Hypothesis / aims of study
Around 1 in 10 hospital appointments are missed every year in the NHS (1) costing approximately £120 per missed appointment. Incidence of missed appointments ranges from 12% to 42%(2) and multiple risk-factors have been identified such as age, gender, distance to the hospital, socioeconomic level, ethnicity, unemployment, and type of health insurance coverage (3–6).
Posterior compartment pelvic floor disorders (PC-PFD) present as anal incontinence, incomplete evacuation or constipation and affect 20% of women in the general population. Considering the high incidence and its significant impact on quality of life, we determined the incidence of missed hospital appointments and associated sociodemographic and clinical predictors in patients with PC-PFD.
Study design, materials and methods
This is a single-institution study of patients with PC-PFD referred to a tertiary colorectal pelvic floor unit (PFU).
Treatment Pathway in Pelvic Floor Unit
A mixture of urban and rural referrals are received in the PFU. A multidisciplinary approach is taken to assess the patients with PC-PFD which starts with an initial evaluation using a structured interview along with standardised questionnaires( (7) in telephone triage assessment clinic (TTAC). Following TTAC, patients are reviewed in a face-to-face bowel function clinic (BFC) for examination and conservative treatment. If patients' symptoms persist after 3-4 BFC sessions, then investigations such as pelvic floor ultrasound (PFUS), endoanal ultrasound (EAUS) defaecating proctogram (DP) and anorectal manometry (ARM) are organised as considered appropriate. Patients are then discussed in the PFU multi-disciplinary meeting (MDM) consisting of consultant surgeons, nurses, physiotherapists, radiologists, and clinical scientists to review symptoms, the treatment offered, and investigations to plan future management.
Missed appointment
An appointment was marked missed if, the patient 1) didn’t attend without informing or asking to re-schedule the appointment or 2) didn’t contact the hospital to inform their decision when the appointment was left open for 6 months.
Missed appointments were recorded for attendance in 1) TTAC, 2) BFC, 3) Investigations appointments (EAUS and ARM, PFUS and DP). Data regarding not completing the treatment was also recorded.
Data Sources and Study Variables
Patients were identified from a prospectively maintained database (PMD) between March 2013 and May 2019. Data for socio-demographics such as gender, age, ethnicity, and socio-economic was collected from PMD while clinical characteristics such as main presenting complaint and treatment offered were collected retrospectively from electronic records.
A total of eight ethnicities were recorded and socioeconomic status was proxied by the English Indices of Deprivation Measure 2019 (IMD)(9) which is an official measure of relative deprivation in England. The IMD scale ranges from 1 to 10 where the IMD score was divided into quintiles (1-5), by combining adjacent decile groups. The lowest quintile represented the most deprived group of patients.
The main presenting complaints recorded were obstructive defaecation (incomplete , anal incontinence, both, rectal prolapse, vaginal prolapse with incomplete rectal emptying, and other symptoms (anal pain or rectal bleeding).
The treatment recorded was preliminary conservative management and rectal irrigation along with the type (low versus high-volume). Preliminary conservative management involved pharmacological therapy, dietary and lifestyle advice, teaching correct toilet positioning techniques, retraining pelvic floor muscles, and psycho-social support.
Rectal irrigation is the introduction of warm water into the rectum through the anal canal. The National Institute for Health and Care Excellence recommends it be considered in patients with PC-PFD who fail to respond to preliminary conservative measures (10). Two alternative irrigation systems based on volume delivered exist: low-volume irrigation system (LVRI) which delivers up to 250ml and high-volume irrigation system (HVRI) which delivers between 250ml-4 litres (11).
Electronic patient records were reviewed for all patients up till the point where they were either considered treated and discharged or lost to follow-up (LTFU). LTFU meant patients missed two consecutive appointments or did not contact the department after their appointment was left open for 6 months.
Results
Initially, 2001 patients were referred to PFU with a female dominance (1706, 85.3%) and a mean age of 52 years +/- 15.
Missed appointments
A summary of findings is outlined in the Tables 1 and 2. Our analysis also showed that the proportion of patients missing face-to-face appointments (BFC - 15.8%, EAUS – 24.3%, PFUS – 37.2%, DP – 26.2%) was higher when compared to telephone appointments, 2.2%.
Table 1 shows socio-demographic and clinical predictors of missed telephone appointments in patients with PC-PFD
Telephone Triage Assessment Clinic (TTAC)
TTAC appointment was missed by 45 (2.2%) patients. This was associated with male gender (12, 4.1%), age < 50 years, belonging to mixed and other ethnicity, and presenting complaint of rectal bleeding or anal pain, p-value <0.05.
Bowel Function Clinic (BFB)
BFC appointment was missed by 309 (15.8%) patients. This was associated with male gender (56,19.8%), lower socio-economic status, and presenting complaints of anal incontinence. p-value < 0.05.
Diagnostic Tests Appointment
Endoanal ultrasound (EAUS) and anorectal manometry (ARM)
EAUS appointment was missed by 476(24.3%) patients. This was associated male gender (104,36.7%), lower socio-economic status, and presenting complaint of rectal bleeding or anal pain, p-value <0.05.
Pelvic floor ultrasound (PFUS)
PFUS appointment was missed by 484(37.2%) patients. This was associated with presenting complaints of anal incontinence (165, 53.2%) and other complaints such as rectal bleeding and anal pain (14, 63.6%), p-value <0.001.
Defaecating proctogram (DP)
DP appointment was missed by 432(26.2%) patients. This was associated with male gender (96,42.3%) age < 50 years (215, 29.4%), presenting symptoms of rectal bleeding or anal pain (57, 76%) p-value <0.05.
Treatment Completion
We found that 928(57.2%) patients didn’t complete their treatment and were LTFU. Factors associated were age < 50 years, lower socio-economic status, presenting complaints of rectal bleeding or anal pain, preliminary conservative treatment and high-volume rectal irrigation, p-values < 0.05.
Interpretation of results
• Ethnic minorities were more likely to miss telephone appointments, possibly due to a difference in preference for initial appointments to be in person, cultural beliefs, linguistic barriers, severity and bother of the symptoms, knowledge of the diseases, and variability in understanding of the existence of treatment options for symptoms.
• Male patients missed their appointments more than females, possibly due to feeling embarrassed when discussing pelvic floor problems.
• Face-to-face appointments were missed more than telephone ones, perhaps due to difficulty getting time off work, travel costs, and difficulty commuting.
• Patients < 50 years old were more likely to miss telephone appointments and not complete treatment. This could be due to difficulty getting time off work or finding childcare.
• Patients from lower socio-economic groups were more likely to miss face-to-face appointments and didn’t complete treatment. This could be due to difficulty in access to care, education level, or knowledge about the disease and expenses to cover travel costs.
• Anal incontinence was associated with missing face-to-face appointments. This may be due to the fear of having accidental bowel leakage.
Concluding message
Incidence of failed hospital appointments was found to be high. Missed appointments result in inefficiencies, and economic costs and may interrupt continuity of care. Future prospective research, including qualitative studies, is required to identify, and address factors and potential barriers patients face when accessing care for PC-PFD. This will not only improve patient outcomes but also increase clinicians' efficiency, productivity, and better use of limited healthcare resources.