Missed GP appointments ‘substantially’ increase all-cause mortality

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AppointmentMissing GP appointments is associated with early death, and those with long-term mental health conditions are at particular risk, according to a large Scotland study over three-years.

Dr Ross McQueenie led the study from the University of Glasgow along with colleagues from Lancaster University and the University of Aberdeen.

In the largest study of its kind, the team examined over 500,000 patients’ appointment histories in Scotland, tracked for 3 years between 2013 and 2016. All data were provided on condition of patient and practice anonymity. Appointment information was then linked to patient medical histories and death records.

The researchers found that: patients with a greater number of long-term health conditions had an increased risk of missing general practice appointments. These same patients were also at substantially greater risk of death within the following year; patients with long term physical conditions who missed two or more appointments per year had a threefold increase in all-cause mortality compared with those who missed no appointments; and patients with mental-health conditions only who missed more than two appointments per year had an eight times greater risk of death during the follow-up period compared with those who missed no appointments.

These results emerged even after researchers controlled for a variety of other factors already known to affect attendance. McQueenie said “Patients diagnosed with long-term mental health problems, who did die during the follow-up period, died prematurely, often from non-natural external factors such as suicide.

Ellis added “These results align with clinicians own observations. Specifically, patients with long-term mental health conditions are more likely to miss multiple appointments.”

The researchers are now exploring how new interventions might improve attendance however, their research raises important questions when it comes to ensuring that mental health services remain easy to access and are readily available across the UK.

Wilson concluded “These findings are crucially important for GPs wishing to identify patients at high risk of premature death. For people with physical conditions missed appointments are a strong independent risk factor for dying in the near future. Among those without long-term physical conditions, the absolute risk is lower, but missing appointments is an even stronger risk marker for premature death from non-natural causes.”

Abstract
Background: Recently, studies have examined the underlying patient and practice factors for missed appointments, but less is known about the impact on patient health. People with one or more long-term conditions who fail to attend appointments may be at risk of premature death. This is the first study to examine the effect of missed primary healthcare appointments on all-cause mortality in those with long-term mental and physical health conditions.
Methods: We used a large, nationwide retrospective cohort (n = 824,374) extracted from routinely collected general practice data across Scotland over a 3-year period from September 2013 until September 2016. This data encompasses appointment history for approximately 15% of the Scottish population, and was linked to Scottish deaths records for patients who had died within a 16-month follow-up period. We generated appointment attendance history, number of long-term conditions and prescriptions data for patients. These factors were used in negative binomial and Cox’s proportional hazards modelling to examine the risk of missing appointments and all-cause mortality.
Results: Patients with a greater number of long-term conditions had an increased risk of missing general practice appointments despite controlling for number of appointments made, particularly among patients with mental health conditions. These patients were at significantly greater risk of all-cause mortality, and showed a dose-based response with increasing number of missed appointments. Patients with long-term mental health conditions who missed more than two appointments per year had a greater than 8-fold increase in risk of all-cause mortality compared with those who missed no appointments. These patients died prematurely, commonly from non-natural external factors such as suicide.
Conclusions: Missed appointments represent a significant risk marker for all-cause mortality, particularly in patients with mental health conditions. For these patients, existing primary healthcare appointment systems are ineffective. Future interventions should be developed with a particular focus on increasing attendance by these patients.

Authors
Ross McQueenie, David A Ellis, Alex McConnachie, Philip Wilson, Andrea E Williamson

Lancaster University material
BMC Medicine abstract


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