Appointment adherence and disparities in outcomes among patients with diabetes

Patient Factors Associated with Missed Otolaryngology Appointments at an Urban Safety-Net Hospital

OBJECTIVE

To determine if patient factors related to ethnicity, socioeconomic status (SES), medical comorbidities, or appointment characteristics increase the risk of missing an initial adult otolaryngology appointment.

METHODS

This study is a retrospective case control study at Boston Medical Center (BMC) in Boston, Massachusetts, that took place in 2019. Patient demographic and medical comorbidity data as well as appointment characteristic data were collected and compared between those that attended their initial otolaryngology appointment versus those who missed their initial appointment. Chi-square and ANOVA tests were used to calculate differences between attendance outcomes. Multivariate analysis was used to compare the odds of missing an appointment based on various patient- and appointment-related factors.

RESULTS

Patients who were more likely to miss their appointments were more often female, of lower education, disabled, not employed, Black or Hispanic, and Spanish-speaking. Spring and Fall appointments were more likely to be missed. When a multivariate regression was conducted to control for social determinants of health (SDOH) such as race, insurance status, employment, and education status, the odds of females, Spanish-speaking, students, and disabled patients missing their appointment were no longer statistically significant.

CONCLUSION

A majority of patients at BMC come from lower SES backgrounds and have multiple medical comorbidities. Those who reside closer to BMC, often areas of lower average income, had higher rates of missed appointments. Interventions such as decreasing lag time, providing handicap-accessible free transportation, and increasing accessibility of telemedicine for patients could help improve attendance rates at BMC.

LEVEL OF EVIDENCE

IV Laryngoscope, 2024.

Missed Healthcare Visits During the COVID-19 Pandemic: A Longitudinal Study

INTRODUCTION

Missed visits have been estimated to cost the U.S. healthcare system $50 billion annually and have been linked to healthcare inefficiency, higher rates of emergency department visits, and worse outcomes. COVID-19 disrupted existing outpatient healthcare utilization patterns. In our study, we sought to examine the frequency of missed outpatient visits over the course of the COVID-19 pandemic and to examine patient-level characteristics associated with non-attendance.

METHODS

This study utilized data from a longitudinal cohort study (the Chicago COVID-19 Comorbidities (C3) study). C3 participants were enrollees in 1 of 4 active, "parent" studies; they were rapidly enrolled in C3 at the onset of the pandemic. Multiple waves of telephone-based interviews were conducted to collect experiences with the pandemic, as well as socio-demographic and health characteristics, health literacy, patient activation, and depressive and anxiety symptoms. For the current analysis, data from waves 3 to 8 (05/01/20-05/19/22) were analyzed. Participants included 845 English or Spanish-speaking adults with 1 or more chronic conditions.

RESULTS

The percentage of participants reporting missed visits due to COVID-19 across study waves ranged from 3.1 to 22.4%. Overall, there was a decline in missed visits over time. No participant sociodemographic or health characteristic was consistently associated with missed visits across the study waves. In bivariate and multivariate analysis, only patient-reported anxiety was significantly associated with missed visits across all study waves.

CONCLUSION

Findings reveal that anxiety was consistently associated with missed visits during the COVID-19 pandemic, but not sociodemographic or health characteristics. Results can inform future public health initiatives to reduce absenteeism by considering patients' emotional state during times of uncertainty.

Patient "No-Show" Increases the Risk of 90-Day Complications Following Primary Total Knee Arthroplasty: A Retrospective Cohort Study of 6,776 Patients

BACKGROUND

Patients who "no-show" (NS) clinical appointments are at a high risk of adverse health outcomes. The objective of this study was to evaluate and characterize the relationship between NS visits prior to primary total knee arthroplasty (TKA) and 90-day complications after TKA.

METHODS

We retrospectively reviewed 6,776 consecutive patients undergoing primary TKA. Study groups were separated based on whether patients who NS versus always attended their appointment. A NS was defined as an intended appointment that was not canceled or rescheduled ≤2 hours before the appointment in which the patient did not show. Data collected included total number of follow-up appointments prior to surgery, patient demographics, comorbidities, and 90-day postoperative complications.

RESULTS

Patients who have ≥3 NS appointments had 1.5 times increased odds of a surgical site infection (odds ratio (OR) 1.54, P = .002) compared to always attended patients. Patients who were ≤65 years old (OR: 1.41, P < .001), smokers (OR: 2.01, P < .001), and had a Charlson comorbidity index ≥3 (OR: 4.48, P < .001) were more likely to miss clinical appointments.

CONCLUSION

Patients who have ≥3 NS appointments prior to TKA had an increased risk for surgical site infection. Sociodemographic factors were associated with higher odds of missing a scheduled clinical appointment. These data suggest that orthopaedic surgeons should consider NS data as an important clinical decision-making tool to assess risk for postoperative complications to minimize complications following TKA.

To charge or not to charge: reducing patient no-show

BACKGROUND

In order to reduce patient no-show, the Israeli government is promoting legislation that will allow Health Plans to require a co-payment from patients when reserving an appointment. It is hoped that this will create an incentive for patients to cancel in advance rather than simply not show up. The goal of this policy is to improve patient access to medical care and ensure that healthcare resources are utilized effectively. We explore this phenomenon to support evidence-based decision making on this issue, and to determine whether the proposed legislation is aligned with the findings of previous studies.

MAIN BODY

No-show rates vary across countries and healthcare services, with several strategies in place to mitigate the phenomenon. There are three key stakeholders involved: (1) patients, (2) medical staff, and (3) insurers/managed care organizations, each of which is affected differently by no-shows and faces a different set of incentives. The decision whether to impose financial penalties for no-shows should take a number of considerations into account, such as the fine amount, service type, the establishment of an effective fine collection system, the patient's socioeconomic status, and the potential for exacerbating disparities in healthcare access. The limited research on the impact of fines on no-show rates has produced mixed results. Further investigation is necessary to understand the influence of fine amounts on no-show rates across various healthcare services. Additionally, it is important to evaluate the implications of this proposed legislation on patient behavior, access to healthcare, and potential disparities in access.

CONCLUSION

It is anticipated that the proposed legislation will have minimal impact on attendance rates. To achieve meaningful change, efforts should focus on enhancing medical service availability and improving the ease with which appointments can be cancelled or alternatively substantial fines should be imposed. Further research is imperative for determining the most effective way to address the issue of patient no-show and to enhance healthcare system efficiency.

Sauver JL, Shah P, Vella A, Ryu E, Liu H, Marshall GD, Cerhan JR, Singh D, Summers RL. Predictors of Metformin Failure: Repurposing Electronic Health Record Data to Identify High-Risk Patients

CONTEXT

Metformin is the first-line drug for treating diabetes but has a high failure rate.

OBJECTIVE

To identify demographic and clinical factors available in the electronic health record (EHR) that predict metformin failure.

METHODS

A cohort of patients with at least 1 abnormal diabetes screening test that initiated metformin was identified at 3 sites (Arizona, Mississippi, and Minnesota). We identified 22 047 metformin initiators (48% female, mean age of 57 ± 14 years) including 2141 African Americans, 440 Asians, 962 Other/Multiracial, 1539 Hispanics, and 16 764 non-Hispanic White people. We defined metformin failure as either the lack of a target glycated hemoglobin (HbA1c) (<7%) within 18 months of index or the start of dual therapy. We used tree-based extreme gradient boosting (XGBoost) models to assess overall risk prediction performance and relative contribution of individual factors when using EHR data for risk of metformin failure.

RESULTS

In this large diverse population, we observed a high rate of metformin failure (43%). The XGBoost model that included baseline HbA1c, age, sex, and race/ethnicity corresponded to high discrimination performance (C-index of 0.731; 95% CI 0.722, 0.740) for risk of metformin failure. Baseline HbA1c corresponded to the largest feature performance with higher levels associated with metformin failure. The addition of other clinical factors improved model performance (0.745; 95% CI 0.737, 0.754, P < .0001).

CONCLUSION

Baseline HbA1c was the strongest predictor of metformin failure and additional factors substantially improved performance suggesting that routinely available clinical data could be used to identify patients at high risk of metformin failure who might benefit from closer monitoring and earlier treatment intensification.

Shared Decision-Making in Acute Pain Services

PURPOSE OF REVIEW

The implementation of shared decision-making (SDM) in acute pain services (APS) is still in its infancies especially when compared to other medical fields.

RECENT FINDINGS

Emerging evidence fosters the value of SDM in various acute care settings. We provide an overview of general SDM practices and possible advantages of incorporating such concepts in APS, point out barriers to SDM in this setting, present common patient decisions aids developed for APS and discuss opportunities for further development. Especially in the APS setting, patient-centred care is a key component for optimal patient outcome. SDM could be included into everyday clinical practice by using structured approaches such as the "seek, help, assess, reach, evaluate" (SHARE) approach, the 3 "MAking Good decisions In Collaboration"(MAGIC) questions, the "Benefits, Risks, Alternatives and doing Nothing"(BRAN) tool or the "the multifocal approach to sharing in shared decision-making"(MAPPIN'SDM) as guidance for participatory decision-making. Such tools aid in the development of a patient-clinician relationship beyond discharge after immediate relief of acute pain has been accomplished. Research addressing patient decision aids and their impact on patient-reported outcomes regarding shared decision-making, organizational barriers and new developments such as remote shared decision-making is needed to advance participatory decision-making in acute pain services.

Using the National Institute on Minority Health and Health Disparities framework to better understand disparities in major amputations

Recently, the United States experienced its first resurgence of major amputations in more than 20 years. Compounding this rise is a longstanding history of disparities. Patients identifying as non-Hispanic Black are twice as likely to lose a limb as those identifying as non-Hispanic White. Those identifying as Latino face a 30% increase. Rural patients are also more likely to undergo major amputations, and the rural-urban disparity is widening. We used the National Institute on Minority Health and Health Disparities framework to better understand these disparities and identify common factors contributing to them. Common factors were abundant and included increased prevalence of diabetes, possible lower rates of foot self-care, transportation barriers to medical appointments, living in disadvantaged neighborhoods, and lack of insurance. Solutions within and outside the health care realm are needed. Health care-specific interventions that embed preventative and ambulatory care services within communities may be particularly high yield.

Factors associated with delaying medical care: cross-sectional study of Nebraska adults

BACKGROUND

Delayed medical care may result in adverse health outcomes and increased cost. Our purpose was to identify factors associated with delayed medical care in a primarily rural state.

METHODS

Using a stratified random sample of 5,300 Nebraska households, we conducted a cross-sectional mailed survey with online response option (27 October 2020 to 8 March 2021) in English and Spanish. Multiple logistic regression models calculated adjusted odds ratios (aOR) and 95% confidence intervals.

RESULTS

The overall response rate was 20.8% (n = 1,101). Approximately 37.8% of Nebraskans ever delayed healthcare (cost-related 29.7%, transportation-related 3.7%), with 22.7% delaying care in the past year (10.1% cost-related). Cost-related ever delay was associated with younger age [< 45 years aOR 6.17 (3.24-11.76); 45-64 years aOR 2.36 (1.29-4.32)], low- and middle-income [< $50,000 aOR 2.85 (1.32-6.11); $50,000-$74,999 aOR 3.06 (1.50-6.23)], and no health insurance [aOR 3.56 (1.21-10.49)]. Transportation delays were associated with being non-White [aOR 8.07 (1.54-42.20)], no bachelor's degree [≤ high school aOR 3.06 (1.02-9.18); some college aOR 4.16 (1.32-13.12)], and income < $50,000 [aOR 8.44 (2.18-32.63)]. Those who did not have a primary care provider were 80% less likely to have transportation delays [aOR 0.20 (0.05-0.80)].

CONCLUSIONS

Delayed care affects more than one-third of Nebraskans, primarily due to financial concerns, and impacting low- and middle-income families. Transportation-related delays are associated with more indicators of low socio-economic status. Policies targeting minorities and those with low- and middle-income, such as Medicaid expansion, would contribute to addressing disparities resulting from delayed care.

Social determinants of health: modeling and targeting patient propensity to attend pain clinic appointments

Aim: We sought to investigate the impact of social determinants of health on pain clinic attendance. Materials & methods: Retrospective data were collected from the Pain Center at Montefiore Medical Center from 2016 to 2020 and analyzed with multivariable logistic regression. Results: African-Americans were less likely to attend appointments compared with White patients (odds ratio [OR]: 0.73; 95% CI: 0.70-0.77; p < 0.001). Males had decreased attendance compared with females (OR: 0.89; 95% CI: 0.87-0.92; p < 0.001). Compared with Commercial, those with Medicaid (OR: 0.69; 95% CI: 0.66-0.72; p < 0.001) and Medicare (OR: 0.76; 95% CI: 0.73-0.80; p < 0.001) insurance had decreased attendance. Conclusion: Significant disparities exist in pain clinic attendance based upon social determinants of health including race, gender and insurance type.

Medicaid insured persons with diabetes have increased proportion of missed appointments and high HbA1c

Objective

This study was conducted to evaluate whether the type of insurance coverage is associated with missed appointments and to evaluate the effect of missed appointments on diabetes control.

Methods

All patients with diabetes mellitus (DM) managed at a major academic medical center between Jan 2015 and Dec 2020 were included in analysis. Association between insurance coverage and the proportion of missed appointments was evaluated with adjustments for demographic variables and social determinants of health. The relationship between proportion of missed appointments and glycemic control was also evaluated.

Results

The dataset included 30,633 patients, out of which 14,064 (46%) reported commercial insurance, 13,376 (44%) reported Medicare and 3,193 (10%) reported Medicaid coverage. Proportion of missed appointments was 18.1 ± 18.1% among Medicaid covered patients,12.1 ± 15.3% among commercially insured and 10.2 ± 14.1% among Medicare covered patients (p < 0.001). Type of insurance was found to be a significant predictor of proportion of missed appointments after adjusting for age, race, language, marital status, smoking, BMI, HbA1c and type of diabetes (p < 0.001) in series regression analysis. Proportion of missed appointments was associated with HbA1c with partial correlation coefficient +0.104 (p < 0.005) after adjusting for age, race, gender, type of insurance coverage, BMI and type of diabetes.

Conclusions

Medicaid covered patients with diabetes have higher proportion of missed clinic appointments and higher HbA1c. More research is needed to evaluate the root causes of inability to keep appointments in this population so that strategies for improved healthcare delivery can be designed.

The Health Belief Model Modifying Factors Associated with Missed Clinic Appointments among Individuals with Sickle Cell Disease in the Jazan Province, Saudi Arabia

In treating chronic illnesses, such as sickle cell disease (SCD), outpatient care is essential; poor adherence in attending clinic appointments can lead to serious outcomes. SCD is highly prevalent in Saudi Arabia, and patients with SCD are advised to follow up with their treating physician in order to control this disease manifestation and to better forecast its complications. Studies evaluating missed appointments among patients with SCD are rare. Therefore, the current study aimed to use the health belief model's modifying factors in order to evaluate the variables associated with poor adherence in attending appointments. A total of 381 participants with SCD from various regions in the Jazan Province, southwestern Saudi Arabia, were included. The survey instrument included socioeconomic determinants, factors associated with poor adherence in attending outpatient appointments, and solutions under the conceptual framework of the health belief model. A descriptive analysis was conducted and the factors that impacted adherence in attending the appointments were evaluated. In the current sample, respondents with SCD from 21 to 30 years represented 41%, which was followed by participants who were 11 to 20 years at 21.5%. In addition, about 60% of the participants were women. Further, approximately 62% of the patients admitted were missing one or more outpatient appointments in the previous year, which was significantly related to various factors, such as socioeconomic characteristics and patient residence. Forgetting the appointment was the main reason for skipping outpatient appointments for patients with SCD; as such, reminders appear to be a good solution for most participants. Our findings indicated that modifying components of the health belief model, including age, level of education, income, patients' residence, and lacking cues to action (such as reminders) are important in explaining the reason for poor adherence in attending appointments. Thus, efforts are needed to address these factors and to ensure that SCD patients uphold their appointments. Future studies should examine the clinical, psychological, and epidemiological aspects that are linked with missed consultations.

Geriatric Health Care During the COVID-19 Pandemic: Managing the Health Crisis

COVID-19 pandemic significantly threatens the health and well-being of older adults. Aging-related changes, including multimorbidity, weakened immunity and frailty, may make older people more susceptible to severe infection and place them at higher risk of morbidity and mortality from COVID-19. Various quarantine measures have been implemented to control the spread of COVID-19. Nevertheless, such social distancing has disrupted routine health care practices, such as accessibility of medical services and long-term continuous care services. The medical management of older adults with multimorbidity is significantly afflicted by COVID-19. Older persons with frailty or multiple chronic disease may poorly adapt to the altered health care system, having detrimental consequences on their physical and mental health. COVID-19 pandemic has posed great challenges to the health of older adults. We highlighted the difficulties and obstacles of older adults during this unprecedented time. Also, we provided potential strategies and recommendations for actions to mitigate the COVID-19 pandemic threats. Certain strategies like community primary health care, medication delivery and home care support are adopted by many health facilities and caregivers, whereas other services such as internet hospital and virtual medical care are promoted to be accessible in many regions. However, guidelines and policies based on high-quality data are still needed for better health promotion of older groups with increasing resilience during the COVID-19 pandemic.

Risk Factors for Operating Room No-Show in an Academic Otolaryngology Practice

OBJECTIVES/HYPOTHESIS

A no-show to the operating room date negatively impacts a hospital and can lead to increased costs for an institution in terms of time, materials, and manpower. Our objectives are to identify the factors associated with operating room no-shows in order to increase clinical efficiency, reduce hospital costs, and increase patient access to care.

STUDY DESIGN

Single institution retrospective chart review.

METHODS

A retrospective review was performed of all surgeries within the Otolaryngology department performed at a single tertiary academic center between 2006 and 2019. Demographic and surgical data were collected from the charts. Descriptive, univariate, and multivariate statistics were performed on the data.

RESULTS

There were a total of 1,752 no-shows and 46,440 patients who did show with an overall no-show rate of 3.63%. A multivariate logistic regression analysis was performed to compare patients who did not show for surgery to those who did. Analysis found multiple risk factors for not showing to surgery that were statistically significant (P < .05) and included decreasing age, planned outpatient case, head and neck oncology subspecialty, increasing distance from the facility, higher number of clinic no-shows, and not having private insurance. African-American race was more likely to show for surgery as scheduled.

CONCLUSIONS

Numerous factors may play a role on whether or not a patient attends a scheduled surgical date. Some of these factors may be preventable or modifiable to mitigate increased hospital costs associated with no-show to surgery and increase access to care.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:1738-1742, 2022.

Impact of United States 2017 Immigration Policy changes on missed appointments at two Massachusetts Safety-Net Hospitals

INTRODUCTION

Studies have shown mixed findings regarding the impact of immigration policy changes on immigrants' utilization of primary care.

METHODS

We used a difference-in-differences analysis to compare changes in missed primary care appointments over time across two groups: patients who received care in Spanish, Portuguese, or Haitian Creole, and non-Hispanic, white patients who received care in English.

RESULTS

After adjustment for age, sex, race, insurance, hospital system, and presence of chronic conditions, immigration policy changes were associated with an absolute increase in the missed appointment prevalence of 0.74 percentage points (95% confidence interval: 0.34, 1.15) among Spanish, Portuguese and Haitian-Creole speakers. We estimated that missed appointments due to immigration policy changes resulted in lost revenue of over $185,000.

CONCLUSIONS

We conclude that immigration policy changes were associated with a significant increase in missed appointments among patients who receive medical care in languages other than English.

Delayed medical care due to transportation barriers among adults with atherosclerotic cardiovascular disease

BACKGROUND

In patients with atherosclerotic cardiovascular disease (ASCVD), barriers related to transportation may impair access to care, with potential implications for prognosis. Although few studies have explored transportation barriers among patients with ASCVD, the correlates of delayed care due to transportation barriers have not been examined in this population. We aimed to examine this in U.S. patients with ASCVD using nationally representative data.

METHODS

Using data from the 2009-2018 National Health Interview Survey, we estimated the self-reported prevalence of delayed medical care due to transportation barriers among adults with ASCVD, overall and by sociodemographic characteristics. Logistic regression was used to examine the association between various sociodemographic characteristics and delayed care due to transportation barriers.

RESULTS

Among adults with ASCVD, 4.5% (95% CI; 4.2, 4.8) or ∼876,000 annually reported delayed care due to transportation barriers. Income (low-income: odds ratio [OR] 4.43, 95% CI [3.04, 6.46]; lowest-income: OR 6.35, 95% CI [4.36, 9.23]) and Medicaid insurance (OR 4.53; 95% CI [3.27, 6.29]) were strongly associated with delayed care due to transportation barriers. Additionally, younger individuals, women, non-Hispanic Black adults, and those from the U.S. South or Midwest, had higher odds of reporting delayed care due to transportation barriers.

CONCLUSIONS

Approximately 5% of adults with ASCVD experience delayed care due to transportation barriers. Vulnerable groups include young adults, women, low-income people, and those with public/no insurance. Future studies should analyze the feasibility and potential benefits of interventions such as use of telehealth, mobile clinics, and provision of transportation among patients with ASCVD in the U.S.

Sex and Gender Related Differences in Diabetic Kidney Disease

Diversity in sex and gender are important considerations in the pathogenesis, prognostication, research, and management of diabetic kidney disease (DKD). Sex and gender differences in the disease risk, disease-specific mechanisms, and outcomes in DKD may be attributed to biological differences between males and females at the cellular and tissue level, inconsistencies in the diagnostic and assessment tools used in chronic kidney disease and DKD, as well societal differences in the way men, women, and gender-diverse individuals self-manage and interact with health care systems. This review outlines key considerations related to the impact of sex on DKD, specifically elaborating on how they contribute to observed differences in disease epidemiology, pathogenesis, and treatment strategies. We also highlight the effect of gender on DKD progression and care.

Association of Differences in Treatment Intensification, Missed Visits, and Scheduled Follow-up Interval With Racial or Ethnic Disparities in Blood Pressure Control

Importance

Black patients with hypertension often have the lowest rates of blood pressure (BP) control in clinical settings. It is unknown to what extent variation in health care processes explains this disparity.

Objective

To assess whether and to what extent treatment intensification, scheduled follow-up interval, and missed visits are associated with racial and ethnic disparities in BP control.

Design, Setting, and Participants

In this cohort study, nested logistic regression models were used to estimate the likelihood of BP control (defined as a systolic BP [SBP] level <140 mm Hg) by race and ethnicity, and a structural equation model was used to assess the association of treatment intensification, scheduled follow-up interval, and missed visits with racial and ethnic disparities in BP control. The study included 16 114 adults aged 20 years or older with hypertension and elevated BP (defined as an SBP level ≥140 mm Hg) during at least 1 clinic visit between January 1, 2015, and November 15, 2017. A total of 11 safety-net clinics within the San Francisco Health Network participated in the study. Data were analyzed from November 2019 to October 2020.

Main Outcomes and Measures

Blood pressure control was assessed using the patient's most recent BP measurement as of November 15, 2017. Treatment intensification was calculated using the standard-based method, scored on a scale from -1.0 to 1.0, with -1.0 being the least amount of intensification and 1.0 being the most. Scheduled follow-up interval was defined as the mean number of days to the next scheduled visit after an elevated BP measurement. Missed visits measured the number of patients who did not show up for visits during the 4 weeks after an elevated BP measurement.

Results

Among 16 114 adults with hypertension, the mean (SD) age was 58.6 (12.1) years, and 8098 patients (50.3%) were female. A total of 4658 patients (28.9%) were Asian, 3743 (23.2%) were Black, 3694 (22.9%) were Latinx, 2906 (18.0%) were White, and 1113 (6.9%) were of other races or ethnicities (including American Indian or Alaska Native [77 patients (0.4%)], Native Hawaiian or Pacific Islander [217 patients (1.3%)], and unknown [819 patients (5.1%)]). Compared with patients from all racial and ethnic groups, Black patients had lower treatment intensification scores (mean [SD], -0.33 [0.26] vs -0.29 [0.25]; β = -0.03, P < .001) and missed more visits (mean [SD], 0.8 [1.5] visits vs 0.4 [1.1] visits; β = 0.35; P < .001). In contrast, Asian patients had higher treatment intensification scores (mean [SD], -0.26 [0.23]; β = 0.02; P < .001) and fewer missed visits (mean [SD], 0.2 [0.7] visits; β = -0.20; P < .001). Black patients were less likely (odds ratio [OR], 0.82; 95% CI, 0.75-0.89; P < .001) and Asian patients were more likely (OR, 1.13; 95% CI, 1.02-1.25; P < .001) to achieve BP control than patients from all racial or ethnic groups. Treatment intensification and missed visits accounted for 21% and 14%, respectively, of the total difference in BP control among Black patients and 26% and 13% of the difference among Asian patients.

Conclusions and Relevance

This study's findings suggest that racial and ethnic inequities in treatment intensification may be associated with more than 20% of observed racial or ethnic disparities in BP control, and racial and ethnic differences in visit attendance may also play a role. Ensuring more equitable provision of treatment intensification could be a beneficial health care strategy to reduce racial and ethnic disparities in BP control.

Exploring Primary Care Non-Attendance: A Study of Low-Income Patients

INTRODUCTION

While evidence has been established on the impact of medical appointment non-attendance on the healthcare system and patient health, previous research has not focused on how poverty and rurality may influence patient experiences with non-attendance. This paper explores patient perceptions of non-attendance among those experiencing poverty in a rural U.S county to better inform providers to the context in which their patients make attendance-related decisions.

METHODS

Using a grounded theory approach, we conducted semi-structured interviews with 32 U.S. low-income adults in the rural Western U.S. who recurrently missed primary care appointments. We also used a questionnaire to assess individual characteristics related to health, resiliency, personal mastery, medical mistrust, life chaos, and adverse childhood experiences.

RESULTS

Participants identified 3 barriers to attending appointments: appointment disinterest, competing demands, and insufficient systems. Appointment disinterest stemmed from physical and mental health issues, misalignment between needs and treatment, and comfort with the provider. Competing demands included family responsibilities, employment, and relationships. Finally, participants reported that current scheduling and transportation systems were helpful but insufficient. To provide further context, participants also reported low overall health, moderate levels of medical mistrust, life chaos, and mastery, moderate to low resilience, and very a high number of adverse childhood experiences.

CONCLUSIONS

Results point to the need for modified structures that allow low-income patients more control over their personal health and highlight opportunities for clinics to address patients' lack of interest and fear in the medical encounter.

Impact of New York State's Health Home program on access to care among patients with diabetes

INTRODUCTION

Access to care is essential for patients with diabetes to maintain health and prevent complications, and is important for health equity. New York State's Health Homes (HHs) provide care management services to Medicaid-insured patients with chronic conditions, including diabetes, and aim to improve quality of care and outcomes. There is inconsistent evidence on the impact of HHs, and care management programs more broadly, on access to care.

RESEARCH DESIGN AND METHODS

Using a cohort of patients with diabetes derived from electronic health records from the INSIGHT Clinical Research Network, we analyzed Medicaid data for HH enrollees and a matched comparison group of HH non-enrollees. We estimated HH impacts on several access measures using natural experiment methods.

RESULTS

We identified and matched 11 646 HH enrollees; patients were largely non-Hispanic Black (29.9%) and Hispanic (48.7%), and had high rates of dual eligibility (33.0%), Supplemental Security Income disability enrollment (49.1%), and multiple comorbidities. In the 12 months following HH enrollment, HH enrollees had one more month of Medicaid coverage (p<0.001) and 4.6 more outpatient visits than expected (p<0.001, evenly distributed between primary and specialty care). There were also positive impacts on the proportions of patients with follow-up visits within 7 days (4 percentage points (pp), p<0.001) and 30 days (6pp, p<0.001) after inpatient care, and on the proportion of patients with follow-up visits within 30 days after emergency department (ED) care (4pp, p<0.001). We did not find meaningful differences in continuity of care. We found small positive impacts on the proportion of patients with an inpatient visit and the proportion with an ED visit.

CONCLUSIONS

New York State's HH program improved access to care for Medicaid recipients with diabetes. These findings have implications for New York State Medicaid as well as other providers and care management programs.

Factors Associated With Adherence to Outpatient Follow-Up in Patients With Idiopathic Intracranial Hypertension (IIH)

Idiopathic intracranial hypertension (IIH) is a chronic condition characterized by raised intracranial pressure of undetectable origin, that causes morbidity due to debilitating headaches and vision loss. Continuity of outpatient care is important to monitor for permanent vision loss, manage symptoms and limit emergency care. The purpose of this retrospective study was to identify factors associated with neuro-ophthalmology follow-up appointment completion among patients with IIH at a US academic medical center in order to establish evidence-based interventions to improve adherence patterns. Included are 111 completed or no-show neuro-ophthalmology return outpatient appointments by 23 subjects with IIH. Generalized estimating equation models were used to assess association between appointment completion status and factors previously shown to be associated with appointment adherence. Appointments were more likely to be completed during the summer (p=0.08) and by subjects with headache symptoms (p=0.06), however none of the patient factors reached statistical significance. Completed and no-show appointments did not differ by subject demographic or insurance factors. Further studies are needed to identify risk factors for lack of appointment adherence by patients with IIH, particularly those amenable to intervention, in order to improve continuity of care for IIH.

An Enhanced SMS Text Message-Based Support and Reminder Program for Young Adults With Type 2 Diabetes (TEXT2U): Randomized Controlled Trial

Background

Clinic attendance, metabolic control, engagement in self-management, and psychological health are suboptimal in young-onset (age of onset <40 years) type 2 diabetes.

Objective

We examined the effectiveness of an enhanced SMS text message–based support and reminder program in improving clinic attendance, metabolic control, engagement in self-management, and psychological health in young-onset type 2 diabetes.

Methods

A 12-month, parallel-arm, randomized controlled trial comparing an enhanced, semipersonalized SMS text message–based intervention (incorporating 1-8 supportive and/or informative text messages per month) against standard care was conducted in a specialized clinic for young adult type 2 diabetes. The primary outcome was maintenance of 100% attendance at scheduled quarterly clinical appointments. Secondary outcomes included (1) metabolic indices, (2) pathology and self-monitored blood glucose (SMBG) data availability, and (3) psychosocial well-being.

Results

A total of 40 participants were randomized, and 32 completed their 12-month study visit. The average participant age was 32.7 (SD 5.1) years, 50% (20/40) were male, and baseline glycated hemoglobin A_1c (HbA_1c) was 7.3% (SD 1.9%) (56 mmol/mol, SD 20). A higher proportion of the intervention group achieved 100% attendance (12/21, 57%, vs 5/19, 26%, for the control group); Kaplan-Meier analysis demonstrated significantly greater cumulative attendance in the intervention group (P=.04). There were no between-group differences in HbA_1c, BMI, lipids, or availability of pathology and SMBG data. Odds of recording an improvement in the Diabetes Empowerment Scale–Short Form score were higher in the intervention group at 6 months (odds ratio [OR] 4.3, 95% CI 1.1-17), with attenuation of this effect at study end (OR 3.1, 95% CI 0.9-11). Program acceptability was high; >90% of participants would recommend the program to new patients.

Conclusions

An enhanced SMS text message–based support and reminder program doubled scheduled clinic attendance rates for patients with young-onset type 2 diabetes. The program was highly acceptable and provided early support for patient empowerment but had no significant effect on measures of metabolic control or self-management.

Trial Registration

Australian and New Zealand Clinical Trials Registry (ACTRN12618000479202); https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373579

The effect of unobserved preferences and race on vaccination hesitancy for COVID-19 vaccines: implications for health disparities

BACKGROUND: Reducing the extra burden COVID-19 has on people already facing disparities is among the main national priorities for the COVID-19 vaccine rollout. Early reports from states releasing vaccination data by race show that White residents are being vaccinated at significantly higher rates than Black residents. Public health efforts are being targeted to address vaccine hesitancy among Black and other minority populations. However, health care interventions intended to reduce health disparities that do not reflect the underlying values of individuals in underrepresented populations are unlikely to be successful. OBJECTIVE: To identify key factors underlying the disparities in COVID-19 vaccination. METHODS: Primary data were collected from an online survey of a representative sample of the populations of the 4 largest US states (New York, California, Texas, and Florida) between August 10 and September 3, 2020. Using latent class analysis, we built a model identifying key factors underlying the disparities in COVID-19 vaccination. RESULTS: We found that individuals who identify as Black had lower rates of vaccine hesitancy than those who identify as White. This was true overall, by latent class and within latent class. This suggests that, contrary to what is currently being reported, Black individuals are not universally more vaccine hesitant. Combining the respondents who would not consider a vaccine (17%) with those who would consider one but ultimately choose not to vaccinate (11%), our findings indicate that more than 1 in 4 (28%) persons will not be willing to vaccinate. The no-vaccine rate is highest in White individuals and lowest in Black individuals. CONCLUSIONS: Results suggest that other factors, potentially institutional, are driving the vaccination rates for these groups. Our model results help point the way to more effective differentiated policies. DISCLOSURES: No funding was received for this study. The authors have nothing to disclose.

Valuing diversity in value assessment: introducing the PhRMA Foundation Health Disparities Challenge Award

DISCLOSURES:: No funding supported the writing of this article. The author has received grants from BeiGene, Ltd., and Pfizer, Inc., and advisory board fees from PhRMA Foundation.

'Missingness' in health care: Associations between hospital utilization and missed appointments in general practice. A retrospective cohort study

Objectives

Are multiple missed appointments in general practice associated with increased use of hospital services and missingness from hospital care? This novel study explores this in a population representative sample for the first time.

Design, setting, participants

A large, retrospective cohort (n = 824,374) of patient records from a nationally representative sample of GP practices, Scotland, 2013–2016. Requested data were extracted by a Trusted Third Party for the NHS, anonymised and linked to a unique patient ID, in the NHS Safehaven for analysis using established NHS Scotland linkage. We calculated the per-patient number of GP missed appointments from individual appointments and investigated the likelihood of hospital appointment or admission outcomes using a negative binomial model offset by number of GP appointments made. These models also controlled for age, sex, Scottish Index of Multiple Deprivation (SIMD) and number of long- term conditions (LTCs).

Main outcome measures

Hospital attendance: Outpatient clinic attendances; hospital admissions; Emergency Department (ED) attendances. Hospital missingness: ‘Did not attend’ (DNAs) outpatient clinic appointments, ‘irregular discharges’ from admissions, and ‘left before care completed’ ED care episodes.

Results

Attendance: Patients in the high missed GP appointment (HMA) category were higher users of outpatient services (rate ratio (RR) 1.90, 95% confidence intervals (CI) 1.88–1.93) compared to those who missed none (NMA) with a much higher attendance risk at mental health services (RR 4.56, 95% CI 4.31–4.83). HMA patients were more likely to be admitted to hospital; general admissions (RR 1.67, 95% CI 1.65–1.68), maternity (RR 1.24, 95% CI 1.20–1.28) and mental health (RR 1.23, 95% CI 1.15–1.31), compared to NMA patients. Missing GP appointments was not associated with ED attendance; (RR 1.00, CI 0.99–1.01).

Missingness: HMA patients were at greater risk of missing outpatient appointments (RR 1.62, 95% CI 1.60–1.64) than NMA patients; with a much higher risk of non-attendance at mental health services (RR 7.83, 95% CI 7.35–8.35). Patients were more likely to leave hospital before their care plan was completed-taking ‘irregular discharges’ (RR 4.56, 95% CI 4.31–4.81). HMA patients were no more at risk of leaving emergency departments ‘without care being completed’ (RR1.02, 95 CI 0.95–1.09).

Conclusions

Patients who miss high numbers of GP appointments are higher users of outpatient and inpatient hospital care but not of emergency departments, signalling high treatment burden.

The pattern of ‘missingness’ is consistent from primary care to hospital care: patients who have patterns of missing GP appointments have patterns of missing many outpatient appointments and are more likely to experience ‘irregular discharge’ from in-patient care. Missingness from outpatient mental health services is very high.

Policymakers, health service planners and clinicians should consider the role and contribution of ‘missingness’ in health care to improving patient safety and care.

Association of Weight Loss With Type 2 Diabetes Remission Among Adults in Medically Underserved Areas: A Retrospective Cohort Study

PURPOSE

To examine the association between weight loss and type 2 diabetes remission among vulnerable populations living in medically underserved areas of the Mid-Southern United States.

DESIGN

Quantitative, retrospective cohort study.

SETTING

114 ambulatory sites and 5 adults' hospitals in the Mid-South participating in a regional diabetes registry.

PARTICIPANTS

9,900 adult patients with type 2 diabetes, stratified by remission status, with 1 year of baseline electronic medical record data, and 1 year of follow-up data for the 2015-2018 study period.

MEASURES

The outcomes were diabetes remissions, categorized as any remission, partial remission, and complete remission based on the guidelines of the American Diabetes Association. The exposure was weight loss, calculated by the change in the Body Mass Index (BMI) as a proxy measure.

ANALYSIS

χ² tests, Fisher's exact tests, and the Mann-Whitney U-test were used to examine the differences in patient characteristics by remission status across the 3 remission categories, as appropriate. Multiple multivariable logistic regressions adjusting for confounders were performed to estimate the adjusted odds ratios (aORs) for the associations between weight loss and diabetes remission.

RESULTS

Among 9,900 patients identified, a reduction of 0.3 kg/m² (standard deviation: 2.5) in the average BMI from the baseline to the follow-up was observed. 10.8% achieved any type of remission, with 9.8% for partial and 1.0% for complete remissions. Greater weight loss was significantly associated with an increased likelihood of any (aOR = 1.07, 95% confidence interval (CI), 1.06-1.08), partial (aOR 1.06, 95% CI, 1.04-1.07), and complete diabetes remission (aOR 1.10, 95% CI, 1.07-1.13).

CONCLUSIONS

Weight loss is significantly associated with diabetes remission among patients living in medically underserved areas, but complete remission is rare.

The Use of Mobile Messaging for Telecommunications with Patients in Ophthalmology: A Systematic Review

Background: Communication and concordance between patients and providers are crucial for improved outcomes and disease prevention. Mobile health strategies have been shown to improve patient accessibility and convenience. Mobile messaging is one strategy that has demonstrated varying degrees of effectiveness in patient care. The aim of this review is to investigate methods, outcomes, and conclusions of studies that have assessed mobile messaging interventions in ophthalmology. Methods: A qualitative systematic review of PubMed, Scopus, Web of Science, and Embase databases was conducted to identify studies that investigated the implementation and efficacy of mobile messaging services in ophthalmology practice. Included articles were categorized based on study content: appointment attendance, patient preference and willingness, education, concordance, and other clinical outcomes. Three tools were used to assess for potential bias. Results: Out of a total of 3,655 unique titles retrieved, 15 articles were included in the final qualitative synthesis after abstract and full-text screening. Included studies were published between 2008 and 2020 from seven different countries and across various contexts. All but one study found that the use of mobile messaging in ophthalmology care led to improved process measures or patient outcomes. Evidence for a positive effect was the strongest for appointment follow-up. Survey and feedback data suggest that patients, more so younger patients, are open to mobile message interventions. Conclusion: Mobile messaging interventions can play a role in improving appointment attendance, patient education, and patient practices for ophthalmology patients. Further study is necessary to determine the effectiveness of this tool across various groups and settings.

Impact of the COVID-19 Shutdown on Mental Health in Appalachia by Working Status

Introduction

To slow the spread of COVID-19 in the United States, businesses shutdown in Spring 2020. Research has indicated the impact on frontline workers, yet little is known about the impact on those who were not working outside the home or switched to working remotely.

Purpose

The purpose of this report is to identify the financial and healthcare issues and mental health impact of the COVID-19 shutdown on Appalachians by worker categories.

Methods

An online survey was administered from May 8 – June 6, 2020 to a convenience sample of previous research participants and shared through social media networks, i.e., snowball sampling. Questions investigated mental health, financial and healthcare issues, and employment status. Survey responses were summarized by percentages overall and by working categories.

Results

Of the 751 participants, 276 (42%) resided in Appalachia. After removing 17 who lost their job due to COVID-19, 59 (23%) indicated not working outside the home prior to COVID-19, whereas 111 (43%) and 89 (34%) switched to working remotely and continued working outside the home during the shutdown. Respondents were predominately Caucasian and female. Nearly a quarter of participants had lost or reduced income due to the shutdown. Approximately half missed or postponed healthcare appointments. Mental health impacts were similar across the groups, with half of the respondents reporting anxiety due to COVID-19.

Implications

Further research is needed to explore health outcomes associated with missed healthcare appointments during the shutdown. Mental health support may be needed equally by those isolated at home and frontline workers.

Factors associated with missed appointments by adults with type 2 diabetes mellitus: a systematic review

Keeping regular medical appointments is a key indicator of patient engagement in diabetes care. Nevertheless, a significant proportion of adults with type 2 diabetes mellitus (T2DM) miss their regular medical appointments. In order to prevent and delay diabetes-related complications, it is essential to understand the factors associated with missed appointments among adults with T2DM. We synthesized evidence concerning factors associated with missed appointments among adults with T2DM. Using five electronic databases, including PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Web of Science, a systematic literature search was done to identify studies that describe factors related to missed appointments by adults with T2DM. A total of 18 articles met the inclusion criteria. The majority of studies included in this review were cohort studies using medical records. While more than half of the studies were of high quality, the operational definitions of missed appointments varied greatly across studies. Factors associated with missed appointments were categorized as patient characteristics, healthcare system and provider factors and interpersonal factors with inconsistent findings. Patient characteristics was the most commonly addressed category, followed by health system and provider factors. Only three studies addressed interpersonal factors, two of which were qualitative. An increasing number of people live with one or more chronic conditions which require more careful attention to patient-centered care and support. Future research is warranted to address interpersonal factors from patient perspectives to better understand the underlying causes of missed appointments among adults with T2DM.

Diabetes distress and peripheral neuropathy are associated with medication non-adherence in individuals with type 2 diabetes in primary care

BACKGROUND

Psychosocial factors like diabetes distress and social support, as well as the presence of complications, affect an individual's self-management ability; however, their role in adherence behaviours is not yet clear. We examined the role of psychosocial factors and complications in non-adherence behaviours in individuals with diabetes in primary care.

METHODS

Baseline survey with nine-month follow up through medical records of patients with type 2 diabetes attending primary care. Medication adherence and diabetes distress were assessed using Morisky Green Levine Medication Adherence Scale and Problem Areas in Diabetes, respectively. Appointment adherence was assessed through medical records.

RESULTS

Of the 448 participants studied, 59.8% had medication non-adherence and 21.7% were non-adherent to scheduled appointments. PAID score (odds ratio (OR) 1.01, 95% confidence interval 1.00-1.03, p = 0.013), peripheral neuropathy (OR 1.99, 95%CI 1.18-3.37, p = 0.01), home glucose monitoring (OR 0.46, 95%CI 0.30-0.69, p < 0.001), HbA1c (OR 1.34, 95%CI 1.13-1.61, p = 0.001), and age (OR 0.96, 95%CI 0.93-0.98, p = 0.001) were associated with medication non-adherence. Indian ethnicity (OR 2.93, 95%CI 1.59-5.39, p = 0.001), secondary or higher education (OR 1.94, 95%CI 1.14-3.27, p = 0.014), and HbA1c (OR 1.38, 95%CI 1.18-1.63, p < 0.001) were associated with appointment non-adherence.

CONCLUSIONS

Non-adherence behaviours were prevalent and significantly associated with higher HbA1c. Medication non-adherence was more likely in younger individuals, those with higher diabetes distress or peripheral neuropathy. Appointment non-adherence was more likely in individuals of Indian ethnicity or those with higher education. Greater support for these groups may help improve adherence behaviours and outcomes.

Barriers to diabetic foot care in a disadvantaged population: A qualitative assessment

OBJECTIVE

We explored barriers to proper foot care in this population using a qualitative approach with focus group discussions (FGD).

METHODS

Participants were recruited from clinics at a safety-net hospital in Atlanta, Georgia and stratified into two groups: diabetic foot ulcer (DFU) and minor amputation (below ankle). The FGDs addressed patient experience in receiving care with a goal of understanding: foot care knowledge, barriers to care, and preferred educational methods. Surveys were performed to supplement FGDs.

RESULTS

Forty participants (90% Black) were enrolled. Dominant themes emerging from FGDs were: 1-Patients reported adequate understanding of recommended foot care practices; 2-Personal barriers to self-care included lack of motivation, high cost, poor insurance coverage of supplies, and difficulty limiting activity for proper offloading; 3-Hospital system barriers included difficulty making timely appointments and reaching a provider to arrange care; 4-Access to footcare-related information and services improved with greater disease severity. Participants stressed that improved access often came too late to alter their course. They expressed interest in developing peer support groups to facilitate learning and sharing information relating to DFU.

CONCLUSION

We found that patients with DFU or minor amputations have adequate footcare-related knowledge, but personal and systemic barriers limited appropriate foot care.

Into the Storm: a Mixed Methods Evaluation of Reasons for Non-attendance of Appointments in the Free Clinic Setting

Non-attendance of healthcare appointments impact individual health outcomes and the capacity and financial stability of clinics. While non-attendance of appointments has been associated with a variety of factors, interventions to increase attendance have had mixed success. The most widely used intervention, reminder systems like phone calls or text messages, generally improves attendance rates but is insufficient for many clinics as a sole intervention. This study of underresourced patients who did not attend appointments at two clinics for uninsured individuals describes the multifactorial, individualized, and interacting reasons for non-attendance among these methods: Forty-three patients were interviewed by phone within 3 weeks of missing a clinic appointment using a scripted interview based on the literature. Responses were coded and analyzed. For 57% of respondents, a competing priority such as work or caregiving was a reason for missing an appointment. Forgetting about the appointment was a barrier for 38% of participants despite reminder systems being in place. Contributions to non-attendance were identified through thematic analysis: emotional and physical exhaustion, prioritization of work over healthcare, unreliable transportation, financial stress, and being unaware of an appointment. These findings demonstrate the need to test multiple patient-centered interventions, particularly in the context of underresourced communities.

Improvement in Outpatient Follow-up With a Postdischarge Phone Call Intervention

INTRODUCTION

Attending clinic appointments after injury is crucial for orthopaedic trauma patients to evaluate healing and to update recommendations. However, attendance at these appointments is inconsistent. The purpose of this study was to assess the effect of a personalized phone call placed 3 to 5 days after hospital discharge on attendance at the first postdischarge outpatient clinic visit.

METHODS

This prospective study was done at an urban level 1 trauma center. One hundred fifty-nine patients were exposed to a reminder phone call, with 33% of patients being reached for a conversation and 28% receiving a voicemail reminder. Phone calls were made by a trained trauma recovery coach, and the main outcome measure was attendance at the first postdischarge clinic visit.

RESULTS

Eighty-six patients (54%) attended their scheduled appointments. Appointment adherence was more common among the group reached for a conversation (70% versus 51% for voicemail cohort and 34% for no contact group). Patients exposed to the Trauma Recovery Services (TRS) during their hospital stay attended appointments more often (91% versus 61%, P = 0.026). Age, sex, mechanism of injury, and distance from the hospital were not associated with specific follow-up appointment adherence. Insured status was associated with higher attendance rates (71% versus 46%, P = 0.0036). Other economic factors such as employment were also indicative of attendance (64% versus 48%, P = 0.05). Current tobacco use was associated with poor appointment attendance (30%) versus 56% for nonsmokers (P = 0.001).

DISCUSSION

Patients reached by telephone after discharge had better rates of subsequent clinic attendance. Economic factors and substance use appear vital to postoperative clinic visit compliance. Patients with met psychosocial needs, as identified by individuals with satisfactory emotional support, and exposure to TRS had the highest rates of postdischarge appointment attendance.

Effect of Visit Frequency of Pharmacist-Led Diabetes Medication Management Program

BACKGROUND

Pharmacists have a positive effect on clinical outcomes in chronic disease state management, however, few studies have evaluated the effect that frequency of visits may have on diabetes biomarkers such as hemoglobin A1c and blood pressure readings.

METHODS

Under the medication management program (MMP), patients with diabetes were seen monthly by pharmacists until early 2015, when time between visits was increased to every 3 months. A retrospective chart review was conducted to evaluate the primary outcome of the percent change in hemoglobin A1c and blood pressure after the change in visit frequency.

RESULTS

In the 303 patients enrolled, no statistical difference existed between the pre and post average A1c (p-value = 0.10). The intermediate average A1c was statistically lower from the preintervention mean A1c (p-value = 0.001) but not from the postintervention mean A1c (p-value = 0.30). No statistical differences were seen between systolic blood pressure and diastolic blood pressure.

CONCLUSION

Patients who have been seen by a clinical pharmacist more frequently (every month or every other month) for several years may be able to maintain their reduction in A1c with less-frequent visits (every 3 to 6 months).

Patient No-Show Prediction: A Systematic Literature Review

Nowadays, across the most important problems faced by health centers are those caused by the existence of patients who do not attend their appointments. Among others, these patients cause loss of revenue to the health centers and increase the patients’ waiting list. In order to tackle these problems, several scheduling systems have been developed. Many of them require predicting whether a patient will show up for an appointment. However, obtaining these estimates accurately is currently a challenging problem. In this work, a systematic review of the literature on predicting patient no-shows is conducted aiming at establishing the current state-of-the-art. Based on a systematic review following the PRISMA methodology, 50 articles were found and analyzed. Of these articles, 82% were published in the last 10 years and the most used technique was logistic regression. In addition, there is significant growth in the size of the databases used to build the classifiers. An important finding is that only two studies achieved an accuracy higher than the show rate. Moreover, a single study attained an area under the curve greater than the 0.9 value. These facts indicate the difficulty of this problem and the need for further research.

Activation in individuals with vision loss

Vision loss and blindness are significant causes of disability. Patient activation has been previously unstudied in individuals with vision loss. Among our 146 participants, visual acuities for 38.3 percent were better than 20/70, 43.2 percent had acuities between 20/70 and 20/400, and 12.3 percent had acuities of <20/400. Participants with lower Patient Activation Measure scores missed more clinic visits (p = 0.017); those participants with caregivers also had lower PAM scores (p = 0.002). Targeting interventions to address patient activation in patients with vision loss may increase patient involvement in their care, increase treatment protocol adherence, and improve outcomes.

A Bibliometric Analysis on No-Show Research: Status, Hotspots, Trends and Outlook

No-show is a thorny issue within the social scope. It not only affects the sustainability of service system operation but also causes heavy irretrievable losses. To maintain and develop the sustainability of service, this paper adopts bibliometric technology to reflect the current status and future prospects about no-show research. And we strive to explore and summarize appointment scheduling methods for no-show problems. The bibliometric analysis was carried out from various aspects including research areas, countries/regions, institutions, journals, authors and author keywords based on papers harvested from Web of Science Core Collection database. The total 1197 papers show that the United States is in a leading position in this field, followed by England and Canada. University of London is the most productive institution with the highest total citations and H-Index. BMC Health Services Research ranks first as the most productive journal, followed by European Journal of Operational Research and Production and Operations Management. Through the analysis of hot articles, we can conclude that how to reduce the impact of no-shows on the sustainability of service systems has become the main research direction. In addition to appointment scheduling, other effective methods are also mentioned. Further study on these methods will be a major research direction in the future.

Factors associated with withdrawal from insulin pump therapy: A large-population-based study

BACKGROUND

Although, number of diabetic patients received insulin pump (IP) therapy is increasing; there are limited data regarding factors associated with IP withdrawal.

METHODS

We conducted a cross-sectional study using data from an Israeli health maintenance organization. All patients, 21 or older, with type 1 (T1DM) or type 2 (T2DM) diabetes, who received IP therapy for a 7-year period were identified. Patients who did not purchase IP maintenance supplies for at least six consecutive months were defined as withdrawn (N = 355). Patients who purchased supplies were defined as adherent (N = 352).

RESULTS

In both T1DM and T2DM patients, withdrawal from IP therapy was positively associated with duration of diabetes longer than 5 years (odds ratio [OR] = 13.26 [CI, 7.16-23.34; P < .001] and OR = 10.92 [CI, 5.64-21.14; P < .001], respectively), nonadherence to dietician follow-up (OR = 5.78 [CI, 3.65-9.14; P < .001] and OR = 3.41 [CI, 1.99-5.85; P < .001], respectively), and poor glycaemic control prior to IP treatment (OR = 4.04 [CI, 2.18-7.48; P < .001] and OR = 4.59 [CI, 2.71-7.81; P < .001], respectively]. Co-morbid neuro-psychiatric disorders were also risk factors for IP withdrawal: diagnosis of depression (OR = 2.22 [CI, 1.16-4.27; P = .017] and Attention Deficit Hyperactivity Disorder (ADHD) OR = 2.45 [CI, 1.003-5.087; P = .043]) among T1DM patients; and diagnosis of depression (OR = 1.85 [CI, 1.05-5.27; P = .046] and dementia OR = 4.03 [CI, 1.03-19.77; P = .048]) among T2DM patients.

CONCLUSION

In our large real-world population-based study, we found that smoking, obesity, poor glycaemic control, and co-morbid neuro-psychiatric disorders were associated with a high rate of withdrawal from IP therapy. Health care providers ought to familiarize themselves with patient characteristics predictive of nonadherence and should intensify patient follow-up when incorporating this new, costly, and challenging technology.

Transportation Barriers to Health Care in the United States: Findings From the National Health Interview Survey, 1997-2017

Objectives. To quantify the number of people in the US who delay medical care annually because of lack of available transportation and to examine the differential prevalence of this barrier for adults across sociodemographic characteristics and patient populations.Methods. We used data from the National Health Interview Survey (1997-2017) to examine this barrier over time and across groups. We used joinpoint regression analysis to identify significant changes in trends and multivariate analysis to examine correlates of this barrier for the year 2017.Results. In 2017, 5.8 million persons in the United States (1.8%) delayed medical care because they did not have transportation. The proportion reporting transportation barriers increased between 2003 and 2009 with no significant trends before or after this window within our study period. We found that Hispanic people, those living below the poverty threshold, Medicaid recipients, and people with a functional limitation had greater odds of reporting a transportation barrier after we controlled for other sociodemographic and health characteristics.Conclusions. Transportation barriers to health care have a disproportionate impact on individuals who are poor and who have chronic conditions. Our study documents a significant problem in access to health care during a time of rapidly changing transportation technology.

Receipt of recommended complications and comorbidities screening in youth and young adults with type 1 diabetes: Associations with metabolic status and satisfaction with care

OBJECTIVES

This study sought to: (a) assess the prevalence of diabetes complications and comorbidities screening as recommended by the American Diabetes Association (ADA) for youth and young adults (YYAs) with type 1 diabetes (T1D), (b) examine the association of previously measured metabolic status related to diabetes complications with receipt of recommended clinical screening, and (c) examine the association of satisfaction with diabetes care with receipt of recommended clinical screening.

METHODS

The study included 2172 SEARCH for Diabetes in Youth participants with T1D (>10 years old, diabetes duration >5 years). Mean participant age was 17.7 ± 4.3 years with a diabetes duration of 8.1 ± 1.9 years. Linear and multinomial regression models were used to evaluate associations.

RESULTS

Sixty percent of participants reported having three or more hemoglobin A1c (HbA1c) measurements in the past year. In terms of diabetes complications screening, 93% reported having blood pressure measured, 81% having an eye examination, 71% having lipid levels checked, 64% having a foot exam, and 63% completing albuminuria screening in accordance with ADA recommendations. Youth known to have worse glycemic control in the past had higher odds of not meeting HbA1c screening criteria (OR 1.11, 95% CI = 1.05, 1.17); however, after adjusting for race/ethnicity, this was no longer statistically significant. Greater satisfaction with diabetes care was associated with increased odds of meeting screening criteria for most of the ADA-recommended measures.

CONCLUSIONS

Efforts should be made to improve diabetes complications screening efforts for YYAs with T1D, particularly for those at higher risk for diabetes complications.

Impact of a Multidisciplinary, Endocrinologist-Led Shared Medical Appointment Model on Diabetes-Related Outcomes in an Underserved Population

A multidisciplinary endocrinologist-led shared medical appointment (SMA) model showed statistically significant reductions in A1C from baseline over 3 years that were not significantly different from appointments with endocrinologists or primary care providers alone within a resource-poor population. Similarly, the SMA model achieved clinical outcomes on par with endocrinologist-only visits with the added benefit of improving endocrine provider productivity and specialty access for patients. Greater patient engagement with the SMA model was associated with significantly lower A1C.

Opioid Taper Is Associated with Subsequent Termination of Care: a Retrospective Cohort Study

BACKGROUND

Opioid tapering is increasingly utilized by providers to decrease risks of chronic opioid therapy, but it is unknown whether tapering is associated with termination of care.

OBJECTIVE

To determine whether patients taking chronic opioid therapy who experienced opioid tapers were at greater risk of subsequently terminating their care compared with those who were continued on their doses.

DESIGN

Retrospective cohort study of patients in a large, urban health system between 2008 and 2012 with 2 years of follow-up.

PARTICIPANTS

Adult patients prescribed a stable baseline dose of chronic opioid therapy of at least 25 morphine milligram equivalents per day during a baseline year.

MAIN MEASURES

An opioid taper during an exposure year, defined as a reduction in the average daily dose of at least 30% from the baseline dose in both of the two 6-month periods in the year following the baseline year. Opioid dose continuation was defined as any increase in dose, no change in dose, or any decrease up to 30% compared with baseline dose in the exposure year. The primary outcome was termination of care, defined as no outpatient encounters in the health system, in the year following the exposure year.

KEY RESULTS

Of 1624 patients on chronic opioid therapy, 207 (15.5%) experienced an opioid taper and 78 (4.8%) experienced termination of care. Compared with opioid dose continuation, opioid taper was significantly associated with termination of care (AOR 4.3 [95% CI 2.2-8.5]).

CONCLUSIONS

Opioid taper is associated with subsequent termination of care. These findings invite caution and demonstrate the need to fully understand the risks and benefits of opioid tapers.

Assessing outpatient follow-up care compliance, complications, and sequelae in children hospitalized for isolated traumatic abdominal injuries

BACKGROUND

Currently there is limited knowledge on compliance with follow-up care in pediatric patients after abdominal trauma. The Indiana Network for Patient Care (INPC) is a large regional health information exchange with both structured clinical data (e.g., diagnosis codes) and unstructured data (e.g., provider notes). The objective of this study is to determine if regional health information exchanges can be used to evaluate whether patients receive all follow-up care recommended by providers.

METHODS

We identified 61 patients treated at a Pediatric Level I Trauma Center who were admitted for isolated abdominal injuries. We analyzed medical records for two years following initial hospital discharge for injury using the INPC. The encounters were classified by the type of encounter: outpatient, emergency department, unplanned readmission, surgery, imaging studies, and inpatient admission; then further categorized into injury- and non-injury-related care, based on provider notes. We determined compliance with follow-up care instructions given at discharge and subsequent outpatient visits, as well as the prevalence of complications and sequelae.

RESULTS

After reviewing patient records, we found that 78.7% of patients received all recommended follow-up care, 6.6% received partial follow-up care, and 11.5% did not receive follow-up care. We found that 4.9% of patients developed complications after abdominal trauma and 9.8% developed sequelae in the two years following their initial hospitalization.

CONCLUSIONS

Our findings suggest that health information exchanges such as the INPC are useful in evaluation of follow-up care compliance and prevalence of complications/sequelae after abdominal trauma in pediatric patients.

LEVEL OF EVIDENCE

Level IV.

Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study

Background

It is critical to understand whether providing health insurance coverage, assigning a dedicated Primary Care Physician (PCP), and arranging timely post-Emergency Department (ED) clinic follow-up can improve compliance with clinic visits and reduce ED discharge failures. We aim to determine the benefits of providing these common step-wise interventions and further investigate the necessity of urgent PCP referrals on behalf of ED discharged patients.

Methods

This is a single-center retrospective observational study. All patients discharged from the ED over the period Jan 1, 2015 through Dec 31, 2017 were included in the study population. Step-wise interventions included providing charity health insurance, assigning a dedicated PCP, and providing ED follow-up clinics. PCP clinic compliance and ED discharge failures were measured and compared among groups receiving different interventions.

Result

A total of 227,627 patients were included. Fifty-eight percent of patients receiving charity insurance had PCP visits in comparison to 23% of patients without charity insurance (p < 0.001). Seventy-seven percent of patients with charity insurance and PCP assignments completed post-ED discharge PCP visits in comparison to only 4.5% of those with neither charity insurance nor PCP assignments (p < 0.001).

Conclusions

Step-wise interventions increased patient clinic follow-up compliance while simultaneously reducing ED discharge failures. Such interventions might benefit communities with similar patient populations.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4300-1) contains supplementary material, which is available to authorized users.

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study

OBJECTIVES

Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models.

DESIGN, SETTING AND PARTICIPANTS

This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days.

METHODS

Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models.

RESULTS

A total of 227 627 patients were included. The Screening for Healthcare fOllow-Up Tool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80).

CONCLUSION

The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions.

Social and Psychosocial Determinants of Health Associated With Uncontrolled Diabetes in a Federally Qualified Health Center Population

PURPOSE

Many people with diabetes have difficulty achieving glycemic targets, and social and psychosocial determinants of health may influence their ability to obtain glycemic goals. The objective of this study was to identify characteristics independently associated with A1C >9% or untested A1C compared to those with A1C ≤9% at a federally qualified health center.

METHODS

This retrospective cohort study included people with a diagnosis of diabetes, who were 18-89 years of age and had a medical evaluation from a primary care provider between 1 September 2016 and 31 August 2017. The primary outcome was to identify characteristics associated with an A1C >9% or untested A1C compared to those with an A1C ≤9%.

RESULTS

Of 6,185 patients meeting inclusion criteria, 2,965 (48%) had uncontrolled A1C. In the uncontrolled A1C group, 1,549 patients (52%) were female, 1,296 (44%) preferred care in a language other than English (1,273 [43%] in Spanish), and 535 (18%) had a concurrent mental health diagnosis. Multivariable logistic regression of 4,774 patients with complete data revealed that poor appointment adherence (odds ratio [OR] 3.24, 95% CI 2.30-4.57) and/or a positive Patient Health Questionnaire-2 depression screen (OR 1.35, 95% CI 1.12-1.62) had an increased risk of being in the uncontrolled A1C group. Patients with a prescription for antidepressant medication were more likely to be in the controlled group.

CONCLUSION

Poor adherence to appointments and presence of depressive symptoms were associated with high A1C values. Interventions can be developed targeting these determinants to improve blood glucose levels.

Reducing Patient No-Shows: An Initiative at an Integrated Care Teaching Health Center

Background

Patient no-shows impede the effectiveness and efficiency of health care services delivery.

Objective

To evaluate a 2-phase intervention to reduce no-show rates at an integrated care community health center that incorporates a teaching program for osteopathic family medicine residents.

Methods

The Elmont Teaching Health Center (ETHC) is 1 of 5 community-based health centers comprising the Long Island Federally Qualified Health Centers. In August 2015, the ETHC implemented a centerwide No-Show Rates Reduction Initiative divided into an assessment phase and implementation phase. The assessment phase identified reasons most frequently cited by patients for no-shows at the ETHC. The implementation phase, initiated in mid-September, addressed these reasons by focusing on reminder call verification, patient education, personal responses to patient calls, institutional awareness, and integration with multiple departments. To assess the initiative, monthly no-show rates were compared by quarter for 2015 and against rates for the previous year.

Results

We recorded 27,826 appointments with 6147 no-shows in 2014 and 31,696 appointments with 5690 no-shows in 2015. No-show rates in the first 3 quarters of 2015 (range, 18.2%-20.0%) were slightly lower than the rates in 2014 (20.1%-23.4%) and then changed by an increasingly wide margin in the last quarter of 2015 (15.3%), leading to a significant year (2014, 2015) by quarter (Q1, Q2, Q3, Q4) interaction (P=.004). Also, the change observed in Q4 in 2015 differed significantly from Q1 (P=.017), Q2 (P=.004), and Q3 (P=.027) in 2015, while Q1, Q2, and Q3 in 2015 did not significantly differ from one another.

Conclusion

No-show rates were successfully reduced after a 2-phase intervention was implemented at 1 health center within a larger health care organization. Future directions include dismantling the individual components of the intervention, evaluating the role of patient volumes in no-show rates, assessing patient outcomes (eg, costs, health) in integrative care settings that treat underserved populations, and evaluating family medicine residents' training on continuity of care and no-show rates.