A descriptive study of missed appointments: families' perceptions of barriers to care

A pilot randomized controlled trial of text messages to improve well-child visit attendance after no-show

OBJECTIVE

Evaluate the effectiveness of text messages to systematically engage parents/guardians ("caregivers") to reschedule a well-child visit (WCV) that was missed ("no-show") and attend that rescheduled WCV visits.

METHODS

Patients <18 years in one of five pediatrics or family medicine clinics, in one health system in the Southeast U.S., were eligible. Patients without a rescheduled WCV after a no-show were randomized into intervention (text messages) or care-as-usual comparison, stratified by language (English/Spanish). Enrollment occurred May-July 2022. Up to three text messages were sent to caregivers one week apart via REDCap and Twilio, advising how to reschedule the missed appointment by phone or health portal. Primary outcomes were (1) rescheduling a WCV within 6 weeks of no-show and (2) completing a rescheduled WCV within 6 weeks. Risk differences (RD) and odds ratios (OR) were used to evaluate the effect of text messages.

RESULTS

720 patients were randomized and analyzed (texts: 361, comparison: 359). The proportion rescheduling WCV after text versus usual care was English: 18.85% vs. 15.02%, respectively, and Spanish: 5.94% vs. 8.14%, with overall RD +1.98% (95% CI: -1.85, 5.81) and OR 1.21 (95% CI: 0.79, 1.84; p-value 0.38). Completed WCV rates in text or usual care were English: 13.08% vs. 6.59%, and Spanish: 5.81% vs. 5.94% with texts associated with RD +2.83% (95% CI: 1.66, 4.00) and OR 1.86 (95% CI: 1.09, 3.19).

CONCLUSION

Text message follow-up after a no-show WCV may positively impact attendance at WCVs rescheduled in the subsequent 6 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05086237.

Understanding barriers to well-child visit attendance among racial and ethnic minority parents

OBJECTIVES

To assess racial and ethnic minority parents' perceptions about barriers to well-child visit attendance.

METHODS

For this cross-sectional qualitative study, we recruited parents of pediatric primary care patients who were overdue for a well-child visit from the largest safety net healthcare organization in central Massachusetts to participate in semi-structured interviews. The interviews focused on understanding potential knowledge, structural, and experiential barriers for well-child visit attendance. Interview content was inductively coded and directed content analysis was performed to identify themes.

RESULTS

Twenty-five racial and ethnic minority parents participated; 17 (68%) of whom identified Spanish as a primary language spoken at home. Nearly all participants identified the purpose, significance, and value of well-child visits. Structural barriers were most cited as challenges to attending well-child visits, including parking, transportation, language, appointment availability, and work/other competing priorities. While language emerged as a distinct barrier, it also exacerbated some of the structural barriers identified. Experiential barriers were cited less commonly than structural barriers and included interactions with office staff, racial/ethnic discrimination, appointment reminders, methods of communication, wait time, and interactions with providers.

CONCLUSIONS

Racial and ethnic minority parents recognize the value of well-child visits; however, they commonly encounter structural barriers that limit access to care. Furthermore, a non-English primary language compounds the impact of these structural barriers. Understanding these barriers is important to inform health system policies to enhance access and delivery of pediatric care with a lens toward reducing racial and ethnic-based inequities.

Caregiver Perspectives on Barriers and Facilitators to Timely Well-Child Visits for Black Infants

OBJECTIVES

Missed infant well-child visits (WCV) result in lost opportunities for critical preventive care. Black infants consistently receive less WCV care than other racial groups. We sought to understand barriers and facilitators to timely infant WCV for Black families in the context of COVID-19.

METHODS

We conducted 21 semi-structured interviews with caregivers of Medicaid-insured Black children aged 15- to 24-months who attended six or fewer of eight recommended well-child visits within the first 15 months of life. Interviews focused on WCV value, barriers, and facilitators. After developing our initial coding structure through rapid qualitative analysis, we inductively derived the final codebook and themes through line-by-line content analysis.

RESULTS

Caregivers attended a mean of 3.53 of eight infant visits. Structural (e.g., transportation) and psychological (e.g., maternal depression) barriers delayed Black infant WCV. Families most frequently valued monitoring development and addressing concerns. Caregivers perceived visits as less urgent when infants seemed healthy or more recently avoided visits due to fears around COVID-19. Long waits and feeling rushed/dismissed were linked to WCV delays; positive provider relationships encouraged WCV attendance. Most caregivers reported reluctance to vaccinate. Vaccine hesitancy contributed to delayed infant WCV.

CONCLUSIONS

Caregivers described several factors that impacted WCV attendance for Black infants. Persistent structural and psychological barriers are compounded by perceptions that caregiver time is not respected and by notable vaccine hesitancy. To address these barriers, well-care can meet Black families in their communities, better address caregiver wellbeing, more efficiently use caregiver and provider time, and cultivate partnerships with Black caregivers.

Cross-sectional analysis of primary care clinics' policies, practices, and availability of patient support services during the COVID-19 pandemic

BACKGROUND

Healthcare accessibility and utilization are important social determinants of health. Lack of access to healthcare, including missed or no-show appointments, can have negative health effects and be costly to patients and providers. Various office-based approaches and community partnerships can address patient access barriers.

OBJECTIVES

(1) To understand provider perceptions of patient barriers; (2) to describe the policies and practices used to address late or missed appointments, and (3) to evaluate access to patient support services, both in-clinic and with community partners.

METHODS

Mailed cross-sectional survey with online response option, sent to all Nebraska primary care clinics (n = 577) conducted April 2020 and January through April 2021. Chi-square tests compared rural-urban differences; logistic regression of clinical factors associated with policies and support services computed odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Response rate was 20.3% (n = 117), with 49 returns in 2020. Perceived patient barriers included finances, higher among rural versus urban clinics (81.6% vs. 56.1%, p =.009), and time (overall 52.3%). Welcoming environment (95.5%), telephone appointment reminders (74.8%) and streamlined admissions (69.4%) were the top three clinic practices to reduce missed appointments. Telehealth was the most commonly available patient support service in rural (79.6%) and urban (81.8%, p =.90) clinics. Number of providers was positively associated with having a patient navigator/care coordinator (OR = 1.20, CI = 1.02-1.40). For each percent increase in the number of privately insured patients, the odds of providing legal aid decreased by 4% (OR = 0.96, CI = 0.92-1.00). Urban clinics were less likely than rural clinics to provide social work services (OR = 0.16, CI = 0.04-0.67) or assist with applications for government aid (OR = 0.22, CI = 0.06-0.90).

CONCLUSIONS

Practices to reduce missed appointments included a variety of reminders. Although finances and inability to take time off work were the most frequently reported perceived barriers for patients' access to timely healthcare, most clinics did not directly address them. Rural clinics appeared to have more community partnerships to address underlying social determinants of health, such as transportation and assistance applying for government aid. Taking such a wholistic partnership approach is an area for future study to improve patient access.

[How much does a specialized medical consultation cost for families of pediatric patients in the Brazilian Unified National Health System?]

In this study, we investigated the costs of transportation for each outpatient consultation in patients referred to specialized surgical evaluation in a tertiary hospital in Rio de Janeiro, Brazil. Descriptive study with guardians of pediatric patients scheduled for pediatric surgery, questioning transportation cost, and opportunity costs (loss of remuneration, food, payment of caregivers for other children, expenses for other companions). About half patients were aged up to five years; about two thirds had diseases of simple and definitive surgical resolution; and 181 families (89.17%) presented monthly family income up to BRL 1,999.00. The proportion of families that benefited from free transportation ranged from 4.26% to 15.56% for patients living up to 100 km away from the hospital (45.83% for patients living more than 100 km away from the institution). A total of 176 (87.13%) guardians reported expenses buying food, 12 (5.94%) paid caregivers to the other children on the day of the consultation, and 80 (39.6%) reported loss of remuneration for the working day. Among the high complexity cases, 9.33% of the mothers have given up their regular paid employment. Transportation expenses for a pediatric surgery consultation at a reference hospital in Rio de Janeiro cost about 4.42% of the current minimum wage, spending around 217.32 minutes of displacement/consultation. Expenses with food and loss of remuneration due to absence at work also entail significant financial charges or loss of remuneration for the patient at each consultation.

Short-Term Outcomes of the Boston Brace 3D Program Based on SRS and SOSORT Criteria: A Retrospective Study

Background: Adolescent idiopathic scoliosis (AIS) is characterized by a lateral curvature of the spine with a Cobb angle greater than 10 degrees, accompanied by rotation of the vertebral body. Bracing has been shown to be effective in halting the progression of at-risk curves, and, in some cases, even improving the Cobb angle by 6° or more. The Boston Brace 3D is part of the Boston Orthotics and Prosthetics standardized scoliosis program. The orthosis is custom-fabricated from scans, computer-aided design (CAD), and computer-aided manufactured (CAM) thoracolumbosacral orthosis used in the non-operative management of AIS. Aim: To evaluate the outcomes of a scoliosis program utilizing the Boston Brace 3D orthosis for patients with AIS, based on SRS and SOSORT criteria. Design: Retrospective study. Methods: An electronic medical records search was conducted to identify first-time brace wearers fitted between 1 January 2018, and 30 June 2019, at Boston Orthotics and Prosthetics Boston area clinics that met the SRS/SOSORT research guidelines. The initial out-of-brace, in-brace, and last follow-up X-rays (taken at least 12 months after fitting) were compared. Results: 84% of patients presenting with a single curve and 69% of patients with a double curve saw their curves improve (reduced 6° or more) or remain unchanged (±5°). Thirty-one patients started with a single curve between 25° and 30°, and thirty-two presented at 30° or below. Fifty-nine patients started with a double curve between 25° and 30°, and 59 patients presented at 30° or below. In general, the patients who wore their brace for more hours per day saw improved results. Conclusion: The Boston Brace 3D program is effective in controlling (and in some cases improving) curve progression in the non-operative management of adolescent idiopathic scoliosis. The approach is a repeatable system, as shown in this cohort of thirteen clinicians across six area clinics following the Boston Brace 3D clinical guidelines.

Patient Personality and Illness Perceptions in Relation to Follow-Up Appointment Adherence in Neuro-Ophthalmology

BACKGROUND

Improving patient attendance at medical follow-up visits may have a notable impact on disease and overall health outcomes. Understanding factors contributing to poor attendance is important for identifying at-risk patients and designing interventions to improve clinical outcomes. Our objective was to identify personality and illness perception factors associated with attendance at recommended follow-up visits in a neuro-ophthalmology practice.

METHODS

New or established patients (≥18 years) with scheduled neuro-ophthalmology (study) or glaucoma (comparison) appointments at a tertiary care academic medical center completed the Brief Illness Perception Questionnaire and Ten-Item Personality Inventory. Physician recommendations made during the visit were recorded (medications, referrals, follow-up, testing, and procedures). A chart review was performed 18 months after enrollment to assess attendance at follow-up appointment and adherence with other physician recommendations. Multiple variable logistic regression models studied associations between follow-up appointment attendance and demographic factors, appointment factors, and survey responses.

RESULTS

Among 152 respondents (97% response rate (152 of 157), aged 19-97 years, 58% female, 34% new, 80 neuro-ophthalmology, 72 glaucoma), neuro-ophthalmology subjects were younger, more likely to be White, non-Hispanic, female and new to the practice than subjects with glaucoma. They reported higher emotional impact, identity, and consequences related to their illness (P = 0.001-0.03). Neuro-ophthalmology physician recommendations included more referrals to other services (17.5% vs 1.4%, P = 0.001, chi-square) and more radiology studies (15% vs 0%, P = 0.001, chi-square), but fewer follow-up visits (75% vs 97%, P < 0.0005, chi-square). Among those with recommended follow-up visits, neuro-ophthalmology subjects had lower rates of on-time appointment attendance (55% vs 77%, P = 0.009, chi-square). In a multiple variable model, on-time follow-up attendance was associated with shorter recommended follow-up interval (≤90 days, P < 0.0005), established (vs new) patient status at enrollment visit (P = 0.04), and glaucoma (P = 0.08), but not subject demographics, illness perception, or personality factors.

CONCLUSIONS

Patient demographics, illness perception, and personality traits were not associated with follow-up appointment attendance and therefore unlikely to be useful for identifying patients at risk of being lost to follow-up. New neuro-ophthalmology patients with a follow-up recommended ≥90 days in advance may benefit from targeted interventions to improve follow-up appointment adherence.

Urbanicity, Health, and Access to Services for People With Intellectual Disability and Developmental Disabilities

Previous research suggests that residence in non-metropolitan areas is associated with lower access to preventive care and poorer health. However, this research has been largely restricted to the general population, despite data demonstrating disparities in health status and access to healthcare services for people with intellectual and developmental disabilities (IDD). The current study examined several hypotheses involving the effects of rurality on access to preventive healthcare and services and health status: (1) individuals in non-metropolitan areas will have lower preventive healthcare utilization, (2) individuals in non-metropolitan areas will have poorer health outcomes, and (3) individuals in non-metropolitan areas will have poorer access to services. The current study uses data from the National Core Indicators (NCI) Adult Consumer Survey 2015-2016: Final Report which included Rural-Urban Commuting Area (RUCA) Codes for the first time. Results of logistic regression suggest that, despite connection to disability services, the health status and access to preventive healthcare services of people with IDD generally follow patterns similar to those observed in the general population. Namely, people with IDD in non-metropolitan areas have decreased access to healthcare services, preventive healthcare utilization, and health status. Despite some exceptions, it appears effects of rurality are not completely mitigated by current state and federal efforts.

The life of a laboratory requisition form: Patient compliance with clinical laboratory testing in a Canadian primary care health region

OBJECTIVE

To examine patient laboratory testing compliance by tracking time to submission of laboratory requisitions in Southern Alberta, Canada as part of a quality improvement initiative.

METHODS

Data was collected retrospectively from patients from the Chinook Primary Care Network in Alberta, Canada, who received a laboratory requisition consisting of a complete blood count (CBC) test order between September 1, 2016 and August 31, 2017. To allow for all laboratory requisitions created to be submitted within one year, the study collection period was from September 1, 2016 to August 31, 2018. Patient age, sex, and dates of laboratory requisition creation and submission were collected. The days-to-test-submission served as a marker of compliance. Association of age, sex, and clinic location with time to laboratory requisition completion was determined using Cox regression analysis.

RESULTS

During the study period, 70.4% (n = 1607) of laboratory requisitions created were completed within one year, and over half (50.5%) of the laboratory requisitions ordered were completed within two weeks. There were no significant associations between time to laboratory requisition submission and sex or clinic locations (P > 0.05), but there were significant associations between patients who were 20-49 or 70-79 and increased laboratory requisition compliance (P < 0.05). However, 26.0% of the laboratory requisitions created were not submitted at all.

CONCLUSIONS

This was the first study that quantified the proportion and timing of laboratory requisitions that were submitted by patients in a primary care setting. Community patients should be engaged and educated regarding the importance of complying with their physician-ordered laboratory requests in a timely manner.

Risk Factors for Loss to Follow-Up in the Lower Extremity Limb Salvage Population

BACKGROUND

Limb salvage for chronic lower extremity wounds requires long-term care best delivered by specialized multidisciplinary centers. This optimizes function, reduces amputation rates, and improves mortality. These centers may be limited to urban/academic settings, making access and appropriate follow-up challenging. Therefore, the authors hypothesize that both system- and patient-related factors put this population at exceedingly high risk for loss to follow-up.

METHODS

Records were reviewed retrospectively for 200 new patients seen at the Georgetown Center for Wound Healing in 2013. The primary outcome was loss to follow-up, defined as three consecutive missed appointments despite explicit documentation indicating the need for return visits. Demographic, clinical, and geographic data were compared. Multivariate logistic regression analysis for loss to follow-up status controlled for variables found significant in the bivariate analysis. Spatial dependency was evaluated using variograms.

RESULTS

Over a 6.5-year-period, 49.5 percent of patients followed were lost to follow-up. Male sex and increased driving distance to the limb salvage center were risk factors for loss to follow-up. Wound-specific characteristics including ankle and knee/thigh location were also associated with higher rates of loss to follow-up. There was no spatial dependency or discrete clustering of at-risk patients.

CONCLUSIONS

This study is the first of its kind to investigate the demographic and clinical characteristics that predispose chronic lower extremity wound patients to loss to follow-up. These findings inform stakeholders of the high rates of loss to follow-up and support decentralized specialty care, in the form of telemedicine, satellite facilities, and/or dedicated case managers. Future work will focus on targeting vulnerable populations through focused interventions to reduce patient and system burden.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Improving Outpatient Infusion Clinic Wait Times at a Comprehensive Cancer Center

PURPOSE

Many factors contribute to long wait times for patients on the day of their chemotherapy infusion appointments. Longer wait time leads to nonoptimal care, increased costs, and decreased patient satisfaction. We conducted a quality improvement project to reduce the infusion wait times at a Comprehensive Cancer Center.

METHODS

A multidisciplinary working group of physicians, infusion center nurses, pharmacists, information technology analysts, the Chief Medical Officer, and patient advocates formed a working group. Wait times were analyzed, and the contributing factors to long wait time were identified. Plan-Do-Study-Act cycles were implemented and included labeling patients ready to treat earlier, loading premedications into the medication dispensing system, increasing the number of pharmacy staff, and improving communication using a secure messaging system. The outcome measure was time from patient appointment to initiation of first drug at the infusion center. The secondary outcome measure was patient wait time satisfaction on the basis of Press Ganey score.

RESULTS

Postintervention, the mean time from appointment to initiation of first drug decreased 17.6 minutes (P < .001; 95% CI, 16.3 to 18.9), from 58.1 minutes to 40.5 minutes (43.5% decrease). Patient wait time satisfaction score increased 8.9 points (P < .001; 95% CI, 6.0 to 11.82), from 76.2 to 85.1 (11.7% increase).

CONCLUSION

Exploring real-time data and using a classic quality improvement methodology allowed a Comprehensive Cancer Center to identify deficiencies and prevent delays in chemotherapy initiation. This significantly improved patient wait time and patient satisfaction.

Evaluation of Patient No-Shows in a Tertiary Hospital: Focusing on Modes of Appointment-Making and Type of Appointment

No-show appointments waste resources and decrease the sustainability of care. This study is an attempt to evaluate patient no-shows based on modes of appointment-making and types of appointments. We collected hospital information system data and appointment data including characteristics of patients, service providers, and clinical visits over a three-month period (1 September 2018 to 30 November 2018), at a large tertiary hospital in Seoul, Korea. We used multivariate logistic regression analyses to identify the factors associated with no-shows (Model 1). We further assessed no-shows by including the interaction term (“modes of appointment-making” X “type of appointment”) (Model 2). Among 1,252,127 appointments, the no-show rate was 6.12%. Among the modes of appointment-making, follow-up and online/telephone appointment were associated with higher odds of no-show compared to walk-in. Appointments for treatment and surgery had higher odds ratios of no-show compared to consultations. Tests for the interaction between the modes of appointment-making and type of appointment showed that follow-up for examination and online/telephone appointments for treatment and surgery had much higher odds ratios of no-shows. Other significant factors of no-shows include age, type of insurance, time of visit, lead time (time between scheduling and the appointment), type of visits, doctor’s position, and major diagnosis. Our results suggest that future approaches for predicting and addressing no-show should also consider and analyze the impact of modes of appointment-making and type of appointment on the model of prediction.

Factors associated with dropout from treatment: An exploratory study

AIM

To evaluate the factors associated with treatment dropout among patients attending the psychiatric outpatient services.

MATERIALS AND METHODS

Seventy-two patients who dropped out from treatment were contacted and they were compared with 200 regular attendees for sociodemographic and clinical variables, medication adherence, treatment satisfaction, attitude toward medication, insight, and therapeutic alliance.

RESULTS

Compared to "regular attendees," those who dropped out from treatment were significantly older, were more likely to be married, had higher age of onset, had longer duration of illness, received less supervision for medication at home, higher proportion of them continued to remain symptomatic, had more negative attitude toward medications, had poorer insight, were poorly complaint with medication, were less satisfied with the treatment provided, and had poor quality of therapeutic alliance.

CONCLUSION

This study suggests that dropout from treatment can be avoided by addressing issues of negative attitude toward medications, improving satisfaction with the treatment contact and enhancing therapeutic alliance.

Predicting no-shows in paediatric orthopaedic clinics

Background

Clinic ‘no shows’ (NS) can be a burden on the healthcare system, and efforts to minimise them can reduce lost revenue and improve patient care. Leveraging a large data set via the electronic health record (EHR) has not been previously attempted to identify ‘high risk’ groups in paediatric orthopaedics.

Objective

To use discrete data captured by the EHR system to identify predictors of non-attendance at paediatric orthopaedic outpatient appointments.

Methods

Appointments from January 2014 to March 2016 were included. Variables included appointment status, age, gender, type of visit, payor type (government vs private insurance), distance of residence to clinic, region of residence, clinic location, clinic type, and appointment day of the week, hour and month. Classification and regression trees (CART) were constructed to identify predictors of NS.

Results

131 512 encounters were included, 15 543 of which were in the NS group (11.8%). CART identified three predictive covariates for NS: days in between scheduling and appointment, insurance type, and specific orthopaedic clinic type. The combination of covariates provided predictability of NS: if they had ≤38.5 days of waiting for appointment and had private insurance, the NS rate was 7.8% (the best result), compared with waiting >38.5 days for either a fracture or sports clinic, which had an NS rate of 29.3% (OR=4.9).

Conclusion

Payor type and duration between scheduling and appointment may predict non-attendance at outpatient paediatric orthopaedic appointments. Although these findings allow for predicting and interventions for at-risk groups, even the best performing NS group occurred 7.8% of the time, highlighting the complexity of the NS phenomenon.

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.

Staying Out of the Way: Perceptions of Digital Non-Emergency Medical Transportation Services, Barriers, and Access to Care Among Young Black Male Survivors of Firearm Violence

With a reduction in primary barriers to healthcare access as a result of the Affordable Care Act, there is an increased need to address secondary barriers faced by low-income young Black male survivors of violent injury. While transportation is often characterized as a barrier for individuals with chronic disease and disability, it also acts as a significant barrier in accessing cognitive behavioral therapy and mentoring services through hospital-based violence intervention programs (HVIPs). These services address the traumatic stress associated with surviving gun violence. Although there are many challenges associated with the current practices of non-emergency medical transportation, participants in HVIPs face additional risk factors. We highlight the application of a digital transportation intervention to increase the use of psychosocial services among low-income young Black male survivors of violent injury participating in an HVIP. Digital non-emergency medical transportation services (DNEMT) address issues concerning financial barriers, personal safety, program credibility, and program participation. We conducted qualitative interviews and a focus group with this population to assess the impact of Uber Health, a DNEMT service, on their participation in an HVIP located in a suburban Maryland hospital immediately outside of Washington, D.C. Survivors identified the use of Uber Health as essential to addressing the multifaceted and interconnected barriers to treatment. These barriers included reluctance to use alternative forms of transportation services (i.e., bus or subway) due to potential encounters with rivals, increased risk of repeat violent victimization, the need to carry a weapon for protection, stigmatization, and symptoms associated with traumatic stress. We found that integrating digital transportation services into the standard practices of HVIPs, as a part of a patient-centered outcomes framework, contributes to a reduction in violent injury and re-traumatization by addressing the multi-layered risks experienced by survivors of gun violence.

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.

"Having a Normal Life": A Qualitative Study on Client Goal-Setting Within a Health Care and Social Needs Navigation Program

Client goals within healthcare and social needs navigation programs are neither well understood nor incorporated into ambulatory care practices. This study provides a qualitative analysis of client-established goals within the Interprofessional Care Access Network (I-CAN), a community-based health care and social needs navigation program. One hundred eleven client goal lists were analyzed using conventional content analysis. Twenty-two codes were developed and grouped into 4 main categories including Physical/Mental Health, Social/Social Services, Health Care System, and Daily Living. The results of this study offer insight into client goals within health care and social needs navigation programs and provide suggestions for future research.

Impact of Transportation Interventions on Health Care Outcomes: A Systematic Review

INTRODUCTION

Lack of reliable transportation can be a barrier to keeping appointments or accessing other health care services. Increasingly, insurers and health care delivery systems subsidize transportation services for patients. This systematic review synthesizes existing research on nonemergency medical transportation interventions.

METHODS

We searched 3 databases (Embase, PubMed, Google) for studies of health care sector-sponsored programs that provided patients assistance with nonemergency transportation and directly assessed the impact of transportation assistance on health and health care utilization outcomes. Studies meeting inclusion criteria were graded for quality using standard grading criteria.

FINDINGS

Eight studies met all inclusion criteria. Most were rated as low quality. All studies included examined process or health care utilization outcomes, such as uptake of transportation services, return for follow-up, or missed appointment rates; only 1 included health outcomes, such as illness severity and blood pressure. Results were mixed. More rigorous studies showed low patient uptake of transportation services and inconsistent impacts on health and utilization outcomes.

CONCLUSIONS

Despite considerable interest in subsidizing transportation services to improve health for patients facing transportation barriers, little rigorously conducted research has demonstrated the impact of transportation services on health or health care utilization. Some extant literature suggests that transportation assistance is more likely to be effective when offered with other interventions to reduce social and economic barriers to health.

Caregiver and Clinician Perspectives on Missed Well-Child Visits

PURPOSE

Despite the benefits of well-child care visits, up to one-half of these visits are missed. Little is known about why children miss them, so we undertook a qualitative study to elucidate these factors.

METHODS

We interviewed 17 caregivers whose children had missed well-child visits and 6 clinicians, focusing on 3 areas: the value of well-child visits, barriers to attendance, and facilitators of attendance. Transcripts were analyzed with a grounded theory approach and thematic analysis.

RESULTS

Caregivers and clinicians identified similar important aspects of well-child visits: immunizations, detection of disease, and monitoring of growth and development. Both groups identified similar barriers to attendance: transportation, difficulty taking time off from work, child care, and other social stressors.

CONCLUSIONS

Further work to explore how addressing social determinants of health might improve attendance of well-child visits is needed.

Environmental Factors Predictive of No-Show Visits in Radiology: Observations of Three Million Outpatient Imaging Visits Over 16 Years

PURPOSE

To evaluate the impact of environmental and socioeconomic factors on outpatient cancellations and "no-show visits" (NSVs) in radiology.

MATERIALS AND METHODS

We conducted a retrospective analysis by collecting environmental factor data related to outpatient radiology visits occurring between 2000 and 2015 at our multihospital academic institution. Appointment attendance records were joined with daily weather observations from the National Oceanic and Atmospheric Administration and estimated median income from the US Census American Community Survey. A multivariate logistic regression model was built to examine relationships between NSV rate and median income, commute distance, maximum daily temperature, and daily snowfall.

RESULTS

There were 270,574 (8.0%) cancellations and 87,407 (2.6%) NSVs among 3,379,947 scheduled outpatient radiology appointments and 575,206 unique patients from 2000 to 2015. Overall cancellation rates decreased from 14% to 8%, and NSV rates decreased from 6% to 1% as median income increased from $20,000 to $120,000 per year. In a multivariate model, the odds of NSV decreased 10.7% per $10,000 increase in median income (95% confidence interval [CI]: 10.3%-11.1%) and 2.0% per 10°F increase in maximum daily temperature (95% CI: 1.3%-1.6%). The odds of NSV increased 1.4% per 10-mile increase in commute distance (95% CI: 1.3%-1.6%) and 4.5% per 1-inch increase in daily snowfall (95% CI: 3.6%-5.3%). Commute distance was more strongly associated with NSV for those in the two lower tertiles of income than the highest tertile (P < .001).

CONCLUSION

Environmental factors are strongly associated with patients' attendance at scheduled outpatient radiology examinations. Modeling of appointment failure risk based on environmental features can help increase the attendance of outpatient radiology appointments.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Mothers' Perceived Barriers to and Recommendations for Health Care Appointment Keeping for Children Who Have Cerebral Palsy

Children with cerebral palsy (CP) require ongoing rehabilitation services to address complex health care needs. Attendance at appointments ensures continuity of care and improves health and well-being. The study's aim was to gain insight into mothers' perspectives of the factors associated with nonattendance. A qualitative descriptive design was conducted to identify barriers and recommendations for appointment keeping. Semi-structured interviews were conducted with 15 mothers of children with CP. Data underwent inductive qualitative analysis. Mothers provided rich context regarding barriers confronted for appointment keeping-transportation and travel, competing priorities for the child and family, and health services. Mothers' recommendations for improving the experience of attending appointments included virtual care services, transportation support, multimethod scheduling and appointment reminders, extended service hours, and increased awareness among staff of family barriers to attendance. The results inform services/policy strategies to facilitate appointment keeping, thereby promoting access to ongoing rehabilitation services for children with CP.

Clinical audit to assess delays in chemotherapy administration at daycare oncology center at a tertiary care hospital in Karachi, Pakistan

Aim

There were delays reported by patients in chemotherapy administration in daycare oncology. Therefore, we decided to audit all processes which are involved in chemotherapy administration. The objective was to improve our service by decreasing the time between admission and initiation of chemotherapy and identify the reasons for delays.

Materials and Methods

The audit was conducted in three parts. In Review I, audit tool was developed and information documented of 109 patients receiving chemotherapy at daycare center from April 14 to May 13, 2015. Five processes were assessed out of which delay in initial assessment by the nurse was the only factor identified leading to delay in chemotherapy. Review II was done from March 1 to 31, 2016 of 208 patients after increasing the number of nurses and Review III from June 7 to August 25, 2016 of 287 patients by dividing the initial assessment process at two different areas to decrease delay in initial assessment.

Results

Seventy-two percent of patients had their initial assessment done within 15 min of arrival in daycare in the first audit. In the second part of audit this percentage decreased to 55%, and finally, in the third part of the audit, percentage was improved and increased to 75% after separating initial assessment process into two areas (P < 0.001, Kruskal-Wallis test).

Conclusion

After separating initial assessment process into two different areas, delays in chemotherapy administration were reduced.

Providing no-cost transport to patients in an underserved area: Impact on access to physical therapy

Background: Barriers to accessing outpatient health care services are common and contribute to poor health outcomes. We describe the efforts of a private practice physical therapy (PT) clinic to reduce these barriers by offering a door-to-door van service at no cost to patients. Methods: Clinic records and national census databases were retrospectively reviewed to explore the impact of offering no-cost van rides to patients attending outpatient PT appointments. We used descriptive statistics and linear regression to describe volume of utilization of the van service over a 40-month period. Paired t-tests compared PT clinic attendance rates (percentage of scheduled visits that were attended) before and after implementation of the van service. Results: Use of the van service increased significantly over time, from a mean of 83 riders per month in 2010 to 205 riders per month in 2013 (p < 0.001). Overall clinic attendance rate increased from 80.1% to 84.1% after implementation of the service (p = 0.002). Following introduction of the van service, 48% of patients using the van, compared to 25% of clinic patients overall, were uninsured or insured by Medicaid. Conclusion: Use of the van service increased over time, and availability of no-cost van transportation was associated with increased visit attendance for patients at an outpatient PT clinic.

Why don't patients attend their appointments? Maintaining engagement with psychiatric services

Patients miss about 20% of scheduled appointments for mental health treatment, almost twice the rate in other medical specialties. Up to 50% of patients who miss appointments drop out of scheduled care. Many who miss appointments because of slips and lapses later rearrange their appointments without adverse consequences. Those that do not are at risk of further deterioration, relapse and hospital readmission. Predictors of non-attendance are complex and linked with the predictors of missed medication. Service barriers and administrative errors are common but are often overlooked in the absence of feedback from patients. Of prime importance are the therapeutic alliance and degree of ‘helpfulness’ of the clinician but again these are rarely measured routinely. Useful markers of engagement include patient-rated trust, satisfaction and degree of perceived participation in treatment decisions. Much can be done to improve attendance in most services. Simple measures such as offering prompt, convenient appointments, offering reminders and augmenting with telephone contact have a reasonable evidence base. Scales to assess therapeutic alliance are now available. Complex interventions need to be evaluated carefully in order that the overall benefits outweigh costs. We suggest that clinicians consider accessibility, discharge policies and patient feedback when examining local rates of non-attendance.

Adherence behavior in an acute pediatric hand trauma population: A pilot study of parental report of adherence levels and influencing factors

INTRODUCTION

Descriptive and cross-sectional study.

PURPOSE OF THE STUDY

The hand is a common site of injury in children; however, little is known regarding adherence to hand trauma management in this population.

PURPOSE

This pilot study aimed to describe adherence to plaster slab immobilization, advice regarding return to sport, appointment attendance, and the factors influencing nonadherence.

METHOD

Forty-seven parents of children with hand trauma completed an online questionnaire reporting their child's adherence to the initial medical management.

RESULTS

Parents reported that 34% (16 of 47) of children were adherent to all aspects of management. Nonadherence with plaster slab immobilization was reported by 38% (18 of 47), and 45% (21 of 47) reported nonadherence with advice regarding return to sport. Hygiene, discomfort, and restriction were the most common reasons for plaster removal. Belief that sport would not cause harm and social factors influenced return to sport against medical advice.

CONCLUSION

Nonadherence behavior is commonly reported in children with acute hand trauma.

LEVEL OF EVIDENCE

4.

What Teens Do Not Know Can Hurt Them: An Assessment of Disease Knowledge in Adolescents and Young Adults with IBD

BACKGROUND

Although adequate disease-related knowledge is recognized as an important component of transition readiness, little empirical attention has been directed toward understanding the levels of disease knowledge of adolescents and young adults (AYAs) with inflammatory bowel diseases (IBDs) or factors associated with higher levels of knowledge. This study described disease knowledge in a sample of AYAs with IBDs and examined individual, family, and patient-provider relationship factors associated with higher knowledge.

METHODS

Seventy-five AYAs (ages 16-20) and their parents participated. AYAs and parents reported on demographics, parent autonomy granting behaviors, health care satisfaction, patient-provider transition-related communication, and disease knowledge. AYAs self-reported on disease self-efficacy. Disease information was abstracted from the medical record.

RESULTS

On average, AYAs answered 8.20 (SD = 1.75) of 12 knowledge questions correctly. Over 85% of AYAs correctly identified their type of IBD, number and type of IBD-related surgeries, and name of their current IBD medical provider. In contrast, knowledge about frequency of medication refills, effects of drugs and alcohol on IBD, and number to call to schedule medical appointments was suboptimal (i.e., 50% or fewer provided a correct response). Older AYA age, greater AYA health care satisfaction, higher AYA self-efficacy, and more frequent patient-provider transition-related communication were each associated with higher IBD-related knowledge.

CONCLUSIONS

To promote disease knowledge, providers should foster AYA self-efficacy by encouraging age-appropriate involvement in IBD management and make discussion of transition-related issues a priority during clinical appointments. Moreover, fostering collaborative and positive relationships with patients will improve satisfaction and may also enhance knowledge.

PREDICTORS OF NONATTENDANCE AT AN ENDOCRINOLOGY OUTPATIENT CLINIC

OBJECTIVE

To identify predictors potentially contributing to patients' nonattendance or to same-day cancellation of scheduled appointments at an adult endocrinology office practice.

METHODS

A retrospective, records-based, cross-sectional study was conducted using data from 9,305 electronic medical records of patients presenting at a U.S. metropolitan adult endocrinology clinic in 2013. Statistical analyses included multivariate regression, calculated odds ratios, and posttest probabilities.

RESULTS

Of 29,178 total patient visits analyzed, 68% were attended by patients. Of total scheduled appointments, 7% resulted in nonattendance and 5% in same-day cancellation. The most significant predictors of nonatten-dance were a previous history of nonattendance (P<.001), uncontrolled diabetes (P<.001), and new patients to the practice (P<.001). Long lead-time to appointment (P = .001), younger age (P<.001), and certain insurance carriers (P<.001) also were significant predictors.

CONCLUSION

Specific predictors of nonattendance at scheduled appointments were identified using statistical analysis of electronic medical record data. Previous history of nonattendance and having uncontrolled diabetes (especially in patients newly referred to the practice) are among these significant predictors. Identifying specific predictors for nonattendance enables targeted strategies to be developed.

ABBREVIATIONS

APRN = Advanced Practice Registered Nurse CI = confidence interval DM = diabetes mellitus EMR = electronic medical record HbA1c = glycated hemoglobin NS = no-show OR = odds ratio SDC = same-day cancellation.

Ethical Issues in Pediatric Global Health

Children are vulnerable to the priorities and decision-making of adults. Usually, parents/caregivers make the difficult healthcare decisions for their children based on the recommendations from the child's healthcare providers. In global health work, healthcare team members from different countries and cultures may guide healthcare decisions by parents and children, and as a result ethical assumptions may not be shared. As a result, ethical issues in pediatric global health are numerous and complex. Here we discuss critical ethical issues in global health at an individual and organizational level in hopes this supports optimized decision-making on behalf of children worldwide.

Pediatric Return Appointment Adherence for Child Welfare-Involved Children in Los Angeles California

OBJECTIVES

This study of primarily Latino caregivers and Latino child welfare-involved children had the following aims: (1) explore the return appointment adherence patterns at a pediatric medical clinic; and (2) determine the relationship of adherence to return appointments and caregiver, child, and clinic variables.

METHODS

The sample consisted of caregivers of child welfare-involved children who were asked to make a pediatric outpatient clinic return appointment (N = 87). Predictors included caregiver demographics, child medical diagnoses and age, and clinic/convenience factors including distance from the clinic to caregiver's home, days until the return appointment, reminder telephone call, Latino provider, and additional specialty appointment. Predictors were examined using χ(2) and t tests of significance.

RESULTS

Thirty-nine percent of all caregivers were nonadherent in returning for pediatric appointments. When return appointments were scheduled longer after the initial appointment, caregivers were less likely to bring children back for medical care.

CONCLUSIONS

The 39 % missed return appointment rate in this study is higher than other similar pediatric populations. Better coordination between pediatricians and caregivers in partnership with child welfare case workers is needed to ensure consistent follow-up regarding health problems, especially when appointments are not scheduled soon after the initial appointment.

Factors Associated with Low Socioeconomic Status Predict Poor Postoperative Follow-up after Meningioma Resection

Objectives To quantify the rates of loss of follow-up after meningioma resection and to identify any key demographical associations. Design Retrospective cohort. Setting Vanderbilt University Medical Center, 2001-2013. Participants A total of 281 patients surgically treated for an intracranial meningioma at a single institution between 2001 and 2013. Main Outcome Measures Patient clinical follow-up within the first postoperative year. Results A history of tobacco use (p < 0.0001), ongoing alcohol abuse at time of presentation (p = 0.0014), Medicaid coverage (p < 0.0001), and lack of a college degree (p < 0.0001) were all found to be predictors of loss of follow-up at a statistically significant level. Conclusions Several factors associated with low socioeconomic status are predictors of poor clinical follow-up after meningioma resection. The health risk of poor follow-up in this patient population is significant, and increased measures are needed to ensure regular appointment attendance.

Missed Appointments: Factors Contributing to High No-Show Rates in an Urban Pediatrics Primary Care Clinic

BACKGROUND

Missed appointments complicate primary care services.

OBJECTIVE

To determine factors associated with missed pediatric appointments.

DESIGN/METHODS

A convenience sample of 1537 patients who missed appointments were called and 386 (25%) families completed the 26-item survey. Those with high no-show rates were compared with the rest using χ(2) and Fisher's exact tests. Initial covariates with P < .2 were included in a multivariate logistic regression model.

RESULTS

Common reasons for missing appointments were the following: forgot (27%), transportation problems (21%), and time off of work (14%). The high no-show group had more African Americans (P = .030) and older patients (P = .003). Higher no-show rates correlated with well child visits (P = .029) and perception of "excellent health" (P = .022). In the logistic regression model, well child appointments (odds ratio = 2.56) and increasing age in years (odds ratio = 1.11) were associated with higher no-show rates.

CONCLUSIONS

Efforts to decrease no-show rates should target older patients and well child visits.

‘You Just Went In and You Got It All Sorted Straightaway’ – What is the Appeal of a Community-Based Mobile Stop Smoking Service?

Introduction: Not enough smokers access existing stop smoking services (SSS). Developing more accessible and effective SSS is important, particularly for smokers from socioeconomically disadvantaged groups where smoking is more prevalent.

Aims: To consider smokers’ reasons for accessing a community-based mobile SSS (MSSS) for initial and follow-up consultations, and to explore their experiences of the service over time.

Methods: The MSSS was delivered in socioeconomically disadvantaged areas of Nottingham (UK). Thirty-six smokers were interviewed, and 11 of these also completed follow-up interviews four to six weeks after their quit date. Interviews were analysed using the framework approach.

Results: Many participants had considered quitting before they had knowledge of the MSSS. Features of the MSSS participants found appealing for both initial and follow-up consultations included the drop-in format, convenient times and locations that fit around their existing routines, and that the service was informal and held in a non-health setting. Participants found visiting standard SSS, particularly clinics held in health settings, stressful and formal resulting in them feeling uncomfortable discussing smoking in these settings.

Conclusions: Developing instantly accessible and convenient SSS that can be delivered in familiar and informal settings within smokers’ communities may facilitate access and help to retain service users over time.

Measuring the use of examination room time in oncology clinics: a novel approach to assessing clinic efficiency and patient flow

PURPOSE

The use of time in outpatient cancer clinics is a marker of quality and efficiency. Inefficiencies such as excessive patient wait times can have deleterious effects on clinic flow, functioning, and patient satisfaction. We propose a novel method of objectively measuring patient time in cancer clinic examination rooms and evaluating its impact on overall system efficiency.

METHODS

We video-recorded patient visits (N = 55) taken from a larger study to determine patient occupancy and flow in and out of examination rooms in a busy urban clinic in a National Cancer Institute-designated comprehensive cancer center. Coders observed video recordings and assessed patient occupancy time, patient wait time, and physician-patient interaction time. Patient occupancy time was compared with scheduled occupancy time to determine discrepancy in occupancy time. Descriptive and correlational analyses were conducted.

RESULTS

Mean patient occupancy time was 94.8 minutes (SD = 36.6), mean wait time was 34.9 minutes (SD = 28.8), and mean patient-physician interaction time was 29.0 minutes (SD = 13.5). Mean discrepancy in occupancy time was 40.3 minutes (range, 0.75 to 146.5 minutes). We found no correlation between scheduled occupancy time and patient occupancy time, patient-physician interaction time, and patient wait time, or between discrepancy in occupancy time and patient-physician interaction time.

CONCLUSION

The method is useful for assessing clinic efficiency and patient flow. There was no relationship between scheduled and actual time patients spend in exam rooms. Such data can be used in the design of interventions that reduce patient wait times, increase efficient use of resources, and improve scheduling patterns.

Factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension

BACKGROUND

Missed appointments are associated with an increased risk of hospitalization and mortality. Despite its widespread prevalence, little data exists regarding factors related to appointment non-adherence among hypertensive African-Americans.

OBJECTIVE

To investigate factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension.

DESIGN AND PARTICIPANTS

A cross-sectional survey of 185 African-Americans admitted to an urban medical center in Maryland, with severe, poorly controlled hypertension from 1999-2004. Categorical and continuous variables were compared using chi-square and t-tests. Adjusted multivariable logistic regression was used to assess correlates of appointment non-adherence.

MAIN OUTCOME MEASURES

Appointment non-adherence was the primary outcome and was defined as patient-report of missing greater than 3 appointments out of 10 during their lifetime.

RESULTS

Twenty percent of participants (n = 37) reported missing more than 30% of their appointments. Patient characteristics independently associated with a higher odds of appointment non-adherence included not finishing high school (Odds ratio [OR]  = 3.23 95% confidence interval [CI] (1.33-7.69), hypertension knowledge ([OR]  = 1.20 95% CI: 1.01-1.42), lack of insurance ([OR]  = 6.02 95% CI: 1.83-19.88), insurance with no medication coverage ([OR]  = 5.08 95% CI: 1.05-24.63), cost of discharge medications ([OR]  = 1.20 95% CI: 1.01-1.42), belief that anti-hypertensive medications do not work ([OR]  = 3.67 95% CI: 1.16-11.7), experience of side effects ([OR]  = 3.63 95% CI: 1.24-10.62), medication non-adherence ([OR]  = 11.31 95% CI: 3.87-33.10). Substance abuse was not associated with appointment non-adherence ([OR]  = 1.05 95% CI: 0.43-2.57).

CONCLUSIONS

Appointment non-adherence among African-Americans with poorly controlled hypertension was associated with many markers of inadequate access to healthcare, knowledge, attitudes and beliefs.

Examining Sexual Orientation Disparities in Unmet Medical Needs among Men and Women

Using the National Longitudinal Study of Adolescent Health (N = 13,810), this study examines disparities in unmet medical needs by sexual orientation identity during young adulthood. We use binary logistic regression and expand Andersen's health care utilization framework to identify factors that shape disparities in unmet medical needs by sexual orientation. We also investigate whether the well-established gender disparity in health-seeking behaviors among heterosexual persons holds for sexual minorities. The results show that sexual minority women are more likely to report unmet medical needs than heterosexual women, but no differences are found between sexual minority and heterosexual men. Moreover, we find a reversal in the gender disparity between heterosexual and sexual minority populations: heterosexual women are less likely to report unmet medical needs than heterosexual men, whereas sexual minority women are more likely to report unmet medical needs compared to sexual minority men. Finally, this work advances Andersen's model by articulating the importance of including social psychological factors for reducing disparities in unmet medical needs by sexual orientation for women.

Traveling towards disease: transportation barriers to health care access

Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.

Mobile phone messaging reminders for attendance at healthcare appointments

BACKGROUND

This review is an update of the original Cochrane review published in July 2012. Missed appointments are a major cause of inefficiency in healthcare delivery with substantial monetary costs for the health system, leading to delays in diagnosis and appropriate treatment. Patients' forgetfulness is one of the main reasons for missed appointments. Patient reminders may help reduce missed appointments. Modes of communicating reminders for appointments to patients include face-to-face communication, postal messages, calls to landlines or mobile phones, and mobile phone messaging. Mobile phone messaging applications, such as Short Message Service (SMS) and Multimedia Message Service (MMS), could provide an important, inexpensive delivery medium for reminders for healthcare appointments.

OBJECTIVES

To update our review assessing the effects of mobile phone messaging reminders for attendance at healthcare appointments. Secondary objectives include assessment of costs; health outcomes; patients' and healthcare providers' evaluation of the intervention and perceptions of safety; and possible harms and adverse effects associated with the intervention.

SEARCH METHODS

Original searches were run in June 2009. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 8), MEDLINE (OvidSP) (January 1993 to August 2012), EMBASE (OvidSP) (January 1993 to August 2012), PsycINFO (OvidSP) (January 1993 to August 2012) and CINAHL (EbscoHOST) (January 1993 to August 2012). We also reviewed grey literature (including trial registers) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing mobile phone messaging as reminders for healthcare appointments. We only included studies in which it was possible to assess effects of mobile phone messaging independent of other technologies or interventions.  

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all studies against the inclusion criteria, with any disagreements resolved by a third review author. Study design features, characteristics of target populations, interventions and controls, and results data were extracted by two review authors and confirmed by a third author. Two authors assessed the risk of bias of the included studies. As the intervention characteristics and outcome measures were similar across included studies, we conducted a meta-analysis to estimate an overall effect size.

MAIN RESULTS

We included eight randomised controlled trials involving 6615 participants. Four of these studies were newly identified during this update.We found moderate quality evidence from seven studies (5841 participants) that mobile text message reminders improved the rate of attendance at healthcare appointments compared to no reminders (risk ratio (RR) 1.14 (95% confidence interval (CI) 1.03 to 1.26)). There was also moderate quality evidence from three studies (2509 participants) that mobile text message reminders had a similar impact to phone call reminders (RR 0.99 (95% CI 0.95 to 1.02). Low quality evidence from one study (291 participants) suggests that mobile text message reminders combined with postal reminders improved the rate of attendance at healthcare appointments compared to postal reminders alone (RR 1.10 (95% CI 1.02 to 1.19)). Overall, the attendance to appointment rates were 67.8% for the no reminders group, 78.6% for the mobile phone messaging reminders group and 80.3% for the phone call reminders group. One study reported generally that there were no adverse effects during the study period; none of the studies reported in detail on specific adverse events such as loss of privacy, data misinterpretation, or message delivery failure. Two studies reported that the costs per text message per attendance were respectively 55% and 65% lower than costs per phone call reminder. The studies included in the review did not report on health outcomes or people's perceptions of safety related to receiving reminders by text message.

AUTHORS' CONCLUSIONS

Low to moderate quality evidence included in this review shows that mobile phone text messaging reminders increase attendance at healthcare appointments compared to no reminders, or postal reminders.Text messaging reminders were similar to telephone reminders in terms of their effect on attendance rates, and cost less than telephone reminders. However, the included studies were heterogeneous and the quality of the evidence therein is low to moderate. Further, there is a lack of information about health effects, adverse effects and harms, user evaluation of the intervention and user perceptions of its safety. The current evidence therefore still remains insufficient to conclusively inform policy decisions.There is a need for more high-quality randomised trials of mobile phone messaging reminders, that measure not only patients' attendance rates, but also focus on the cost-effectiveness of these interventions. Health outcomes, patients' and healthcare providers' evaluation and perceptions of the safety of the interventions, potential harms, and adverse effects of mobile phone messaging reminders should be assessed. Studies should report message content and timing in relation to the appointment.

STRUCTURAL AND HIDDEN BARRIERS TO A LOCAL PRIMARY HEALTH CARE INFRASTRUCTURE: AUTONOMY, DECISIONS ABOUT PRIMARY HEALTH CARE, AND THE CENTRALITY AND SIGNIFICANCE OF POWER

PURPOSE

To examine a local primary health care infrastructure and the reality of primary health care from the perspective of residents of a small, urban community in the southern United States.

METHODOLOGY/APPROACH

Data derive from 13 semi-structured focus groups, plus three semi-structured interviews, and were analyzed inductively consistent with a grounded theory approach.

FINDINGS

Structural barriers to the local primary health care infrastructure include transportation, clinic and appointment wait time, and co-payments and health insurance. Hidden barriers consist of knowledge about local health care services, non-physician gatekeepers, and fear of medical care. Community residents have used home remedies and the emergency department at the local academic medical center to manage these structural and hidden barriers.

RESEARCH LIMITATIONS/IMPLICATIONS

Findings might not generalize to primary health care infrastructures in other communities, respondent perspectives can be biased, and the data are subject to various interpretations and conceptual and thematic frameworks. Nevertheless, the structural and hidden barriers to the local primary health care infrastructure have considerably diminished the autonomy community residents have been able to exercise over their decisions about primary health care, ultimately suggesting that efforts concerned with increasing the access of medically underserved groups to primary health care in local communities should recognize the centrality and significance of power.

ORIGINALITY/VALUE

This study addresses a gap in the sociological literature regarding the impact of specific barriers to primary health care among medically underserved groups.

Traveling towards disease: transportation barriers to health care access

Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.

To attend or not attend? A critical review of the factors impacting on initial appointment attendance from an approach-avoidance perspective

BACKGROUND

A large proportion of initial therapy appointments are not attended. Whether this reflects service-user choice or an unmet need for therapy, non-attendance can impact on patients, therapists, services and research evaluation.

AIMS

To understand the complexities of this phenomenon, this paper reviews the mental health literature to gain further insight into how predictor variables can influence professional help-seeking decisions.

METHODS

This review reveals a modest success at identifying specific demographic and psychological factors, yet methodological issues surrounding data collection techniques have often led to contradictory and inconclusive findings.

CONCLUSIONS

This paper examines the possibility that approach-avoidance conflict [Kushner, M.G. & Sher, K.J. (1989, 1991). Fear of psychological treatment and its relation to mental health service avoidance. Professional Psychology: Research and Practice, 20, 251-257; The relation of treatment fearfulness and psychological service utilization: An overview. Professional Psychology: Research and practice, 22, 196-203] could explain the contradictions in the literature because, in this model, different factors involved in driving engagement versus avoidance become more salient depending on a dynamic interplay of timing, the individual and their service context. The core principles behind this approach-avoidance conceptualisation are explained and further avenues for research are identified.

Improving wait time for chemotherapy in an outpatient clinic at a comprehensive cancer center

PURPOSE

We conducted our study at the Ambulatory Treatment Center (ATC) of the MD Anderson Cancer Center, a network of six outpatient treatment units for patients receiving infusion therapies. Excessive patient wait time for chemotherapy was a primary source of ATC patient dissatisfaction. ATC employees expressed frustration, because often, patients arrived physically on time but were not treatment ready. Additionally, ATC staff emphasized challenges associated with obtaining finalized treatment orders for prescheduled appointments (ie, placeholder appointments without associated physician treatment orders). We aimed to decrease mean patient wait time from check-in to treatment in one ATC unit by 25%.

METHODS

We studied appointment cycle time in the ATC Green Unit, stratifying appointments by type (ie, prescheduled [no finalized treatment orders] and scheduled [finalized treatment orders]). We obtained mean wait times at baseline (control) and again after our intervention period. We conducted interviews and observations in ATC Green, from which we developed a three-part plan to reduce wait time: increase process efficiency within ATC Green, enhance communications with MD Anderson clinics and centers, and incorporate information technology applications.

RESULTS

After our intervention, we observed a 15% decrease in wait time for patients with prescheduled appointments and a 29% decrease for those with scheduled appointments. Overall, there was a 26.8% reduction in mean patient wait time relative to baseline (control).

CONCLUSION

We observed a significantly decreased mean patient wait time after implementing our intervention. This decrease may improve patient satisfaction, relieve employee frustration with appointment scheduling, and create opportunities for increasing institutional revenue.

Mobile phone messaging reminders for attendance at healthcare appointments

BACKGROUND

Missed appointments are a major cause of inefficiency in healthcare delivery, with substantial monetary costs for the health system, leading to delays in diagnosis and appropriate treatment. Patients' forgetfulness is one of the main reasons for missed appointments, and reminders may help alleviate this problem. Modes of communicating reminders for appointments to patients include face-to-face communication, postal messages, calls to landlines or mobile phones, and mobile phone messaging. Mobile phone messaging applications such as Short Message Service (SMS) and Multimedia Message Service (MMS) could provide an important, inexpensive delivery medium for reminders for healthcare appointments.

OBJECTIVES

To assess the effects of mobile phone messaging reminders for attendance at healthcare appointments. Secondary objectives include assessment of patients' and healthcare providers' evaluation of the intervention; costs; and possible risks and harms associated with the intervention.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2009, Issue 2), MEDLINE (OvidSP) (January 1993 to June 2009), EMBASE (OvidSP) (January 1993 to June 2009), PsycINFO (OvidSP) (January 1993 to June 2009), CINAHL (EbscoHOST) (January 1993 to June 2009), LILACS (January 1993 to June 2009) and African Health Anthology (January 1993 to June 2009). We also reviewed grey literature (including trial registers) and reference lists of articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised controlled trials (QRCTs), controlled before-after (CBA) studies, or interrupted time series (ITS) studies with at least three time points before and after the intervention. We included studies assessing mobile phone messaging as reminders for healthcare appointments. We only included studies in which it was possible to assess effects of mobile phone messaging independent of other technologies or interventions.  

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all studies against the inclusion criteria, with any disagreements resolved by a third review author. Study design features, characteristics of target populations, interventions and controls, and results data were extracted by two review authors and confirmed by a third author. Primary outcomes of interest were rate of attendance at healthcare appointments. We also considered health outcomes as a result of the intervention, patients' and providers' evaluation of the intervention, perceptions of safety, costs, and potential harms or adverse effects. As the intervention characteristics and outcome measures were similar across included studies, we conducted a meta-analysis to estimate an overall effect size.

MAIN RESULTS

We included four randomised controlled trials involving 3547 participants. Three studies with moderate quality evidence showed that mobile text message reminders improved the rate of attendance at healthcare appointments compared to no reminders (risk ratio (RR) 1.10 (95% confidence interval (CI) 1.03 to 1.17)). One low quality study reported that mobile text message reminders with postal reminders, compared to postal reminders, improved rate of attendance at healthcare appointments (RR 1.10 (95% CI 1.02 to 1.19)). However, two studies with moderate quality of evidence showed that mobile phone text message reminders and phone call reminders had a similar impact on healthcare attendance (RR 0.99 (95% CI 0.95 to 1.03). The costs per attendance of mobile phone text message reminders were shown to be lower compared to phone call reminders. None of the included studies reported outcomes related to harms or adverse effects of the intervention, nor health outcomes or user perception of safety related to the intervention.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that mobile phone text message reminders are more effective than no reminders, and low quality evidence that text message reminders with postal reminders are more effective than postal reminders alone. Further, according to the moderate quality evidence we found, mobile phone text message reminders are as effective as phone call reminders. Overall, there is limited evidence on the effects of mobile phone text message reminders for appointment attendance, and further high-quality research is required to draw more robust conclusions.

A qualitative exploration of smokers' views regarding aspects of a community-based mobile stop smoking service in the United Kingdom

Background

Developing more accessible stop smoking services (SSS) is important, particularly for reaching smokers from socio-economically deprived groups who are more likely to smoke and less likely to quit in comparison to their more affluent counterparts. A drop-in mobile SSS (MSSS) was piloted across 13 locations in socio-economically deprived areas of Nottingham.

Methods

Semi-structured telephone interviews were conducted to explore the views of 40 smokers who registered with the MSSS.

Results

The MSSS appeared to trigger quit attempts. For some of the participants the attempt was totally unplanned; for others, it built on pre-existing thoughts about quitting which had not yet been acted upon. Smokers interested in quitting were comfortable about approaching the MSSS, whilst acknowledging that they did not feel pressured to register with the service. The drop-in format of the MSSS was found to be more appealing than making an appointment. In addition, several participants articulated that they may not have utilised other SSS had they not come across the MSSS.

Conclusions

A MSSS may be an effective way to prompt quit attempts for smokers not planning to quit and also reach smokers who would not engage with SSS.