Non-attendance at outpatients departments

Editor—The trial by Hamilton et al1 examining the effect of giving patients a copy of their referral letter on non-attendance at outpatient departments raises several interesting and controversial issues, but it is difficult to assess for an international audience who may not be familiar with the British healthcare system. This issue of being international has been raised by others,2 and surely if the BMJ aspires to be an international journal, the research setting needs to be clarified for international readers. For example, what is the usual referral procedure in the United Kingdom? In Hong Kong a referral letter is always given to the patient and is required for access to secondary care. Patients make their own appointments. Hamilton et al also fail to establish the justification for the research under discussion. What was the rationale for this randomised controlled trial? They hypothesise that a lack of communication between the patient and the referring doctor is the cause of non-attendance. If so, how will a copy of the referral letter be expected to improve this communication or guarantee attendance? An explanation of the topic antecedents and justification of the research question are required together with a discussion of the cost implications of this intervention. Although Hamilton et al quote a national (England or United Kingdom) non-attendance rate of 12%, their own study had a much lower non-attendance rate. The situation in Hong Kong is very different, despite patients receiving a referral letter, and such low rates would be welcomed in Hong Kong. The authors offer no explanation to account for the difference between the study and the national non-attendance rates. This may be due to the study selection criteria. Excluding patients because of severity of disease, previous suboptimal care, or patients' attitude or lifestyle may have biased the sample and led to an incorrect estimate of the non- attendance rates. The intervention was intended to reduce non-attendance and it did not target the appropriate population, the non-attenders. As the authors have not specified the reasons for patients' non-attendance, the reader does not know whether the intervention is appropriate. The BMJ is a widely read journal, and to reach an international audience enough information should be provided to facilitate the assessment of the research and its potential for application elsewhere.