding patients of their appointment, is to contact those who do not attend to check on their wellbeing and encourage attendance. The availability of routine appointments is at a premium.
It is estimated that more than five million people in the UK are affected by asthma, with approximately 5% experiencing persistent symptoms and frequent exacerbations despite high levels of treatment (Asthma UK, 2012). Factors contributing to difficult asthma include:
- Poor adherence to treatment;
- Psychosocial factors, such as psychological dysfunction;
- Dysfunctional breathing;
- Monitoring airway response (adapted from British Thoracic Society and Scottish Intercollegiate Guidelines Network, 2008).
Psychosocial problems, including anxiety and depression, have long been identified in those with asthma and are associated with risk-taking behaviour, such as smoking and poor adherence to treatment.
Gamble et al (2009) found that more than a third of patients with difficult asthma, who initially denied poor adherence, collected fewer than 50% of prescriptions and were likely to have been admitted to hospital in the previous 12 months.
Non-adherence to treatment, however, may not be the only explanation of poor symptom control. Coughing, wheeziness, chest tightness and breathlessness caused by vocal-cord dysfunction, gastro-oesophageal reflux disease or dysfunctional breathing can be confused with the symptoms associated with asthma. For these reasons, the guidance from BTS/SIGN (2008) recommends that patients diagnosed with difficult asthma are systematically evaluated by a multidisciplinary team to confirm the diagnosis of asthma and assess concordance with therapy.
The high level of DNAs at our clinic led us to explore the reasons given by patients who failed to attend their appointment. We also aimed to evaluate whether telephone contact after they had missed appointments made them more likely to attend in future.
We attempted to contact patients by telephone within one week of their missed appointment. During the phone calls, reasons for non-attendance were explored in a non-confrontational manner and asthma control was gauged using the Royal College of Physicians’ “three questions” (Pearson et al, 1999) (Box 1). Patients were offered a further appointment and contact details for the ASN were provided, in case patients needed more information.
Following contact, each call was discussed with the consultant in charge of the clinic and triaged to a further appointment depending on urgency.
To audit our activity, we reviewed database logs between April 2011 and March 2012 inclusive. We then compared this information with records on the electronic appointment system to see whether the patient had attended their next scheduled appointment at the clinic.
During the 12-month period of our study, a total of 153 appointments were missed by 98 people. Sixty-three of these people (64%) had missed their appointment once, 22 (23%) twice and the remaining thirteen (13%) had failed to attend between three and six appointments. The mean age of patients was 33 years (range 16‑83 years) and 55 (61%) were women.
We attempted to contact patients following 101 missed appointments and successfully completed telephone interviews with 51 people. Several explanations were given for failing to attend but the most common - evident in almost half the cases - was memory lapse (n=24, 47%): 12 (24%) people stated they forgot and 12 (24%) thought the appointment was on another day. Of these missed appointments, four were allocated to new patients and 20 to follow up (Fig 2). The remaining patients gave reasons such as non-receipt of appointment letter 10 (20%) - a fifth of these were new to the clinic. Five (10%) reported feeling too unwell to attend and five (10%) said they had already cancelled their appointment. Two (4%) patients cited family problems and a further two (4%) were inpatients at the time of their appointment. One (2%) patient had moved out of the area and the remaining two (4%) did not have any reason recorded.
Following each missed appointment, of the patients we contacted, 20 (39%) attended their next appointment. We tried but failed to contact 50 patients, of whom five (10%) attended their next appointment. Similarly, of the 52 we did not try to contact, five (10%) attended their next scheduled appointment (Fig 2).
Our findings confirm those of previously published work citing memory lapses as the most common reason for non-attendance at hospital asthma clinics (van Baar et al, 2006).
Attempting to contact patients led to an increase in attendance at the next appointment scheduled. Those who were successfully contacted were four times more likely to attend than “failed contacts” and patients with “no contact”.
Telephone reminders have been shown to improve attendance at respiratory outpatient appointments (Roberts et al, 2007) but those in Roberts et al’s study were carried out before appointments whereas our telephone interviews were conducted after patients did not attend. During our interview, future appointment times and dates were not always confirmed and were scheduled between two and 12 weeks in advance. Since our hospital was already using telephone reminders, other factors may have influenced future attendance.
Our interviews were conducted by ASNs who not only asked about reasons for non-attendance but also assessed asthma control. Interviews conducted by van Baar et al (2006) found themes that encouraged attendance included “doctors who showed a genuine interest” and “not wanting to let the doctor down”. Our approach may have had a similar effect in motivating patients to attend their next appointment.
We had difficulty in contacting the patients due at two thirds of the appointments; one third of these had no telephone number recorded. Similar issues were raised by Roberts et al (2007) who were unable to find contact details for 51% of their patients. Other possible administration errors occurred in a third of the patients we contacted. These issues highlight the importance of ensuring contact details are up to date.
We also observed that our patients with difficult asthma are younger than those attending the general respiratory clinic. The practice of frequently changing mobile phones among younger people may explain some of the contact difficulties we experienced. It should be the responsibility of all staff as well as patients to ensure contact details are current.
Our interviews were openly conducted by ASNs directly involved in patients’ care; if patients had been able to feed back anonymously, reasons other than memory lapses may have been offered. Other causes for non-attendance may also explain the failure of telephone reminders issued before the scheduled appointment.
Although our study demonstrates increased attendance following telephone contact, our patient groups were not matched in terms of age, sex or frequency of missed appointments.
Those who we were able to contact may value health intervention and ensure their contact details are kept up to date.
Other possible causes for DNAs may include our clinic being held on Monday afternoon whereas the general respiratory clinic led by the same consultant is held on Tuesday morning. Ellis and Jenkins (2012), in a study of over four and a half million appointments in Scotland, found patients were more likely to miss appointments at the beginning of the week and non-attenders were more likely to be younger and male.
As the literature has uncovered many possible causes for DNAs, there may be other factors influencing non-attendance at our difficult-asthma clinic; for example failure to attend appointments may reflect poor concordance, which, in itself, may contribute to the patient’s difficult asthma.
The NHS Institute for Innovation and Improvement (2008) encouraged hospitals to examine the reasons behind non-attendance. As such, we plan to complete a pilot study by sending an anonymous questionnaire to those patients who do attend the clinic and those who fail to attend; this will include a section relating to problems associated with attending the appointment. Patients may feel more able to give an opinion anonymously than to an ANS, who is directly involved with the clinic.
DNA rates for our difficult-asthma clinic are higher than those in other specialities and in respiratory clinics in general. Patients who are successfully contacted after not attending an appointment are four times more likely to attend their next scheduled appointment.
Despite our efforts, 31 out of 51 (61%) patients who missed an appointment missed their subsequent appointment, despite a telephone reminder service and telephone contact with an ASN. Contacting patients is difficult as telephone numbers are not always available, so hospital staff and patients should ensure contact details, especially telephone numbers, are kept up to date.
Forgetfulness may not be the only factor relating to missed appointments for the majority of our patients.
Acknowledgements: the authors would like to thank Paul Currie for his help in providing data.
Asthma UK (2012) What is Severe Asthma? All About Asthma. London: Asthma UK.
British Thoracic Society, Scottish Intercollegiate Guidelines Network (2008) British Guideline on the Management of Asthma: A National Clinical Guideline. London: BTS/Edinburgh: SIGN.
Department of Health (2012) Referrals and Attendances for Outpatient Appointments: Hospital Activity Statistics. London: DH.
Ellis DA, Jenkins R (2012) Weekday affects attendance rate for medical appointments: large-scale data analysis and implications. PLoS ONE; 7, 12.
Gamble et al (2009) The prevalence of non-adherence in difficult asthma. American Journal of Respiratory Critical Care Medicine; 180: 9, 817-822.
NHS Institute for Innovation and Improvement (2008) DNAs: Reducing did not Attends. Coventry: NHS III.
Pearson MG et al (1999) Measuring Clinical Outcome in Asthma: A Patient-Focused Approach. London: Royal College of Physicians.
Roberts N et al (2007) The effect of telephone reminders on attendance in respiratory outpatient clinics. Journal of Health Service Research and Policy; 12: 2, 69-72.
van Baar JD et al (2006) Understanding reasons for asthma outpatient (non)-attendance and exploring the role of telephone and e-consulting in facilitating access to care: exploratory qualitative study. Quality and Safety in Health Care; 15: 3, 191-195.