No‐shows to hidradenitis suppurativa clinic visits: Patient perspectives

Abstract Background Hidradenitis suppurativa (HS) is a debilitating chronic inflammatory skin condition that typically requires consistent care. Contributory factors to why patients with HS miss their clinic appointments have not been investigated. Objectives This article seeks to characterise reasons that HS patients do not keep their appointments and identify strategies to minimise no‐show rates and improve delivery of care to HS patients. Methods An anonymous survey was distributed to online HS support groups. Results Of the 254 respondents, 18.9% reported ever missing an appointment for HS. Common reasons for missing an appointment include: patient was experiencing an HS flare (72.9%), prior poor experience with a healthcare provider (54.2%) or healthcare staff member (37.5%), embarrassment of condition (41.7%), and distrust that the appointment would help with management of HS (39.6%). Respondents who were non‐White, who were disabled, or who had lower socioeconomic status were more likely to have missed an appointment (p < 0.05). Conclusions This study highlights areas where dermatologists may help improve appointment attendance, including encouraging patients to seek care during flares and striving to optimise the patient experience.

Hidradenitis suppurativa is a chronic inflammatory skin condition that often severely impacts patient quality of life. 1 Missed clinic visits or "no-shows" can hinder care delivery.Hidradenitis suppurativa patient perspectives regarding missed clinic visits are not wellcharacterised.Understanding the reasons why HS patients miss visits can help dermatologists try to minimise no-shows and deliver much-needed care.

| PATIENTS AND METHODS
An anonymous survey (Appendix S1) was distributed with group administrator permission through online HS support groups (Hope for HS, HS Connect, and HS Warriors) between August and October 2022 and respondents 18 years or older were eligible to participate.Data were analysed in R version 4.2.1 and a p-value of <0.05 was considered significant.Multivariable logistic regression was used to examine the likelihood of missing an appointment based on gender (female VS other), disability (disabled VS not disabled), race (non-White VS White), educational level (completed high school/higher education VS less than high school), insurance status (public VS non-public), primary HS provider (dermatologist VS non-dermatologist), Hurley stage (stage II/III VS stage I), duration of HS, and household income (≤$50,000 VS >$50,000 annually) while controlling for all other variables above.Of note, the data analysis was limited by a small sample size and a non-normal distribution.Patients self-reported their Hurley stage based on descriptions provided of each stage in the survey.Any missed appointment for HS was considered a no-show.

| RESULTS
254 participants responded to the survey; their demographics are listed in Table 1.Forty-eight (18.9%) participants had previously missed an appointment with their primary HS provider (provider who has seen them for >50% of their visits).Overall, top categories of reasons for missing appointments include health barriers (85.4%) and disappointment with a previous healthcare experience (66.7%), followed by financial or logistical barriers (56.3%), personal reasons (52.1%), and other obligations (37.5%).The top five reasons for missing an appointment were: HS flare (72.9%), poor experience with a healthcare provider (54.2%), embarrassment of skin condition (41.7%), distrust that the appointment would help with management of HS (39.6%), and poor experience with a healthcare staff member (37.5%) (Figure 1).A minority of patients reported forgetting the appointment (6.3%) or that the visit was too soon after the previous one (4.2%).Participant- What is already known about this topic?
� Missing clinic appointments can negatively impact care delivery, however, the reasons that hidradenitis suppurativa (HS) patients miss appointments have not been wellstudied.

What does this study add?
� This study found that 18.9% of respondents reported having ever missed an HS clinic appointment.� Top reasons for missing an HS clinic visit included: HS flare, prior poor experience with a healthcare provider or staff member, embarrassment, and belief that the appointment would not be helpful.� Patients who were non-White, disabled, or with a lower household income were more likely to miss appointments.
Compared to respondents who were not disabled, respondents who reported that they were disabled were more likely (odds ratio (OR) 3.51, p = 0.007) to miss an appointment.Respondents with an annual household income of ≤50,000 per year were more likely to have missed an appointment compared to those who earned >$50,000 per year (OR 2.38, p = 0.04).Non-White respondents were more likely to have missed a  previous HS appointment compared to White respondents (OR 2.6, p = 0.03).There was no statistical difference in reporting missed appointments based on gender, educational level, insurance status, primary HS provider, duration of HS, or Hurley stage.
Of the 187 participants who had never missed an appointment, reasons for appointment adherence included motivation to manage their HS (75%), concern about potential HS flare (37.8%), and desire to avoid being charged a fee for missing the appointment (18.8%).

| DISCUSSION
Nearly a fifth (18.9%) of respondents reported missing an HS appointment before.The most highly-reported reasons for missing appointments in this study were due to HS flare, poor experience with a healthcare provider, and embarrassment of skin condition.This contrasts with a previous survey study in the literature of general dermatology patients at an academic dermatology clinic in the United States that found that top patient reasons for missed appointments included forgetting about the appointment, lack of appointment reminders, work, and transportation problems. 2articipants reported HS flares as the most common reason for missing an appointment.Potential contributing factors to this finding include the increased pain, physical debilitation, and/or fatigue that patients experience during flares that make travel difficult.Unfortunately, a missed appointment may mean a missed opportunity for needed treatment modifications, contributing to more flares in the future and giving rise to a vicious cycle.This highlights the importance of patient education regarding treatment options for HS flares,  including oral antibiotics and in-office procedures such as intralesional steroid injections, incision and drainage, and focal de-roofing.Patients should also be educated that scheduling or keeping an appointment with their primary HS provider during a flare is vastly preferred over seeking acute care at an urgent care clinic or emergency room.Of note, over a third of patients reported keeping their appointments due to concern for flares, and in the authors' experience, a contingent of patients will call the clinic to be urgently added on to the clinic schedule because of a flare.In both cases, providing patients with a written action plan for flares can help patients selfmanage flares at home and also provide guidance on when to call the clinic. 3ith two-thirds of participants reporting a previous negative experience with a healthcare provider or staff member as a reason for missing an appointment, the impact of establishing a positive, empathetic providerpatient relationship cannot be overstated.Strengthening this relationship can help counter the pervasive distrust of medical care that exists among HS patients, 1 which was also captured in this survey.Physician communication strategies should be examined for opportunities to help lower this barrier. 4For example, patients may prefer that sensitive topics such as weight loss and sexual health be addressed at a later visit, after rapport has been developed. 5Further, all staff, starting from the front-desk and extending to the back office, should be trained to facilitate patient-centred and non-judgemental interactions, especially given the embarrassment patients with HS have reported feeling regarding their skin condition.
Over half of respondents reported a financial or logistical reason for missing an appointment, including issues with transportation and concerns regarding the cost of the visit, transportation, and/or treatment.Offering telehealth visits to avoid transportation issues entirely may also be beneficial, especially as HS is associated with low socioeconomic status. 6Of note, patient and provider opinions on the effectiveness of telehealth appointments are mixed. 7,8Importantly, requests for photographs to aid medical assessments during telehealth appointments should be handled delicately, given that HS tends to affect sensitive areas. 8roviders may consider offering telehealth visits after an in-person consultation has been performed and a treatment plan initiated.Implementing appointment reminder services may also help prevent no-shows.Particular care should be paid to addressing barriers to access to care for vulnerable populations such as patients with a racial minority background, patients who are disabled, and patients with lower income, who were also more likely to report missing an appointment in this study.
Limitations of this study include that participants were predominantly White and female, response bias, recall bias, and unknown response rate, limiting generalisability of the results.The percentage of patients who have missed an HS appointment in our study was 18.9%, which is nearly the same as a previous study that found a rate of 18.6% for missed medical dermatology appointments at a large academic dermatology department. 9One Denmark study found no difference in no-show rates between patients seen in HS-specific clinics when compared with patients seen in general dermatology outpatient clinics, though a limitation may be that HS patients are less likely to miss an appointment in an HS specialty clinic. 10In addition, patients who are engaged in online HS forums and were sent our survey may be more likely to seek care for their HS and attend appointments, which could have lowered the reported no-show rate in our study.
In conclusion, dermatologists may help minimise HS appointment no-shows by educating patients about options for treatment during flares, encouraging patients to attend appointments during flares, striving to develop rapport and build trust with patients throughout all aspects of their encounter, and offering telehealth appointments in appropriate circumstances.It is important for dermatologists to help overwrite the previous negative healthcare experiences that many patients with this highly-stigmatised and under-recognized condition have faced before they come through our clinic doors.

T A B L E 2
Recommendations to reduce Hidradenitis suppurativa (HS) clinic visit no-shows.Reason for missed appointment Recommendation for minimising future no-shows Health-related barriers � Educate patients about treatment options for flares, including inoffice procedures � Encourage patient to seek care during flares when needed � Create a written action plan for patients with stepwise treatment approach based on flare severity � Implement a clinic protocol for managing patient messages regarding flares

F I G U R E 1
Participant reasons for missed clinic appointments.