Barriers to long-term follow-up among patients in cardiovascular-metabolic clinics: a qualitative study based on the COM-B model

Cardiometabolic diseases are major chronic conditions requiring long-term follow-up to optimize management and prevent complications, yet discontinuation of follow-up is common and may compromise patient outcomes. Evidence on the specific barriers to sustained follow-up in the Chinese healthcare context remains limited. This study aimed to explore these barriers using the COM-B (Capability, Opportunity, Motivation–Behavior) model, to provide insights for improving follow-up strategies and chronic disease management. A qualitative descriptive study was conducted using semi-structured interviews. Sixteen patients who had discontinued follow-up at a cardiovascular-metabolic clinic in Beijing completed in-depth interviews. Interviews were audio-recorded, transcribed verbatim, and analysed using content-structuring qualitative content analysis. Analysis identified three COM-B domains comprising 10 barrier-related and 6 facilitator-related subthemes. Capability barriers included limited disease knowledge and age-related constraints. Opportunity barriers centred on logistical burdens and limited family support, while facilitators involved easier appointment access and caregiver assistance. Reflective motivational barriers included distrust and cognitive bias between traditional Chinese medicine and Western medicine and a low perceived benefit of follow-up, while automatic motivational barriers involved weak habit formation for routine clinic attendance. Patients’ loss to follow-up reflected the combined effects of limited disease understanding, weak self-management ability, logistical and access barriers, insufficient family support, and belief-driven motivational challenges. Improving follow-up adherence requires coordinated, patient-centred strategies that enhance understanding, ease practical barriers, and strengthen motivation through supportive and trust-based care.