Investigation into the TRVR and its relevant factors
Overall TRVR
In total, 2843 cases meeting inclusion criteria entered statistical analysis, and 1689 completed at least one return visit 30 days after the first visit. The overall TRVR was 59.4%, and 1154 cases (40.6%) missed the TRV (34.2% in patients with psychotic disorders). Thus, participants were divided into two groups: TRV (n=1689) and NTRV (n=1154).
Demographic data
Table 1 shows the participants’ demographic data and the TRVR distribution among subgroups. There were statistically significant TRVR differences among age, job status, and residence subgroups. Regarding the age groups, the TRVR was highest for the 46–55-year-old subgroup (66.8%) and lowest for the 26–35-year-old subgroup (55.3%) (χ2 = 15.409, P=0.004). The TRVR of the on-the-job subgroup was 56.2%, which was significantly higher than that of students or no-job subgroups (χ2 = 16.297, P<0.001). The rural residence subgroup had a higher TRVR (63.2%) than the urban residence subgroup (58.2%) (χ2 = 10.243, P=0.017).
Table 1
General data, attitudes towards pharmacotherapy, primary diagnosis, and distributions of TRVR (N, %)
|
N, %
|
TRV
|
NTRV
|
χ2
|
P-value
|
Gender
|
|
|
|
0.091
|
0.763
|
Male
|
1165, 41.0
|
696, 59.7
|
469, 40.3
|
|
|
Female
|
1678, 59.0
|
993, 59.2
|
685, 40.8
|
|
|
Age group
|
|
|
|
15.409
|
0.004
|
18~25 years
|
1056, 37.1
|
630, 59.7
|
426, 40.3
|
|
|
26~35 years
|
823, 28.9
|
455, 55.3
|
368, 44.7
|
|
|
36~45 years
|
473, 16.6
|
279, 59.0
|
194, 41.0
|
|
|
46~55 years
|
358, 12.6
|
239, 66.8
|
119, 33.2
|
|
|
56~65 years
|
133, 4.7
|
86, 64.7
|
47, 35.3
|
|
|
Educational stage
|
|
|
|
4.240
|
0.237
|
Primary school
|
158, 5.6
|
101, 63.9
|
57, 36.1
|
|
|
Junior high school
|
458, 16.1
|
280, 61.1
|
178, 38.9
|
|
|
Senior high school or equivalent
|
567, 19.9
|
347, 61.2
|
220, 38.8
|
|
|
College and higher
|
1660, 58.4
|
961, 57.9
|
699, 42.1
|
|
|
Marital status
|
|
|
|
2.721
|
0.437
|
Unmarried
|
1368, 48.1
|
816, 59.6
|
552, 40.4
|
|
|
Married
|
1355, 47.7
|
802, 59.2
|
553, 40.8
|
|
|
Divorced
|
103, 3.6
|
64, 62.1
|
39, 37.9
|
|
|
Widowed
|
17, 0.6
|
7, 41.2
|
10, 58.8
|
|
|
Work status
|
|
|
|
16.297
|
<0.001
|
Work
|
1616, 56.8
|
908, 56.2
|
708, 43.8
|
|
|
Student
|
562, 19.8
|
354, 63.0
|
208, 37.0
|
|
|
Housework or workless
|
665, 23.4
|
427, 64.2
|
238, 35.8
|
|
|
Monthly income in RMB
|
|
|
|
3.900
|
0.272
|
<5 thousands
|
685, 24.1
|
412, 60.1
|
273, 39.9
|
|
|
5~10 thousands
|
1095, 38.5
|
668, 61.0
|
427, 39.0
|
|
|
10~30 thousands
|
774, 27.2
|
449, 58.0
|
325, 42.0
|
|
|
>30 thousands
|
289, 10.2
|
160, 55.4
|
129, 44.6
|
|
|
Residence
|
|
|
|
10.243
|
0.017
|
Urban
|
2138, 75.2
|
1244, 58.2
|
894, 41.8
|
|
|
Rural
|
705, 24.8
|
445, 63.2
|
260, 36.9
|
|
|
Family atmosphere
|
|
|
|
10.677
|
0.014
|
Happy
|
498, 17.5
|
323, 64.9
|
175, 35.1
|
|
|
Relaxed
|
900, 31.7
|
518, 57.6
|
382, 42.4
|
|
|
Tense
|
1189, 41.8
|
710, 59.7
|
479, 40.3
|
|
|
Worse
|
256, 9.0
|
138, 53.9
|
118, 46.1
|
|
|
Living status
|
|
|
|
8.962
|
0.011
|
With family members
|
1917, 67.4
|
1171, 61.1
|
746, 38.9
|
|
|
With a lover
|
165, 5.8
|
84, 50.9
|
81, 49.1
|
|
|
Alone
|
761, 26.8
|
434, 57.0
|
327, 43.0
|
|
|
Attitudes towards pharmacotherapy
|
|
|
|
50.807
|
<0.001
|
Willing
|
387, 13.6
|
252, 65.1
|
135, 34.9
|
|
|
Could accept if necessary
|
1856, 65.3
|
1155, 62.2
|
701, 37.8
|
|
|
Afraid of side effects
|
374, 13.2
|
182, 48.7
|
192, 51.3
|
|
|
Refusing
|
226, 7.9
|
100, 44.2
|
126, 55.8
|
|
|
Primary diagnoses
|
|
|
|
6.858
|
0.444
|
Consultation or observation
|
239, 8.4
|
143, 59.8
|
96, 40.2
|
|
|
Depression
|
1257, 44.2
|
738, 58.7
|
519, 41.3
|
|
|
Anxiety
|
624, 21.9
|
380, 60.9
|
244, 39.1
|
|
|
Bipolar disorder
|
288, 10.1
|
178, 61.8
|
110, 38.2
|
|
|
Psychotic disorders
|
73, 2.6
|
48, 65.8
|
25, 34.2
|
|
|
Sleep disorders
|
141, 5.0
|
72, 51.1
|
69, 48.3
|
|
|
Obsessive-compulsion
|
54, 1.9
|
32, 59.3
|
22, 40.7
|
|
|
Others
|
167, 5.9
|
98, 58.7
|
69, 41.3
|
|
|
TRVR: timely return visit rate; TRV: timely return visit; NTRV: non-timely return visit |
Family atmosphere and living status
Table 1 also lists the TRVR distributions related to family atmosphere and living status. Participants with a worse family atmosphere had the lowest TRVR (53.9%), and those with a happy atmosphere had the highest (64.9%) (χ2 = 10.677, P=0.014). Participants living with family members had a higher TRVR (61.1%) than those living with a lover or alone (χ2 = 8.962, P=0.011).
Mean EPQ and SCL-90 factor scores
As shown in Table 2, there were no significant differences in mean factor scores of Extraversion, Neuroticism, Psychoticism, and Lie on the EPQ between the TRV and NTRV groups. The TRV group had significantly higher mean factor scores of SCL-90 Somatization (2.05±0.78 vs. 1.99±0.80, P=0.04), Anxiety (2.60±0.93 vs. 2.52±0.95, P=0.026), and Phobic anxiety (2.02±0.84 vs. 1.93±0.84, P=0.009) than the NTRV group.
Table 2
Comparisons of EPQ and SCL-90 scores between the timely and non-timely return visit groups (M±SD)
|
TRV
|
NTRV
|
t
|
P-value
|
EPQ
|
|
|
|
|
Psychoticism
|
53.88±10.19
|
54.53±10.61
|
−1.662
|
0.097
|
Extraversion
|
47.43±11.04
|
47.95±11.45
|
−1.208
|
0.227
|
Neuroticism
|
60.36±11.72
|
59.73±12.23
|
1.402
|
0.639
|
Lie
|
46.49±10.44
|
46.83±10.24
|
−0.870
|
0.384
|
SCL-90
|
|
|
|
|
Somatization
|
2.05±0.78
|
1.99±0.80
|
2.053
|
0.040
|
Obsessive-compulsive
|
2.59±0.88
|
2.55±0.89
|
1.302
|
0.193
|
Interpersonal sensitivity
|
2.31±0.92
|
2.29±0.93
|
0.477
|
0.633
|
Depression
|
2.68±0.96
|
2.65±0.98
|
0.781
|
0.435
|
Anxiety
|
2.60±0.93
|
2.52±0.95
|
2.234
|
0.026
|
Hostility
|
2.23±0.91
|
2.27±0.94
|
−1.364
|
0.173
|
Phobic anxiety
|
2.02±0.84
|
1.93±0.84
|
2.631
|
0.009
|
Paranoid ideation
|
2.07±0.89
|
2.07±0.89
|
−0.132
|
0.895
|
Psychoticism
|
2.13±0.80
|
2.11±0.82
|
0.628
|
0.530
|
Additional items
|
2.54±0.82
|
2.48±0.83
|
1.919
|
0.055
|
TRV: timely return visit; NTRV: non-timely return visit; SCL-90: symptoms checklist-90; EPQ: Eysenck Personality Questionnaire |
Attitudes towards pharmacotherapy and diagnoses
Attitudes towards pharmacotherapy might influence TRVR. Patients willing to receive pharmacotherapy had the highest TRVR (65.1%), and those refusing pharmacotherapy had the lowest (44.2%). The TRVR differences among subgroups of attitudes towards medicine were significant (χ2 = 50.807, P<0.001). Regarding the primary diagnosis, patients with psychotic and bipolar disorder had the two highest TRVRs of 65.8% and 61.8%, respectively, and those with sleep disorders had the lowest (51.1%). However, the TRVR differences among patients with primary diagnoses were not significant (P=0.444). See Table 1.
Logistic regression model of the NTRV
Let return visit status (0 – TRV, 1 – NTRV) be the dependent variable and significant variables (α = 0.1) related to TRVR in the above statistics such as age groups, working status, residence, family atmosphere, living status, attitudes towards pharmacotherapy, EPQ psychoticism score, and SCL-90 subscale scores of somatization, anxiety, and phobic anxiety be independent variables. The result of the stepwise forward binary logistic regression showed that variables of age groups, working status, family atmosphere, attitudes towards pharmacotherapy, psychoticism score, and phobic anxiety score entered the regression model (χ2=99.060, df=14, P<0.001; overall predicted percentage correct=61.5%). People aged 46–55 years (OR=0.674, P=0.007, reference to age 18–25 years) with higher SCL-90 phobic anxiety scores (OR=0.851, P=0.001) were at lower risk for NTRV. People with worse (OR=1.540, P=0.008) or relaxed family atmosphere (OR=1.364, P=0.008, reference to happy family atmosphere), attitudes towards pharmacotherapy of refusing medicine (OR=2.265, P<0.001), fear of side effects (OR=1.950, P<0.001, reference to being willing to pharmacotherapy), on the job (OR=1.328, P=0.004, reference to housework or no-job), and higher EPQ psychoticism scores (OR=1.008, P=0.049) were at higher risk for NTRV. See Table 3.
Table 3
Logistic regression model of the non-timely return visit
|
B
|
S.E.
|
Wald
|
df
|
P-value
|
Exp(B)
|
95% C.I. for EXP(B)
|
Lower
|
Upper
|
Age groups
|
|
|
10.792
|
4
|
0.029
|
|
|
|
18~25 years
|
|
|
Ref.
|
|
|
|
|
|
26~35 years
|
0.022
|
0.114
|
0.038
|
1
|
0.846
|
1.022
|
0.818
|
1.278
|
36~45 years
|
−0.126
|
0.131
|
0.922
|
1
|
0.337
|
0.882
|
0.682
|
1.140
|
46~55 years
|
−0.394
|
0.146
|
7.301
|
1
|
0.007
|
0.674
|
0.506
|
0.897
|
56~65 years
|
−0.209
|
0.207
|
1.025
|
1
|
0.311
|
0.811
|
0.541
|
1.217
|
Family atmosphere
|
|
|
9.452
|
3
|
0.024
|
|
|
|
Happy
|
|
|
Ref.
|
|
|
|
|
|
Relax
|
0.310
|
0.118
|
6.935
|
1
|
0.008
|
1.364
|
1.083
|
1.719
|
Tense
|
0.219
|
0.115
|
3.653
|
1
|
0.056
|
1.245
|
0.994
|
1.558
|
Worse
|
0.432
|
0.164
|
6.928
|
1
|
0.008
|
1.540
|
1.117
|
2.123
|
Attitude towards pharmacotherapy
|
|
|
45.289
|
3
|
<0.001
|
|
|
|
Willing
|
|
|
Ref.
|
|
|
|
|
|
Could accept if necessary
|
0.120
|
0.119
|
1.030
|
1
|
0.310
|
1.128
|
0.894
|
1.423
|
Afraid of side effects
|
0.668
|
0.152
|
19.377
|
1
|
<0.001
|
1.950
|
1.449
|
2.626
|
Refusing pharmacotherapy
|
0.818
|
0.174
|
22.014
|
1
|
<0.001
|
2.265
|
1.610
|
3.187
|
Working status
|
|
|
13.270
|
2
|
0.001
|
|
|
|
On the job
|
0.283
|
0.098
|
8.326
|
1
|
0.004
|
1.328
|
1.095
|
1.610
|
Student
|
−0.074
|
0.141
|
0.277
|
1
|
0.599
|
0.928
|
0.704
|
1.224
|
Housework or no job
|
|
|
Ref.
|
|
|
|
|
|
SCL-90 Phobic anxiety score
|
−0.162
|
0.049
|
10.827
|
1
|
0.001
|
0.851
|
0.773
|
0.937
|
EPQ Psychoticism
|
0.008
|
0.004
|
3.886
|
1
|
0.049
|
1.008
|
1.000
|
1.015
|
Constant
|
−1.019
|
0.284
|
12.918
|
1
|
<0.001
|
0.361
|
|
|
Ref: the reference category of the variable; SCL-90: symptoms checklist-90; EPQ: Eysenck Personality Questionnaire |
Investigation of reasons for NTRV via telephone follow-up
The profile of telephone follow-up
Among 1154 clients with NTRVs after the first interview, 693 (60.1%) accepted the telephone investigation, and 461 cases (39.9%) did not. Conditions of follow-up failure included 333 clients (72.2%) that rejected calls, 98 (21.3%) that provided the wrong telephone numbers at the first visit, and 30 (6.5%) that answered the call but refused the investigation.
Conditions after the first interview
Among 693 cases in which the investigation was completed, 473 (68.4%) clients continued taking medicines according to the prescription (128 of these accepted the advice of return visit as soon as possible, and 346 refused this advice), 73 (10.5%) had continued to visit other hospitals, and 146 (21.1%) had stopped taking medicine and abandoned treatment.
Self-reported reasons for NTRVs
According to respondents’ answers, the main reasons for NTRVs were as follows: 383 (55.3%) considered the return visit unnecessary because they felt better, 87 (12.6%) felt no improvement, 60 (8.7%) felt noticeable side effects of the medicine, 20 (2.9%) were afraid of side effects of the medicine, 51 (7.4%) reported inconvenience of traveling to the hospital, 61 (8.8%) had no time, 24 (3.5%) failed to make appointments, 4 (0.6%) reported rejecting the return visit, 1 (0.1%) acknowledged difficult economic circumstances, and 2 (0.3%) were unsatisfied with the hospital environment. These reasons were merged and divided into four groups to meet the statistical conditions: improvement and consideration of no need for a return visit (55.3%), no improvement (12.6%), side effects of medicines (11.5%), and various limitations (20.6%). The distribution of self-reported reasons for the NTRV differed significantly among 4 conditions after the first interview (χ2 = 221.989, P<0.001). See Table 4.
Table 4
The distribution of reasons for non-timely return visit among conditions after the first interview
Conditions
|
N, %
|
Self-reported reasons (N, %)
|
χ2
|
P-value
|
A (n=87)
|
B (n=383)
|
C (n=80)
|
D (n=143)
|
Ⅰ
|
128, 18.5
|
9, 7.0
|
60, 46.9
|
11, 8.6
|
48, 37.5
|
221.989
|
<0.001
|
Ⅱ
|
346, 49.9
|
28, 8.1
|
239, 69.1
|
22, 6.4
|
57, 16.5
|
|
|
Ⅲ
|
73, 10.5
|
34, 46.6
|
7, 9.6
|
3, 4.1
|
29, 39.7
|
|
|
Ⅳ
|
146, 21.1
|
16, 11.0
|
77, 52.7
|
44, 30.1
|
9, 6.2
|
|
|
Self-reported reasons: A: No improvement; B: Improvement and belief there is no need for a return visit; C: Medicine side effects; D: Limitations
Conditions: Ⅰ: Taking medicine and accepting to complete a return visit; Ⅱ: Taking medicine and unwilling to complete a return visit; Ⅲ: Transferred to another hospital; Ⅳ: Treatment abandonment