Characteristics and direct costs of academic pediatric subspecialty outpatient no-show events

Barriers and facilitators to accessing pediatric specialty care for rural-dwelling children with complex chronic conditions: An integrative review

PROBLEM

Pediatric specialty services are often geographically concentrated in urban areas, leaving up to 1 in 5 rural-dwelling children in the United States without access to advanced care. The purpose of this review was to identify and review extant literature related to barriers and facilitators to accessing specialty care for rural-dwelling children with complex chronic conditions.

ELIGIBILITY CRITERIA

The Whittemore and Knafl (2005) integrative review method guided the review which included a critical appraisal and analysis of relevant articles published between 2012 and 2023.

SAMPLE

Twenty-three studies were identified for inclusion in the integrative review.

RESULTS

Using the domains of the Levesque et al. (2013) conceptual framework, findings were categorized according to the access to care continuum. Barriers included broadband access, transportation, and inadequate care coordination. Facilitators included telehealth, social support, and outreach clinics.

CONCLUSIONS

To improve access to pediatric specialty care for rural-dwelling children, nurses, physicians, and policymakers will need to consider how the social determinants of health impact the healthcare access continuum from diagnosis to continuing healthcare.

IMPLICATIONS

The findings of this integrative review will aid researchers in developing interventions to improve access to pediatric specialty care for rural-dwelling children.

Analysis of missed clinic visits, preferred languages, and telemedicine in a pediatric gastroenterology practice

OBJECTIVES

Previous studies have demonstrated a relationship between socioeconomic disparities and missed clinic visits (MCV). However, the relationship between patient-preferred language and MCVs, particularly with respect to telemedicine, remains relatively underexplored. We sought to characterize the associations between MCV and patient-level predictors, including preferred language, in a large single-center pediatric gastroenterology, hepatology, and nutrition practice.

METHODS

This retrospective longitudinal cohort study included all missed or completed outpatient visits in the Gastroenterology, Hepatology, and Nutrition Programs at Boston Children's Hospital from January 1, 2016 to May 20, 2022. Univariate and multivariate hierarchical generalized linear mixed models were employed to identify associations between visit- and patient-level predictors and an MCV outcome.

RESULTS

A total of 300,201 visits from 70,710 patients residing in Massachusetts were included. Univariate analyses revealed higher MCV odds for Hispanic patients and those from areas with the highest Social Vulnerability Index (SVI), and these odds increased with telemedicine (Hispanic in-person odds ratio [OR] 5.21 [(95% confidence interval) 4.93-5.52] vs. telemedicine OR 8.79 [7.85-9.83]; highest SVI in-person OR 5.28 [4.95-5.64] vs. telemedicine OR 7.82 [6.84-8.96]). Controlled multivariate analyses revealed that among six language groups, only Spanish language preference was associated with higher MCV odds, which increased with telemedicine (Spanish in-person adjusted OR [aOR] 1.35 [1.24-1.48] vs. telemedicine aOR 2.1 [1.83-2.44]).

CONCLUSIONS

Patients preferring Spanish experience unique barriers to care beyond those faced by other language preference groups, and telemedicine may exacerbate these barriers.

Effects of Implementing a Standardized Surveillance Program on Cardiac Neurodevelopmental Program Referral Completion

Differences in surveillance methods have resulted in significant variability in referral volumes and referral completion rates across cardiac neurodevelopmental programs, with frequent barriers to referral completion including high no-show rates, lack of education, and inaccessibility for underrepresented populations. The purpose of this study was to describe implementation of a standardized surveillance program and investigate impact on referral volume and completion over a two-year period. Between fiscal years 2021 and 2022, a surveillance program was implemented which standardized assessment of neurodevelopmental risk via a checklist as well as family education and referral procedures. All patients referred to the cardiac neurodevelopmental program during these two fiscal years were included in the analysis, and patient referrals were categorized as complete or incomplete (due to physician-related or patient-related factors). Referral completion rates between fiscal years were compared using two sample Z test of proportions, while associations between referral completion and demographic/anatomical variables were completed using chi-square tests of independence. Implementation of the formal surveillance program resulted in a 66.7% increase in referral volume. Proportions of both incomplete referrals (z = 2.00, p < 0.05) and incomplete referrals due to physician-related factors (z = 4.34, p < 0.01) were significantly lower after implementation. A significant association was found after implementation between referral completion and race/ethnicity (x2 = 14.08, p < 0.01) due to a significantly high proportion of completed referrals for patients identifying as Hispanic/Latino within the overall distribution of patients. This study describes the successful implementation of a standardized surveillance program, including improvements to referral volume and completion rate. Findings also support implementation of methods that emphasize physician surveillance methods and improve accessibility for historically marginalized groups at greatest risk for disparities in access and quality of care.

Improving Outpatient Follow-Up Rates for New In-Hospital Consults

OBJECTIVE(S)

This investigation aimed to define the rate of outpatient follow-up after in-hospital consultation, identify factors associated with establishing care, and evaluate an alternative scheduling process to improve outpatient adherence.

METHODS

Two-phase, prospective study at an academic, tertiary-care institution from March 2020 to August 2022. First, all patients not previously known to our practice encountered via inpatient consult who warranted outpatient follow-up were prospectively captured. Logistic regression analysis was used to identify demographic, disease, and practice factors predictive of follow-up. Second, a randomized control trial was performed to validate the effects of pre-assigning appointments prior to discharge.

RESULTS

Six hundred subjects were included in the final study cohort; 500 in phase-one, and 100 randomized during phase-two. In the phase-one cohort, 54% (n = 272) were lost to follow-up. Multivariate analysis showed increased odds of outpatient follow-up when appointments were pre-assigned before discharge (odds ratio [OR]: 3.69 [95% confidence interval [CI]: 2.29-5.96], p < 0.001), the primary reason for hospitalization was ENT and consult-related (OR: 3.29 [1.92-5.64], p < 0.001), and the diagnosis was one of Oncology (OR: 1.93 [1.02-3.69], p = 0.045) or Pediatrics (OR: 3.36 [1.41-7.98], p = 0.006) subspecialties. During phase-two, subjects randomized for pre-assigned appointments had higher outpatient follow-up (82%) compared to the control group (20%) (p < 0.001).

CONCLUSION

Hospital-based consultations represent an important referral pathway for new patients. Disease characteristics may identify patients less likely to follow-up upon discharge. Appointment scheduling protocols, including pre-assigning appointments, are modifiable targets for improving adherence to care. Laryngoscope, 133:2540-2545, 2023.

Predicting and explaining absenteeism risk in hospital patients before and during COVID-19

In order to address one of the most challenging problems in hospital management - patients' absenteeism without prior notice - this study analyses the risk factors associated with this event. To this end, through real data from a hospital located in the North of Portugal, a prediction model previously validated in the literature is used to infer absenteeism risk factors, and an explainable model is proposed, based on a modified CART algorithm. The latter intends to generate a human-interpretable explanation for patient absenteeism, and its implementation is described in detail. Furthermore, given the significant impact, the COVID-19 pandemic had on hospital management, a comparison between patients' profiles upon absenteeism before and during the COVID-19 pandemic situation is performed. Results obtained differ between hospital specialities and time periods meaning that patient profiles on absenteeism change during pandemic periods and within specialities.

Sociodemographic Factors and Health Care Utilization in Pediatric Chronic Suppurative Otitis Media

OBJECTIVES

Access to and utilization of perioperative healthcare may influence outcomes in patients with chronic suppurative otitis media (CSOM); however, the influencing factors are poorly understood. The objective of this study was to assess the association of sociodemographic factors with perioperative health care utilization for pediatric CSOM patients.

METHODS

We conducted a review on pediatric CSOM patients (≤18 years old) who underwent tympanoplasty with/without mastoidectomy between 2010 and 2020. Sociodemographic data and clinical were collected on all participants. Univariate and multivariate logistic regression analysis was conducted to assess the association between these factors and perioperative care utilization.

RESULTS

427 patients were included in the study. The primary factor associated with health care utilization was insurance status. Rural children were more likely to have Medicaid insurance (p = 0.048). For tympanoplasty patients, Medicaid patients have 1.66 higher odds of pre-operative no-shows (p = 0.01), 1.31 higher odds of post-operative no-shows (p = 0.02), and 59% lower odds of having a postoperative audiogram (p = 0.01), and 2.64 higher odds of being from a rural community (p = 0.02). For patients undergoing mastoidectomy, Medicaid patients have 1.25 higher odds of postoperative no-shows (p = 0.01), 39% lower odds of having a revision procedure for ossicular reconstruction (p = 0.045). Appalachian rural mastoidectomy patients had 3.62 higher odds of having cholesteatoma (p = 0.05).

CONCLUSION

Pediatric patients with CSOM who have Medicaid insurance, especially those who reside in rural regions, are at risk for lower perioperative hearing health care utilization. As these findings may impact care delivery and clinical outcomes, efforts should be focused on promoting utilization among these populations.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:700-705, 2023.

Missed appointments in a tertiary academic pediatric ophthalmology and adult strabismus service: cross-sectional study and literature review

PURPOSE

To investigate the rate of missed appointments in a Canadian academic hospital-based pediatric ophthalmology and adult strabismus practice and the demographic and clinical factors associated with missed appointments.

METHODS

This cross-sectional study included all consecutive patients seen from June 1, 2018, to May 31, 2019. Multivariable logistic regression model assessed associations between clinical and demographic variables with no-show status. A literature review on evidence-based interventions to reduce no-show appointments in ophthalmology was performed.

RESULTS

Of 3,922 visits, 718 (18.3%) were no-shows. Characteristics associated with no-shows included new patient (OR = 1.4; 95% CI, 1.1-1.7 [P = 0.001]), age 4-12 years (OR = 1.6; 95% CI, 1.1-2.3 [P = 0.011]) or age 13-18 years (OR = 1.8; 95% CI, 1.2-2.7 [P = 0.007]) compared with age 19+ years, history of previous no-shows (OR = 2.2; 95% CI, 1.8-2.7 [P = 0.001]), referrals from nurse practitioners (OR = 1.8; 95% CI, 1.0-3.2 [P = 0.037]), nonsurgical diagnoses such as retinopathy of prematurity (OR = 3.2; 95% CI, 1.8-5.6 [P < 0.001]), and winter season (OR = 1.4; 95% CI, 1.2-1.7 [P < 0.001]).

CONCLUSIONS

Missed appointments in our pediatric ophthalmology and strabismus academic center are more likely new patient referrals, prior no-shows, referrals from nurse practitioners, and nonsurgical diagnoses. These findings may facilitate targeted strategies to help improve utilization of healthcare resources.

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.

Patient Characteristics Associated With Missed Appointments in Pediatric Subspecialty Clinics

OBJECTIVES

Missed appointments negatively affect patients, providers, and health systems. This study aimed to (1) quantify the percentage of missed appointments across 14 pediatric subspecialties in a tertiary-care children's hospital and (2) identify patient characteristics associated with missed appointments in those subspecialties.

METHODS

We extracted patient characteristics from 267,151 outpatient appointments, between January 1, 2013, and December 31, 2018, across 14 subspecialty clinics. Medical complexity was categorized using the Pediatric Medical Complexity Algorithm. The primary outcome was appointment nonattendance. Cancellations, imaging/laboratory visits, patients older than 18 years, and duplicate visits were excluded. Characteristics associated with nonattendance were analyzed with chi-square tests and included in the multivariable model if p < .1. Missing data were addressed using random forest imputation, and assuming data were "missing at random." Variables were considered statistically significant if p < .05.

RESULTS

Of the 128,117 scheduled appointments analyzed, 23,204 (18.1%) were missed. In the multivariable model, clinical nutrition had the greatest subspecialty odds of missed appointments, whereas cardiology had the lowest. Patient characteristics most strongly associated with missed appointments were public insurance, history of >2 missed appointments, appointment lead time, lesser medical complexity, Black race/ethnicity, and fewer medications.

CONCLUSIONS

Clinical characteristics including lesser medical complexity and fewer medications are associated with missed appointments in pediatric subspecialties.

Missed initial appointments at Israeli child development centres: Rate, reasons, and associated characteristics

INTRODUCTION

Missed appointments (MAs) at child development centres (ChDCs) cause multiple problems: they preclude timely diagnosis and treatment of both the invited child and children whose appointment was delayed due to overbooking, as well as disrupting efficient organisational management. The aim of this study was to assess the rate and describe the reasons for missed appointments at Israeli ChDCs, and to evaluate the association of socio-demographic, clinical, and administrative variables with MA rates.

METHODS

This nested case-control study included all children scheduled for initial appointments (N = 1143) at three centres during 1 year. Parents of children who missed their appointment and a sample of those who attended were interviewed by telephone.

RESULTS

The rate of missed appointments was 26.6%, and the most frequent reasons were unexpected events (26.0%) and lack of insurance coverage (23.4%). Variables associated with lower MA rates were: having had ≥3 types of rehabilitative interventions (odds ratios (OR) = 0.26; 95% confidence interval [CI] 0.16-0.44), detailed referral letter (OR = 0.48; 95%CI 0.30-0.75), telephone reminder (OR = 0.37; 95%CI 0.24-0.57) and health maintenance organisations or private insurance coverage (OR = 0.12; 95%CI 0.06-0.17 and OR = 0.56; 95% CI 0.38-0.89, respectively).

CONCLUSION

Encouraging physician's referral letters and personal-contact reminders can reduce missed appointments. Understanding the family's and the child's personal characteristics, and the organisational/administrative aspects of missed appointments may guide efforts to ensure timely care for every child.

Sociodemographic and Appointment Factors Affecting Missed Opportunities to Provide Neonatal Ultrasound Imaging

PURPOSE

The aim of this study was to assess disparities in outpatient imaging missed care opportunities (IMCOs) for neonatal ultrasound by sociodemographic and appointment factors at a large urban pediatric hospital.

METHODS

A retrospective review was performed among patients aged 0 to 28 days receiving one or more outpatient appointments for head, hip, renal, or spine ultrasound at the main hospital or satellite sites from 2008 to 2018. An IMCO was defined as a missed ultrasound or cancellation <24 hours in advance. Population-average correlated logistic regression modeling estimated the odds of IMCOs for six sociodemographic (age, sex, race/ethnicity, language, insurance, and region of residence) and seven appointment (type of ultrasound, time, day, season, site, year, and distance to appointment) factors. The primary analysis included unknown values as a separate category, and the secondary analysis used multiple imputation to impute genuine categories from unknown variables.

RESULTS

The data set comprised 5,474 patients totaling 6,803 ultrasound appointments. IMCOs accounted for 4.4% of appointments. IMCOs were more likely for Black (odds ratio [OR], 3.31; P < .001) and other-race neonates (OR, 2.66; P < .001) and for patients with public insurance (OR, 1.78; P = .002). IMCOs were more likely for appointments at the main hospital compared with satellites (P < .001), during work hours (P = .021), and on weekends (P < .001). Statistical significance for primary and secondary analyses was quantitatively similar and qualitatively identical.

CONCLUSIONS

Marginalized racial groups and those with public insurance had a higher rate of IMCOs in neonatal ultrasound. This likely represents structural inequities faced by these communities, and more research is needed to identify interventions to address these inequities in care delivery for vulnerable neonatal populations.

Characteristics Associated With New Patient Appointment No-Shows at an Academic Ophthalmology Department in the United States

PURPOSE

This study aimed to identify patient and appointment characteristics associated with no-shows to new patient appointments at a US academic ophthalmology department.

DESIGN

Cross-sectional study.

METHODS

This was a study of all adult patients with new patient appointments scheduled with an attending ophthalmologist at Penn State Eye Center between January 1^st and December 31^st of 2019. A multiple logistic regression model was used to assess the association between characteristics and no-show status.

RESULTS

Of 4,628 patients, 759 (16.4%) were no-shows. From the multiple logistic regression model, characteristics associated with no-shows were age (Odds Ratio (OR) for 18-40 years vs. >60 years: 3.41, 95% Confidence Interval (CI) 2.57, 4.51, p <0.001 and OR for 41-60 years vs. >60 years: 2.14, 95% CI 1.67, 2.74, p<0.001), median household income (OR for <$35,667 vs. >$59,445: 1.59, 95% CI 1.08, 2.34, p<0.001), insurance (OR for None vs. Medicare: 6.92, 95% CI 4.41, 10.86, p<0.001 and OR for Medicaid vs. Medicare: 1.54, 95% CI 1.18, 2.01, p=0.002), race (OR for Black vs. White: 2.62, 95% CI 2.00, 3.43, p<0.001 and OR for Other vs. White: 2.02, 95% CI 1.58, 2.59, p<0.001), and commute distance (OR for 5-10 mi vs. ≤5 mi: 1.73, 95% CI 1.17, 2.55, p=0.006). Appointments with longer lead times and scheduled with glaucoma or retina specialists were also significantly associated with greater no-shows.

CONCLUSION

Certain patient and appointment characteristics were associated with no-show status. These findings may assist in the development of targeted interventions at the patient, practice, and health system levels to improve appointment attendance.

Analysis of socioeconomic and demographic factors and imaging exam characteristics associated with missed appointments in pediatric radiology

BACKGROUND

Missed appointments can have an adverse impact on health outcomes by delaying appropriate imaging, which can be critical in influencing treatment decisions.

OBJECTIVE

To assess for socioeconomic and imaging exam factors associated with missed appointments among children scheduled for diagnostic imaging.

MATERIALS AND METHODS

We retrospectively analyzed children (<18 years) scheduled for outpatient diagnostic imaging during a 12-month period. In doing so, we obtained socioeconomic and radiology exam characteristics (modality, intravenous contrast administration, radiation and use of sedation) data from the electronic medical record. We employed multivariate logistic regression to assess the association of socioeconomic, demographic and imaging exam characteristics with imaging missed appointments.

RESULTS

In total, 7,275 children met inclusion criteria. The mean age was 8.8 years (standard deviation [SD] = 6.2 years) and the study population consisted of 52% female gender, 69% White race, 38% adolescent age group and 32% with a median household income by ZIP-code category of <$50,000. Logistic regression showed increased likelihood of missed appointments among children of Black/African-American race (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.4-2.5); with insurance categories including Medicaid (OR=2.0; 95% CI=1.6-2.4), self-pay (OR=2.1; 95% CI=1.3-3.6) and other (OR=2.7; 95% CI=1.3-5.4); with <$50,000 median household income by ZIP-code category (OR=1.7; 95% CI=1.4-2.0); and with examination wait time of 7-21 days (OR=2.7; 95% CI=2.1-3.5) and >21 days (OR=3.7; 95% CI=2.9-4.8). The use of radiation, intravenous contrast agent or sedation was not associated with increased likelihood of missed appointments.

CONCLUSION

Expanding our knowledge of how different socioeconomic and imaging-related factors influence missed appointments among children can serve as a foundational step to better understand existing and emerging disparities and inform strategies to advance health equity efforts in radiology.

Improving Attendance and Patient Experiences During the Expansion of a Telehealth-Based Pediatric Otolaryngology Practice

OBJECTIVE

To determine the rates and primary causes of missed appointments (MAs) for telehealth visits and present remedies for improvement.

METHODS

This cross-sectional survey was conducted at a tertiary care pediatric otolaryngology practice during expansion of telehealth-based visits. A review of questionnaire responses was performed for 103 consecutive patients with MAs over 50 business days from March 20, 2020, to May 29, 2020. Families were asked a brief survey regarding the cause of the MA and assisted with technical support and rescheduling. MA rates and causes were analyzed.

RESULTS

The overall MA rate during the initiation of telehealth services was significantly increased at 12.4% as compared with clinic-based visits of a similar duration before COVID of 5.2% (P < .001). Technical issues were the most common causes of MAs (51.3%). Of the caregivers, 23.8% forgot or reported cancellation of the appointment. Five percent of patients were non-English speaking and scheduled without translator support. Minorities and patients with public insurance represented 53.6% and 61.9% of MAs, respectively.

DISCUSSION

Technical difficulties were the most commonly reported cause of missed telehealth appointments. Optimization of applications by providing patient reminders, determining need for translator assistance, and reducing required upload/download speeds may significantly reduce rates of MAs and conversions to other communication.

IMPLICATIONS FOR PRACTICE

Clear, concise education materials on the technical aspects of telehealth, platform optimization, and robust technical and administrative support may be necessary to reduced missed telehealth appointments and support large-scale telehealth operations. An assessment of institutional capacity is critical when considering telehealth expansion.

Using the Six Sigma Methodology to Reduce Missed Appointments at a Pediatric Inner-City Clinic

Pediatric missed appointments impact patient outcomes and the financial well-being of clinics. Our purpose was to implement the Six Sigma methodology at a pediatric clinic to (1) identify significant predictor factors of missed appointments and develop a prediction model and (2) implement interventions to reduce the missed appointment rate. Binary logistic regression identified historical no-show rate, high-risk visit types, lack of insurance, the number of provider visits, and appointment lead time as significant predictor factors. Interventions led to a significant drop in the missed appointment rate and the no-show rate.

Assessing the Practice Characteristics of Otolaryngology Same-Day Appointments in an Academic Center

OBJECTIVES

to Examine the practice characteristics of same-day clinic appointments and the use of same-day appointment scheduling to provide access to care in an otolaryngology-head and neck surgery clinic.

METHODS

Retrospective chart review of same-day clinic appointments from January 1, 2016, to December 31, 2018, in patients aged >19 years at a single academic center. Demographic data, diagnoses, procedures completed, and operations completed were analyzed.

RESULTS

There were 2696 visits by 2324 patients during the 3-year study period. More men than women (57% vs 43%) made same-day appointments. The mean age was 50.7 years (range, 19-99 years). Sinonasal and otologic diagnoses were the most frequently coded. A total of 1452 procedures were completed on the day of the visit, and 239 operations were completed as a result of the visit. Overall, a broad spectrum of otolaryngology care was delivered within the organizational new patient access goals.

DISCUSSION

Access to otolaryngology-head and neck surgery care can be challenging. Many patients will seek care when they feel they need it, and patient conditions can change unexpectedly. Offering same-day scheduling can allow patients timely health care and appropriate care.

IMPLICATIONS FOR PRACTICE

Same-day appointment scheduling can provide access to care and urgent care for patients. The department of otolaryngology-head and neck surgery has been able to maintain a high rate of providing new patient appointments within 10 days with this method. Further considerations for the impact of same-day scheduling on no-show rates and patient satisfaction can be evaluated.

An Evaluation of the Effect of Pharmacist-Led Comprehensive Chemotherapy Consultation Services on Outpatient Appointment Adherence

BACKGROUND

The North Carolina Cancer Hospital at the University of North Carolina Medical Center serves patients with a variety of malignant conditions and discharges more than 130 patients each month. Processes to improve transitions of care prompted implementation of a first-cycle, pharmacist-led chemotherapy consultation service on the inpatient oncology units. This process provides education to improve patient engagement and activation. High patient activation has been associated with better patient outcomes; poor patient activation has been associated with increased health care costs.

OBJECTIVE

To determine the effect of pharmacist-led comprehensive chemotherapy consultation services on adherence to outpatient follow-up appointments within 30 days of discharge.

METHODS

This was a single-center, retrospective chart review. This study consisted of 2 groups: adult patients who received comprehensive consultation services between April 2017 and September 2017 and a 2:1 historical group of adult control patients randomly selected from a list of patients who received their first cycle of chemotherapy during a hospital admission between April 2014 and April 2017. The primary endpoint was the effect of comprehensive consultation services on adherence to outpatient follow-up appointments within 1 month after discharge.

RESULTS

Ninety-six patients were included in this study. The percentage of appointments attended was 98.0% for the intervention group and 92.3% for the control group (P = 0.0018).

CONCLUSIONS

This study demonstrates that pharmacy consultation in the inpatient oncology setting is associated with improved adherence to outpatient appointments within 30 days of discharge. This represents the first published data on pharmacist interventions resulting in improved outpatient appointment adherence.

DISCLOSURES

Funding for this study was contributed by the Hematology/Oncology Pharmacy Association (HOPA). This publication was also supported by Grant Number UL1TR002489 from the National Center for Advancing Translational Sciences at the National Institutes of Health. Auten reports fees from PTCE and ASHP/ACCP, unrelated to this study. Clark reports consulting fees from Ellion Benson Research, unrelated to this study. The other authors do not have any conflicts of interest to report. This study was presented as a trainee poster on April 5, 2019, at the HOPA Ahead 15th Annual Conference in Fort Worth, TX.

No-Show Rates in Employed Otolaryngology Practice

OBJECTIVE

To report baseline no-show rates in the hospital-employed otolaryngology practice setting and to identify factors that may affect clinic show rates that are targets for potential improvement.

STUDY DESIGN

Retrospective chart review.

METHODS

Electronic medical records from October 2012 through July 2014 of a hospital-employed otolaryngology practice were reviewed. Patients were classified by insurance type: commercial, Medicare, Medicaid, and self-pay. Clinic visits were classified as new patient, follow-up, or postoperative. No-show rates were tabulated for each type of clinic visit and compared. Factors to improve no-show rates are discussed.

RESULTS

There was an overall no-show rate of 8.3% for 5817 scheduled clinic visits. Among visit types, follow-up visits had the highest no-show rates. Among insurance types, Medicaid had the highest no-show rates. New patient Medicaid patients, follow-up Medicaid patients, and follow-up commercial insurance patients had the highest rate of no-shows among visit/insurance type combinations. Persistent reminders are a key factor in improving rate of clinic visit adherence.

CONCLUSION

A previously unreported baseline no-show rate was established for hospital-employed otolaryngology clinics. The utilization of repeated, live-person reminders to mitigate the impact of clinic no-show rates needs to be further investigated.

Discharge against medical advice in culturally and linguistically diverse Australian children

OBJECTIVES

This study quantifies the prevalence and rates of discharge against medical advice (DAMA) in culturally and linguistically diverse (CALD) children and assesses the independent association between CALD status and DAMA accounting for key demographic confounders in a large tertiary Australian hospital network.

METHODS

Prospectively collected data between 2010 and 2018 were extracted from the hospital network electronic medical records system for admitted patients (n=192 037), outpatients (n=268 904) and between 2015 and 2018 for emergency department (ED) patients (n=158 903). CALD status was defined as 'preferred language being not English' and DAMA was measured as 'discharge at own risk' in admissions, 'no show' in outpatients, 'left without being seen' and 'did not wait' in ED. Data were analysed using χ² test, bivariate analysis and multivariate logistic regression.

RESULTS

The prevalence of DAMA was 1.34% in admitted patients, 19.31% in outpatients and 12.64% in ED patients. Rates of DAMA were higher among CALD children compared to non-CALD children (1.75% vs 1.29% in admitted patients, 26.53% vs 17.92% in outpatients and 18.74% vs 11.61% in ED patients). CALD status was independently associated with DAMA in admitted children (OR=1.30, 95% CI 1.15 to 1.44), outpatients (OR=1.55; 95% CI 1.51 to 1.58) and ED patients (OR=1.60; 95% CI 1.53 to 1.66).

CONCLUSION

Being from a CALD background places children at increased risks to DAMA. Implementing appropriate health service responses may ensure equitable access and quality care for children from CALD backgrounds to reduce the rates of DAMA and its associated ramifications.

Wait times, health care touchpoints, and nonattendance in an academic pediatric dermatology clinic

BACKGROUND AND OBJECTIVES

Timely access to pediatric dermatology care remains a challenge. While awaiting appointments, many patients and families utilize so-called health care touchpoints outside of the dermatology clinic such as primary care or emergency department visits to address dermatologic concerns. Long waiting periods also factor into nonattendance rates at pediatric dermatology appointments. This observational retrospective study investigated wait times, relevant health care touchpoints, and factors related to nonattendance at a pediatric dermatology clinic.

METHODS

We reviewed demographic, health care touchpoint, and nonattendance data for patients referred by a primary care affiliate to the Children's Hospital of Philadelphia (CHOP) pediatric dermatology clinic from February 2016 to May 2017. Descriptive statistics were used to identify trends among analyzed variables.

RESULTS

We reviewed 250 patient records. The average number of touchpoints per patient was 0.56, and factors that significantly correlated with increased numbers of touchpoints included younger patient age and longer wait time while payer, primary diagnosis, and time of year were not associated. The nonattendance rate was 26%, and factors significantly associated with increased nonattendance rate included longer wait times and winter and spring appointments.

CONCLUSION

Long wait times impact numbers of touchpoints and appointment attendance rate when referring to pediatric dermatology. A platform such as teledermatology may represent an opportunity to improve access to care by allowing for earlier input from the pediatric dermatologist.

Improving nonattendance rates among pediatric patients with Medicaid or private insurance

BACKGROUND

Access to dermatologists is low among Medicaid-insured patients. Higher clinic nonattendance among Medicaid-insured patients might affect provider decisions to accept these patients.

OBJECTIVE

To determine the effect of different scheduling policies on the attendance among children seen at a pediatric dermatology clinic.

METHODS

In this retrospective review, we compared nonattendance among children for 3 different scheduling policies implemented over 3 consecutive years. The scheduling policies used were a first-available open scheduling policy, a 2-week in advance scheduling policy, and a 4-week in advance scheduling policy. Subset analyses were performed by clinic location and insurance type.

RESULTS

The interval between scheduling and appointment date was directly related to nonattendance rates; rates were higher for Medicaid-insured than privately insured patients. Open scheduling was associated with a 37% nonattendance rate for Medicaid-insured patients and 18% nonattendance rate for privately insured patients. A 4-week in advance scheduling policy significantly decreased the nonattendance rate to 19% among Medicaid-insured and 7% among privately insured patients. A 2-week in advance policy further decreased the nonattendance rate to 11% among Medicaid-insured patients and 4% among privately insured patients.

LIMITATIONS

This is a retrospective study, and same-day cancellations were not tracked.

CONCLUSION

Decreasing the time interval between scheduling and appointment dates can significantly decrease nonattendance. This strategy might help dermatologists incorporate more Medicaid-insured patients into their practices.

Transportation characteristics associated with non-arrivals to paediatric clinic appointments: a retrospective analysis of 51 580 scheduled visits

BACKGROUND

Prior work has not studied the effects of transportation accessibility and patient factors on clinic non-arrival.

OBJECTIVES

Our objectives were: (1) to evaluate transportation characteristics and patient factors associated with clinic non-arrival, (2) to evaluate the comparability of bus and car drive time estimates, and (3) to evaluate the combined effects of transportation accessibility and income on scheduled appointment non-arrival.

METHODS

We queried electronic administrative records at an urban general pediatrics clinic. We compared patient and transportation characteristics between arrivals and non-arrivals for scheduled appointments using multivariable modeling.

RESULTS

There were 15 346 (29.8%) clinic non-arrivals. In separate car and bus multivariable models that controlled for patient and transit characteristics, we identified significant interactions between income and drive time, and clinic non-arrival. Patients in the lowest quartile of income who were also in the longest quartile of travel time by bus had an increased OR of clinic non-arrival compared with patients in the lowest quartile of income and shortest quartile of travel time by bus (1.55; P<0.01). Similarly, patients in the lowest quartile of income who were also in the longest quartile of travel time by car had an increased OR of clinic non-arrival compared with patients in the lowest quartile of income and shortest quartile of travel time by car (1.21, respectively; P<0.01).

CONCLUSIONS

Clinic non-arrival is associated with the interaction of longer travel time and lower income.

Factors associated with patient no-show rates in an academic otolaryngology practice

OBJECTIVES/HYPOTHESIS

Factors affecting access to healthcare is an expanding area of research. This study seeks to identify factors associated with no-show rates in an academic otolaryngology practice to improve clinical efficiency and patient access to care.

STUDY DESIGN

Retrospective review.

METHODS

A retrospective review of scheduled clinical appointments from February 1, 2015 to January 30, 2016 at a single academic otolaryngology department was performed. Statistical analysis was completed to examine the association of no-show rates with the following: otolaryngology subspecialty, clinic location (e.g., main campus vs. satellite), patient demographic factors, attending seniority, temporal factors, insurance types, rurality, and visit type.

RESULTS

There was an overall no-show rate of 20% for 22,759 scheduled clinic visits. Satellite clinics had the highest no-show rates at 25% (P < .001). New patient visits had the highest no-show rate at 24% (P < .001). Among subspecialties, facial plastic surgery had the lowest no-show rate (12.6%), whereas Pediatrics had the highest (23%) (P < .001). No significant association between gender and no-show rates was observed (P = .29), but patients over 60 years old had the lowest no-show rate (12.7%, P < .0001). Patients with Medicaid (28%), Medicare (15.3%), and commercial insurance (12.9%) had significantly different overall no-show rates (P < .0001).

CONCLUSIONS

Increased clinic no-show rates are associated with satellite clinics, new patient visits, younger age, and insurance type. No-show rates varied among subspecialties. Further investigation is warranted to assess barriers to appointment compliance and to develop interventions to improve access to care.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:626-631, 2018.

If You Book It, Will They Come? Attendance at Postdischarge Follow-Up Visits Scheduled by Inpatient Providers

BACKGROUND

Postdischarge follow-up visits (PDFVs) are widely recommended to improve inpatient-outpatient transitions of care.

OBJECTIVE

To measure PDFV attendance rates.

DESIGN

Observational cohort study.

SETTING

Medical units at an academic quaternary-care hospital and its affiliated outpatient clinics.

PATIENTS

Adult patients hospitalized between April 2014 and March 2015 for whom at least 1 PDFV with our health system was scheduled. Exclusion criteria included nonprovider visits, visits cancelled before discharge, nonaccepted health insurance, and visits scheduled for deceased patients.

MEASUREMENTS

The study outcome was the incidence of PDFVs resulting in no-shows or same-day cancellations (NS/SDCs).

RESULTS

Of all hospitalizations, 6136 (52%) with 9258 PDFVs were analyzed. Twenty-five percent of PDFVs were NS/SDCs, 23% were cancelled before the visit, and 52% were attended as scheduled. In multivariable regression models, NS/SDC risk factors included black race (odds ratio [OR] 1.94, 95% confidence interval [CI], 1.63-2.32), longer lengths of stay (hospitalizations ≥15 days: OR 1.51, 95% CI, 1.22- 1.88), and discharge to facility (OR 2.10, 95% CI, 1.70-2.60). Conversely, NS/SDC visits were less likely with advancing age (age ≥65 years: OR 0.39, 95% CI, 0.31-0.49) and driving distance (highest quartile: OR 0.65, 95% CI, 0.52-0.81). Primary care visits had higher NS/SDC rates (OR 2.62, 95% CI, 2.03-3.38) than oncologic visits. The time interval between discharge and PDFV was not associated with NS/SDC rates.

CONCLUSIONS

PDFVs were scheduled for more than half of hospitalizations, but 25% resulted in NS/SDCs. New strategies are needed to improve PDFV attendance.

Patient- and Visit-Level Variables Associated With Late Arrival to Pediatric Clinic Appointments

We conducted a cross-sectional study to evaluate timeliness of patient arrival at a pediatric multispecialty clinic. Bivariate and ordered logistic regression analyses were conducted to determine the odds of late arrival by specified patient- and visit-level characteristics. A total of 64 856 visits were available for analysis, of which 6513 (10.0%) were late arrivals. The odds of late arrival were higher for patients who spoke English (odds ratio [OR] = 1.34, P < .001) compared with those who spoke Spanish, had Medicaid (OR = 1.54, P < .001) or no insurance (OR = 1.49, P < .001) compared with those with insurance other than Medicaid, and were late to their previous visit (OR = 2.46, P < .001). Visit-level variables associated with late arrival included appointment time earlier in the day (i.e. 8-10 am, OR = 2.77, P < .001 compared with 4-6 pm), earlier in the week (i.e. on Mondays, OR = 1.21, P < .001 compared with Wednesdays), and for certain subspecialty clinics ( P < .001). Numerous variables are significantly associated with late arrival for pediatric clinic appointments.

Effect of patient navigator program on no-show rates at an academic referral colposcopy clinic

BACKGROUND

Patient navigators have been used successfully to guide vulnerable patients through barriers to cancer care and reduce disparities in cancer outcomes. This study evaluated the effect of a patient navigator program on no-show rates at a tertiary care referral colposcopy center and explored factors associated with missed appointments.

METHODS

No-show rates prior and subsequent to implementation of the intervention were compared by chi-square test. We compared patient demographic, lifestyle, and diagnostic characteristics between patients who had ever and never missed appointments. We described patient-reported barriers to care.

RESULTS

Of 4,199 women evaluated in our clinic from January 2006 to December 2013, 2,441 (58%) had at least one missed appointment. African American, Hispanic, and publicly insured women tended to miss appointments more frequently than did white and privately insured women (p<0.0001). Patients who missed appointments tended to have more abnormal cytology (p<0.0001), cervical pathology (p=0.007), and vulvar pathology (p=0.001). No-show rates declined from 49.7% to 29.5% after implementation of the patient navigator program (p<0.0001). We found that 45% of patient no-shows were anticipated or a result of patient misunderstanding and could be mediated with targeted education by the patient navigator.

CONCLUSIONS

Patient navigator programs at referral centers reduce no-show rates, thus improving patient follow-up, which may reduce disparities in cervical cancer screening and treatment.