Post-hospitalization followup appointment-keeping among the medically indigent

Self-Identified Social Determinants of Health during Transitions of Care in the Medically Underserved: a Narrative Review

BACKGROUND

Medically underserved or low socioeconomic status (SES) patients face significant vulnerability and a high risk of adverse events following hospital discharge. The environmental, social, and economic factors, otherwise known as social determinants, that compound this risk have been ineffectually described in this population. As the underserved comprise 30% of patients discharged from the hospital, improving transitional care and preventing readmission in this group has profound quality of care and financial implications.

METHOD

EMBASE and MEDLINE searches were conducted to examine specific barriers to care transitions in underserved patients following an episode of acute care. Articles were reviewed for barriers and categorized within the context of five general themes.

RESULTS

This review yielded 17 peer-reviewed articles. Common factors affecting care transitions were cost of medications, access to care, housing instability, and transportation. When categorized within themes, social fragility and access failures, as well as therapeutic misalignment, disease behavior, and issues with accountability were noted.

DISCUSSION

Providers and health systems caring for medically underserved patients may benefit through dedicating increased resources and broadening collaboration with community partners in order to expand health care access and enhance coordination of social services within this population. Future studies are needed to identify potential interventions targeting underserved patients to improve their post-hospital care.

Factors associated with failure to follow-up at a medical clinic after an ED visit

BACKGROUND

Although emergency department (ED) discharge is often based on the presumption of continued care, the reported compliance rate with follow-up appointments is low.

STUDY OBJECTIVES

The objectives of this study are to identify factors associated with missed follow-up appointments from the ED and to assess the ability of clinicians to predict which patients will follow-up.

METHODS

Patients without insurance or an outpatient primary care provider (PCP) were given a follow-up clinic appointment before discharge. Information identifying potential follow-up barriers was collected, and the physician's perception of the likelihood of follow-up was recorded. Patients who missed their appointment were contacted via telephone and were offered a questionnaire and a rescheduled clinic appointment.

RESULTS

A total of 125 patients with no PCP were enrolled. Sixty (48%; 95% confidence interval, 39-57) kept their scheduled appointment. Sex, distance from clinic, availability of transportation, or time since last nonemergent physician visit was associated with attendance to the follow-up visit. Clinicians were unable to predict which patients would follow-up. Contact by telephone was made in 48 (74%) of patients who failed to follow-up. Of the 14 patients willing to reschedule, none returned for follow-up.

CONCLUSION

Among ED patients who lack a PCP and are given a clinic appointment from the ED, less than half keep the appointment. Moreover, clinicians are unable to predict which patients will follow up. This study highlights the difficulty in maintaining continuity of care in populations who are self-pay or have Medicaid and lack regular providers. This may have implications on discharge planning from the ED.

Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up

BACKGROUND

The transition between the inpatient and outpatient setting is a high-risk period for patients. The presence and role of the primary care provider (PCP) is critical during this transition. This study evaluated characteristics and outcomes of discharged patients lacking timely PCP follow-up, defined as within 4 weeks of discharge.

METHODS

This prospective cohort enrolled 65 patients admitted to University of Colorado Hospital, an urban 425-bed tertiary care center. We collected patient demographics, diagnosis, payer source and PCP information. Post-discharge phone calls determined PCP follow-up and readmission status. Thirty-day readmission rate and hospital length of stay (LOS) were compared in patients with and without timely PCP follow-up.

RESULTS

The rate of timely PCP follow-up was 49%. For a patient's same medical condition, the 30-day readmission rate was 12%. Patients lacking timely PCP follow-up were 10 times more likely to be readmitted (odds ratio [OR] = 9.9, P = 0.04): 21% in patients lacking timely PCP follow-up vs. 3% in patients with timely PCP follow-up, P = 0.03. Lack of insurance was associated with lower rates of timely PCP follow-up: 29% vs. 56% (P = 0.06), but did not independently increase readmission rate or LOS (OR = 1.0, P = 0.96). Index hospital LOS was longer in patients lacking timely PCP follow-up: 4.4 days vs. 6.3 days, P = 0.11.

CONCLUSIONS

Many patients discharged from this large urban academic hospital lacked timely outpatient PCP follow-up resulting in higher rates of readmission and a non-significant trend toward longer hospital LOS. Effective transitioning of care for vulnerable patients may require timely PCP follow-up.

The effects of barriers on Health Related Quality of Life (HRQL) and compliance in adult asthmatics who are followed in an urban community health care facility

This cross sectional descriptive study sought to identify perceived barriers to follow-up care for adult asthmatics who are followed in two community health care facilities. A second purpose of the study was to determine the effect of any barriers to Health Related Quality of Life (HRQL) and compliance in the sample. Thirty-four adults completed a demographic and health status survey, the MiniAQLQ and the EWash Access to Health Care Survey. "Long waiting time in provider's office," "someone had to miss work," "cost of care too much, "and "long wait for an appointment" were the most prevalent perceived barriers in the sample. "Lack of transportation" was significantly associated with study participants who receive health care at one site or who stated the emergency room as their usual place of care. "Someone had to miss work" was significantly correlated with the following variables: employment, a higher annual household income, 1-2 daily medications for asthma, no overnight hospitalizations for asthma and no psychological co-morbidities. A higher reported HQOL was significantly correlated with study participants whose medical care needs were met and found access to local health care services. The only perceived barrier that was significantly correlated with compliance was study participants who "sometimes" had to reschedule an appointment with a health care provider due to "lack of transportation." The present study suggests that strategies designed to decrease the perceived barriers might improve compliance with the treatment regime, thus decreasing costs, absenteeism, and lack of continuity.

Noncompliance with medical follow-up after pediatric intensive care

OBJECTIVES

To describe the medical follow-up ordered, the health care utilization, the appointment compliance, and the risk factors associated with noncompliance in patients who are discharged after a pediatric intensive care unit (PICU) stay.

METHODS

A prospective, analytic, cohort study of 111 critically ill children, age 1 day to 16 years, who were admitted to a 30-bed PICU in an urban, tertiary-care, pediatric teaching hospital compared children who were compliant with medical follow-up with those who were not. The main outcomes measured were emergent and unscheduled physician visits during the first 6 weeks after hospital discharge; compliance with ordered medical follow-up after hospital discharge; and comparisons of socioeconomic, demographic, and medical need factors between compliant and noncompliant children. Discharge orders for follow-up appointments with general pediatricians and subspecialists were collected from the chart at hospital discharge. Patients were contacted after hospital discharge to determine whether and when they received medical follow-up; 28% were found to be noncompliant. Risk factors associated with noncompliance were evaluated. Emergent and unscheduled physician visits were tracked during the first 6 weeks after hospital discharge.

RESULTS

Lack of follow-up orders at hospital discharge did not affect the frequency of emergent visits. Children fell into 2 groups: those who were 100% compliant and those with < or =67% compliance. No socioeconomic or demographic risk factors could be identified between the 2 groups. Compared with the 100% compliant patients, patients who were compliant with < or =67% of appointments were more severely ill, as defined by higher peak pediatric risk of mortality scores during their PICU stay (11.5 vs 8.4), longer PICU length of stays (10.1 days vs 4.6 days), and longer hospital length of stays (25.5 days vs 14 days). Most predictive of noncompliance was the number of medical appointments ordered by physicians. Patients with 3 or more appointments were less likely to be compliant with follow-up. After hospital discharge, children were more likely to visit a primary care physician compared with a subspecialist (95% vs 82%). When patients were ordered to see a specialist, scheduled appointments were much better attended than the recommended appointments (92% vs 67%).

CONCLUSIONS

Lack of ordered medical follow-up did not affect emergent visits. In this group of critically ill children, a significant percentage (28%) did not receive timely medical follow-up. No socioeconomic or demographic risk factors were identified in noncompliant children. However, severity of illness (higher peak pediatric risk of mortality score, longer PICU stay, and longer hospital stay) and the number of follow-up appointments ordered were predictors of noncompliance. Potential exists for implementing strategies to improve compliance in identified populations.

A telephone call reminder to improve outpatient attendance in patients referred from the emergency department: a randomised controlled trial

BACKGROUND

Poor compliance with attendance at outpatient clinic appointments in patients referred from emergency departments (EDs) is a major problem in public hospitals.

AIMS

To determine whether the intervention of a telephone call within three days of ED attendance would improve: 1. the proportion of patients making recommended outpatient appointments; and 2. the proportion of patients attending scheduled appointments. To characterise reasons for non-attendance at appointments made by patients referred from the ED.

METHODS

A randomised controlled trial was undertaken of 400 patients recommended to make outpatient appointments during attendance at The Royal Melbourne Hospital ED in July-August 1999.

INTERVENTION

a telephone call one to three days after attendance to remind the patient about the appointment (and its importance for medical follow-up) if one had been made and to offer to make an appointment if one had not been made.

OUTCOME MEASURES

1. making the recommended appointment; 2. attendance at the scheduled appointment; and 3. reasons for non-attendance at scheduled appointments.

RESULTS

The telephone intervention improved attendance at scheduled appointments from 54.4% to 70.7% (p=0.002). The proportion of patients making appointments was not significantly affected. The commonest reasons given for non-attendance were: attended general practitioner (13%), attended private specialist (6.6%), inpatient in hospital at time of appointment (6.6%), too busy or inconvenient (5.3%), claimed to have attended (5.3%) and did not differ by intervention.

CONCLUSIONS

A significant improvement in the proportion of patients attending outpatients appointments can be made by a simple reminder telephone call one to three days after attendance at the ED.

Living on the edge: a phenomenological study of medically uninsured working Americans

An estimated 35 to 50 million Americans have no medical insurance; the vast majority are employed persons and their dependents. This phenomenological study was developed to make visible the experience of working Americans living on the edge-forced to walk a fine line between health and illness without the safety net of medical insurance. A purposive sample of 12 individuals was asked, "What is it like to be working and without medical insurance? Based on textual analysis, using an adaptation of Colazzi's method, themes were grouped into four theme clusters: A Marginalized Life, Up Against Rocks and Hard Places, Making Choices-Chancing It, and Getting By-More or Less. These are illustrated through commentary and direct quotation to depict an overall sense of the experience. Implications for nurses charged with addressing the needs of the medically uninsured and for nursing as a whole are discussed.

Using the health belief model to explain clinic appointment-keeping for the management of a chronic disease condition

Broken appointments have untoward repercussions for patients' health and well-being. Although the literature on missed appointments has been largely atheoretical, several studies have tested the Health Belief Model (HBM) in this context. Those studies have found HBM dimensions are not predictive of keeping appointments for the management of a chronic condition. Given several limitations that characterize these studies, questions can be raised about the validity of this conclusion. This study investigated the utility of HBM for explaining appointment-keeping for Systemic Lupus Erythematosus (SLE), a potentially fatal chronic disease. A questionnaire, operationalizing HBM dimensions and exhibiting acceptable psychometric properties, was developed for this research and administered to 153 SLE patients enrolled at an outpatient clinic of a major teaching hospital. In addition to measuring intention to keep appointments, data were abstracted from medical records regarding actual appointment-keeping during 12 months prior to and 6 months following questionnaire completion. Regression analysis indicated that general health motivation and perceived severity of SLE were uniquely associated in the theoretically predicted direction with, respectively, intent and the percentage of scheduled appointments kept (PSAK) during the 12 month retrospective period. Perceived costs was associated in the expected direction with intent, 12 month retrospective and 6 month prospective PSAK. Typical of HBM research the effect sizes uncovered were modest in magnitude. Questions for future investigation are discussed.

Factors predictive of poor compliance with follow-up care after facial trauma: A prospective study

We performed a prospective study of 59 consecutive patients with facial trauma who were treated at an urban public hospital. We obtained demographic and clinical data before treatment, then recorded compliance with clinic follow-up care. As expected, young, minority male patients, victims of assault, and blunt mechanisms of injury predominated in our series, and midface fractures and soft tissue injuries were most commonly seen. Thirty-one (52%) patients were admitted, and 28 (48%) were treated as outpatients. Although 66% of patients kept their initial follow-up appointment, only 46% of patients were seen to completion of the follow-up period. We used univariate and multivariate analyses to identify factors predictive of poor compliance with follow-up care. Factors predictive of poor compliance with the initial follow-up appointment identified in the multivariate analysis were orbital injury site ( p < 0.001), Caucasian race ( p = 0.007), and not having a telephone at home ( p = 0.043). Factors predictive of poor compliance with completion of follow-up were failure to keep initial appointment ( p < 0.001), and treatment with observation, suture only, or open reduction internal fixation only ( p = 0.018). Age, marital status, employment status, education level, and hospital admission of the patient were not predictive of compliance with follow-up care. Because compliance with follow-up care may be poor, patients with facial trauma should be managed aggressively initially. In particular, patients with orbital fractures, and those treated with watchful waiting only may have poorer long-term compliance with follow-up care. (Otolaryngol Head Neck Surg 1997;117:72–5.)

Patient compliance and medical research: issues in methodology

Compliance with medication and medical appointments is presumed to have a critical influence on outcomes of medical interventions. However, compliance may not always be easily defined or accurately measured. No single method of measuring compliance with appointments or medication is applicable in all settings. The apparent effects of compliance on outcome may be both direct and indirect; research is needed to define more clearly how these effects may be mediated. Identifying effective methods of enhancing compliance requires accurate methods of measuring compliance. In addition, the effectiveness of interventions may decay over time, and differences in effectiveness in acute versus long-term settings have not been well studied. Researchers conducting clinical trials of medical interventions must evaluate compliance in the population studied and consider the potential impact of noncompliance on trial results and their generalizability. In some trial designs, data may best be analyzed by considering compliance a dependent or an outcome variable. Under appropriate circumstances, compliance may be considered an independent variable. Readers of the medical literature should consider how compliance was measured and analyzed when interpreting the results of clinical trials. Table 4 suggests criteria for critical appraisal of compliance-related issues in reports of clinical trials.