Patient factors associated with appointment non-attendance at an ophthalmology department in Aotearoa New Zealand
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Non-attendance to appointments, also referred to as missed appointment, “no-shows” or “DNAs” (Did Not Attend), are a common problem for all medical outpatient clinics with rates between 5% to 55%.[[1,2]] Non-attendance has widespread implications for the individual, health system and society. Most importantly for patients, non-attendance may result in delayed diagnosis and treatment and inferior health outcomes. Reasons for non-attendance are likely multifactorial, but it has been suggested that non-attendance is a surrogate of a damaged relationship between the patient and the health system. For the health system, non-attendance results in inefficiency. The economic cost to the health system is also significant. In the United Kingdom (UK), non-attendance to general practice appointments is estimated to cost approximately £162 million each year,[[3]] while overall missed appointments in the United States (US) costs more than $150 billion per year.[[4]]
There is a paucity of data exploring non-attendance outside of and within ophthalmology outpatient clinics.[[5–12]] The aim of this study was to identify patient characteristics associated with appointment non-attendance in a large-public ophthalmology clinic in Aotearoa New Zealand.
Methods
This was a retrospective study with institutional audit approval for analysis of de-identified visit data. The methods of this study adhered to the tenets of the Declaration of Helsinki and was examined and approved by Auckland Health Research Ethics Committee (#AH24132). A de-identified list of all patients who were scheduled to attend outpatient ophthalmology clinic appointments at Auckland District Health Board (DHB), specifically Greenlane Clinical Centre based in Central Auckland and Waitākere Public Hospital based in West Auckland, between 1 January 2018 to 31 December 2019 were retrieved from the hospital records (catchment population numbers are 1,053,939 for Auckland and Waitematā DHBs combined based on 2018 New Zealand Census). Non-attendance was defined as any scheduled appointment that was not attended by the patient, or not cancelled or rescheduled before the time of the appointment by the clinic or patient.
Variables
Demographic information retrieved included: age, gender, ethnicity recorded in the National Health Index (NHI) health system, address and attendance or non-attendance to the appointment. Gender was categorised as either male, female or other (in the data identified as gender diverse, gender unknown or gender unspecified).
Ethnicity classification was based on the New Zealand Census Level 1 ethnicity categories. These included European, Māori, Pacific peoples, Asian and Other. The “Other” category included Middle Eastern, Latin American, African (MELAA), and patients that identified as Other ethnicity.
New Zealand Deprivation (NZDep) Index, an area-based measure of socio-economic status (SES) with a scale ranging from 1 (least deprived) to 10 (most deprived), was linked to each patient address using ArcGIS Pro, a geographic information systems (GIS) software. A spatial join was performed between the dataset of geocoded patient addresses with a dataset of meshblock codes retrieved from Statistics New Zealand (smallest geographic unit for which statistical data are reported) associated with a NZDep Index value based on nine Census variables from the 2018 New Zealand Census. This allowed for analysis of deprivation status for each patient.
Non-attendance numbers were recorded for gender, age in 20-year age bands, ethnicity and deprivation index, scheduled outpatient and acute referral clinic, new appointments and follow-ups.
Statistical analysis
Data were collected in an Excel spreadsheet and analysed in STATA version 15 (StataCorp, College Station, TX, USA). Categorical values are reported as n (%) and continuous variables as median (interquartile range [IQR]). Values for patient demographics were recorded as a proportion of the total number of patients, while all non-attendance data were analysed and reported as a proportion of the total number of appointments. A logistic regression was performed to compare the likelihood of non-attendance between gender, age, ethnicity and NZDep Index for all appointments. Odds ratio (OR) values for each comparison group can be calculated from the reported group as the inverse of the reported group OR value (i.e., 1/OR). A separate logistic regression analysis was performed for patients who had two or more missed appointments to assess multiple clinic visit non-attendance. A p value of <0.05 was considered statistically significant.
Indigenous health and research capacity
The expertise of the research team in Māori and Pacific health covers adequate representation and research capacity in line with the consolidated criteria for strengthening the reporting of health research involving Indigenous peoples (CONSIDER) statement guidelines.[[13]] The research team consists of two members who have been involved in the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Māori and Pasifika Committee, with one current member and one formerly the chair, who consult extensively with Māori. Although there was no direct consultation or partnership with Māori during the research conduct process, the research team aimed to utilise research approaches to support Indigenous health advancement in this study. The consultation and guidance of one of the members (William Cunningham), who is of Samoan ethnicity amongst one of few Māori and Pacific ophthalmologists in Aotearoa New Zealand, enhanced research conduct for this study in alignment with Pasifika priorities. He is also a current board member of The Fred Hollows Foundation New Zealand focussed on eradicating preventable blindness in the Pasifika population. Another member (Rachael Niederer) is one of four RANZCO ophthalmologists engaged with Kapo Māori developing the Te Tiriti Action Plan to address Māori eye health inequities. The research team have been involved with extensive research and internationally recognised publications in ophthalmology, including exploring health disparities and ethnicity related issues in ophthalmology in Aotearoa New Zealand.
Results
During the 2-year time period between 1 January 2018 and 31 December 2019, 52,512 patients were scheduled to attend 227,028 outpatient visits. The median number of outpatient visits per patient was 3 [IQR 1–5]. Demographics of patients who received one or more outpatient scheduled appointments are presented in Table 1. Of the patients who were scheduled to attend ophthalmology clinics, 51.7% were female, 48.3% were male, and less than 0.1% self-identified as other gender; median age was 60.5 years [IQR 34.7–74.6], non-Europeans comprised 55.0% with Māori comprising 7.9% and Pacific peoples 13.5%. The median NZDep Index was 6 [IQR 3–8].
View Tables 1–4 and Figures 1–2.
The overall non-attendance rate for the entire cohort was 20,580 visits (9.1%) but varied across individual demographic characteristics and clinic and appointment type (see Table 2). All demographic variables were significantly associated with greater probability of non-attendance. The non-attendance rate for males was 9.8% compared to females (8.4%, p<0.001), and Other gender (8.7%) was proportionally similar to that of male and female across all scheduled appointment visits. Patients under the age of 40 had the highest non-attendance rate, with highest non-attendance at age 20–30 years at 28.0% (see Figure 1). With respect to ethnicity, European ethnicity and Asian ethnicity (5.8% and 6.7% respectively) had the lowest rate of non-attendance, with rates for Māori being 21.1% and Pacific peoples 20.3%. Non-attendance increased with NZDep Index and the rate was three times greater for the lowest, compared to the highest, index (5.9% for NZDep Index 1 compared to 17.7% for NZDep Index 10, see Figure 2). Non-attendance was greater for acute referral clinics (14.4%) compared to non-acute scheduled clinic (8.9%), and for new patient appointments (15.0%) compared to follow-up appointments (8.2%).
Results of univariate and multivariate analysis are presented in Table 3. All variables were significant predictors of clinic non-attendance. Results of the multivariate regression model adjusted for all covariates, including age, gender ethnicity and deprivation status. The multivariate analysis showed that males and younger patients, ethnicity other than European and Asian, higher deprivation status, new patient appointments and acute referral clinics were more likely to be non-attenders. The odds ratio of non-attendance for Māori was 2.7 (p<0.001) and 2.9 (p<0.001) for Pacific peoples compared to European (p<0.001) when controlled for gender, age, deprivation index, and type of clinic visit.
A sub-analysis of patients who missed two or more appointments (n=4,969, 4.5%) revealed that the same variables remained significant predictors of non-attendance (see Table 4).
Discussion
To our knowledge, this first study of this size to report on ophthalmology outpatient clinic non-attendance in Aotearoa New Zealand. This study identified an overall non-attendance rate of 9.1%, with previous ophthalmology studies reporting rates between 5.5% to 17.2%.[[9,10,12,14]] We observed an increased likelihood of non-attendance for those who are younger, male gender, self-identified as Māori or Pacific peoples, and those with higher NZDep score. These demographic factors associated with higher rate of non-attendance are consistent with previous studies in different specialty outpatient clinics in Aotearoa New Zealand.[[5,6,8,11]]
The most striking finding of the present study was the impact of ethnicity on non-attendance with Māori demonstrating an OR of 4.34 times, and 4.13 times for Pacific peoples (p<0.001). In the multivariate analysis which adjusted for age, gender and NZDep scale, non-attendance rates remained significantly higher at 2.69 times for Māori of 2.82 for Pacific peoples (p<0.001). This suggests that there are critical barriers to accessing public outpatient eye care that disproportionately impact Māori and Pacific peoples. This is particularly relevant as burden of eye disease is disproportionately distributed to ethnic and racial minorities.[[15–18]]
While this is the first study to systematically review attendance to general ophthalmology clinics in Aotearoa New Zealand, a similar inequity in attendance was observed in diabetic screening in the Wellington area between 2006 and 2015. In that study, the overall non-attendance rate was 27.9% for new appointments, but patients who identified as Pacific peoples had non-attendance rate of 44.0% and Māori of 31.7%.[[19]] In a 1-year retrospective cross-sectional study in an academic ophthalmology department in the US, a 16.4% non-attendance rate was identified with the OR for Black Americans being 2.6 times compared to White Americans (p<0.001).[[20]] Other studies have also demonstrated significantly greater risk of non-attendance for Native American peoples and Indigenous Australians.[[15,16,21,22]]
Higher rates of non-attendance among Māori and Pacific peoples are not limited to ophthalmology. Other researchers who have identified that race and ethnicity were strongly associated with non-attendance with higher non-attendance rates generally for Indigenous peoples.[[1,23]]
Potential reasons for non-attendance among different racial or ethnic populations have been explored and are likely multifactorial. Research focussed on Indigenous people in colonised nations has identified that addressing health outcomes, such as non-attendance, requires moving beyond individualistic approaches and addressing the wider issues in relation to the inequities in the social determinants of health.[[24–30]] The healthcare system in Aotearoa New Zealand provides free outpatient public hospital services. However, there has been criticism that the health service is designed in the framework of European biomedical paradigm with this structure disadvantaging Māori.[[26]]
In a systematic review, Graham et al. identified three core themes that may explain the higher non-attendance in Māori and Pacific peoples: organisational structure, staff interactions, and practical barriers.[[26]] These core themes underpin the ongoing negative health experiences that Māori patients and their whānau (family) face.
“Organisational structures” refers to experiences of both explicit and implicit racism within the healthcare system. In multiple studies, Māori patients and whānau report that their wider spiritual and cultural practices were devalued within the mainstream health system.[[26,31–33]] In addition, a lack of understanding of rongoā (traditional medicinal applications and treatment) created an additional barrier with healthcare professionals and vice versa a lack of understanding from the patient about what their medical team is attempting to convey.[[34]] In Aotearoa New Zealand, we have recently seen the establishment of Te Aka Whai Ora – Māori Health Authority to work alongside Te Whatu Ora – Health New Zealand, Aotearoa New Zealand’s largest public health employer, with the aim to develop systems and improve organisational structures to improve health inequities affecting Māori.[[35,36]] Locally, Auckland DHB has also initiated the Kaiārangi Nāhi rōpū and Pacific Planned Care Navigation services assigning a team of clinical nurse specialists with the task of improving the long waiting times for Māori and Pacific peoples on the surgical waitlist.[[ 37]] As well as supporting patients, this program collects invaluable data to identify where the systems are failing.
Previous negative staff interactions with healthcare professionals can cause reluctance to attend appointments.[[38]] Evidence suggests that Māori were aware of negative perceptions by health professionals and reported more actively hostile experiences in their interactions leads to mistrust.[[39]] One potential antidote is to improve representation within the medical workforce—healthcare for Māori by Māori. RANZCO and other medical colleges across Australasia have recently made changes to their selection processes to improve Indigenous representation amongst their respective workforces. However, even with these changes medical colleges are a long way from achieving proportionality. For example, in Aotearoa New Zealand only 5% of 147 vocationally trained ophthalmologists identify as Māori or Pacific peoples based on the 2018 New Zealand Medical Workforce Survey,[[40]] when these groups make up close to one quarter of the total Aotearoa New Zealand population.[[41]]
Poor communication between the referring health practitioner and patient is associated with initial appointment non-attendance.[[42]] This, in turn, negatively impacts health literacy, as patients are less aware of the importance and relevance of attending their scheduled appointment and less likely to utilise health services.[[43]]
In comparison to initial patient appointments, we observed lower rates of non-attendance for follow-up appointments. This suggests that patients are less likely to miss appointments once they are under the care of the ophthalmologist, which is consistent with previous studies in various specialist outpatient clinics.[[12,44,45]] This also suggests that the care provided by ophthalmologists, including explaining the patient’s eye condition to them and emphasising the importance of follow-up in a way that is understood and taken on board by the patient, positively contributes to enhancing ongoing patient care and reducing the likelihood of non-attendance to follow-up appointments.
Practical barriers include financial costs, transportation issues and practicalities such as organising leave and/or childcare as obstacles to accessing clinics, attending appointments during working clinic hours, and receiving appropriate levels of healthcare. Public transports options were identified as being insufficient or impossible, particularly for new mothers.[[26,46–48]] Another practical barrier observed is that, although the public eye services at Greenlane Clinical Centre and Waitākere Hospital are free to patients, patients are required to pay for parking at these facilities. The costs incurred for parking create a financial burden affecting many, particularly those with a high NZDep Index score.
These practical barriers are also relevant in explaining the increased non-attendance observed with increasing NZDep Index. Once adjustment was made for ethnicity, NZDep status had an OR of 1.06 (95% CI = 1.05–1.07). Other studies have found that lower socio-economic status (SES), lower median household incomes or other surrogate variables for SES—such as zip codes—were significantly associated with non-attendance.[[1,49,50]] Reasons for non-attendance in higher NZDep status are likely to be multi-factorial but social and financial barriers, transport, childcare, and less flexibility with time off work are relevant variables.[[4,51,52]] Transport has been identified in multiple studies to be a significant contributor to non-attendance.[[26,52]]
Other demographic variables that our study identified to be associated with non-attendance were age and gender. Age, which is inversely proportional to the probability of non-attendance, is corroborated by other investigators.[[1,53]] Younger patients may not be as adherent to their appointments due to more fixed obligations, such as getting time off during working hours.[[10,54]] We also note that Māori and Pacific peoples are more likely to be affected by various eye diseases, namely keratoconus and diabetic retinopathy, more aggressively and at a younger age compared to the general population, potentially compounding the reasons to not attend and downstream health consequences for these groups.[[55–57]] While the present study identified male gender as being a predictor of non-attendance, this is not a consistent finding in other studies.[[1,58]]
Other factors that have been shown to be related to non-attendance include forgetting to attend the appointment, not receiving the appointment or being unable to reach the clinic to cancel the appointment.[[43,59]] The non-attendance dataset encompasses all appointments that were not attended, cancelled or rescheduled by the patient, but did not consider the possibility of the patients who may have attempted to reschedule or cancel their appointment and were unable to. A recent study conducted in Dunedin Hospital, exploring communcation systems between the patient and hospital, reported that some participants found that it was difficult to contact the hospital to cancel or reschedule their appointments.[[7]] These factors suggests that improvements in communication systems and better access to the clinic appointment schedulers may be an important intervention.[[60]]
This study has several limitations. The retrospective aspect of the study prevents conclusion regarding causal relationships between variables. It is an analysis of a single ophthalmology department based across two locations. Furthermore, the accuracy of the data is dependent on the information entered at the time of scheduling. Patients who did not show are not contacted to verify the accuracy of the entered information. Another limitation is that the study used patient ethnicity data recorded on the NHI health system, which may not accurately reflect the individual’s ethnicity that they self-identify with. Similarly, for some individuals the area-based measure of SES may not be an accurate representation of their NZDep status; we acknowledge there are patients who live in lower socio-economic deciles who are not socially or economically deprived.
In summary, non-attendance is a significant barrier to providing timely, high-quality eye care. The greatest impact of non-attendance is on Māori and Pacific peoples, further exacerbating pre-existing inequalities in healthcare. This present study identifies that non-attendance is a significant problem and implies a greater need for our health workforce and health system to further improve on providing better patient care for our Māori and Pasifika, young and socially disadvantaged patients. Further research, which should incorporate kaupapa Māori (knowledge, skills, attitudes and values underpinning and guiding Māori society) approach, need to be undertaken to identify strategies to address the multi-faceted and complex factors.[[61–63]] This may facilitate the development of targeted interventions at the patient, clinic, and health system levels to address these barriers and thereby improve healthcare delivery, health outcomes, and resource management.
Summary
Abstract
Aim
Appointment non-attendance is a problem for medical outpatient clinics, which can result in interruption of continuity of care and poor health outcomes for patients. Furthermore, non-attendance creates a significant economic burden to the health sector. This study aimed to identify factors that are associated with appointment non-attendance in a large public ophthalmology clinic in Aotearoa New Zealand.
Method
This study was a retrospective analysis of clinic non-attendance within Auckland District Health Board’s (DHB) Ophthalmology Department between 1 January 2018 to 31 December 2019. Demographic data collected included: age, gender and ethnicity. Deprivation Index was calculated. Appointments were classified as new patients and follow-ups, and acute or routine. Categorical and continuous variables were analysed using logistic regression to assess likelihood of non-attendance. The research team’s expertise and capacity align with the CONSIDER statement guidelines for Indigenous health and research.
Results
In total, 52,512 patients were scheduled to attend 227,028 outpatient visits, of which 20,580 visits (9.1%) were not attended. Median age of patients who received one or more scheduled appointments were 66.1 years (interquartile range [IQR] 46.9–77.9). Fifty-one point seven percent of patients were female. Ethnicity comprised 55.0% European, 7.9% Māori, 13.5% Pacific peoples, 20.6% Asian and 3.1% Other. Multivariate logistic regression analysis for all appointments showed that males (odds ratio [OR] 1.15 p<0.001), younger patients (OR 0.99 p<0.001), Māori (OR 2.69 p<0.001), Pacific peoples (OR 2.82 p<0.001), higher deprivation status (OR 1.06 p<0.001), new patient appointments (OR 1.61 p<0.001) and patients referred to acute clinics (OR 1.22 p<0.001) were more likely to not attend appointments.
Conclusion
Māori and Pacific peoples disproportionately experience higher rates of appointment non-attendance. Further investigation of access barriers will enable Aotearoa New Zealand health strategy planning to develop targeted interventions addressing unmet patient needs of at-risk groups.
Author Information
Acknowledgements
Correspondence
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Competing Interests
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Patient factors associated with appointment non-attendance at an ophthalmology department in Aotearoa New Zealand
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Non-attendance to appointments, also referred to as missed appointment, “no-shows” or “DNAs” (Did Not Attend), are a common problem for all medical outpatient clinics with rates between 5% to 55%.[[1,2]] Non-attendance has widespread implications for the individual, health system and society. Most importantly for patients, non-attendance may result in delayed diagnosis and treatment and inferior health outcomes. Reasons for non-attendance are likely multifactorial, but it has been suggested that non-attendance is a surrogate of a damaged relationship between the patient and the health system. For the health system, non-attendance results in inefficiency. The economic cost to the health system is also significant. In the United Kingdom (UK), non-attendance to general practice appointments is estimated to cost approximately £162 million each year,[[3]] while overall missed appointments in the United States (US) costs more than $150 billion per year.[[4]]
There is a paucity of data exploring non-attendance outside of and within ophthalmology outpatient clinics.[[5–12]] The aim of this study was to identify patient characteristics associated with appointment non-attendance in a large-public ophthalmology clinic in Aotearoa New Zealand.
Methods
This was a retrospective study with institutional audit approval for analysis of de-identified visit data. The methods of this study adhered to the tenets of the Declaration of Helsinki and was examined and approved by Auckland Health Research Ethics Committee (#AH24132). A de-identified list of all patients who were scheduled to attend outpatient ophthalmology clinic appointments at Auckland District Health Board (DHB), specifically Greenlane Clinical Centre based in Central Auckland and Waitākere Public Hospital based in West Auckland, between 1 January 2018 to 31 December 2019 were retrieved from the hospital records (catchment population numbers are 1,053,939 for Auckland and Waitematā DHBs combined based on 2018 New Zealand Census). Non-attendance was defined as any scheduled appointment that was not attended by the patient, or not cancelled or rescheduled before the time of the appointment by the clinic or patient.
Variables
Demographic information retrieved included: age, gender, ethnicity recorded in the National Health Index (NHI) health system, address and attendance or non-attendance to the appointment. Gender was categorised as either male, female or other (in the data identified as gender diverse, gender unknown or gender unspecified).
Ethnicity classification was based on the New Zealand Census Level 1 ethnicity categories. These included European, Māori, Pacific peoples, Asian and Other. The “Other” category included Middle Eastern, Latin American, African (MELAA), and patients that identified as Other ethnicity.
New Zealand Deprivation (NZDep) Index, an area-based measure of socio-economic status (SES) with a scale ranging from 1 (least deprived) to 10 (most deprived), was linked to each patient address using ArcGIS Pro, a geographic information systems (GIS) software. A spatial join was performed between the dataset of geocoded patient addresses with a dataset of meshblock codes retrieved from Statistics New Zealand (smallest geographic unit for which statistical data are reported) associated with a NZDep Index value based on nine Census variables from the 2018 New Zealand Census. This allowed for analysis of deprivation status for each patient.
Non-attendance numbers were recorded for gender, age in 20-year age bands, ethnicity and deprivation index, scheduled outpatient and acute referral clinic, new appointments and follow-ups.
Statistical analysis
Data were collected in an Excel spreadsheet and analysed in STATA version 15 (StataCorp, College Station, TX, USA). Categorical values are reported as n (%) and continuous variables as median (interquartile range [IQR]). Values for patient demographics were recorded as a proportion of the total number of patients, while all non-attendance data were analysed and reported as a proportion of the total number of appointments. A logistic regression was performed to compare the likelihood of non-attendance between gender, age, ethnicity and NZDep Index for all appointments. Odds ratio (OR) values for each comparison group can be calculated from the reported group as the inverse of the reported group OR value (i.e., 1/OR). A separate logistic regression analysis was performed for patients who had two or more missed appointments to assess multiple clinic visit non-attendance. A p value of <0.05 was considered statistically significant.
Indigenous health and research capacity
The expertise of the research team in Māori and Pacific health covers adequate representation and research capacity in line with the consolidated criteria for strengthening the reporting of health research involving Indigenous peoples (CONSIDER) statement guidelines.[[13]] The research team consists of two members who have been involved in the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Māori and Pasifika Committee, with one current member and one formerly the chair, who consult extensively with Māori. Although there was no direct consultation or partnership with Māori during the research conduct process, the research team aimed to utilise research approaches to support Indigenous health advancement in this study. The consultation and guidance of one of the members (William Cunningham), who is of Samoan ethnicity amongst one of few Māori and Pacific ophthalmologists in Aotearoa New Zealand, enhanced research conduct for this study in alignment with Pasifika priorities. He is also a current board member of The Fred Hollows Foundation New Zealand focussed on eradicating preventable blindness in the Pasifika population. Another member (Rachael Niederer) is one of four RANZCO ophthalmologists engaged with Kapo Māori developing the Te Tiriti Action Plan to address Māori eye health inequities. The research team have been involved with extensive research and internationally recognised publications in ophthalmology, including exploring health disparities and ethnicity related issues in ophthalmology in Aotearoa New Zealand.
Results
During the 2-year time period between 1 January 2018 and 31 December 2019, 52,512 patients were scheduled to attend 227,028 outpatient visits. The median number of outpatient visits per patient was 3 [IQR 1–5]. Demographics of patients who received one or more outpatient scheduled appointments are presented in Table 1. Of the patients who were scheduled to attend ophthalmology clinics, 51.7% were female, 48.3% were male, and less than 0.1% self-identified as other gender; median age was 60.5 years [IQR 34.7–74.6], non-Europeans comprised 55.0% with Māori comprising 7.9% and Pacific peoples 13.5%. The median NZDep Index was 6 [IQR 3–8].
View Tables 1–4 and Figures 1–2.
The overall non-attendance rate for the entire cohort was 20,580 visits (9.1%) but varied across individual demographic characteristics and clinic and appointment type (see Table 2). All demographic variables were significantly associated with greater probability of non-attendance. The non-attendance rate for males was 9.8% compared to females (8.4%, p<0.001), and Other gender (8.7%) was proportionally similar to that of male and female across all scheduled appointment visits. Patients under the age of 40 had the highest non-attendance rate, with highest non-attendance at age 20–30 years at 28.0% (see Figure 1). With respect to ethnicity, European ethnicity and Asian ethnicity (5.8% and 6.7% respectively) had the lowest rate of non-attendance, with rates for Māori being 21.1% and Pacific peoples 20.3%. Non-attendance increased with NZDep Index and the rate was three times greater for the lowest, compared to the highest, index (5.9% for NZDep Index 1 compared to 17.7% for NZDep Index 10, see Figure 2). Non-attendance was greater for acute referral clinics (14.4%) compared to non-acute scheduled clinic (8.9%), and for new patient appointments (15.0%) compared to follow-up appointments (8.2%).
Results of univariate and multivariate analysis are presented in Table 3. All variables were significant predictors of clinic non-attendance. Results of the multivariate regression model adjusted for all covariates, including age, gender ethnicity and deprivation status. The multivariate analysis showed that males and younger patients, ethnicity other than European and Asian, higher deprivation status, new patient appointments and acute referral clinics were more likely to be non-attenders. The odds ratio of non-attendance for Māori was 2.7 (p<0.001) and 2.9 (p<0.001) for Pacific peoples compared to European (p<0.001) when controlled for gender, age, deprivation index, and type of clinic visit.
A sub-analysis of patients who missed two or more appointments (n=4,969, 4.5%) revealed that the same variables remained significant predictors of non-attendance (see Table 4).
Discussion
To our knowledge, this first study of this size to report on ophthalmology outpatient clinic non-attendance in Aotearoa New Zealand. This study identified an overall non-attendance rate of 9.1%, with previous ophthalmology studies reporting rates between 5.5% to 17.2%.[[9,10,12,14]] We observed an increased likelihood of non-attendance for those who are younger, male gender, self-identified as Māori or Pacific peoples, and those with higher NZDep score. These demographic factors associated with higher rate of non-attendance are consistent with previous studies in different specialty outpatient clinics in Aotearoa New Zealand.[[5,6,8,11]]
The most striking finding of the present study was the impact of ethnicity on non-attendance with Māori demonstrating an OR of 4.34 times, and 4.13 times for Pacific peoples (p<0.001). In the multivariate analysis which adjusted for age, gender and NZDep scale, non-attendance rates remained significantly higher at 2.69 times for Māori of 2.82 for Pacific peoples (p<0.001). This suggests that there are critical barriers to accessing public outpatient eye care that disproportionately impact Māori and Pacific peoples. This is particularly relevant as burden of eye disease is disproportionately distributed to ethnic and racial minorities.[[15–18]]
While this is the first study to systematically review attendance to general ophthalmology clinics in Aotearoa New Zealand, a similar inequity in attendance was observed in diabetic screening in the Wellington area between 2006 and 2015. In that study, the overall non-attendance rate was 27.9% for new appointments, but patients who identified as Pacific peoples had non-attendance rate of 44.0% and Māori of 31.7%.[[19]] In a 1-year retrospective cross-sectional study in an academic ophthalmology department in the US, a 16.4% non-attendance rate was identified with the OR for Black Americans being 2.6 times compared to White Americans (p<0.001).[[20]] Other studies have also demonstrated significantly greater risk of non-attendance for Native American peoples and Indigenous Australians.[[15,16,21,22]]
Higher rates of non-attendance among Māori and Pacific peoples are not limited to ophthalmology. Other researchers who have identified that race and ethnicity were strongly associated with non-attendance with higher non-attendance rates generally for Indigenous peoples.[[1,23]]
Potential reasons for non-attendance among different racial or ethnic populations have been explored and are likely multifactorial. Research focussed on Indigenous people in colonised nations has identified that addressing health outcomes, such as non-attendance, requires moving beyond individualistic approaches and addressing the wider issues in relation to the inequities in the social determinants of health.[[24–30]] The healthcare system in Aotearoa New Zealand provides free outpatient public hospital services. However, there has been criticism that the health service is designed in the framework of European biomedical paradigm with this structure disadvantaging Māori.[[26]]
In a systematic review, Graham et al. identified three core themes that may explain the higher non-attendance in Māori and Pacific peoples: organisational structure, staff interactions, and practical barriers.[[26]] These core themes underpin the ongoing negative health experiences that Māori patients and their whānau (family) face.
“Organisational structures” refers to experiences of both explicit and implicit racism within the healthcare system. In multiple studies, Māori patients and whānau report that their wider spiritual and cultural practices were devalued within the mainstream health system.[[26,31–33]] In addition, a lack of understanding of rongoā (traditional medicinal applications and treatment) created an additional barrier with healthcare professionals and vice versa a lack of understanding from the patient about what their medical team is attempting to convey.[[34]] In Aotearoa New Zealand, we have recently seen the establishment of Te Aka Whai Ora – Māori Health Authority to work alongside Te Whatu Ora – Health New Zealand, Aotearoa New Zealand’s largest public health employer, with the aim to develop systems and improve organisational structures to improve health inequities affecting Māori.[[35,36]] Locally, Auckland DHB has also initiated the Kaiārangi Nāhi rōpū and Pacific Planned Care Navigation services assigning a team of clinical nurse specialists with the task of improving the long waiting times for Māori and Pacific peoples on the surgical waitlist.[[ 37]] As well as supporting patients, this program collects invaluable data to identify where the systems are failing.
Previous negative staff interactions with healthcare professionals can cause reluctance to attend appointments.[[38]] Evidence suggests that Māori were aware of negative perceptions by health professionals and reported more actively hostile experiences in their interactions leads to mistrust.[[39]] One potential antidote is to improve representation within the medical workforce—healthcare for Māori by Māori. RANZCO and other medical colleges across Australasia have recently made changes to their selection processes to improve Indigenous representation amongst their respective workforces. However, even with these changes medical colleges are a long way from achieving proportionality. For example, in Aotearoa New Zealand only 5% of 147 vocationally trained ophthalmologists identify as Māori or Pacific peoples based on the 2018 New Zealand Medical Workforce Survey,[[40]] when these groups make up close to one quarter of the total Aotearoa New Zealand population.[[41]]
Poor communication between the referring health practitioner and patient is associated with initial appointment non-attendance.[[42]] This, in turn, negatively impacts health literacy, as patients are less aware of the importance and relevance of attending their scheduled appointment and less likely to utilise health services.[[43]]
In comparison to initial patient appointments, we observed lower rates of non-attendance for follow-up appointments. This suggests that patients are less likely to miss appointments once they are under the care of the ophthalmologist, which is consistent with previous studies in various specialist outpatient clinics.[[12,44,45]] This also suggests that the care provided by ophthalmologists, including explaining the patient’s eye condition to them and emphasising the importance of follow-up in a way that is understood and taken on board by the patient, positively contributes to enhancing ongoing patient care and reducing the likelihood of non-attendance to follow-up appointments.
Practical barriers include financial costs, transportation issues and practicalities such as organising leave and/or childcare as obstacles to accessing clinics, attending appointments during working clinic hours, and receiving appropriate levels of healthcare. Public transports options were identified as being insufficient or impossible, particularly for new mothers.[[26,46–48]] Another practical barrier observed is that, although the public eye services at Greenlane Clinical Centre and Waitākere Hospital are free to patients, patients are required to pay for parking at these facilities. The costs incurred for parking create a financial burden affecting many, particularly those with a high NZDep Index score.
These practical barriers are also relevant in explaining the increased non-attendance observed with increasing NZDep Index. Once adjustment was made for ethnicity, NZDep status had an OR of 1.06 (95% CI = 1.05–1.07). Other studies have found that lower socio-economic status (SES), lower median household incomes or other surrogate variables for SES—such as zip codes—were significantly associated with non-attendance.[[1,49,50]] Reasons for non-attendance in higher NZDep status are likely to be multi-factorial but social and financial barriers, transport, childcare, and less flexibility with time off work are relevant variables.[[4,51,52]] Transport has been identified in multiple studies to be a significant contributor to non-attendance.[[26,52]]
Other demographic variables that our study identified to be associated with non-attendance were age and gender. Age, which is inversely proportional to the probability of non-attendance, is corroborated by other investigators.[[1,53]] Younger patients may not be as adherent to their appointments due to more fixed obligations, such as getting time off during working hours.[[10,54]] We also note that Māori and Pacific peoples are more likely to be affected by various eye diseases, namely keratoconus and diabetic retinopathy, more aggressively and at a younger age compared to the general population, potentially compounding the reasons to not attend and downstream health consequences for these groups.[[55–57]] While the present study identified male gender as being a predictor of non-attendance, this is not a consistent finding in other studies.[[1,58]]
Other factors that have been shown to be related to non-attendance include forgetting to attend the appointment, not receiving the appointment or being unable to reach the clinic to cancel the appointment.[[43,59]] The non-attendance dataset encompasses all appointments that were not attended, cancelled or rescheduled by the patient, but did not consider the possibility of the patients who may have attempted to reschedule or cancel their appointment and were unable to. A recent study conducted in Dunedin Hospital, exploring communcation systems between the patient and hospital, reported that some participants found that it was difficult to contact the hospital to cancel or reschedule their appointments.[[7]] These factors suggests that improvements in communication systems and better access to the clinic appointment schedulers may be an important intervention.[[60]]
This study has several limitations. The retrospective aspect of the study prevents conclusion regarding causal relationships between variables. It is an analysis of a single ophthalmology department based across two locations. Furthermore, the accuracy of the data is dependent on the information entered at the time of scheduling. Patients who did not show are not contacted to verify the accuracy of the entered information. Another limitation is that the study used patient ethnicity data recorded on the NHI health system, which may not accurately reflect the individual’s ethnicity that they self-identify with. Similarly, for some individuals the area-based measure of SES may not be an accurate representation of their NZDep status; we acknowledge there are patients who live in lower socio-economic deciles who are not socially or economically deprived.
In summary, non-attendance is a significant barrier to providing timely, high-quality eye care. The greatest impact of non-attendance is on Māori and Pacific peoples, further exacerbating pre-existing inequalities in healthcare. This present study identifies that non-attendance is a significant problem and implies a greater need for our health workforce and health system to further improve on providing better patient care for our Māori and Pasifika, young and socially disadvantaged patients. Further research, which should incorporate kaupapa Māori (knowledge, skills, attitudes and values underpinning and guiding Māori society) approach, need to be undertaken to identify strategies to address the multi-faceted and complex factors.[[61–63]] This may facilitate the development of targeted interventions at the patient, clinic, and health system levels to address these barriers and thereby improve healthcare delivery, health outcomes, and resource management.
Summary
Abstract
Aim
Appointment non-attendance is a problem for medical outpatient clinics, which can result in interruption of continuity of care and poor health outcomes for patients. Furthermore, non-attendance creates a significant economic burden to the health sector. This study aimed to identify factors that are associated with appointment non-attendance in a large public ophthalmology clinic in Aotearoa New Zealand.
Method
This study was a retrospective analysis of clinic non-attendance within Auckland District Health Board’s (DHB) Ophthalmology Department between 1 January 2018 to 31 December 2019. Demographic data collected included: age, gender and ethnicity. Deprivation Index was calculated. Appointments were classified as new patients and follow-ups, and acute or routine. Categorical and continuous variables were analysed using logistic regression to assess likelihood of non-attendance. The research team’s expertise and capacity align with the CONSIDER statement guidelines for Indigenous health and research.
Results
In total, 52,512 patients were scheduled to attend 227,028 outpatient visits, of which 20,580 visits (9.1%) were not attended. Median age of patients who received one or more scheduled appointments were 66.1 years (interquartile range [IQR] 46.9–77.9). Fifty-one point seven percent of patients were female. Ethnicity comprised 55.0% European, 7.9% Māori, 13.5% Pacific peoples, 20.6% Asian and 3.1% Other. Multivariate logistic regression analysis for all appointments showed that males (odds ratio [OR] 1.15 p<0.001), younger patients (OR 0.99 p<0.001), Māori (OR 2.69 p<0.001), Pacific peoples (OR 2.82 p<0.001), higher deprivation status (OR 1.06 p<0.001), new patient appointments (OR 1.61 p<0.001) and patients referred to acute clinics (OR 1.22 p<0.001) were more likely to not attend appointments.
Conclusion
Māori and Pacific peoples disproportionately experience higher rates of appointment non-attendance. Further investigation of access barriers will enable Aotearoa New Zealand health strategy planning to develop targeted interventions addressing unmet patient needs of at-risk groups.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Patient factors associated with appointment non-attendance at an ophthalmology department in Aotearoa New Zealand
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Non-attendance to appointments, also referred to as missed appointment, “no-shows” or “DNAs” (Did Not Attend), are a common problem for all medical outpatient clinics with rates between 5% to 55%.[[1,2]] Non-attendance has widespread implications for the individual, health system and society. Most importantly for patients, non-attendance may result in delayed diagnosis and treatment and inferior health outcomes. Reasons for non-attendance are likely multifactorial, but it has been suggested that non-attendance is a surrogate of a damaged relationship between the patient and the health system. For the health system, non-attendance results in inefficiency. The economic cost to the health system is also significant. In the United Kingdom (UK), non-attendance to general practice appointments is estimated to cost approximately £162 million each year,[[3]] while overall missed appointments in the United States (US) costs more than $150 billion per year.[[4]]
There is a paucity of data exploring non-attendance outside of and within ophthalmology outpatient clinics.[[5–12]] The aim of this study was to identify patient characteristics associated with appointment non-attendance in a large-public ophthalmology clinic in Aotearoa New Zealand.
Methods
This was a retrospective study with institutional audit approval for analysis of de-identified visit data. The methods of this study adhered to the tenets of the Declaration of Helsinki and was examined and approved by Auckland Health Research Ethics Committee (#AH24132). A de-identified list of all patients who were scheduled to attend outpatient ophthalmology clinic appointments at Auckland District Health Board (DHB), specifically Greenlane Clinical Centre based in Central Auckland and Waitākere Public Hospital based in West Auckland, between 1 January 2018 to 31 December 2019 were retrieved from the hospital records (catchment population numbers are 1,053,939 for Auckland and Waitematā DHBs combined based on 2018 New Zealand Census). Non-attendance was defined as any scheduled appointment that was not attended by the patient, or not cancelled or rescheduled before the time of the appointment by the clinic or patient.
Variables
Demographic information retrieved included: age, gender, ethnicity recorded in the National Health Index (NHI) health system, address and attendance or non-attendance to the appointment. Gender was categorised as either male, female or other (in the data identified as gender diverse, gender unknown or gender unspecified).
Ethnicity classification was based on the New Zealand Census Level 1 ethnicity categories. These included European, Māori, Pacific peoples, Asian and Other. The “Other” category included Middle Eastern, Latin American, African (MELAA), and patients that identified as Other ethnicity.
New Zealand Deprivation (NZDep) Index, an area-based measure of socio-economic status (SES) with a scale ranging from 1 (least deprived) to 10 (most deprived), was linked to each patient address using ArcGIS Pro, a geographic information systems (GIS) software. A spatial join was performed between the dataset of geocoded patient addresses with a dataset of meshblock codes retrieved from Statistics New Zealand (smallest geographic unit for which statistical data are reported) associated with a NZDep Index value based on nine Census variables from the 2018 New Zealand Census. This allowed for analysis of deprivation status for each patient.
Non-attendance numbers were recorded for gender, age in 20-year age bands, ethnicity and deprivation index, scheduled outpatient and acute referral clinic, new appointments and follow-ups.
Statistical analysis
Data were collected in an Excel spreadsheet and analysed in STATA version 15 (StataCorp, College Station, TX, USA). Categorical values are reported as n (%) and continuous variables as median (interquartile range [IQR]). Values for patient demographics were recorded as a proportion of the total number of patients, while all non-attendance data were analysed and reported as a proportion of the total number of appointments. A logistic regression was performed to compare the likelihood of non-attendance between gender, age, ethnicity and NZDep Index for all appointments. Odds ratio (OR) values for each comparison group can be calculated from the reported group as the inverse of the reported group OR value (i.e., 1/OR). A separate logistic regression analysis was performed for patients who had two or more missed appointments to assess multiple clinic visit non-attendance. A p value of <0.05 was considered statistically significant.
Indigenous health and research capacity
The expertise of the research team in Māori and Pacific health covers adequate representation and research capacity in line with the consolidated criteria for strengthening the reporting of health research involving Indigenous peoples (CONSIDER) statement guidelines.[[13]] The research team consists of two members who have been involved in the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Māori and Pasifika Committee, with one current member and one formerly the chair, who consult extensively with Māori. Although there was no direct consultation or partnership with Māori during the research conduct process, the research team aimed to utilise research approaches to support Indigenous health advancement in this study. The consultation and guidance of one of the members (William Cunningham), who is of Samoan ethnicity amongst one of few Māori and Pacific ophthalmologists in Aotearoa New Zealand, enhanced research conduct for this study in alignment with Pasifika priorities. He is also a current board member of The Fred Hollows Foundation New Zealand focussed on eradicating preventable blindness in the Pasifika population. Another member (Rachael Niederer) is one of four RANZCO ophthalmologists engaged with Kapo Māori developing the Te Tiriti Action Plan to address Māori eye health inequities. The research team have been involved with extensive research and internationally recognised publications in ophthalmology, including exploring health disparities and ethnicity related issues in ophthalmology in Aotearoa New Zealand.
Results
During the 2-year time period between 1 January 2018 and 31 December 2019, 52,512 patients were scheduled to attend 227,028 outpatient visits. The median number of outpatient visits per patient was 3 [IQR 1–5]. Demographics of patients who received one or more outpatient scheduled appointments are presented in Table 1. Of the patients who were scheduled to attend ophthalmology clinics, 51.7% were female, 48.3% were male, and less than 0.1% self-identified as other gender; median age was 60.5 years [IQR 34.7–74.6], non-Europeans comprised 55.0% with Māori comprising 7.9% and Pacific peoples 13.5%. The median NZDep Index was 6 [IQR 3–8].
View Tables 1–4 and Figures 1–2.
The overall non-attendance rate for the entire cohort was 20,580 visits (9.1%) but varied across individual demographic characteristics and clinic and appointment type (see Table 2). All demographic variables were significantly associated with greater probability of non-attendance. The non-attendance rate for males was 9.8% compared to females (8.4%, p<0.001), and Other gender (8.7%) was proportionally similar to that of male and female across all scheduled appointment visits. Patients under the age of 40 had the highest non-attendance rate, with highest non-attendance at age 20–30 years at 28.0% (see Figure 1). With respect to ethnicity, European ethnicity and Asian ethnicity (5.8% and 6.7% respectively) had the lowest rate of non-attendance, with rates for Māori being 21.1% and Pacific peoples 20.3%. Non-attendance increased with NZDep Index and the rate was three times greater for the lowest, compared to the highest, index (5.9% for NZDep Index 1 compared to 17.7% for NZDep Index 10, see Figure 2). Non-attendance was greater for acute referral clinics (14.4%) compared to non-acute scheduled clinic (8.9%), and for new patient appointments (15.0%) compared to follow-up appointments (8.2%).
Results of univariate and multivariate analysis are presented in Table 3. All variables were significant predictors of clinic non-attendance. Results of the multivariate regression model adjusted for all covariates, including age, gender ethnicity and deprivation status. The multivariate analysis showed that males and younger patients, ethnicity other than European and Asian, higher deprivation status, new patient appointments and acute referral clinics were more likely to be non-attenders. The odds ratio of non-attendance for Māori was 2.7 (p<0.001) and 2.9 (p<0.001) for Pacific peoples compared to European (p<0.001) when controlled for gender, age, deprivation index, and type of clinic visit.
A sub-analysis of patients who missed two or more appointments (n=4,969, 4.5%) revealed that the same variables remained significant predictors of non-attendance (see Table 4).
Discussion
To our knowledge, this first study of this size to report on ophthalmology outpatient clinic non-attendance in Aotearoa New Zealand. This study identified an overall non-attendance rate of 9.1%, with previous ophthalmology studies reporting rates between 5.5% to 17.2%.[[9,10,12,14]] We observed an increased likelihood of non-attendance for those who are younger, male gender, self-identified as Māori or Pacific peoples, and those with higher NZDep score. These demographic factors associated with higher rate of non-attendance are consistent with previous studies in different specialty outpatient clinics in Aotearoa New Zealand.[[5,6,8,11]]
The most striking finding of the present study was the impact of ethnicity on non-attendance with Māori demonstrating an OR of 4.34 times, and 4.13 times for Pacific peoples (p<0.001). In the multivariate analysis which adjusted for age, gender and NZDep scale, non-attendance rates remained significantly higher at 2.69 times for Māori of 2.82 for Pacific peoples (p<0.001). This suggests that there are critical barriers to accessing public outpatient eye care that disproportionately impact Māori and Pacific peoples. This is particularly relevant as burden of eye disease is disproportionately distributed to ethnic and racial minorities.[[15–18]]
While this is the first study to systematically review attendance to general ophthalmology clinics in Aotearoa New Zealand, a similar inequity in attendance was observed in diabetic screening in the Wellington area between 2006 and 2015. In that study, the overall non-attendance rate was 27.9% for new appointments, but patients who identified as Pacific peoples had non-attendance rate of 44.0% and Māori of 31.7%.[[19]] In a 1-year retrospective cross-sectional study in an academic ophthalmology department in the US, a 16.4% non-attendance rate was identified with the OR for Black Americans being 2.6 times compared to White Americans (p<0.001).[[20]] Other studies have also demonstrated significantly greater risk of non-attendance for Native American peoples and Indigenous Australians.[[15,16,21,22]]
Higher rates of non-attendance among Māori and Pacific peoples are not limited to ophthalmology. Other researchers who have identified that race and ethnicity were strongly associated with non-attendance with higher non-attendance rates generally for Indigenous peoples.[[1,23]]
Potential reasons for non-attendance among different racial or ethnic populations have been explored and are likely multifactorial. Research focussed on Indigenous people in colonised nations has identified that addressing health outcomes, such as non-attendance, requires moving beyond individualistic approaches and addressing the wider issues in relation to the inequities in the social determinants of health.[[24–30]] The healthcare system in Aotearoa New Zealand provides free outpatient public hospital services. However, there has been criticism that the health service is designed in the framework of European biomedical paradigm with this structure disadvantaging Māori.[[26]]
In a systematic review, Graham et al. identified three core themes that may explain the higher non-attendance in Māori and Pacific peoples: organisational structure, staff interactions, and practical barriers.[[26]] These core themes underpin the ongoing negative health experiences that Māori patients and their whānau (family) face.
“Organisational structures” refers to experiences of both explicit and implicit racism within the healthcare system. In multiple studies, Māori patients and whānau report that their wider spiritual and cultural practices were devalued within the mainstream health system.[[26,31–33]] In addition, a lack of understanding of rongoā (traditional medicinal applications and treatment) created an additional barrier with healthcare professionals and vice versa a lack of understanding from the patient about what their medical team is attempting to convey.[[34]] In Aotearoa New Zealand, we have recently seen the establishment of Te Aka Whai Ora – Māori Health Authority to work alongside Te Whatu Ora – Health New Zealand, Aotearoa New Zealand’s largest public health employer, with the aim to develop systems and improve organisational structures to improve health inequities affecting Māori.[[35,36]] Locally, Auckland DHB has also initiated the Kaiārangi Nāhi rōpū and Pacific Planned Care Navigation services assigning a team of clinical nurse specialists with the task of improving the long waiting times for Māori and Pacific peoples on the surgical waitlist.[[ 37]] As well as supporting patients, this program collects invaluable data to identify where the systems are failing.
Previous negative staff interactions with healthcare professionals can cause reluctance to attend appointments.[[38]] Evidence suggests that Māori were aware of negative perceptions by health professionals and reported more actively hostile experiences in their interactions leads to mistrust.[[39]] One potential antidote is to improve representation within the medical workforce—healthcare for Māori by Māori. RANZCO and other medical colleges across Australasia have recently made changes to their selection processes to improve Indigenous representation amongst their respective workforces. However, even with these changes medical colleges are a long way from achieving proportionality. For example, in Aotearoa New Zealand only 5% of 147 vocationally trained ophthalmologists identify as Māori or Pacific peoples based on the 2018 New Zealand Medical Workforce Survey,[[40]] when these groups make up close to one quarter of the total Aotearoa New Zealand population.[[41]]
Poor communication between the referring health practitioner and patient is associated with initial appointment non-attendance.[[42]] This, in turn, negatively impacts health literacy, as patients are less aware of the importance and relevance of attending their scheduled appointment and less likely to utilise health services.[[43]]
In comparison to initial patient appointments, we observed lower rates of non-attendance for follow-up appointments. This suggests that patients are less likely to miss appointments once they are under the care of the ophthalmologist, which is consistent with previous studies in various specialist outpatient clinics.[[12,44,45]] This also suggests that the care provided by ophthalmologists, including explaining the patient’s eye condition to them and emphasising the importance of follow-up in a way that is understood and taken on board by the patient, positively contributes to enhancing ongoing patient care and reducing the likelihood of non-attendance to follow-up appointments.
Practical barriers include financial costs, transportation issues and practicalities such as organising leave and/or childcare as obstacles to accessing clinics, attending appointments during working clinic hours, and receiving appropriate levels of healthcare. Public transports options were identified as being insufficient or impossible, particularly for new mothers.[[26,46–48]] Another practical barrier observed is that, although the public eye services at Greenlane Clinical Centre and Waitākere Hospital are free to patients, patients are required to pay for parking at these facilities. The costs incurred for parking create a financial burden affecting many, particularly those with a high NZDep Index score.
These practical barriers are also relevant in explaining the increased non-attendance observed with increasing NZDep Index. Once adjustment was made for ethnicity, NZDep status had an OR of 1.06 (95% CI = 1.05–1.07). Other studies have found that lower socio-economic status (SES), lower median household incomes or other surrogate variables for SES—such as zip codes—were significantly associated with non-attendance.[[1,49,50]] Reasons for non-attendance in higher NZDep status are likely to be multi-factorial but social and financial barriers, transport, childcare, and less flexibility with time off work are relevant variables.[[4,51,52]] Transport has been identified in multiple studies to be a significant contributor to non-attendance.[[26,52]]
Other demographic variables that our study identified to be associated with non-attendance were age and gender. Age, which is inversely proportional to the probability of non-attendance, is corroborated by other investigators.[[1,53]] Younger patients may not be as adherent to their appointments due to more fixed obligations, such as getting time off during working hours.[[10,54]] We also note that Māori and Pacific peoples are more likely to be affected by various eye diseases, namely keratoconus and diabetic retinopathy, more aggressively and at a younger age compared to the general population, potentially compounding the reasons to not attend and downstream health consequences for these groups.[[55–57]] While the present study identified male gender as being a predictor of non-attendance, this is not a consistent finding in other studies.[[1,58]]
Other factors that have been shown to be related to non-attendance include forgetting to attend the appointment, not receiving the appointment or being unable to reach the clinic to cancel the appointment.[[43,59]] The non-attendance dataset encompasses all appointments that were not attended, cancelled or rescheduled by the patient, but did not consider the possibility of the patients who may have attempted to reschedule or cancel their appointment and were unable to. A recent study conducted in Dunedin Hospital, exploring communcation systems between the patient and hospital, reported that some participants found that it was difficult to contact the hospital to cancel or reschedule their appointments.[[7]] These factors suggests that improvements in communication systems and better access to the clinic appointment schedulers may be an important intervention.[[60]]
This study has several limitations. The retrospective aspect of the study prevents conclusion regarding causal relationships between variables. It is an analysis of a single ophthalmology department based across two locations. Furthermore, the accuracy of the data is dependent on the information entered at the time of scheduling. Patients who did not show are not contacted to verify the accuracy of the entered information. Another limitation is that the study used patient ethnicity data recorded on the NHI health system, which may not accurately reflect the individual’s ethnicity that they self-identify with. Similarly, for some individuals the area-based measure of SES may not be an accurate representation of their NZDep status; we acknowledge there are patients who live in lower socio-economic deciles who are not socially or economically deprived.
In summary, non-attendance is a significant barrier to providing timely, high-quality eye care. The greatest impact of non-attendance is on Māori and Pacific peoples, further exacerbating pre-existing inequalities in healthcare. This present study identifies that non-attendance is a significant problem and implies a greater need for our health workforce and health system to further improve on providing better patient care for our Māori and Pasifika, young and socially disadvantaged patients. Further research, which should incorporate kaupapa Māori (knowledge, skills, attitudes and values underpinning and guiding Māori society) approach, need to be undertaken to identify strategies to address the multi-faceted and complex factors.[[61–63]] This may facilitate the development of targeted interventions at the patient, clinic, and health system levels to address these barriers and thereby improve healthcare delivery, health outcomes, and resource management.
Summary
Abstract
Aim
Appointment non-attendance is a problem for medical outpatient clinics, which can result in interruption of continuity of care and poor health outcomes for patients. Furthermore, non-attendance creates a significant economic burden to the health sector. This study aimed to identify factors that are associated with appointment non-attendance in a large public ophthalmology clinic in Aotearoa New Zealand.
Method
This study was a retrospective analysis of clinic non-attendance within Auckland District Health Board’s (DHB) Ophthalmology Department between 1 January 2018 to 31 December 2019. Demographic data collected included: age, gender and ethnicity. Deprivation Index was calculated. Appointments were classified as new patients and follow-ups, and acute or routine. Categorical and continuous variables were analysed using logistic regression to assess likelihood of non-attendance. The research team’s expertise and capacity align with the CONSIDER statement guidelines for Indigenous health and research.
Results
In total, 52,512 patients were scheduled to attend 227,028 outpatient visits, of which 20,580 visits (9.1%) were not attended. Median age of patients who received one or more scheduled appointments were 66.1 years (interquartile range [IQR] 46.9–77.9). Fifty-one point seven percent of patients were female. Ethnicity comprised 55.0% European, 7.9% Māori, 13.5% Pacific peoples, 20.6% Asian and 3.1% Other. Multivariate logistic regression analysis for all appointments showed that males (odds ratio [OR] 1.15 p<0.001), younger patients (OR 0.99 p<0.001), Māori (OR 2.69 p<0.001), Pacific peoples (OR 2.82 p<0.001), higher deprivation status (OR 1.06 p<0.001), new patient appointments (OR 1.61 p<0.001) and patients referred to acute clinics (OR 1.22 p<0.001) were more likely to not attend appointments.
Conclusion
Māori and Pacific peoples disproportionately experience higher rates of appointment non-attendance. Further investigation of access barriers will enable Aotearoa New Zealand health strategy planning to develop targeted interventions addressing unmet patient needs of at-risk groups.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Contact diana@nzma.org.nz
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Patient factors associated with appointment non-attendance at an ophthalmology department in Aotearoa New Zealand
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Non-attendance to appointments, also referred to as missed appointment, “no-shows” or “DNAs” (Did Not Attend), are a common problem for all medical outpatient clinics with rates between 5% to 55%.[[1,2]] Non-attendance has widespread implications for the individual, health system and society. Most importantly for patients, non-attendance may result in delayed diagnosis and treatment and inferior health outcomes. Reasons for non-attendance are likely multifactorial, but it has been suggested that non-attendance is a surrogate of a damaged relationship between the patient and the health system. For the health system, non-attendance results in inefficiency. The economic cost to the health system is also significant. In the United Kingdom (UK), non-attendance to general practice appointments is estimated to cost approximately £162 million each year,[[3]] while overall missed appointments in the United States (US) costs more than $150 billion per year.[[4]]
There is a paucity of data exploring non-attendance outside of and within ophthalmology outpatient clinics.[[5–12]] The aim of this study was to identify patient characteristics associated with appointment non-attendance in a large-public ophthalmology clinic in Aotearoa New Zealand.
Methods
This was a retrospective study with institutional audit approval for analysis of de-identified visit data. The methods of this study adhered to the tenets of the Declaration of Helsinki and was examined and approved by Auckland Health Research Ethics Committee (#AH24132). A de-identified list of all patients who were scheduled to attend outpatient ophthalmology clinic appointments at Auckland District Health Board (DHB), specifically Greenlane Clinical Centre based in Central Auckland and Waitākere Public Hospital based in West Auckland, between 1 January 2018 to 31 December 2019 were retrieved from the hospital records (catchment population numbers are 1,053,939 for Auckland and Waitematā DHBs combined based on 2018 New Zealand Census). Non-attendance was defined as any scheduled appointment that was not attended by the patient, or not cancelled or rescheduled before the time of the appointment by the clinic or patient.
Variables
Demographic information retrieved included: age, gender, ethnicity recorded in the National Health Index (NHI) health system, address and attendance or non-attendance to the appointment. Gender was categorised as either male, female or other (in the data identified as gender diverse, gender unknown or gender unspecified).
Ethnicity classification was based on the New Zealand Census Level 1 ethnicity categories. These included European, Māori, Pacific peoples, Asian and Other. The “Other” category included Middle Eastern, Latin American, African (MELAA), and patients that identified as Other ethnicity.
New Zealand Deprivation (NZDep) Index, an area-based measure of socio-economic status (SES) with a scale ranging from 1 (least deprived) to 10 (most deprived), was linked to each patient address using ArcGIS Pro, a geographic information systems (GIS) software. A spatial join was performed between the dataset of geocoded patient addresses with a dataset of meshblock codes retrieved from Statistics New Zealand (smallest geographic unit for which statistical data are reported) associated with a NZDep Index value based on nine Census variables from the 2018 New Zealand Census. This allowed for analysis of deprivation status for each patient.
Non-attendance numbers were recorded for gender, age in 20-year age bands, ethnicity and deprivation index, scheduled outpatient and acute referral clinic, new appointments and follow-ups.
Statistical analysis
Data were collected in an Excel spreadsheet and analysed in STATA version 15 (StataCorp, College Station, TX, USA). Categorical values are reported as n (%) and continuous variables as median (interquartile range [IQR]). Values for patient demographics were recorded as a proportion of the total number of patients, while all non-attendance data were analysed and reported as a proportion of the total number of appointments. A logistic regression was performed to compare the likelihood of non-attendance between gender, age, ethnicity and NZDep Index for all appointments. Odds ratio (OR) values for each comparison group can be calculated from the reported group as the inverse of the reported group OR value (i.e., 1/OR). A separate logistic regression analysis was performed for patients who had two or more missed appointments to assess multiple clinic visit non-attendance. A p value of <0.05 was considered statistically significant.
Indigenous health and research capacity
The expertise of the research team in Māori and Pacific health covers adequate representation and research capacity in line with the consolidated criteria for strengthening the reporting of health research involving Indigenous peoples (CONSIDER) statement guidelines.[[13]] The research team consists of two members who have been involved in the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Māori and Pasifika Committee, with one current member and one formerly the chair, who consult extensively with Māori. Although there was no direct consultation or partnership with Māori during the research conduct process, the research team aimed to utilise research approaches to support Indigenous health advancement in this study. The consultation and guidance of one of the members (William Cunningham), who is of Samoan ethnicity amongst one of few Māori and Pacific ophthalmologists in Aotearoa New Zealand, enhanced research conduct for this study in alignment with Pasifika priorities. He is also a current board member of The Fred Hollows Foundation New Zealand focussed on eradicating preventable blindness in the Pasifika population. Another member (Rachael Niederer) is one of four RANZCO ophthalmologists engaged with Kapo Māori developing the Te Tiriti Action Plan to address Māori eye health inequities. The research team have been involved with extensive research and internationally recognised publications in ophthalmology, including exploring health disparities and ethnicity related issues in ophthalmology in Aotearoa New Zealand.
Results
During the 2-year time period between 1 January 2018 and 31 December 2019, 52,512 patients were scheduled to attend 227,028 outpatient visits. The median number of outpatient visits per patient was 3 [IQR 1–5]. Demographics of patients who received one or more outpatient scheduled appointments are presented in Table 1. Of the patients who were scheduled to attend ophthalmology clinics, 51.7% were female, 48.3% were male, and less than 0.1% self-identified as other gender; median age was 60.5 years [IQR 34.7–74.6], non-Europeans comprised 55.0% with Māori comprising 7.9% and Pacific peoples 13.5%. The median NZDep Index was 6 [IQR 3–8].
View Tables 1–4 and Figures 1–2.
The overall non-attendance rate for the entire cohort was 20,580 visits (9.1%) but varied across individual demographic characteristics and clinic and appointment type (see Table 2). All demographic variables were significantly associated with greater probability of non-attendance. The non-attendance rate for males was 9.8% compared to females (8.4%, p<0.001), and Other gender (8.7%) was proportionally similar to that of male and female across all scheduled appointment visits. Patients under the age of 40 had the highest non-attendance rate, with highest non-attendance at age 20–30 years at 28.0% (see Figure 1). With respect to ethnicity, European ethnicity and Asian ethnicity (5.8% and 6.7% respectively) had the lowest rate of non-attendance, with rates for Māori being 21.1% and Pacific peoples 20.3%. Non-attendance increased with NZDep Index and the rate was three times greater for the lowest, compared to the highest, index (5.9% for NZDep Index 1 compared to 17.7% for NZDep Index 10, see Figure 2). Non-attendance was greater for acute referral clinics (14.4%) compared to non-acute scheduled clinic (8.9%), and for new patient appointments (15.0%) compared to follow-up appointments (8.2%).
Results of univariate and multivariate analysis are presented in Table 3. All variables were significant predictors of clinic non-attendance. Results of the multivariate regression model adjusted for all covariates, including age, gender ethnicity and deprivation status. The multivariate analysis showed that males and younger patients, ethnicity other than European and Asian, higher deprivation status, new patient appointments and acute referral clinics were more likely to be non-attenders. The odds ratio of non-attendance for Māori was 2.7 (p<0.001) and 2.9 (p<0.001) for Pacific peoples compared to European (p<0.001) when controlled for gender, age, deprivation index, and type of clinic visit.
A sub-analysis of patients who missed two or more appointments (n=4,969, 4.5%) revealed that the same variables remained significant predictors of non-attendance (see Table 4).
Discussion
To our knowledge, this first study of this size to report on ophthalmology outpatient clinic non-attendance in Aotearoa New Zealand. This study identified an overall non-attendance rate of 9.1%, with previous ophthalmology studies reporting rates between 5.5% to 17.2%.[[9,10,12,14]] We observed an increased likelihood of non-attendance for those who are younger, male gender, self-identified as Māori or Pacific peoples, and those with higher NZDep score. These demographic factors associated with higher rate of non-attendance are consistent with previous studies in different specialty outpatient clinics in Aotearoa New Zealand.[[5,6,8,11]]
The most striking finding of the present study was the impact of ethnicity on non-attendance with Māori demonstrating an OR of 4.34 times, and 4.13 times for Pacific peoples (p<0.001). In the multivariate analysis which adjusted for age, gender and NZDep scale, non-attendance rates remained significantly higher at 2.69 times for Māori of 2.82 for Pacific peoples (p<0.001). This suggests that there are critical barriers to accessing public outpatient eye care that disproportionately impact Māori and Pacific peoples. This is particularly relevant as burden of eye disease is disproportionately distributed to ethnic and racial minorities.[[15–18]]
While this is the first study to systematically review attendance to general ophthalmology clinics in Aotearoa New Zealand, a similar inequity in attendance was observed in diabetic screening in the Wellington area between 2006 and 2015. In that study, the overall non-attendance rate was 27.9% for new appointments, but patients who identified as Pacific peoples had non-attendance rate of 44.0% and Māori of 31.7%.[[19]] In a 1-year retrospective cross-sectional study in an academic ophthalmology department in the US, a 16.4% non-attendance rate was identified with the OR for Black Americans being 2.6 times compared to White Americans (p<0.001).[[20]] Other studies have also demonstrated significantly greater risk of non-attendance for Native American peoples and Indigenous Australians.[[15,16,21,22]]
Higher rates of non-attendance among Māori and Pacific peoples are not limited to ophthalmology. Other researchers who have identified that race and ethnicity were strongly associated with non-attendance with higher non-attendance rates generally for Indigenous peoples.[[1,23]]
Potential reasons for non-attendance among different racial or ethnic populations have been explored and are likely multifactorial. Research focussed on Indigenous people in colonised nations has identified that addressing health outcomes, such as non-attendance, requires moving beyond individualistic approaches and addressing the wider issues in relation to the inequities in the social determinants of health.[[24–30]] The healthcare system in Aotearoa New Zealand provides free outpatient public hospital services. However, there has been criticism that the health service is designed in the framework of European biomedical paradigm with this structure disadvantaging Māori.[[26]]
In a systematic review, Graham et al. identified three core themes that may explain the higher non-attendance in Māori and Pacific peoples: organisational structure, staff interactions, and practical barriers.[[26]] These core themes underpin the ongoing negative health experiences that Māori patients and their whānau (family) face.
“Organisational structures” refers to experiences of both explicit and implicit racism within the healthcare system. In multiple studies, Māori patients and whānau report that their wider spiritual and cultural practices were devalued within the mainstream health system.[[26,31–33]] In addition, a lack of understanding of rongoā (traditional medicinal applications and treatment) created an additional barrier with healthcare professionals and vice versa a lack of understanding from the patient about what their medical team is attempting to convey.[[34]] In Aotearoa New Zealand, we have recently seen the establishment of Te Aka Whai Ora – Māori Health Authority to work alongside Te Whatu Ora – Health New Zealand, Aotearoa New Zealand’s largest public health employer, with the aim to develop systems and improve organisational structures to improve health inequities affecting Māori.[[35,36]] Locally, Auckland DHB has also initiated the Kaiārangi Nāhi rōpū and Pacific Planned Care Navigation services assigning a team of clinical nurse specialists with the task of improving the long waiting times for Māori and Pacific peoples on the surgical waitlist.[[ 37]] As well as supporting patients, this program collects invaluable data to identify where the systems are failing.
Previous negative staff interactions with healthcare professionals can cause reluctance to attend appointments.[[38]] Evidence suggests that Māori were aware of negative perceptions by health professionals and reported more actively hostile experiences in their interactions leads to mistrust.[[39]] One potential antidote is to improve representation within the medical workforce—healthcare for Māori by Māori. RANZCO and other medical colleges across Australasia have recently made changes to their selection processes to improve Indigenous representation amongst their respective workforces. However, even with these changes medical colleges are a long way from achieving proportionality. For example, in Aotearoa New Zealand only 5% of 147 vocationally trained ophthalmologists identify as Māori or Pacific peoples based on the 2018 New Zealand Medical Workforce Survey,[[40]] when these groups make up close to one quarter of the total Aotearoa New Zealand population.[[41]]
Poor communication between the referring health practitioner and patient is associated with initial appointment non-attendance.[[42]] This, in turn, negatively impacts health literacy, as patients are less aware of the importance and relevance of attending their scheduled appointment and less likely to utilise health services.[[43]]
In comparison to initial patient appointments, we observed lower rates of non-attendance for follow-up appointments. This suggests that patients are less likely to miss appointments once they are under the care of the ophthalmologist, which is consistent with previous studies in various specialist outpatient clinics.[[12,44,45]] This also suggests that the care provided by ophthalmologists, including explaining the patient’s eye condition to them and emphasising the importance of follow-up in a way that is understood and taken on board by the patient, positively contributes to enhancing ongoing patient care and reducing the likelihood of non-attendance to follow-up appointments.
Practical barriers include financial costs, transportation issues and practicalities such as organising leave and/or childcare as obstacles to accessing clinics, attending appointments during working clinic hours, and receiving appropriate levels of healthcare. Public transports options were identified as being insufficient or impossible, particularly for new mothers.[[26,46–48]] Another practical barrier observed is that, although the public eye services at Greenlane Clinical Centre and Waitākere Hospital are free to patients, patients are required to pay for parking at these facilities. The costs incurred for parking create a financial burden affecting many, particularly those with a high NZDep Index score.
These practical barriers are also relevant in explaining the increased non-attendance observed with increasing NZDep Index. Once adjustment was made for ethnicity, NZDep status had an OR of 1.06 (95% CI = 1.05–1.07). Other studies have found that lower socio-economic status (SES), lower median household incomes or other surrogate variables for SES—such as zip codes—were significantly associated with non-attendance.[[1,49,50]] Reasons for non-attendance in higher NZDep status are likely to be multi-factorial but social and financial barriers, transport, childcare, and less flexibility with time off work are relevant variables.[[4,51,52]] Transport has been identified in multiple studies to be a significant contributor to non-attendance.[[26,52]]
Other demographic variables that our study identified to be associated with non-attendance were age and gender. Age, which is inversely proportional to the probability of non-attendance, is corroborated by other investigators.[[1,53]] Younger patients may not be as adherent to their appointments due to more fixed obligations, such as getting time off during working hours.[[10,54]] We also note that Māori and Pacific peoples are more likely to be affected by various eye diseases, namely keratoconus and diabetic retinopathy, more aggressively and at a younger age compared to the general population, potentially compounding the reasons to not attend and downstream health consequences for these groups.[[55–57]] While the present study identified male gender as being a predictor of non-attendance, this is not a consistent finding in other studies.[[1,58]]
Other factors that have been shown to be related to non-attendance include forgetting to attend the appointment, not receiving the appointment or being unable to reach the clinic to cancel the appointment.[[43,59]] The non-attendance dataset encompasses all appointments that were not attended, cancelled or rescheduled by the patient, but did not consider the possibility of the patients who may have attempted to reschedule or cancel their appointment and were unable to. A recent study conducted in Dunedin Hospital, exploring communcation systems between the patient and hospital, reported that some participants found that it was difficult to contact the hospital to cancel or reschedule their appointments.[[7]] These factors suggests that improvements in communication systems and better access to the clinic appointment schedulers may be an important intervention.[[60]]
This study has several limitations. The retrospective aspect of the study prevents conclusion regarding causal relationships between variables. It is an analysis of a single ophthalmology department based across two locations. Furthermore, the accuracy of the data is dependent on the information entered at the time of scheduling. Patients who did not show are not contacted to verify the accuracy of the entered information. Another limitation is that the study used patient ethnicity data recorded on the NHI health system, which may not accurately reflect the individual’s ethnicity that they self-identify with. Similarly, for some individuals the area-based measure of SES may not be an accurate representation of their NZDep status; we acknowledge there are patients who live in lower socio-economic deciles who are not socially or economically deprived.
In summary, non-attendance is a significant barrier to providing timely, high-quality eye care. The greatest impact of non-attendance is on Māori and Pacific peoples, further exacerbating pre-existing inequalities in healthcare. This present study identifies that non-attendance is a significant problem and implies a greater need for our health workforce and health system to further improve on providing better patient care for our Māori and Pasifika, young and socially disadvantaged patients. Further research, which should incorporate kaupapa Māori (knowledge, skills, attitudes and values underpinning and guiding Māori society) approach, need to be undertaken to identify strategies to address the multi-faceted and complex factors.[[61–63]] This may facilitate the development of targeted interventions at the patient, clinic, and health system levels to address these barriers and thereby improve healthcare delivery, health outcomes, and resource management.
Summary
Abstract
Aim
Appointment non-attendance is a problem for medical outpatient clinics, which can result in interruption of continuity of care and poor health outcomes for patients. Furthermore, non-attendance creates a significant economic burden to the health sector. This study aimed to identify factors that are associated with appointment non-attendance in a large public ophthalmology clinic in Aotearoa New Zealand.
Method
This study was a retrospective analysis of clinic non-attendance within Auckland District Health Board’s (DHB) Ophthalmology Department between 1 January 2018 to 31 December 2019. Demographic data collected included: age, gender and ethnicity. Deprivation Index was calculated. Appointments were classified as new patients and follow-ups, and acute or routine. Categorical and continuous variables were analysed using logistic regression to assess likelihood of non-attendance. The research team’s expertise and capacity align with the CONSIDER statement guidelines for Indigenous health and research.
Results
In total, 52,512 patients were scheduled to attend 227,028 outpatient visits, of which 20,580 visits (9.1%) were not attended. Median age of patients who received one or more scheduled appointments were 66.1 years (interquartile range [IQR] 46.9–77.9). Fifty-one point seven percent of patients were female. Ethnicity comprised 55.0% European, 7.9% Māori, 13.5% Pacific peoples, 20.6% Asian and 3.1% Other. Multivariate logistic regression analysis for all appointments showed that males (odds ratio [OR] 1.15 p<0.001), younger patients (OR 0.99 p<0.001), Māori (OR 2.69 p<0.001), Pacific peoples (OR 2.82 p<0.001), higher deprivation status (OR 1.06 p<0.001), new patient appointments (OR 1.61 p<0.001) and patients referred to acute clinics (OR 1.22 p<0.001) were more likely to not attend appointments.
Conclusion
Māori and Pacific peoples disproportionately experience higher rates of appointment non-attendance. Further investigation of access barriers will enable Aotearoa New Zealand health strategy planning to develop targeted interventions addressing unmet patient needs of at-risk groups.
Author Information
Acknowledgements
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Competing Interests
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Patient factors associated with appointment non-attendance at an ophthalmology department in Aotearoa New Zealand
Non-attendance to appointments, also referred to as missed appointment, “no-shows” or “DNAs” (Did Not Attend), are a common problem for all medical outpatient clinics with rates between 5% to 55%.
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