New Study Linking Missed Appointments to Higher Death Risk Shows Why We Need Better Mental Health Care

A new study published in BMC Medicine found that those who missed more doctors appointments each year had a higher risk of death, especially for those who live with more than one condition or a mental health condition. The study, which was helmed by Dr. Ross McQueenie at the University of Glasgow in Scotland, highlights potential areas for improvement in patient health care.

The study examined health history data from more than 750,000 patients in Scotland across three years between 2013 and 2016. They compared how many appointments those with long-term physical or mental health conditions missed during that time frame. Researchers followed up over the next year by linking health data with death records to determine the correlation between missed appointments and risk of death.

McQueenie and his colleagues found that patients with physical health conditions who missed two or more appointments each year were three times as likely to have died in the follow-up period from any cause, not just their illness. Of particular note, however, were the implications of missed appointments if you live with long-term mental health conditions.

Two or more missed appointments for mental health patients was associated with an eight-fold greater risk of death in the follow-up period. The research also found that those who missed a number of appointments and died in the follow-up period died younger — at around 50 years old — than others in the study. Their deaths were more commonly from “unnatural” causes like suicide or drug overdoses.

Within the mental health conditions McQueenie and his team looked at, 22.2 percent of those with alcohol use disorder and 27.4 percent of those who misused psychoactive substances missed more than two appointments each year. About 14 percent of patients with conditions like depression, anxiety, schizophrenia and anorexia missed two or more appointments per year.

We have published a paper that examines morbidity and mortality in those who miss GP appointments. Need to find solutions to help (often very vulnerable) people feel engaged with primary healthcare, especially in mental health @aewilliamsonl @davidaellis https://t.co/akD9lZcYEV

— Ross McQueenie (@RossMcqueenie) January 11, 2019

This study builds on past research McQueenie has done looking at why patients in Scotland missed doctor’s appointments. That work, which was published in The Lancet in 2017, found that 27 percent of patients included in the study missed one appointment while 19 percent missed two or more appointments over a three-year period. Researchers found that the greatest risk factors for repeat misses included low-income status and seniors.

In the United States, a variety of factors may contribute to missed appointments in addition to lack of access for lower-income patients and high health care costs. For example, one study found 3.6 million Americans miss appointments each year because of transportation difficulties. Another study found that 12 percent of people with disabilities who rely on Medicaid were unable to get a ride to their doctor’s office.

Other reasons range from an aversion to the phone — if you receive an email reminder you’re 36 percent more likely to attend an appointment — to general discontent with the system. A small 2004 study indicated that some patients don’t show up for doctor’s appointments because they “did not feel obligated to keep a scheduled appointment in part because they felt disrespected by the health care system.”

In combination with anxiety about doctors, scheduling confusion and rising health care costs, it’s perhaps not surprising many doctor’s appointments get skipped. Taking these factors into account, McQueenie stressed that patients aren’t missing because they’re forgetful or manipulating the system. He said health services are failing to provide some patients with the support they need.

“A lot of the time when people think of patients who miss appointments, they think that they’re just lazy. They can’t be bothered turning up for appointments. They’re feckless,” McQueenie told The Mighty. “We view it differently. We view it as having what we call unmet need, so these are people that don’t feel as if they’re getting what they need out of the health care service.”

In Scotland and the U.K., McQueenie said they are working on solutions to address the unmet needs of these patients. One strategy includes establishing a mental health first point of contact. Typically in the U.K., if you have a mental health concern you would first visit your general practitioner to get a referral for additional services. This process takes time, and the delay between seeking help and getting help seems to impact whether or not patients go to scheduled appointments.

“We have obviously universal health care and with that comes a lot of people making a lot of appointments so sometimes you have have to wait for an appointment,” McQueenie said. “That long lag time of waiting for an appointment with a mental health specialist might actually cause you these adverse outcomes that we’ve shown.”

By establishing an alternate route that allows patients to skip their GP and go straight to see a mental health practitioner first, the U.K. hopes to more effectively provide mental health services. Similarly, McQueenie added that his research shows that allowing patients to book same-day appointments as opposed to having to wait several days also increases the likelihood patients will attend.

Dr. Howard Samuels, LMFT, Psy.D, founder/CEO of The Hills Treatment Center in the U.S., said he’s not surprised those with substance use disorders had high rates of missed appointments and a higher risk of associated death. Like McQueenie, Samuels said part of the issue is that the current health care system doesn’t always offer the services patients need. Recovery from addiction, for example, is not just about getting sober, but current treatment restrictions can inhibit ongoing care.

“Insurance companies only let you keep a client in there less than 30 days,” Samuels told The Mighty. “Then you’re throwing them back out in the world, which they have no idea how to deal with, and then they go back out to the world and their behavior hasn’t changed. They get depressed. They get overwhelmed with the things that they have to do because they have no support.”

McQueenie hopes his study provides additional compelling evidence to right-size health care services based on individual patients, especially if you have long-term vulnerabilities and unmet needs like within the mental health and addiction recovery communities. He said patients “need to be engaged rather than shunned” for new health care strategies to have a positive impact.

“It’s being talked about a lot more in the U.K. and people are trying to come up with strategies,” McQueenie said. “Actually I’m going to meet the Scottish government in about a month to put forth my findings and discuss with them.”