Non-attending patients in general practice
Authors: David A Ellis, Ross McQueenie, Alex McConnachie, Philip Wilson, Andrea Williamson
Journal: The Lancet Public Health (2018)

We agree with Frans Smits and Gerben ter Riet when, in their comment,1Smits FT ter Riet G Non-attending patients in general practice.Lancet Public Health. 2017; 2: e538Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar they suggest that it could be valuable to frame questions relating to non-attendance in terms of societal benefits and harms. However, we would like to take this opportunity to provide some additional clarification with regards to our analysis and presentation of results.2Ellis DA McQueenie R McConnachie A Wilson P Williamson AE Demographic and practice factors predicting repeated non-attendance in primary care: a national retrospective cohort analysis.Lancet Public Health. 2017; 2: e551-59Summary Full Text Full Text PDF PubMed Scopus (72) Google Scholar Smits and ter Riet argue that we should have included information on medical diagnoses in our study2Ellis DA McQueenie R McConnachie A Wilson P Williamson AE Demographic and practice factors predicting repeated non-attendance in primary care: a national retrospective cohort analysis.Lancet Public Health. 2017; 2: e551-59Summary Full Text Full Text PDF PubMed Scopus (72) Google Scholar rather than provide this analysis in a future publication. Our decision to incorporate this information into a future publication was not taken lightly; the issues were raised during the review process, with one reviewer suggesting that the burden of long-term conditions is likely to be an important factor in the unmet need and behaviours of the patients within this population.3Barnett K Mercer SW Norbury M Watt G Wyke S Guthrie B Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study.Lancet. 2012; 380: 37-43Summary Full Text Full Text PDF PubMed Scopus (3705) Google Scholar However, we judged that presenting these data satisfactorily in a single paper would have been overly complex, with other reviewers supporting this decision. In addition to a paper that will focus specifically on patients with multiple long-term conditions, we also plan to publish a future overarching paper focused on unmet need along with health-care utilisation across the health system. Smits and ter Riet also suggested that our analysis might benefit from a multilevel approach that would involve the use of zero-inflated negative binomial models. Such an approach might be particularly useful, given that 54% of patients did not miss any appointments. We considered that the negative binomial models fitted the data reasonably well. An initial analysis attempted to use a mixed effects regression allowing for random practice effects, but even the simplest of models proved intractable in a dataset of this size, which was held with limited computational capacity (Safe Haven). To counter this limitation, we adjusted the analysis for available practice-level variables. In our article,2Ellis DA McQueenie R McConnachie A Wilson P Williamson AE Demographic and practice factors predicting repeated non-attendance in primary care: a national retrospective cohort analysis.Lancet Public Health. 2017; 2: e551-59Summary Full Text Full Text PDF PubMed Scopus (72) Google Scholar we focused on describing the data, and the main effects of several patient and practice-level factors. To examine cross-factor interactions would have added another layer of complexity, which would have been very difficult to condense into a single paper. Such analyses would probably best be focused on interactions between a single factor (eg, sex) and factors that predict frequent non-attendance to address a coherent research question. Finally, we agree that frequent attenders are indeed an interesting subgroup within themselves, which was why all our models were offset for the number of appointments made.2Ellis DA McQueenie R McConnachie A Wilson P Williamson AE Demographic and practice factors predicting repeated non-attendance in primary care: a national retrospective cohort analysis.Lancet Public Health. 2017; 2: e551-59Summary Full Text Full Text PDF PubMed Scopus (72) Google Scholar However, the claim that frequent attendance would prompt more changes to clinical work than non-attendance is unfounded. Although frequent attenders and frequent non-attenders are qualitatively different in terms of social and socioeconomic problems, they provide two equally important examples of unmet need.2Ellis DA McQueenie R McConnachie A Wilson P Williamson AE Demographic and practice factors predicting repeated non-attendance in primary care: a national retrospective cohort analysis.Lancet Public Health. 2017; 2: e551-59Summary Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 4Smits FT Brouwer HJ ter Riet G van Weert HC Epidemiology of frequent attenders: a 3-year historic cohort study comparing attendance, morbidity and prescriptions of one-year and persistent frequent attenders.BMC Public Health. 2009; 9: 36Crossref PubMed Scopus (111) Google Scholar, 5Williamson AE Ellis DA Wilson P McQueenie R McConnachie A Understanding repeated non-attendance in health services: a pilot analysis of administrative data and full study protocol for a national retrospective cohort.BMJ Open. 2017; 7: e014120Crossref PubMed Scopus (31) Google Scholar We declare no competing interests. Non-attending patients in general practiceIn a large retrospective cohort analysis1 of more than half a million patients and more than 13 million visits in Scottish primary care, David Ellis and colleagues found that 19% of patients missed more than two appointments during a 3 year period. They found that, after adjusting for the number of appointments, men, patients aged 16–30 years or older than 90 years, and patients of low socioeconomic status were significantly more likely to miss multiple appointments. Urban practices in affluent areas with waiting times of a few days were more likely to have patients who repeatedly missed appointments. Full-Text PDF Open AccessDemographic and practice factors predicting repeated non-attendance in primary care: a national retrospective cohort analysisThe 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. Full-Text PDF Open Access