Missed Appointments and Associations with Clinical Outcomes in A Large National Healthcare System

Abstract Importance Missed outpatient appointments, including no-shows and cancellations, may disrupt continuity of care and be associated with worse outcomes, but long-term system-wide patterns and clinical implications are not well characterized. Objective To characterize variation in missed appointment rates in the Veterans Health Administration (VHA) over time and by geographic location, visit modality, and preexisting conditions, and to evaluate associations between missed appointment rates and adverse outcomes among veterans with posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI). Design Cohort study using VHA Corporate Data Warehouse outpatient appointment data from January 1, 2000, through December 31, 2024. Setting National integrated health care system of the VHA. Participants System analysis includes all scheduled outpatient appointments with a valid status, and outcome analysis includes veterans with PTSD (n = 1 429 890) or TBI (n = 554 553), diagnosed before 2023. Exposures For system -level analyses, missed appointment rates were calculated. In outcome analyses, 2023 missed appointment rates were categorized into tertiles within the cohort and appointment type. Main Outcomes and Measures One year risks of all-cause hospitalization, all-cause mortality, and hospitalization or death beginning January 1, 2024. Results Among 2,162,520,880 outpatient appointments from 2000 to 2024, 6.5% were no-shows and 25.4% were canceled. Across facilities, no-show rates ranged from 3.5% to 14.1%, patient-initiated cancellation rates from 9.7% to 26.0%, and clinic-initiated cancellation rates from 8.5% to 17.9%. In 2023, veterans with amputation, Parkinson disease, PTSD, or TBI had higher missed appointment rates than veterans without these conditions. Among veterans with PTSD, the highest no-show tertile, compared with none, was associated with higher mortality (HR, 1.91; 95% CI, 1.84-1.98) and hospitalization or death (HR, 1.07; 95% CI, 1.05-1.08). Among veterans with TBI, the highest no-show tertile was associated with hospitalization or death (HR, 1.65; 95% CI, 1.61-1.69). Conclusions and Relevance Missed outpatient appointments were common in the VHA and varied substantially across facilities and over time. Among veterans with PTSD or TBI, higher missed appointment rates, particularly no-shows, were associated with increased risks of hospitalization and mortality, suggesting that these patterns may help identify high-risk veterans for targeted outreach. Key Points Question What patterns and sources of variation in missed outpatient appointments were observed in the Veterans Health Administration, and were higher missed appointment rates associated with one year hospitalization and mortality among veterans with PTSD or TBI? Findings In this cohort study of 2,162,520,880 outpatient appointments from 2000 to 2024, no-shows accounted for 6.5% and cancellations for 25.4%, with substantial temporal and geographic variation. Higher no-show rates were associated with increased hospitalization and mortality among veterans with PTSD or TBI. Meaning Higher missed appointment rates, particularly no-shows, may signal disengagement from care and elevated clinical risk, supporting targeted outreach for high-risk veterans.