Understanding the causes of missingness in primary care: A realist review

Calum Lindsay, David Baruffati, Mhairi Mackenzie, David Ellis, Michelle Major, Kate O'Donnell, Sharon Simpson, Andrea Williamson, Geoff Wong

Research output: Contribution to journalArticlepeer-review


Background: Although missed appointments in healthcare have been an area of concern for policy, practice and research, the primary focus has been on reducing single ‘situational’ missed appointments to the benefit of services. Little attention has been paid to the causes and consequences of more ‘enduring’ multiple missed appointments in primary care and the role this has in producing health inequalities.

Methods: We conducted a realist review of the literature on multiple missed appointments to identify the causes of ‘missingness.’ We searched multiple databases, carried out iterative citation-tracking on key papers on the topic of missed appointments and identified papers through searches of grey literature. We synthesised evidence from 197 papers, drawing on the theoretical frameworks of candidacy and fundamental causation.

Results: Missingness is caused by an overlapping set of complex factors, including patients not identifying a need for an appointment or feeling it is ‘for them’; appointments as sites of poor communication, power imbalance and relational threat; patients being exposed to competing demands, priorities and urgencies; issues of travel and mobility; and an absence of choice or flexibility in when, where and with whom appointments take place.

Conclusions: Interventions to address missingness at policy and practice levels should be theoretically informed, tailored to patients experiencing missingness and their identified needs and barriers; be cognisant of causal domains at multiple levels and address as many as practical; and be designed to increase safety for those seeking care.
Original languageEnglish
Article number235
JournalBMC medicine
Publication statusPublished - 10 Jun 2024

Data Availability Statement

The papers reported in the realist evidence synthesis are listed in the supplementary file along with the CMOCs which underpin the results. When the paper is published these will be available on the overall study Openscience Framework webpage.

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