In general, numerous studies conducted in previous years noted that the defaulter rate at different outpatient clinic (general adult clinic, orthopedic/trauma clinic, community health clinic, and primary care clinic) ranged from 12% to 42%.[1
] To date, there were only fewer than five studies ever published on defaulter rate among patients with cancer namely colorectal, breast and childhood cancer, which reported that the defaulter rate ranged from 15 to 21%.[12
] In our study, the defaulter rate among suspected lung cancer patients was 21.1%. From our extensive Pubmed search and literature review, we did not find any similar study looking at defaulters among lung cancer patients. However, we have found a study conducted in Singapore by Lee et al
. on predictor of failed attendance in a multi-specialty outpatient centre in which 22864 patients were recruited. Their defaulter rate was 39%.[8
Various studies have looked into features associated with default for instance demographic and socioeconomic status. Several studies concluded that younger adults are more likely to default.[8
] The findings in literature for low socioeconomic status associated with default have yielded inconsistent results in non-cancer patients.[10
] We did not find any significant association of defaulter with socioeconomic factors in our lung cancer study population. However, Klosky et al
. and Johnson et al
. had demonstrated that lower socioeconomic status was associated with default among patients with cancer.[12
] Interestingly, Lee et al
. from Singapore concluded that Malays and Indians had significant higher odds ratio for default compared to Chinese.[8
] Similarly in our study, Malays tend to default more than Chinese (70.0% vs 30.0%). However the P value was not significant probably because of our small sample size. The main association with hospital default was reported as being of the male gender.[9
] We did not find any significant association between gender and default. Similarly, Kosmider et al
. demonstrated that gender was not associated with default in patients with colorectal cancer.[12
A study conducted by Frankel et al
. noted that no significant difference was found between defaulter and non-defaulter according to the seriousness of the illness.[15
] The seriousness of the illness in this study was based on the provisional referral diagnosis, by the degree to which the patient's activity was limited, by the level of the pain, and by the duration of symptoms. There was no study published on the association of the stage of cancer and the performance status of the patients with the defaulter rate. However, our study supported the findings of Frankel et al
. that seriousness of illness as reflected by poor performance status and the advanced stage of lung cancer were not significantly associated with defaults. Johnson R et al
. had shown that patients with full time education were less likely to default.[14
] In our study the only significant factor associated with default was lower children's education level. This had demonstrated the importance of education in driving awareness as well as improving attitude toward better healthcare and compliance. Vernon et al
. and Wong et al
. have reported that younger age group of below 40 years had higher rate of default.[8
] However, we did not find any significant correlation between age and defaulter rate in our study. This is because almost all of our patients were more than 40 years old.
There were several studies looking at reasons for default. Reasons which have been noted for default in various studies include symptom duration or resolution, illness, long waiting periods, forgotten appointments, work commitment, illness, hospital administrative error, and transport problems.[8
] A few studies had consistently reported that “forgotten the appointment” and “work commitment” were the most common causes of default.[9
] However in our study, the two most common reasons for default were illness and logistic difficulties. Debilitating health is the most common reason for default because the majority of our patients had advanced stage of lung cancer which negatively affect their morbidity and well-being. This was supported by the fact that default is not thought to be related to the severity of the patient's condition, except in the case of psychiatric illness, where default may be a marker of severity of illness.[9
In terms of logistic difficulties, most of our patients claimed that they were unable to attend the clinic because of poor access to public transportation, no relative available to send them to hospital, staying far from hospital or unable to afford the transportation expenses. Work commitment was not the commonest cause of default in our study probably because the majority of our patients were unemployed or they had quit their jobs after the diagnosis of lung cancer was made. Others reasons were seeking traditional treatment, and refusing treatment due to side-effect concerns of chemotherapy. Seeking traditional treatment was never reported as a cause for default in our literature search. It is noteworthy that as part of the culture of our country, a proportion of the patients still believe in traditional treatment and object chemotherapy as they believe it may cause death.
Several studies have found that offering telephone reminders before actual appointment date had resulted in reductions in defaulter rate.[1
] Another study had shown that telling patients what to expect reduced defaulter rate overall significantly from 15% to 4.6%.[9
] In our study, we found that despite telephone reminder and adequate counseling, only 10% of our defaulted patients turned up for the appointment after telephone reminder. Our patents also had a much higher absentee rate of 90% as compared to other studies, which ranged from 4.0% to 25.3%.[20
] None of these studies included patients with any form of cancer. This higher absentee rate was probably a result of patients’ negative perception toward the survival benefit of chemotherapy in advanced lung cancer.
In conclusion, defaulter rate among lung cancer patients in our study was 21.1. The two most common reasons for default were illness and logistic difficulties. Telephone reminder was helpful to ensure compliance to follow-up.