Reasons for missed appointments linked to a public-sector intervention targeting patients with stable chronic conditions in South Africa: results from in-depth interviews and a retrospective review of medical records

Abstract

BackgroundMissed appointments serve as a key indicator for adherence to therapy and as such, identifying patient reasons for this inconsistency could assist in developing programmes to improve health outcomes. In this article, we explore the reasons for missed appointments linked to a centralised dispensing system in South Africa. This system dispenses pre-packed, patient-specific medication parcels for clinically stable patients to health facilities. However, at least 8%–12% of about 300,000 parcels are not collected each month. This article aims to establish whether missed appointments for collection of medicine parcels are indicative of loss-to-follow-up and also to characterise the patient and health system factors linked to missed appointments.MethodsWe applied an exploratory mixed-methods design in two overlapping research phases. This involved in-depth interviews to yield healthcare practitioners’ and patients’ experiences and medical record reviews. Data collection was conducted during the period 2014–2015. Qualitative data were analysed through a hybrid process of inductive and deductive thematic analysis which integrated data-driven and theory-driven codes. Data from medical records (N = 89) were analysed in MS excel using both descriptive statistics and textual descriptions.ResultsReview of medical records suggests that the majority of patients (67%) who missed original appointments later presented voluntarily to obtain medicines. This could indicate a temporal effect of some barriers. The remaining 33% revealed a range of CDU implementation issues resulting from, among others, erroneous classification of patients as defaulters. Interviews with patients revealed the following reasons for missed appointments: temporary migration, forgetting appointments, work commitments and temporary switch to private care. Most healthcare practitioners confirmed these barriers to collection but perceived that some were beyond the scope of health services. In addition, healthcare practitioners also identified a lack of patient responsibility, under-utilisation of medicines and use of plural healthcare sources (e.g. traditional healers) as contributing to missed appointments.ConclusionWe suggest developing a patient care model reflecting the local context, attention to improving CDU’s implementation processes and strengthening information systems in order to improve patient monitoring. This model presents lessons for other low-and-middle income countries with increasing need for dispensing of medicines for chronic illnesses.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-017-0655-8) contains supplementary material, which is available to authorized users.

Models of care for chronic conditions in low/middle-income countries: a ‘best fit’ framework synthesis

“…Self-treatment with alternative medication sourced from informal providers (herbalists and traditional healers) was reported and use of plural healthcare sources could result in missed appointments 42…”

Nonattendance rates of scheduled outpatient appointments in a university general hospital

“…Probably within the highest reported nonattendance rates examples are Singapore 18.5% and 35.9% as part of the Predicting Appoint Misses (PAM) project, 18.6% in dermatology clinics in the United States, 18.8% in the United Sates over a 12‐year period, 19% outpatient neurology consultations in Spain, 28% in programmed chronic medication distribution centers in South Africa, and 45.12% in Jordan .…”

Causes of appointment attendance, nonattendance, and cancellation in outpatient consultations at a university hospital

“…However, there are few reports in the literature. Magadzire et al studied the causes of missing appointments with mixed methods in South Africa . Through in‐depth interviews, they identified mobility and temporary migration, forgetfulness or errors with appointments, work‐related problems, and changes in medical insurance as the main causes of nonattendance.…”