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Nonattendance at outpatient appointments has been recognized worldwide as a significant clinical and systemic problem (1). Missed appointments are economically costly to mental health systems and personally costly to patients, who experience a greater risk of relapse and readmission to hospital (2). Rates of missed appointments have been reported to be between 20% and 50% in various mental health settings (1). Previous research on missed appointments in both medical and mental health settings has provided conflicting findings, with some, but not all, researchers finding an association between missed appointments and low socioeconomic status, younger age, low level of education, a history of missed appointments, drug or alcohol abuse, poorer social functioning, having more severe psychiatric problems, and a poor relationship with the physician (2–6). There are few reports examining such diagnostically specific groups as persons with schizophrenia. Our hypothesis, based on clinical experience, was that factors such as male sex, younger age, substance abuse, socioeconomically disadvantaged status, and unsupervised residence would result in poorer attendance. MethodSubjects We examined rates of nonattendance for persons with appointments in the Schizophrenia Treatment and Education Program (STEP) operating out of an inner-city teaching hospital. STEP provides assessment, treatment, and follow-up services for persons with severe and persistent mental illness. Frequency of appointments is individualized according to patient medication regime, level of symptom control, present level of functioning, and current rehabilitative needs. Procedure Instruments Second, we administered the Life Skills Profile (LSP), a measure that allows for the assessment of functioning in persons with schizophrenia (7). The LSP provides a total score derived from 5 subscales that examine the following specific aspects of community functioning: Self-Care, Nonturbulence, Social Contact, Communication, and Responsibility. This instrument has been reported to have high interrater reliability and high test–retest reliability (7). The literature also suggests that LSP scores remain strikingly consistent over time (8). We administered the LSP within 3 months of the first outpatient contact and every 6 months thereafter. We used the most recent LSP score for data analysis. Data Analysis We assessed differences between the groups with the chi- square test for categorical variables and the independent groups t-test for scaled variables. We used 2-tailed tests throughout and applied the Bonferroni correction to control for multiple comparisons. ResultsThere were 5596 appointments during the period of the study, and of these, 1240 were missed (22.2%). Table 1 compares 2 groups (low and high nonattenders). There was no difference between groups in terms of the total number of appointments (16.71 vs 16.05). Between the 2 groups, age was the only demographic variable that showed a statistically significant difference: the average age at first appointment was approximately 3 years lower for patients who missed 20% or more of their appointments. For both groups, a history of substance abuse was also a statistically significant discriminating variable: patients with a greater proportion of missed appointments were rated as having more serious problems with drugs or alcohol. DiscussionThe rate of missed appointments in our study is consistent with the literature. In contrast to others, our study examined attendance rates in a relatively diagnostically homogeneous group. When we examined demographic variables, younger age was associated with greater risk of missing appointments. This may be associated with ambivalence regarding diagnosis and treatment. Younger age of onset has been associated with a greater risk of having concomitant substance use (9), which strongly related to rates of missed appointments in our study. Individuals who tended to miss appointments demonstrated impaired judgement and insight, reflected in lower scores on the Responsibility subscale of the LSP. Those in the high missed appointments group had lower scores on the LSP Social Contact subscale, likely reflecting greater social withdrawal as a result of their illness. Contrary to our initial hypothesis, residence in a supervised group home did not result in better attendance. Similarly, education, work status, and income source had no effect on attendance. Our findings suggest that functional level is a stronger predictor of attendance than are socioeconomic factors. Limitations in the study include our restricting the analysis to visits with nurse therapists and the lack of a concomitant measure of symptom severity. We are aware of the difficulty in applying the results of grouped data to individuals in clinical practice. Ideally, it would be valuable to examine individual patterns of attendance to apply this in treatment planning. However, this was beyond the scope of the present study. ConclusionIt may be possible for clinicians to better predict attendance at outpatient follow-up appointments based on an individual’s functional level. Clinicians should be aware of such factors as substance abuse, lack of responsibility, and other functional deficits. Being able to predict the likelihood of missed appointments can also assist with scheduling professional time and, ultimately, improve patient care. References1. Mason C. Non-attendance at out-patient clinic: a case study. J Adv Nurs 1992;17:554–60. 2. Killaspy H, Banerjee S, King M, Llyod M. Prospective controlled study of psychiatric out-patient non-attendance. Br J Psychiatry 2000;176:160–5. 3. Campbell B, Staley D, Matas M. Who misses appointments? An empirical analysis. Can J Psychiatry 1991;36:223–5. 4. Mooney DK, Johson RD. Rural mental health appointment adherence: implications for therapy. Community Ment Health J 1992;28:135–9. 5. Barron WM. Failed appointments: who misses them, why they are missed and what can be done. Primary Care 1980;7:563–74 6. Goldman L, Freidin R, Cook F, Eigner J, Grich P. A multivariate approach to the prediction of no-show behavior in a primary care center. Arch Intern Med 1982;142:563–7. 7. Parker G, Rosen A, Emdur N, Hadzi-Pavlov D. The Life Skills Profile: psychometric properties of a measure assessing function and disability in schizophrenia. Acta Psychiatr Scand 1991;83:145–52. 8. Trauer T, Duckmanton A, Chiu E. The assessment of clinically significant change using the Life Skills Profile. Aust N Z J Psychiatry 1997;31:257–63. 9. Gearon JS, Bellack AS. Sex differences in illness presentation, course, and level of functioning in substance abusing schizophrenia patients. Schizophr Res 2000;43:65–70 Author(s)Manuscript received July 2002, revised, and accepted April 2003. 1. Medical Director, Program of Assertive Community Treatment, Winnipeg Regional Health Authority, Winnipeg, Manitoba; Associate Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba. . 2. Research Associate, Department of Psychiatry, St Boniface Hospital, Winnipeg, Manitoba. 3. Occupational Therapist, Schizophrenia Treatment and Education Program, PsycHealth Centre, Winnipeg, Manitoba. 4. Nurse Therapist, Schizophrenia Treatment and Education Program, PsycHealth Centre, Winnipeg, Manitoba Address for correspondence: Dr S Coodin, Department of Psychiatry, University of Manitoba, 492 Hargrave St, Winnipeg, MB R3A 0X7 email: scoodin@wrha.mb.ca
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