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      A mixed‐methods exploration of non‐attendance at diabetes appointments using peer researchers

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          Abstract

          Background

          Non‐attendance at diabetes appointments is costly to the health service and linked with poorer patient outcomes.

          Objective

          Peer researchers aimed to conduct interviews and survey people who miss appointments about their beliefs and perceptions regarding their diabetes and diabetes appointments.

          Design

          A mixed‐methods cross‐sectional design with interviews conducted by peer researchers with diabetes and a questionnaire was used.

          Setting and participants

          Peer researchers conducted semi‐structured telephone interviews in one health board in Scotland with ten people who had missed diabetes appointments. A further 34 people who had missed appointments completed a questionnaire. The study was informed by two psychological theories (the Theory of Planned Behaviour and the Self‐Regulation Model), and interviews were analysed using thematic analysis.

          Results

          Interviewees planned to attend appointments but practical barriers, low perceived value of appointments and the feeling that diabetes had little impact upon their lives’ emerged as key reasons for missing appointments. Questionnaire data supported these findings and showed that respondents perceived diabetes to have only mildly serious consequence and cause limited concern and emotional impact. Participants’ understanding of their condition and perceptions of personal control and treatment control were low. Gender, perceived behavioural control and emotional representations were significantly associated with the number of appointments missed in the previous year.

          Conclusions

          These findings highlight the importance of psychological variables in predicting non‐attendance at diabetes appointments and provide avenues for how non‐attendance might be tackled.

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          Most cited references13

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          Patient adherence improves glycemic control.

          The purpose of this study was to assess the influence of appointment keeping and medication adherence on HbA1c. A retrospective evaluation was performed in 1560 patients with type 2 diabetes who presented for a new visit to the Grady Diabetes Clinic between 1991 and 2001 and returned for a follow-up visit and HbA1c after 1 year of care. Appointment keeping was assessed by the number of scheduled intervening visits that were kept, and medication adherence was assessed by the percentage of visits in which self-reported diabetes medication use was as recommended at the preceding visit. The patients had an average age of 55 years, body mass index (BMI) of 32 kg/m2, diabetes duration of 4.6 years, and baseline HbA1c of 9.1%. Ninety percent were African American, and 63% were female. Those who kept more intervening appointments had lower HbA1c levels after 12 months of care (7.6% with 6-7 intervening visits vs 9.7% with 0 intervening visits). Better medication adherence was also associated with lower HbA1c levels after 12 months of care (7.8% with 76%-100% adherence). After adjusting for age, gender, race, BMI, diabetes duration, and diabetes therapy in multivariate linear regression analysis, the benefits of appointment keeping and medication adherence remained significant and contributed independently; the HbA1c was 0.12% lower for every additional intervening appointment that was kept (P = .0001) and 0.34% lower for each quartile of better medication adherence (P = .0009). Keeping more appointments and taking diabetes medications as directed were associated with substantial improvements in HbA1c. Efforts to enhance glycemic outcomes should include emphasis on these simple but critically important aspects of patient adherence.
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            Demographic and practice factors predicting repeated non-attendance in primary care: a national retrospective cohort analysis

            Summary Background Addressing the causes of low engagement in health care is a prerequisite for reducing health inequalities. People who miss multiple appointments are an under-researched group who might have substantial unmet health needs. Individual-level patterns of missed general practice appointments might thus provide a risk marker for vulnerability and poor health outcomes. We sought to ascertain the contributions of patient and practice factors to the likelihood of missing general practice appointments. Methods For this national retrospective cohort analysis, we extracted UK National Health Service general practice data that were routinely collected across Scotland between Sept 5, 2013, and Sept 5, 2016. We calculated the per-patient number of missed appointments from individual appointments and investigated the risk of missing a general practice appointment using a negative binomial model offset by number of appointments made. We then analysed the effect of patient-level factors (including age, sex, and socioeconomic status) and practice-level factors (including appointment availability and geographical location) on the risk of missing appointments. Findings The full dataset included information from 909 073 patients, of whom 550 083 were included in the analysis after processing. We observed that 104 461 (19·0%) patients missed more than two appointments in the 3 year study period. After controlling for the number of appointments made, patterns of non-attendance could be differentiated, with patients who were aged 16–30 years (relative risk ratio [RRR] 1·21, 95% CI 1·19–1·23) or older than 90 years (2·20, 2·09–2·29), and of low socioeconomic status (Scottish Index of Multiple Deprivation decile 1: RRR 2·27, 2·22–2·31) significantly more likely to miss multiple appointments. Men missed fewer appointments overall than women, but were somewhat more likely to miss appointments in the adjusted model (1·05, 1·04–1·06). Practice factors also substantially affected attendance patterns, with urban practices in affluent areas that typically have appointment waiting times of 2–3 days the most likely to have patients who serially miss appointments. The combination of both patient and practice factors to predict appointments missed gave a higher pseudo R 2 value (0·66) than models using either group of factors separately (patients only R 2=0·54; practice only R 2=0·63). Interpretation The findings that both patient and practice characteristics contribute to non-attendance of general practice appointments raise important questions for both the management of patients who miss multiple appointments and the effectiveness of existing strategies that aim to increase attendance. Addressing these issues should lead to improvements in provision of services and public health. Funding Scottish Government Chief Scientist Office and Data Sharing and Linkage Service of the Scottish Government.
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              No-shows to primary care appointments: subsequent acute care utilization among diabetic patients

              Background Patients who no-show to primary care appointments interrupt clinicians’ efforts to provide continuity of care. Prior literature reveals no-shows among diabetic patients are common. The purpose of this study is to assess whether no-shows to primary care appointments are associated with increased risk of future emergency department (ED) visits or hospital admissions among diabetics. Methods A prospective cohort study was conducted using data from 8,787 adult diabetic patients attending outpatient clinics associated with a medical center in Indiana. The outcomes examined were hospital admissions or ED visits in the 6 months (182 days) following the patient’s last scheduled primary care appointment. The Andersen-Gill extension of the Cox proportional hazard model was used to assess risk separately for hospital admissions and ED visits. Adjustment was made for variables associated with no-show status and acute care utilization such as gender, age, race, insurance and co-morbid status. The interaction between utilization of the acute care service in the six months prior to the appointment and no-show was computed for each model. Results The six-month rate of hospital admissions following the last scheduled primary care appointment was 0.22 (s.d. = 0.83) for no-shows and 0.14 (s.d. = 0.63) for those who attended (p < 0.0001). No-show was associated with greater risk for hospitalization only among diabetics with a hospital admission in the prior six months. Among diabetic patients with a prior hospital admission, those who no-showed were at 60% greater risk for subsequent hospital admission (HR = 1.60, CI = 1.17–2.18) than those who attended their appointment. The six-month rate of ED visits following the last scheduled primary care appointment was 0.56 (s.d. = 1.48) for no-shows and 0.38 (s.d. = 1.05) for those who attended (p < 0.0001); after adjustment for covariates, no-show status was not significantly related to subsequent ED utilization. Conclusions No-show to a primary care appointment is associated with increased risk for hospital admission among diabetics recently hospitalized.
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                Author and article information

                Contributors
                Role: Lecturerc.e.eades@stir.ac.uk
                Role: Evaluations Manager
                Journal
                Health Expect
                Health Expect
                10.1111/(ISSN)1369-7625
                HEX
                Health Expectations : An International Journal of Public Participation in Health Care and Health Policy
                John Wiley and Sons Inc. (Hoboken )
                1369-6513
                1369-7625
                05 September 2019
                December 2019
                : 22
                : 6 ( doiID: 10.1111/hex.v22.6 )
                : 1260-1271
                Affiliations
                [ 1 ] Faculty of Health Sciences and Sport University of Stirling Stirling UK
                [ 2 ] NHS Lanarkshire Bothwell UK
                Author notes
                [*] [* ] Correspondence

                Claire Eades, Faculty of Health Sciences and Sport, University of Stirling, Stirling FK9 4LA, UK.

                Email: c.e.eades@ 123456stir.ac.uk

                Author information
                https://orcid.org/0000-0002-4845-332X
                Article
                HEX12959
                10.1111/hex.12959
                6882258
                31486184
                6a990598-5cd8-4ba2-becf-97be798d9657
                © 2019 The Authors Health Expectations Published by John Wiley & Sons Ltd

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                : 21 February 2019
                : 16 August 2019
                : 18 August 2019
                Page count
                Figures: 0, Tables: 7, Pages: 12, Words: 8845
                Funding
                Funded by: Scottish Diabetes Group
                Categories
                Original Research Paper
                Original Research Papers
                Custom metadata
                2.0
                hex12959
                December 2019
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.7.2 mode:remove_FC converted:28.11.2019

                Health & Social care
                diabetes,health psychology,non‐attendance,patient and public involvement

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