Barriers to Long-Term Follow-Up Among Patients in Cardiovascular-Metabolic Clinics: A Qualitative Study Based on the COM-B Model

Background 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. Methods A descriptive qualitative approach was adopted. Guided by the COM-B behavioral framework, a semi-structured interview guide was developed. In-depth interviews were conducted with 16 patients who had discontinued follow-up at a cardiovascular-metabolic collaborative clinic in a tertiary hospital in Beijing between January 2023 and June 2024. The audio data were transcribed verbatim and analyzed using deductive content analysis with the aid of MAXQDA 24 software for systematic coding and thematic extraction. Results A total of three themes and nine subthemes were identified. Capability-related barriers included age-related physical limitations, inadequate cognitive-behavioral capacity, lack of trust in healthcare providers, cognitive bias between traditional Chinese and Western medicine, and insufficient disease-related knowledge. Opportunity-related barriers encompassed long geographical distances, complex clinic procedures, and limited family support. Motivational barriers manifested as low adherence to lifestyle interventions and the absence of habitual follow-up behavior. Conclusion Patients’ discontinuation of follow-up was shaped by the interaction of capability, opportunity, and motivation. From the perspective of lived patient experiences, nursing administrators are advised to develop a multidimensional follow-up support system centering on “capability enhancement, opportunity facilitation, and motivation activation.” Such efforts should involve strengthening health education, streamlining service processes, and fostering behavioral habit formation, thereby improving patient adherence and long-term chronic disease management outcomes.