Prevalence and predictors of patient no-shows to outpatient endoscopic procedures scheduled with anesthesia

Provider perceptions of challenges and facilitators to surgical care in unhoused patients: A qualitative analysis

BACKGROUND

Unhoused patients have worse surgical outcomes than the general population. However, the drivers of this inequity have not been studied.

METHODS

We conducted 26 semi-structured interviews of clinicians who care for patients with surgical disease, using a purposive sampling strategy to intentionally recruit participants with significant experience caring for unhoused patients across different roles. We used thematic analysis to analyze the resulting data.

RESULTS

We conducted 26 interviews: 11 with surgeons (42%), 8 with internal medicine physicians (30%), 2 with surgical advanced practice providers (8%), 3 with social workers or case managers (11%), and 2 with registered nurses (8%). One-third of the participants worked in either medical respite or street medicine programs. We identified 5 themes, each of which was most relevant at a distinct point along the spectrum of surgical care: (1) patients and clinicians face multiple challenges meeting preoperative requirements, (2) although surgeons do not make major operative decisions based on housing status, some take it into consideration for minor care decisions, (3) clinicians perceive that unhoused patients have negative postoperative experiences in the hospital, (4) discharge options for unhoused patients are commonly imperfect, which can lead to inadequate postoperative care, (5) challenges with formal communication between surgeons and non-surgeons are amplified when caring for unhoused patients.

CONCLUSION

Clinicians who care for unhoused patients with surgical disease relayed multiple challenges throughout all phases of surgical care and relied on both formal and informal mechanisms to mitigate these challenges. There may be opportunities to intervene and improve access to surgical care for this vulnerable group.

A scoping review of surgical care for people experiencing homelessness: prevalence, access, and disparities

BACKGROUND

Numerous studies have highlighted the inequitable access to medical and psychiatric care that people experiencing homelessness (PEH) face, yet the surgical needs of this population are not well understood. We sought to assess evidence describing surgical care for PEH and to perform a thematic analysis of the results.

METHODS

Ovid MEDLINE, Embase, and Web of Science were searched using the terms "surgery" AND "homelessness." Grey literature was also searched. We used a stepwise scoping review methodology, followed by thematic analysis using an inductive approach.

RESULTS

We included 104 articles in our review. Studies were included from 5 continents; 63% originated in the United States. All surgical specialties were represented with varying surgical conditions and procedures for each. Orthopedic surgery (21%) was the most frequently reported specialty. Themes identified included characteristics of PEH receiving surgical care, homeless-to-housed participants, interaction with the health care system, educational initiatives, barriers and challenges, and interventions and future strategies.

CONCLUSION

We identified significant variation and gaps, representing opportunities for further research and interventions. Further addressing the barriers and challenges that PEH face when accessing surgical care can better address the needs of this population.

Associations between Missed Colonoscopy Appointments and Multiple Prior Adherence Behaviors in an Integrated Healthcare System: An Observational Study

BACKGROUND

Missed colonoscopy appointments delay screening and treatment for gastrointestinal disorders. Prior nonadherence with other care components may be associated with missed colonoscopy appointments.

OBJECTIVE

To assess variability in prior adherence behaviors and their association with missed colonoscopy appointments.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients scheduled for colonoscopy in an integrated healthcare system between January 2016 and December 2018.

MAIN MEASURES

Prior adherence behaviors included: any missed outpatient appointment in the previous year; any missed gastroenterology clinic or colonoscopy appointment in the previous 2 years; and not obtaining a bowel preparation kit pre-colonoscopy. Other sociodemographic, clinical, and system characteristics were included in a multivariable model to identify independent associations between prior adherence behaviors and missed colonoscopy appointments.

KEY RESULTS

The median age of the 57,590 participants was 61 years; 52.8% were female and 73.4% were white. Of 77,684 colonoscopy appointments, 3,237 (4.2%) were missed. Individuals who missed colonoscopy appointments were more likely to have missed a previous primary care appointment (62.5% vs. 38.4%), a prior gastroenterology appointment (18.4% vs. 4.7%) or not to have picked up a bowel preparation kit (42.4% vs. 17.2%), all p < 0.001. Correlations between the three adherence measures were weak (phi < 0.26). The rate of missed colonoscopy appointments increased from 1.8/100 among individuals who were adherent with all three prior care components to 24.6/100 among those who were nonadherent with all three care components. All adherence variables remained independently associated with nonadherence with colonoscopy in a multivariable model that included other covariates; adjusted odds ratios (with 95% confidence intervals) were 1.6 (1.5-1.8) for outpatient appointments, 1.9 (1.7-2.1) for gastroenterology appointments, and 3.1 (2.9-3.4) for adherence with bowel preparation kits, respectively.

CONCLUSIONS

Three prior adherence behaviors were independently associated with missed colonoscopy appointments. Studies to predict adherence should use multiple, complementary measures of prior adherence when available.

Patient Decisions Regarding Rescheduling Colonoscopies Postponed Due to the COVID-19 Pandemic

BACKGROUND

Due to the COVID-19 pandemic, elective colonoscopies were postponed in Ohio from 3/17/2020 to 5/1/2020. When the ban was lifted, canceled patients determined whether to reschedule their colonoscopy in the midst of the ongoing pandemic.

AIMS

We aim to determine whether demographic, colorectal cancer (CRC) risk, and COVID-19 morbidity and mortality risk factors are associated with rescheduling of colonoscopies canceled by the COVID-19 pandemic.

METHODS

A medical record review of 420 participants ages 40-74 at a midwestern academic health system with elective colonoscopies canceled from 3/17/2020 to 5/1/2020 due to the COVID-19 pandemic was performed.

RESULTS

More than half of participants (71.0%) rescheduled their colonoscopy within the next 8 months. Indication for colonoscopy being 'surveillance following adenoma', colonoscopy ordered by primary care provider rather than gastroenterologist, and dyslipidemia were independently associated with rescheduling colonoscopy. Higher body mass index, indication for colonoscopy being simply 'screening for CRC,' and stool testing were associated with not rescheduling. Diagnoses associated with colorectal cancer risk such as adenomas, personal or family history of colorectal cancer, and inflammatory bowel disease were not associated with rescheduling, nor were other comorbidities associated with increased COVID-19 severity. 4.5% (19/420) opted for stool fecal immunochemical test or Cologuard testing.

CONCLUSIONS

Most patients rescheduled their colonoscopy despite the risk of virus exposure, suggesting that concern of missed colorectal cancer diagnosis outweighed coronavirus concerns. Patient trust in referring providers may be important for rescheduling, and colonoscopy indications were independently associated with rescheduling status.

Racial Disparities in Endoscopy Cancellations During the COVID-19 Pandemic

INTRODUCTION

The coronavirus disease 19 (COVID-19) pandemic has disrupted healthcare delivery including elective endoscopy. We aimed to determine the prevalence of endoscopy cancellations in the COVID-19 era and identify patient characteristics associated with cancellation due to the pandemic.

METHODS

Medical charts were reviewed for adults who cancelled an outpatient endoscopic procedure from 5/2020 to 8/2020. The association of patient characteristics with cancellation of endoscopy due to COVID-19 was assessed using logistic regression.

RESULTS

There were 652 endoscopy cancelations with 211 (32%) due to COVID-19, 384 (59%) due to non-COVID reasons, and 57 (9%) undetermined. Among COVID-19 related cancellations, 75 (36%) were COVID-19 testing logistics related, 121 (57%) were COVID-19 fear related, and 15 (7%) were other. On adjusted analysis, the odds of cancellation due to COVID-19 was significantly higher for black patients (OR 2.04, 95% CI 1.07-3.88, p = 0.03), while patients undergoing EGD (OR 0.56, 95% CI 0.31-0.99, p = 0.05) or advanced endoscopy (OR 0.18, 95% CI 0.07-0.49, p = 0.001) had lower odds of cancellation. The odds of cancelling due to COVID-19 testing logistics was significantly higher among black patients (OR 3.12, 95% CI 1.03-9.46, p = 0.05) and patients with Medi-Cal insurance (OR 2.89, 95% CI 1.21-6.89, p = 0.02).

CONCLUSION

Black race is associated with an increased risk of COVID-19 related cancellation. Specifically, black patients and those with Medi-Cal are at increased risk of cancellation related to logistics of obtaining pre-endoscopy COVID-19 testing. Racial and socioeconomic disparities in access to endoscopy may be further amplified by the COVID-19 pandemic and warrant further study.

New understanding of gut microbiota and colorectal anastomosis leak: A collaborative review of the current concepts

Anastomotic leak (AL) is a life-threatening postoperative complication following colorectal surgery, which has not decreased over time. Until now, no specific risk factors or surgical technique could be targeted to improve anastomotic healing. In the past decade, gut microbiota dysbiosis has been recognized to contribute to AL, but the exact effects are still vague. In this context, interpretation of the mechanisms underlying how the gut microbiota contributes to AL is significant for improving patients' outcomes. This review concentrates on novel findings to explain how the gut microbiota of patients with AL are altered, how the AL-specific pathogen colonizes and is enriched on the anastomosis site, and how these pathogens conduct their tissue breakdown effects. We build up a framework between the gut microbiota and AL on three levels. Firstly, factors that shape the gut microbiota profiles in patients who developed AL after colorectal surgery include preoperative intervention and surgical factors. Secondly, AL-specific pathogenic or collagenase bacteria adhere to the intestinal mucosa and defend against host clearance, including the interaction between bacterial adhesion and host extracellular matrix (ECM), the biofilm formation, and the weakened host commercial bacterial resistance. Thirdly, we interpret the potential mechanisms of pathogen-induced poor anastomotic healing.

Temporal trends and disparities in gastroenterology care use before, during, and after COVID-19 lockdown

Socioeconomic disparities adversely affected healthcare use during COVID-19 lockdown. However, trends in these disparities post lockdown are unknown. Therefore, our aim was to study temporal trends and factors associated with gastroenterology healthcare access and disparities during and after COVID-19 lockdown. This cohort study consisted of patients receiving outpatient care in the Cleveland Clinic gastroenterology department between March 2020 and June 2020 and corresponding time periods in 2019 and 2021. Patient demographics and socioeconomic factors were extracted and analyzed. There were 47,031 patients (mean age 56.3±17.6 years, 61.9% female and 76.4% white) included. Patients ≥65 years sought healthcare less frequently during and after the lockdown (40.1% vs 34.8% vs 35.2% in 2019, 2020, and 2021 respectively). Missed visits (4.2% vs 10% vs 10.4%), tobacco (11.4% vs 15.9% vs 16.1%), alcohol (38.6% vs 45.5% vs 50.9%), and illicit drug use (3.5% vs 5.8% vs 10.7%) have steadily increased during and after the lockdown compared with prepandemic levels. Factors associated with reduced telehealth use were black race (OR 0.89, 95% CI 0.81 to 0.99), Hispanic race (OR 0.63, 95% CI 0.51 to 0.77)), Medicaid/other public insurance (OR 0.87, 95% CI 0.79 to 0.95)), unemployed status (OR 0.85, 95% CI 0.79 to 0.92)), and non-English/Spanish speakers (OR 0.66, 95% CI 0.46 to 0.94)). In conclusion, socioeconomic and ethnic disparities persist in healthcare use even a year after the onset of the COVID-19 pandemic. There is an alarming increase in missed visits and substance abuse. Therefore, efforts should be targeted on improving healthcare access for these aforementioned vulnerable groups.

Surgical Care of Patients Experiencing Homelessness: A Scoping Review Using a Phases of Care Conceptual Framework

Homelessness is a growing concern across the world, particularly as individuals experiencing homelessness age and face an increasing burden of chronic health conditions. Although substantial research has focused on the medical and psychiatric care of patients experiencing homelessness, literature about the surgical care of these patients is sparse. Our objective was to review the literature to identify areas of concern unique to patients experiencing homelessness with surgical disease. A scoping review was conducted using a comprehensive database for studies from 1990 to September 1, 2020. Studies that included patients who were unhoused and discussed surgical care were included. The inclusion criteria were designed to identify evidence that directly affected surgical care, systems management, and policy making. Findings were organized within a Phases of Surgical Care framework: preoperative care, intraoperative care, postoperative care, and global use. Our search strategy yielded 553 unique studies, of which 23 met inclusion criteria. Most studies were performed at public and/or safety-net hospitals or via administrative datasets, and surgical specialties that were represented included orthopedic, cardiac, plastic surgery trauma, and vascular surgery. Using the Surgical Phases of Care framework, we identified studies that described the impact of housing status in pre- and postoperative phases as well as global use. There was limited identification of barriers to surgical and anesthetic best practices in the intraoperative phase. More than half of studies (52.2%) lacked a clear definition of homelessness. Thus, there is a marked gap in the surgical literature regarding the impact of housing status on optimal surgical care, with the largest area for improvement in the intraoperative phase of surgical and anesthetic decision making. Consistent use of clear definitions of homelessness is lacking. To promote improved care, a standardized approach to recording housing status is needed, and studies must explore vulnerabilities in surgical care unique to this population.

Factors associated with non-attendance at appointments in the gastroenterology endoscopy unit: a retrospective cohort study

Background and Aims

Gastrointestinal (GI) endoscopy is a limited health resource because of a scarcity of qualified personnel and limited availability of equipment. Non-adherence to endoscopy appointments therefore wastes healthcare resources and may compromise the early detection and treatment of GI diseases. We aimed to identify factors affecting non-attendance at scheduled appointments for GI endoscopy and thus improve GI healthcare outcomes.

Methods

This was a single-center retrospective cohort study performed at a tertiary hospital gastroenterology endoscopy unit, 12 months before and 12 months after the start of the COVID-19 pandemic. We used multiple logistic regression analysis to identify variables associated with non-attendance at scheduled appointments.

Results

Overall, 5,938 appointments were analyzed, and the non-attendance rate was 18.3% (1,088). The non-attendance rate fell significantly during the pandemic (22.6% vs. 11.6%, p < 0.001). Multivariable regression analysis identified the absence of deep sedation (OR: 3.253, 95% CI [2.386-4.435]; p < 0.001), a referral from a physician other than a gastroenterologist (OR: 1.891, 95% CI [1.630-2.193]; p < 0.001), a longer lead time (OR: 1.006, 95% CI [1.004-1.008]; p < 0.001), and female gender (OR: 1.187, 95% CI [1.033-1.363]; p = 0.015) as associated with appointment non-attendance.

Conclusions

Female patients, those undergoing endoscopic procedures without deep sedation, those referred by physicians other than gastroenterologists, and with longer lead time were less likely to adhere to appointments. Precautions should be directed at patients with one or more of these risk factors, and for those scheduled for screening procedures during the COVID-19 pandemic.

Reinforced education by short message service improves the quality of bowel preparation for colonoscopy

PURPOSE

This study aimed to evaluate the effect of reinforced education (RE) by short message service (SMS) on the bowel preparation quality of patients undergoing colonoscopy.

METHODS

Randomized controlled trials (RCTs), conducted on the effect of RE by SMS on bowel preparation for colonoscopy from inception to November 1, 2021, were queried from databases, including PubMed, Web of Science, the Cochrane Library, and EMBASE. After extracting the data, meta-analysis was conducted using Review Manager Software version 5.3.

RESULTS

A total of seven RCTs with 5889 patients were subjected to meta-analysis. The rate of adequate bowel preparation in the SMS group (81.7%) was significantly higher than that in the control group (75.7%) (RR: 1.10, 95% CI: 1.03-1.17, p < 0.01). Four studies suggested that RE by SMS significantly reduced the non-attendance rate of patients for scheduled colonoscopy (RR: 0.74, 95% CI: 0.56-0.99, p < 0.05).

CONCLUSION

RE by SMS for patients undergoing colonoscopy can significantly improve the quality of bowel preparation and decrease the non-attendance rate of patients for scheduled colonoscopy.

Discharging select patients without an escort after ambulatory anesthesia: identifying return to baseline function

PURPOSE OF REVIEW

The current standard of care requires ambulatory surgical patients to have an escort for discharge. Recent studies have started to challenge this dogma. Modern ultrashort acting anesthetics have minimal psychomotor effects after a couple of hours. Driving simulator performance and psychomotor testing return to baseline as soon as 1 h following propofol sedation.

RECENT FINDINGS

Two recent reports of actual experience with thousands of patients found no increase in complications in patients who were discharged without escort or drove themselves from a sedation center. These studies suggest discharge without escort may be safe in select patients but a method to identify appropriate patients remains undefined.

SUMMARY

A reliable test to document return of function might allow safe discharge without an escort. Currently, there is intense interest in developing reliable, inexpensive, easy to administer psychomotor function testing to improve workplace safety and legally define the effects of drugs on driving impairment. Future studies may be able to adapt this technology and develop a validated test for residual anesthetic impairment.

Short Message Service reminders reduce outpatient colonoscopy nonattendance rate: A randomized controlled study

BACKGROUND AND AIM

Nonattendance of outpatient colonoscopy leads to inefficient use of health-care resources. We aimed to study the effectiveness of using Short Message Service (SMS) reminder prior in patients scheduled for outpatient colonoscopy on their nonattendance rate.

METHODS

Patients who scheduled for an outpatient colonoscopy and had access of SMS were recruited from three clinics in Hong Kong. Patients were randomized to SMS group and standard care (SC) group. All patients were given a written appointment slip on the booking date. In addition, patients in the SMS group received an SMS reminder 7-10 days before their colonoscopy appointment. Patients' demographics, attendance, colonoscopy completion, and bowel preparation quality were recorded. Logistic regression was performed to identify predictors of nonattendance.

RESULTS

From November 2013 to October 2019, a total of 2225 eligible patients were recruited. A total of 1079 patients were allocated to the SMS group and 1146 to the SC group. The nonattendance rate of patients in the SMS group was significantly lower than that in the SC group (8.9% vs 11.9%, P = 0.022). There were no significant differences in their baseline characteristics and colonoscopy completion rate and bowel preparation quality. A trend towards a higher rate of adequate bowel preparation was observed in the SMS group when compared with the SC group (69.9% vs 65.8%, P = 0.053). Independent predictors for nonattendance included younger age, underprivilege, and existing diabetes.

CONCLUSIONS

An SMS reminder for outpatient colonoscopy is effective in reducing the nonattendance rate and may potentially improve the bowel preparation quality.

Racial differences in no-show rates for screening mammography

BACKGROUND

Differences in utilization of screening mammography partly explain the increased breast cancer mortality observed in African American (AA) women compared with non-Hispanic White women. However, the contribution of noncompliance from women who do not come for their scheduled screening mammography appointment (ie, no-shows) is unknown. The purpose of this study was to investigate racial differences in no-show rates for screening mammography.

METHODS

Women scheduled for routine screening mammograms between January 2018 and March 2018 were identified from the Joanne Knight Breast Health Center at Siteman Cancer Center in St. Louis, Missouri. Using a case-control design, this study retrospectively identified patients who no-showed for their mammograms (cases) and randomly sampled an equal number of patients who completed their mammograms (controls). These participants were compared by race. The main outcome measure was whether AA race was associated with no-shows for screening mammography.

RESULTS

During the study period, 5060 women were scheduled for screening mammography, and 316 (6.2%) did not keep their appointment (ie, they no-showed). Women who no-showed were more likely to be AA than women who kept their appointment (odds ratio, 2.64; 95% confidence interval, 1.90-3.67). Even after adjustments for marital status, insurance type, and place of residence, AA race was still significantly associated with no-shows for screening mammography.

CONCLUSIONS

This study identified a no-show rate of 6.2% for screening mammography at the authors' institution. Women who no-showed were more likely to be AA than women who completed their mammogram even after adjustments for multiple factors. These data can be leveraged for future studies aimed at improving mammography attendance rates among AA women.

Effect of Text Messaging on Bowel Preparation and Appointment Attendance for Outpatient Colonoscopy: A Randomized Clinical Trial

IMPORTANCE

Outpatient colonoscopy is important for colorectal cancer screening. However, nonadherence and poor bowel preparation are common.

OBJECTIVE

To determine if an automated text messaging intervention with a focus on informational and reminder functions could improve attendance rates and bowel preparation quality for outpatient colonoscopy.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted in an endoscopy center at an urban academic medical center. Adult patients scheduled for outpatient colonoscopy between January and September 2019 were enrolled by telephone call (early phase) or by automated text message (late phase). Data were analyzed from October 2019 to January 2020.

INTERVENTIONS

After enrollment, patients were randomized in a 1:1 ratio to usual care (ie, written instructions and nurse telephone call) or to the intervention (ie, usual care plus an automated series of 9 educational or reminder text messages in the week prior to scheduled colonoscopy).

MAIN OUTCOMES AND MEASURES

The primary outcome was appointment attendance rate with good or excellent bowel preparation. Secondary outcomes included appointment attendance rate, bowel preparation quality (poor or inadequate, fair or adequate, and good or excellent), and cancellation lead time (in days).

RESULTS

Among 753 patients included and randomized in the trial (median [interquartile range] age, 56 [49-64] years; 364 [48.3%] men; 429 [57.2%] Black), 367 patients were randomized to the intervention group and 386 patients were randomized to the control group. There was no significant difference in the primary outcome between groups (patients attending appointments with good or excellent bowel preparation: intervention, 195 patients [53.1%]; control, 210 patients [54.4%]; P = .73), including when stratified by early or late phase enrollment groups. Similarly, there were no significant differences in secondary outcomes.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found no significant difference in appointment attendance or bowel preparation quality with an automated text messaging intervention compared with the usual care control. Future work could optimize the content and delivery of text message interventions or identify patient subgroups that may benefit from this approach.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03710213.

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.

Evaluation of an educational telephone intervention strategy to improve non-screening colonoscopy attendance: A randomized controlled trial

BACKGROUND

Colonoscopy attendance is a key quality parameter in colorectal cancer population screening programmes. Within these programmes, educative interventions with bidirectional contact carried out by trained personnel have been proved to be an important tool for colonoscopy attendance improvement, and because of its huge clinical and economic impact, they have been widely implemented. However, outside of this population programmes, educative measures to improve colonoscopy attendance have been poorly studied and no navigation interventions are usually performed.

AIM

To investigate the clinical and economic impacts of an educational telephone intervention on colonoscopy attendance outside colorectal cancer screening programmes.

METHODS

This randomized controlled trial included consecutive patients referred to colonoscopy from primary care centres from November 2017 to May 2018. The intervention group (IG) received a telephone intervention, while the control group (CG) did not. Patients assigned to the IG received an educational telephone call 7 d before the colonoscopy appointment. The intervention was carried out by two nurses with deep endoscopic knowledge who were previously trained for a telephone educational intervention for colonoscopy. The impact on patient compliance with preparedness protocols related to bowel cleansing, anti-thrombotic management, and sedation scheduling was also evaluated. A second call was conducted to assess patient satisfaction. Intention-to-treat (ITT) and per-protocol (PP) analyses were performed.

RESULTS

A total of 738 and 746 patients were finally included in the IG and CG respectively. Six hundred thirteen (83%) patients were contacted in the IG. The non-attendance rate was lower in the IG, both in the ITT analysis (IG 8.4% vs CG 14.3%, P < 0.001) and in the PP analysis (4.4% vs 14.3%, P < 0.001). In a multivariable analysis, belonging to the control group increased the risk of non-attendance in both, the ITT analysis (OR 1.81, 95%CI: 1.27 to 2.58, P = 0.001) and the PP analysis (OR 3.56, 95%CI: 2.25 to 5.64, P < 0.001). There was also a significant difference in compliance with preparedness protocols [bowel cleansing: IG 61.7% vs CG 52.6% (P = 0.001), antithrombotic management: IG 92.5% vs CG 62.8% (P = 0.001), and sedation scheduling: IG 78.8% vs CG 0% (P ≤ 0.001)]. We observed a net benefit of €55600/year after the intervention. The information given before the procedure was rated as excellent by 26% (CG) and 51% (IG) of patients, P ≤ 0.001.

CONCLUSION

Educational telephone nurse intervention improves attendance, protocol compliance and patient satisfaction in the non-screening colonoscopy setting and has a large economic impact, which supports its imple-mentation and maintenance over time.

Stop Blaming the Weatherman! A Retrospective Study of Endoscopy Show Rates at a Midwest Urban Safety-Net Hospital

BACKGROUND

Weather patterns are well-known to affect human health and behavior and are often arbitrarily blamed for high no-show rates (NSRs). The NSR for outpatient gastrointestinal procedures ranges from 4% to 41% depending on the population and procedure performed. Identifying potential causes will allow for the optimization of endoscopy resource utilization.

AIM

The aim of this study was to evaluate the effects of a day of the year and weather conditions have on NSRs for outpatient endoscopic procedures at a safety-net hospital in Cleveland, Ohio, United States.

METHODS

A 12-month, retrospective cohort study of the NSR for outpatient endoscopic procedures was performed using local weather data from January 1, 2017 to December 31, 2017. Data was assessed by analysis of variance/t test, and the χ test was used to analyze weather impact on NSR.

RESULTS

A total of 7935 patients had an average overall NSR of 11.8%. Average NSR for esophagogastroduodenoscopies (EGDs) were 9.9%, colonoscopies 12.3%, and advanced endoscopy procedures 11.1%. The NSR was highest in April (15.3%, P=0.01) and lowest in September (9.0%, P=0.04). There is a greater likelihood of procedural no-show for colonoscopies compared with EGDs when mean temperatures were at or below freezing (P=0.02) and with snowfall (P=0.03). NSR were also high for EGDs on federal holidays (25%, P=0.03) and colonoscopies on days following federal holidays (25.3%, P<0.01). Day of the week, wind speed, presence of precipitation, wind chill, the temperature change from the prior day, and temperature (high, low, and mean) had no significant impact on NSR.

CONCLUSIONS

Our study demonstrates that scheduling adjustments on federal holidays, days when temperatures are below freezing, and snowfall may improve department resource utilization. These data, along with other variables that affect NSR for endoscopic procedures, should be taken into consideration when attempting to optimize scheduling and available resources in a safety-net hospital.

Patient Engagement with Interactive Text Message System Improves Successful Colonoscopy Rates in an Outpatient Endoscopy Center

INTRODUCTION

Text message-based interventions reduce colonoscopy no-show rates and improve bowel preparation scores. In this non-randomized study, we assessed whether an interactive text messaging system could improve colonoscopy outcomes.

METHODS

Colonoscopy pre-procedural instructions were programmed into a dedicated software platform created for this study. In the intervention arm, text messages were sent to veterans during a 4-week study period. Validated pre-procedural satisfaction questionnaires were completed by patients during standard protocol and intervention periods. Demographics and colonoscopy outcomes data were compared between the standard protocol and intervention arms, including procedure completion rate on scheduled date, Boston bowel preparation score (BPPS), adenoma detection rate, and satisfaction.

RESULTS

Of 241 patients, 128 were in the standard protocol arm and 113 in the intervention arm. Higher proportions of patients receiving text messages underwent colonoscopy on their scheduled date (69.9%) compared to the ones in the standard protocol (50.8%, p = 0.015). Patients with ≥3 interactions with the system had 80.6% likelihood of completing colonoscopy on the scheduled date compared to 56.9% with <3 interactions and 50.8% with standard protocol (p < 0.001). Frequency of interaction with the system was similar between older (>65 years) and younger patients (p = 1.0). Among older patients, colonoscopy was completed successfully in 84.2% when alert-based human interactions occurred compared to 65.6% in those without and 47.9% with standard protocol (p = 0.018). More than 90% indicated they would recommend the system to patients undergoing future colonoscopy.

CONCLUSION

An interactive text messaging system improves successful colonoscopy rates in a VA setting, with greatest impact in older patients.

Placard in Hand: A Simple, Inexpensive Intervention to Improve On-Treatment Visit Compliance in a Safety Net Radiation Oncology Patient Population

PURPOSE

On-treatment visits (OTVs) for patients undergoing radiotherapy (RT) should occur every five fractions. Compliance with OTVs was identified as a potential issue in a safety-net patient population. This study determined if brightly colored placards given to patients improved OTV compliance.

MATERIALS AND METHODS

A retrospective analysis of all patients with lung cancer receiving RT from October 1, 2015 to September 30, 2017 evaluated OTV compliance before (No Placard) and after (Placard) the placard was introduced in the clinic. Analysis of variance, χ² tests, and Fisher's exact tests were performed to assess differences in continuous and categorical patient and treatment variables, respectively.

RESULTS

The No Placard group included 48 patients who were scheduled for 151 OTVs. The Placard group included 50 patients who were scheduled for 187 OTVs. The percentage of missed OTVs in the No Placard group was 9.3% (14/151), versus 2.1% (4/187) in the Placard group (P = .004). Patients in the No Placard group were more likely to speak English (97.9% v 86.0%; P = .060), were less likely to have stage I-III disease (75% v 88%; P = .097), and received lower mean RT doses (48.2 Gy v 55.6 Gy; P = .007). On multivariate analysis adjusting for language, stage, and RT dose, the adjusted mean rate of missed OTVs in the No Placard group was 7.1%, versus 1.4% in the Placard group (P = .019).

CONCLUSION

A significant increase in compliance of OTVs was observed with the introduction of brightly colored placards. This represents a simple, inexpensive method to improve OTV compliance in a safety-net setting and may be applicable to other patient populations.

A Digital Preprocedure Instruction Program for Outpatient Colonoscopy

Introduction: Many patients struggle with colonoscopy preparation, which is complex and can be an uncomfortable as well as a time-consuming process. The confusion and anxiety from the preprocedure process may lead patients to delay their colonoscopy or skip it altogether. Digital health technology that focuses on patient engagement can play an important role in promoting colorectal cancer screening. Methods: A digital preprocedure instruction program was implemented for outpatient colonoscopy by sending critical reminders and instructions to patients through a series of short message service messages and/or emails. Eligible patients included English speakers on GoLYTELY^®/NuLYTELY^® or MiraLAX^® preparation regimens with a valid cellphone or email address in the electronic health record. We examined the impact of digital instructions on bowel preparation quality, no-show and same-day cancellations over a 3-month period between an intervention group of 756 patients and a control group of 2,103 patients. Patients who enrolled in the digital instructions also received a patient satisfaction survey. Results: Our controlled study demonstrated the effectiveness of digital instructions to reduce no-show and same-day cancellation rates for outpatient colonoscopy from 10.40% to 6.08% (p < 0.001). Bowel preparation quality was not significantly different between the two groups (p = 0.23). However, 90% of patients who enrolled in the program rated their satisfaction with the digital reminders very highly. Discussion: A digital preprocedure instruction program can have a positive impact on operational efficiency, quality of care, and patient satisfaction. This study shows how digital health tools can effectively engage patients scheduled for a colonoscopy, increase appointment adherence, and, therefore, lead to better cancer screening.

Rate and predictors for non-attendance of patients undergoing hospital outpatient treatment for chronic diseases: a register-based cohort study

Background

Failure to keep medical appointments results in inefficiencies and, potentially, in poor outcomes for patients. The aim of this study is to describe non-attendance rate and to investigate predictors of non-attendance among patients receiving hospital outpatient treatment for chronic diseases.

Methods

We conducted a historic, register-based cohort study using data from a regional hospital and included patients aged 18 years or over who were registered in ongoing outpatient treatment courses for seven selected chronic diseases on July 1, 2013. A total of 5895 patients were included and information about their appointments was extracted from the period between July 1, 2013 and June 30, 2015. The outcome measure was occurrence of non-attendance. The associations between non-attendance and covariates (age, gender, marital status, education level, occupational status, specific chronic disease and number of outpatient treatment courses) were investigated using multivariate logistic regression models, including mixed effect.

Results

During the two-year period, 35% of all patients (2057 of 5895 patients) had one or more occurrences of non-attendance and 5% of all appointments (4393 of 82,989 appointments) resulted in non-attendance. Significant predictors for non-attendance were younger age (OR 4.17 for 18 ≤ 29 years as opposed to 80+ years), male gender (OR 1.35), unmarried status (OR 1.39), low educational level (OR 1.18) and receipt of long-term welfare payments (OR 1.48). Neither specific diseases nor number of treatment courses were associated with a higher non-attendance rate.

Conclusions

Patients undergoing hospital outpatient treatments for chronic diseases had a non-attendance rate of 5%. We found several predictors for non-attendance but undergoing treatment for several chronic diseases simultaneously was not a predictor. To reduce non-attendance, initiatives could target the groups at risk.

Trial registration

This study was approved by the Danish Data Protection Agency (Project ID 18/35695).

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4208-9) contains supplementary material, which is available to authorized users.

Homelessness at discharge and its impact on psychiatric readmission and physician follow-up: a population-based cohort study

AIMS

A significant proportion of adults who are admitted to psychiatric hospitals are homeless, yet little is known about their outcomes after a psychiatric hospitalisation discharge. The aim of this study was to assess the impact of being homeless at the time of psychiatric hospitalisation discharge on psychiatric hospital readmission, mental health-related emergency department (ED) visits and physician-based outpatient care.

METHODS

This was a population-based cohort study using health administrative databases. All patients discharged from a psychiatric hospitalisation in Ontario, Canada, between 1 April 2011 and 31 March 2014 (N = 91 028) were included and categorised as homeless or non-homeless at the time of discharge. Psychiatric hospitalisation readmission rates, mental health-related ED visits and physician-based outpatient care were measured within 30 days following hospital discharge.

RESULTS

There were 2052 (2.3%) adults identified as homeless at discharge. Homeless individuals at discharge were significantly more likely to have a readmission within 30 days following discharge (17.1 v. 9.8%; aHR = 1.43 (95% CI 1.26-1.63)) and to have an ED visit (27.2 v. 11.6%; aHR = 1.87 (95% CI 1.68-2.0)). Homeless individuals were also over 50% less likely to have a psychiatrist visit (aHR = 0.46 (95% CI 0.40-0.53)).

CONCLUSION

Homeless adults are at higher risk of readmission and ED visits following discharge. They are also much less likely to receive post-discharge physician care. Efforts to improve access to services for this vulnerable population are required to reduce acute care service use and improve care continuity.

Predictors of No-show Rate in the GI Endoscopy Suite at a Safety Net Academic Medical Center

BACKGROUND/OBJECTIVES

Noncompliance with physician and procedure appointments is associated with poor disease control and worse disease outcomes. This also impacts the quality of care, decreases efficiency, and affects revenue. Studies have shown that no-show rates are higher in clinics caring for underserved populations and may contribute to poorer health outcomes in this group.

METHODS

We performed a 17-month retrospective observational cohort study of patients scheduled for outpatient procedures in the Gastroenterology endoscopy suite at the University of Florida Health, Jacksonville. Multivariate logistic regression analysis was performed to evaluate associations between attendance and predictors of no-show.

RESULTS

In total, 6157 patients were scheduled to undergo different GI procedures during the study period. A total of 4388 (71%) patients completed their procedure, whereas 2349 (29%) failed to attend their appointment and were considered "no-show". There was a significant relationship between the visit attendance and race, insurance, gender, and marital status. Males had a higher no-show rate compared with females (30% vs. 28%; P<0.05). African Americans had the highest no-show rate (32%; P<0.05) amongst different races. Patients scheduled for surveillance colonoscopy (ie, history of polyps, IBD, Colon cancer) were more likely to show (78%) than those obtaining initial colorectal cancer screening (74%) or other indications (71%) (P<0.05).In the logistic regression model, patients with commercial insurance are more likely to show for their appointments than those with noncommercial insurance (eg, Medicare, Medicaid, City contract etc) [odds ratio (OR), 2.6; 95% confidence interval (CI), 2.2-3.0]. The odds of showing up are 1.7 times higher for married men compared with single men (OR, 1.7; 95% CI, 1.3-2.0). Similarly, married females are more likely to show up for appointment than single females (OR, 1.1; 95% CI, 0.9-1.3). We did not find significant association between the type of GI procedure (eg, colonoscopy vs. esophagogastroduodenoscopy vs. advanced endoscopic procedures) (P>0.05).

CONCLUSIONS

Predictors of no-shows for endoscopic gastrointestinal procedures included unpartnered or single patients, African American race and noncommercial insurance providers. Patients scheduled for surveillance colonoscopy had better adherence than initial screening. Further studies are required to better characterize these factors and improve adherence to the outpatient appointments based on the identified predictors.

Living libraries: Nurse integration in interprofessional homeless health care team

Background

Despite an increase in national health care service utilization, entry into the health care system remains inequitable. This disparity in health care access disproportionately affects those experiencing homelessness. Because the homeless population faces significant financial and nonfinancial barriers, health care system engagement with these individuals must be reconsidered.

Objective

This article will describe the piloting of an interprofessional model within an urban library to address barriers to health care access that homeless individuals face.

Design

The library's unique status as a community hub presents an opportunity for partnership in addressing this population's health care access issues. This community‐based model is the first recorded to utilize three distinct professions—nursing, social work, and library science—in a public library.

Results and Conclusions

The implementation of this pilot project resulted in a high retention rate of referrals to community health services for those unstably housed and facilitated a system of warm transfers. Although opportunities to improve generalizability exist, this initiative sets the stage for discussion around co‐location of health and social services in a nontraditional community‐based setting to achieve equitable access to health care.

Impact of Delayed Time to Advanced Imaging on Missed Appointments Across Different Demographic and Socioeconomic Factors

PURPOSE

The aim of this study was to investigate the impact of wait days (WDs) on missed outpatient MRI appointments across different demographic and socioeconomic factors.

METHODS

An institutional review board-approved retrospective study was conducted among adult patients scheduled for outpatient MRI during a 12-month period. Scheduling data and demographic information were obtained. Imaging missed appointments were defined as missed scheduled imaging encounters. WDs were defined as the number of days from study order to appointment. Multivariate logistic regression was applied to assess the contribution of race and socioeconomic factors to missed appointments. Linear regression was performed to assess the relationship between missed appointment rates and WDs stratified by race, income, and patient insurance groups with analysis of covariance statistics.

RESULTS

A total of 42,727 patients met the inclusion criteria. Mean WDs were 7.95 days. Multivariate regression showed increased odds ratio for missed appointments for patients with increased WDs (7-21 days: odds ratio [OR], 1.39; >21 days: OR, 1.77), African American patients (OR, 1.71), Hispanic patients (OR, 1.30), patients with noncommercial insurance (OR, 2.00-2.55), and those with imaging performed at the main hospital campus (OR, 1.51). Missed appointment rate linearly increased with WDs, with analysis of covariance revealing underrepresented minorities and Medicaid insurance as significant effect modifiers.

CONCLUSIONS

Increased WDs for advanced imaging significantly increases the likelihood of missed appointments. This effect is most pronounced among underrepresented minorities and patients with lower socioeconomic status. Efforts to reduce WDs may improve equity in access to and utilization of advanced diagnostic imaging for all patients.

Predicting No-Shows in Radiology Using Regression Modeling of Data Available in the Electronic Medical Record

PURPOSE

To test whether data elements available in the electronic medical record (EMR) can be effectively leveraged to predict failure to attend a scheduled radiology examination.

MATERIALS AND METHODS

Using data from a large academic medical center, we identified all patients with a diagnostic imaging examination scheduled from January 1, 2016, to April 1, 2016, and determined whether the patient successfully attended the examination. Demographic, clinical, and health services utilization variables available in the EMR potentially relevant to examination attendance were recorded for each patient. We used descriptive statistics and logistic regression models to test whether these data elements could predict failure to attend a scheduled radiology examination. The predictive accuracy of the regression models were determined by calculating the area under the receiver operator curve.

RESULTS

Among the 54,652 patient appointments with radiology examinations scheduled during the study period, 6.5% were no-shows. No-show rates were highest for the modalities of mammography and CT and lowest for PET and MRI. Logistic regression indicated that 16 of the 27 demographic, clinical, and health services utilization factors were significantly associated with failure to attend a scheduled radiology examination (P ≤ .05). Stepwise logistic regression analysis demonstrated that previous no-shows, days between scheduling and appointments, modality type, and insurance type were most strongly predictive of no-show. A model considering all 16 data elements had good ability to predict radiology no-shows (area under the receiver operator curve = 0.753). The predictive ability was similar or improved when these models were analyzed by modality.

CONCLUSION

Patient and examination information readily available in the EMR can be successfully used to predict radiology no-shows. Moving forward, this information can be proactively leveraged to identify patients who might benefit from additional patient engagement through appointment reminders or other targeted interventions to avoid no-shows.

The Effects of Negative Reinforcement on Increasing Patient Adherence to Appointments at King Abdullah University Hospital in Jordan

Appointment nonadherence is a health behavior that represents a burden to health care systems. On March 1, 2015, a new negative reinforcement intervention involving "service fees" for a visit without appointment was implemented at King Abdullah University Hospital in Jordan. To evaluate the effect of this intervention in improving patient adherence to medical appointment, a retrospective preintervention and postintervention analysis was used, including all patients (n = 65 535) who had scheduled appointments at 39 outpatient clinics. A repeated-measures analysis of variance was first performed. Then, a multivariate linear regression model was used to identify factors that might predict individuals who are likely to attend or miss their appointments and those who have a greater tendency to visit the hospital with or without appointments. Although the average percentage of appointments attended was more than missed preintervention and postintervention, the decrease in percentage of missed appointments was more pronounced postintervention. Also, the average percentage of visits without appointments was less than visits with appointments in both times, but the decrease in the percentage of visits without appointments was more prominent after. The regression analysis revealed that younger, married and male patients were more likely to miss their appointment before and after the intervention. Also, younger patients had a tendency to attend without appointments. Conversely, patients with the lower copayment rate had a tendency to adhere to appointment times. In conclusion, negative reinforcement interventions could improve patient appointment adherence rates. Accordingly, interventions designed that consider evidence and are theory-based are needed to change patient behavior.