Original Articles

Diabetic clinic defaulters - who are they and why do they default?

1 K Archibald BA MB BS Medical Registrar and G V Gill MSC MD FRCP Consultant Physician Department of Medicine, Arrowe Park Hospital, Wirral, Merseyside

Correspondence to: Dr G V Gill, Diabetes Centre, Walton Hospital, Rice Lane, Liverpool

Abstract To investigate the problem of diabetic clinic defaulting, we studied patients who had lapsed from follow-up for at least 12 months and were referred back during

one calendar year. Of the 37 investigated in detail, sex distribution, age, diabetes duration, treatment and BMI were not significantly different from a control group of regular clinic attenders. However, defaulters had a higher

HbAl (10.0f 2.5% v 8.5 -C 2.0%, p <0.01) and more micro- and macrovascular complications (20 v 11, p <0.05). Most complications had not

been present at the time of default from clinic (mean period of lapse was 26 -C 14 months).

Reasons given for default included: overcrowded clinic; prolonged waiting; seeing different doctors; and not seeing the consultant often enough.

Defaulting is thus a common problem and is associated with poor glycaemic control and increased complication rates. Better education and more

“user-friendly” clinics may reduce the problem.

(p <0.01). The mean lapse period was about two years (26.5 f 14.4 months, range 12-60 months).

Complications The pattern of complications in both groups is detailed in Table 2. Micro- and macrovascular complications were com- moner in defaulters ( ~ ~ 0 . 0 5 ) . Signifi- cant new problems were detected in 14 (38%) defaulters at reassessment - retinopathy seven, nephropathy two, neuropathy one, claudication three, stroke one, coronary artery disease one and hypertension three.

Keywords: defaulters, diabetic clinic

Introduction Diabetes mellitus is a chronic multi- system disease requiring indefinite strdc- tured follow-up and frequent contact with a specialised diabetes clinic is associated with improved outcome and reduced diabetic complication rates’. Previous surveys have also, however, clearly demonstrated that significant numbers of patients default from hospi- tal diabetic clinic^'.^. Reduction of defaulting rates would therefore appear to be an important strategy in improving overall diabetes care and prognosis. To achieve this, it is important to firstly define the clinical characteristics of diabetic clinic defaulters and to explore the reasons for their default. We describe here the results of our attempts to answer these questions in a busy general hospital diabetic clinic.

Patients and methods We identified “lapsers” by examining the records of all patients referred to our New Diabetic Clinic during the calender year of 1988. Referrals of known diabe- tics who had previously attended the clinic, but who had lapsed from follow- up for at least 12 months, were studied.

We recorded details of age, sex, dura- tion ofdiabetes, weight and body mass index (BMI), glycosylated haemoglobin (HbA,) and complications present at the time of lapse from the clinic and at re-

referral. A control group consisted of consecutive regular attenders.

Reasons for default were assessed by questionnaire sent to all identified defaulters. Results were statistically examined using Student’s t-test, and the Chi-squared test.

Results During 1988, 237 patients were referred to the New Patient Diabetic Clinic, of whom 45 (19%) were known diabetic patients who had lapsed from the clinic for at least 12 months. In mid-1988, the total clinic population was 1,356, and the “lapsers” therefore comprised 3.3% of the total clinic.

Notes were obtained from 37 of the 45 lapsers, the rest being unobtainable. The control group therefore also comprised 37 patients. The mode of referral was mainly from the general practioner (25) although nine referred themselves, two were went from the casualty department and one from another consultant.

Clinical characteristics These are summarised in Table 1. The defaulters and controls were well matched for age, duration of diabetes, sex, BMI and type of treatment. The lap- sers had significantly poorer glycaemic control with a mean HbA, of 10.0 f 2.4%0, compared with 8.5 k 2.0% (mean k 1 SD) in the regular attenders

Reasons for default Results of the questionnaire survey are shown in Table 3. All defaulters were sent letters asking them to select reasons for their default from a list of 20 “prob- lems”. Perhaps, not surprisingly, the response rate was poor - only 18 (49%) responding. The major apparent prob- lems were the clinic being too crowded, waiting times too long, patients seeing a. different doctor each time and not seeing the consultant enough.

Discussion This study clearly confirms that default- ing from diabetic clinics is a sizeable problem. Re-referred lapsers made up 19% of the “new patient“ load and they had significant poorer control and more complications than their regularly- attending counterparts. Most of these complications had arisen during the period of default and, indeed, it was fre- quently these tomplications which led to the referral back. In nearly all cases, neither ourselves nor the general prac- titioner involved were aware of these long-term defaulters. The spread of com- puterisation will hopefully solve this problem and allow vigorous “chasing” of lapsed diabetic patients - both by hos- pital clinic and by GPs.

By the very nature of the population we have studied, it is not surprising that the response to the questionnaire was poor. Also not surprising, amongst those who did reply, overcrowded clinics and prolonged waiting times were major

Practical Diabetes January/February Vol9 No 1 13

Original Articles Diabetic clinic defaulters - who are they and why do they default?

reasons given for default. In fact, our clinic underwent major reorganisation in early 1987, resulting in a reduction of waiting times to around 10 minutes on average. Our defaulters, however, stopped attending an average of .26 months prior to their assessment during 1988 and most would not therefore have been aware of these improvements. It is

our impression that the improved “user- friendliness” of the clinic has already led to reduced defaulting rates, though we will need to audit this problem again in one or two years’ time to be certain. The other major reasons for default men- tioned by our patients concerned seeing different doctors each time and not seeing the consultant often enough.

Table 1 Characteristics of diabetic clinic defaulters compared with regular attenders

(means +7 SD)

Defaulters (n = 37)

Age Cy) 49.9f 16.4 Sex ratio 16F:ZlM Duration diabetes (y) 12.6 f 9.8 Body mass index 28.5 f 6.0 HbA, (%) 10.0 f 2 . 4 Treatment Insulin 24

Diet & drugs 13 Lapse period (months) 26.5 k 14.4

(range 12-60)

Regular attenders (n = 37)

53.0f12.4 pNS 18F: 19M p NS 11.2 f 10.4 p NS 30.3 f 4. I p NS.

Insulin 19 Diet & drugs 18 pNS

8.5 2.0 p < o m

Table 2 Patterns of complications in diabetic clinic defaulters and regular attenders

Defaulters Regular attenders (n =37) (n =37)

Microvascular Retinopathy 9 7 Neuropathy 3 2 Nephropathy 2 1

Total 14 10

Coronary artery disease I 0 Cerebrovascular disease 2 1 Peripheral vascular disease 3 0

Total 6 1

Hypertension 3 3 cataract 1 1 Impotence 1 1

Total 5 5

Macrovascular

Other

Note: overall, total micro- and macrovascular complications were commoner in defaulters compared with regular attenders (p < 0.05)

Table 3 Reasons for lapsing from diabetic clinic given by 18 defaulters

Reason % Clinic too crowded 39 Waiting too long 33 Different doctor each visit 33 Not seeing consultant 33 Inadequate explanations 28 Can‘t get time off work 28 Transport difficulties 28 Note: other reasons given in the questionnaires included:

moving away from area 0 transfer to another hospital

unfriendly nursing staff working away bus ride too long

afraid of diabetes doctors lecturing about smoking doctors lecturing about alcohol feeling “too well”

These are more difficult problems to cor- rect, of course, though perhaps a move towards GP clinical assistants rather than junior hospital doctors staffing the diabetic clinic may improve continuity of care and patient satisfaction.

There is scanty literature concerning defaulters from diabetic clinics. Ham- mersley and colleagues’ studied default- ing rates between 1971 and 1981 and found an overall annual default rate of 4.1%. A sample of defaulters were studied in detail and found to have sig- nificantly higher HbA, levels and blood pressure, as well as more retinopathy and neuropathy. Scobie and colleagues3 in London reported a similar 5% annual default rate, but found that most of this was due to deaths or patients moving out of the area.

When these causes of default were removed, the annual loss to the clinic was only 1.4% and the authors con- sidered that most of these were receiving some sort of medical supervision. This latter finding is at variance from the Wol- verhampton survey‘ and our own local impressions. Finally, in a recent letter4 a group from Bristol reported that in a seven-month period 127 of 175 (17.8%) patients missed diabetic clinic appoint- ments. This may, however, have been rather a short period of default to study, as some of the reasons given included being “away” or “ill” at the time of the appointment, “losing appointment card” or “mixing up dates”. In our experience, many such “short-term lapsers” rebook themselves into the clinic during the ensuing weeks or months and may not represent the major problem of long-term defaulters.

In our survey, we looked at the default problem from a different angle - inves- tigating patients referred back to the clinic. Though this may have selected a potentially more problematic group, it ensured that only genuine long-term defaulters were investigated and that they were all thoroughly examined. Our results show that the defaulting problem “rebounds” on the diabetic clinic, caus- ing a considerable ongoing workload. All clinics should actively audit their default rates and attempt to minimise them.

References 1. Deckert T, Poulsen JE, Larsen M. Prognosis

of diabetics with diabetes onset before the age of thirty-one. II Fmton influencing the prognosis. Diabetologia 1978; 14: 371-377

2. Hnmmerssley MS, Holland MR, Walford S, er al. What happens to defaulten from a diabetic clinic? Brit Med J . 1985; 291: 1330-1332

3. Scoble IN, Raffety AB, Franks PC, er al. Why patienu were lost from follow-up at an urban diabetic clinic. Brit Med J , 1983; 286: 189-190

4. Lloyd J: Sherriff R, Flsher M, er al. Non- anendance at ‘the diabetic clinic. Practical Diabetes, 1990; 7: 228-229

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