A systematic review from UK researchers identifies logistics are only part of the problem
Non-attendance at diabetes appointments is a significant problem worldwide and is associated with suboptimal health outcomes for the person with diabetes. Appointments are an opportunity for healthcare professionals to support individuals with diabetes. Understanding the reasons why people do not attend appointments can help reveal barriers that affect their ability to manage their diabetes. A systematic review published in 1998 showed that interventions to reduce non-attendance were focused mostly on providing reminders. But healthcare systems have changed enormously in the past two decades, so this new review is timely for improving our understanding of the factors that influence non-attendance.
In their systematic review, Brewster et al. aimed to describe characteristics, health outcomes and reasons associated with non-attendance of diabetes clinic appointments, as well as interventions to improve attendance. They searched PubMed, EMBASE, CINAHL and PsychInfo from database inception to February 2019. They included 34 studies addressing non-attendance in adults or young people with type 1 or type 2 diabetes, and identified that various study designs were used – 15 observational, 9 qualitative, 5 surveys, 4 service improvements and 1 randomised control trial. Sixteen studies were conducted in the UK, 6 in North America, 4 in Europe, and 8 in the rest of the world. The definition of ‘non-attendance’ varied across the studies.
In terms of their characteristics, those who did not attend diabetes outpatient appointments were typically younger adults with a shorter duration of diabetes, smokers, and those with a lower socio-economic background. Younger age and a lower socio-economic background reflect current literature on non-attendance across medical specialities. Nine studies reported glycaemic outcomes (HbA1c) were worse in those with lower or mixed clinic attendance records. Other outcomes varied but were typically worse in those who did not attend.
Reasons for non-attendance were explored in surveys and qualitative studies and findings were captured by three broad categories:
- Illness perceptions, diabetes distress and coping strategies – diabetes distress can serve as both a motivator to attend or a significant barrier to attendance
- Logistics and characteristics of the appointment or diabetes service – barriers to attendance include lack of clinic flexibility, long waiting times, meeting unfamiliar health professionals (lack of continuity of care), transport and parking problems, conflicting commitments, misunderstandings, physical disability and financial difficulties
- Relationships with the healthcare team – short, impersonal appointments with unfamiliar health professionals had a negative impact on the relationship and future attendance. Younger people were the most negatively affected by criticism, particularly about their HbA1c and self-management. The importance of positive relationships, confidence, trust and emotional support was appreciated by all, and well-documented as facilitating attendance.
Interventions to improve attendance have primarily focused on reminding people about their appointments. However, there has been a shift from blaming non-attenders, toward designing interventions that are more flexible, supportive, informative and empowering. These include service improvements (e.g. improving clinic efficiency), patient navigators (i.e. providing personal guidance to support people as they move through the healthcare system), and telehealth.
Non-attendance is only partially explained by logistical issues. Qualitative studies suggest there are several important issues that contribute to non-attendance, including relationships with the healthcare team and the emotional experience of the person and their coping mechanisms. Interventions have progressed from appointment reminders to providing better support and greater flexibility. Future research must delve deeper to understand issues influencing non-attendance, and interventions are needed that address the complex issues involved, as it is clear that a ‘one size fits all’ approach will not work.
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Brewster S, Bartholomew J, Holt RIG, & Price H. Non-attendance at diabetes outpatient appointments: a systematic review. Diabetic Medicine, 2020. https://doi.org/10.1111/dme.14241
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