Missed antenatal diabetes care appointments and neonatal outcomes for pregnancies with Type 1 and Type 2 diabetes

BACKGROUND

There is limited information regarding the association between missed appointments and neonatal outcomes for diabetes in pregnancy.

STUDY METHODS

This retrospective live birth cohort included pregnant women with Type 1 or 2 diabetes who attended specialized clinics from 2008 to 2020. The association between at least one missed antenatal diabetes appointments and outcomes were assessed using logistic regression and reported as adjusted odds ratios (aOR) (95% confidence interval). Mediation analyses were conducted to examine if above target HbA1c mediated these relationships.

RESULTS

The cohort included 407 and 902 women with Type 1 and 2 diabetes, respectively, of whom 25.1% and 34.5% missed at least one appointment. Women with Type 1 diabetes who missed an appointment were more likely to have a caesarean section (aOR 1.95 [1.15, 3.31]) and their babies more likely to be admitted to the neonatal intensive care unit (aOR 2.25 [1.35, 3.75]). Women with Type 2 diabetes who missed an appointment were more likely to have a large-for-gestational-age infant (aOR 1.61 [1.13, 2.28]), and an extreme large-for-gestational-age infant (aOR 1.69 [1.02, 2.81]) compared with women who did not miss appointments. Above target HbA1c mediated the relationship between missed appointments and caesarean delivery in Type 1 diabetes and large-for-gestational age and extreme large-for-gestational age in Type 2 diabetes.

CONCLUSION

In individuals with Type 1 and 2 diabetes, there are differences in neonatal outcomes between those who missed an appointment compared to those who did not. It remains unclear if missed diabetes appointments are causative or a marker of other health behaviours or risk factors leading to neonatal morbidity.

Quality Improvement Project to Increase Postpartum Clinic Visits for Publicly Insured Women

OBJECTIVE

To increase the percentage of women who attend postpartum visits and decrease the number of days to the first postpartum visit by implementing a scheduling change.

DESIGN

Quality improvement project.

SETTING/LOCAL PROBLEM

A small nurse practitioner maternity care clinic in an academic health center at which only 74% of the women who attended two or more prenatal visits attended postpartum clinic visits.

PARTICIPANTS

A diverse sample of 25 publicly insured women who gave birth during the 5-month implementation period.

INTERVENTION/MEASUREMENTS

We added a 2- to 3-week postpartum appointment to our standard 6-week postpartum appointment. The measurable outcomes were the percentage of women who attended postpartum clinic visits and the number of days to the first postpartum visit.

RESULTS

During the first 4 months of the 5-month project implementation phase, 14 of the 20 (70%) women who gave birth attended postpartum visits. The attendance at postpartum visits in the last month of the project was 100% (all five women). Days to first postpartum visit decreased from a mean of 40.7 in the baseline year to a mean of 21.8 by the last month of project implementation.

CONCLUSION

Despite the small scope of this project, our outcomes support continuing the practice of scheduling an earlier postpartum clinic appointment. The timing for when to preschedule postpartum appointments and contextual factors, such as the availability and use of telehealth technology and COVID-19 pandemic challenges, should be considered when implementing similar projects in other settings.

Attend anywhere clinic: A virtual outpatient clinic experience in otolaryngology during the COVID-19 pandemic

INTRODUCTION

Numerous technological advances have been made during the COVID-19 pandemic. There has been a growing body of evidence highlighting the value of virtual consultations as an adjunct to physical appointments. This study presents the virtual clinic experiences of one ENT department in the UK.

METHODS

Retrospective review of all virtual consultations undertaken at a single ENT department during the COVID-19 pandemic.

RESULTS

A total of 556 virtual consultations took place during the study period across all ENT sub-specialties. Of which 27% of patients were converted to face-to-face follow-up and over 30% were discharged following a virtual consultation. Out of 333 video consultation, 31% were converted to telephone due to patient preference or technological difficulties.

CONCLUSION

This study highlights the benefits and lessons learnt from implementing a virtual clinic system in ENT. The authors recommend the introduction of video consultation as a useful adjunct to face-to-face appointments during the COVID-19 pandemic and beyond.

LEVEL OF EVIDENCE

4.

Patient-Centered Appointment Scheduling: a Call for Autonomy, Continuity, and Creativity

When making an appointment, patients are generally unaware of how much clinician time is available to address their concerns. Similarly, the primary care clinician is often unaware of what the patient expects to accomplish during the visit, leading to uncertainty about how much time they can allot to each sequentially appearing concern, and whether they can reasonably expect to address necessary preventive services and chronic disease management. Neither patient nor clinician expectations can be adequately managed through standardized scheduling templates, which assign a fixed appointment length based on a single stated reason for the visit. As such, standardized appointment scheduling may contribute to inefficient use of valuable face-to-face time, patient and clinician dissatisfaction, and low-value care. Herein, we suggest several potential mechanisms for improving the scheduling process, including (1) entrusting scheduling to the primary care team; (2) advance visit planning; (3) pro-active engagement of ancillary team members including behavioral health, nursing, social work, and pharmacy; and (4) application of innovative, technologically advanced solutions such as telehealth and artificial intelligence to the scheduling process. These changes have the potential to improve efficiency, patient and clinician satisfaction, and health outcomes, while decreasing low-value testing and return visits for unaddressed concerns.

Determining the impact of a clinic coordinator on patient access and clinic efficiency in a pediatric multidisciplinary spina bifida clinic using medical informatics

PURPOSE

The objective of this study was to analyze the effects on patient access by decreasing missed appointments after hiring a clinic coordinator using medical informatics.

METHODS

A single-center retrospective analysis of the rates of missed appointments before and after hiring a clinic coordinator in a multidisciplinary spinal differences clinic were analyzed using a commercially available business software system (SAP® Business Objects). The total number of clinic visits was collected for each month to determine the access available for patients.

RESULTS

The median number of missed appointments per clinic by month before employing the clinic coordinator was higher than in the two years following implementation (p < 0.0005). No differences were seen in the number of available appointment slots per month indicating no new clinics were needed to improve patient access (p = 0.551). Projected billing amounts prior to hiring the clinic coordinator indicated that $91,520 was lost in the 2 years prior to hiring this coordinator compared to $30,160 lost during the 2 years following the creation of this position (p = 0.0009).

CONCLUSION

Hiring a clinic coordinator decreased the rate of missed appointments and was a cost-efficient intervention to improve patient access and provide effective patient care in a multidisciplinary setting.

Building a Brain Tumor Practice: Objective Analysis of Referral Patterns and Implications for the Growth of a Subspecialty Surgical Program

Introduction Growth of surgical caseload among specialties with a large contribution margin is an important financial objective for hospitals. In this study, we examined the diversity of referral patterns to a neurosurgeon over an eight-year interval and examined practice attributes related to surgical growth. Methods The electronic records of all patients undergoing an intracranial surgical procedure between August 2011 and August 2019 by an academic neurosurgeon were reviewed retrospectively. The Herfindahl-Hirschman index (HHI) was used to assess the distribution of referrals among community physicians who referred such patients; a value of HHI <0.15 indicates diversity. The yearly HHI trend was evaluated using meta-regression. Results The neurosurgeon's brain surgery caseload progressively increased on an annual basis from 1.4 to 12.5 cases per week between 2012 and 2018. Among the 1540 cases referred by 1775 different physicians, 78% were from three counties in southeast Florida and 8.1% from two counties in southwest Florida. The HHI declined between 2013 and 2018 by 0.023 per year (0.0046 standard error [SE], p = 0.0073) with the estimated value 0.0063 (0.0014 SE) < 0.15 in 2018 (p < 0.0001). The findings indicate that the base of referring physicians was highly diverse and that growth in caseload was accompanied by significantly less concentration of referrals. Conclusion Surgical growth in the neurosurgeon's practice resulted from a small number of referrals from many physicians, not from many referrals from a small number of physicians. Few physicians referred a sufficient number of patients to warrant attribution of the referral itself to personal knowledge of their patients' eventual outcomes. Rather, factors promoting timely access to patient care appear to have been the driving force for growth.

Managing Alternative Patient Appointments Using P-Graph Methodology

BACKGROUND

Patient appointment scheduling is one of the main challenging tasks in the healthcare administration and is constantly in the focus of theoretical researches.

OBJECTIVES

The aim of this study was to investigate the applicability of the P-graph (Process graph) methodology to find the n-best alternative for patient's scheduling.

METHODS

The patient appointment scheduling task was formalised as an integer linear programming problem and was considered as a process network synthesis problem. The optimal and n-best alternative solutions were determined by an efficient branch and bound algorithm implemented in a decision support system.

RESULTS

Experimental results show, that the P-graph methodology can be effectively applied to produce the optimal scheduling for the examinations and to find the alternatives of the best scheduling.

General practice recording of adverse childhood experiences: a retrospective cohort study of GP records

BACKGROUND

Adverse childhood experiences (ACEs) are linked to negative health outcomes in adulthood. Poor engagement with services may, in part, mediate the association between adverse outcomes and ACEs. While appointment recording is comprehensive, it is not yet known if or how ACEs are recorded in the GP clinical record (GPR).

AIM

To investigate recording of ACEs in the GPR and assess associations between available ACE-related Read codes and missed appointments.

DESIGN & SETTING

Retrospective cohort study of 824 374 anonymised GPRs. Nationally representative sample of 136 Scottish general practices; data collected 2013-2016.

METHOD

Read codes were mapped onto ACE questionnaire and wider ACE-related domains. Natural language processing (NLP) was used to augment capture of non-Read-coded ACEs. Frequency counts and proportions of mapped codes, and associations of these with defined levels of missing GP appointments, are reported.

RESULTS

In total, 0.4% of patients had a record of any code that mapped onto the ACE questionnaire, contrasting with survey-reported rates of 47% in population samples. This increased only modestly by including inferred ACEs that related to safeguarding children concerns, wider aspects of ACEs, and adult consequences of ACEs. Augmentation via NLP did not substantially increase capture. Despite poor recording, there was an association between ever having an ACE code recorded and higher rates of missing GP appointments.

CONCLUSION

General practices would require substantial support to implement the recording of ACEs in the GPR. This study adds to the evidence that patients who often miss appointments are more likely to be socially vulnerable.

How does the duration of consults vary for upper respiratory tract infections in general practice where an antibiotic has been prescribed?

BACKGROUND

There is limited data on the duration of consults resulting in the prescription of antibiotics for upper respiratory tract infections (URTIs) in general practice.

OBJECTIVE

To explore how demographic factors influence consult duration where antibiotics have been prescribed for URTI in Australian general practice.

METHODS

2985 URTI-specific presentations were identified from a national study of patients who were prescribed an antibiotic after presenting to general practice between June and September 2017. Consult duration was analysed to assess for any variation in visit length based on demographic factors.

RESULTS

The overall median consult duration was 11.42 minutes [interquartile range (IQR) 7.95]. Longer consult duration was associated with areas of highest socio-economic advantage where patients living in postcodes of Index of Relative Socio-economic Advantage and Disadvantage (IRSAD) Quintile 5 (highest 20% on the IRSAD) had significantly longer consults [median 13.12 (IQR 8.01)] than all other quintiles (P < 0.001). Females [11.75 (IQR 8.13)] had significantly longer consults than males [10.87 (IQR 7.57); P < 0.001]. Clinics based in State C and State F had significantly shorter consults when compared with all other included states and territories (P < 0.001) and shorter consult duration was associated with visits on Sundays [median 8.18 (IQR 5.04)].

CONCLUSION

There is evidence for the association of demographic and temporal factors with the duration of consultations for URTIs where an antibiotic has been prescribed. These factors warrant further research.

Effects of Tinnitus on Cochlear Implant Programming

Clinical observations suggest that tinnitus may interfere with programming cochlear implants (CIs), the process of optimizing the transmission of acoustic information to support speech perception with a CI. Despite tinnitus being highly prevalent among CI users, its effects and impact on CI programming are obscure. This study characterized the nature, time-course, and impact of tinnitus effects encountered by audiologists and patients during programming appointments. Semistructured interviews with six CI audiologists were analyzed thematically to identify tinnitus effects on programming and related coping strategies. Cross-sectional surveys with 67 adult CI patients with tinnitus and 20 CI audiologists in the United Kingdom examined the prevalence and time-course of those effects. Programming parameters established at CI activation appointments of 10 patients with tinnitus were compared with those of 10 patients without tinnitus. On average, 80% of audiologists and 45% of patients reported that tinnitus makes measurements of threshold (T) levels more difficult because patients confuse their tinnitus with CI stimulation. Difficulties appeared most common at CI activation appointments, at which T levels were significantly higher in patients with tinnitus. On average, 26% of patients reported being afraid of “loud” CI stimulation worsening tinnitus, affecting measurements of loudest comfortable (C) stimulation levels, and 34% of audiologists reported observing similar effects. Patients and audiologists reported that tinnitus makes programming appointments more difficult and tiresome for patients. The findings suggest that specific programming strategies may be needed during CI programming with tinnitus, but further research is required to assess the potential impact on outcomes including speech perception.

Why Patients Miss Scheduled Outpatient Appointments at Urban Academic Residency Clinics: A Qualitative Evaluation

INTRODUCTION

Missed outpatient appointments are a common problem for academic residency clinics, and reducing their rate improves office efficiency, income, and resident education. Identifying specific reasons why some patients miss outpatient appointments may provide insight into developing targeted approaches to reducing their rates. This study sought to find reasons associated with patients' missed appointments at two family medicine residency clinics.

METHODS

The study utilized a qualitative research design involving patients at two urban, university-affiliated family medicine residency outpatient clinics. Twenty-five randomly selected patients who were dismissed from the clinics for missing three or more scheduled appointments during a five-year span (July 2012 to July 2017) were interviewed over the phone about reasons they did not keep their scheduled clinic appointments. The authors, individually and as a group, used an immersion-crystalization approach to analyze the content of the interviews.

RESULTS

Responses from 25 participants (21 females and four males) are presented. Fifty-two percent of patients were Caucasian, 32% Black, 12% Hispanic, and 4% Asian. Five themes emerged from the data analysis as major reasons the patients missed their scheduled outpatient appointments: forgetfulness, transportation issues, personal health issues, family and employer obligations, and other issues, such as anticipated long clinic wait times, bad weather, and financial problems.

CONCLUSIONS

The findings showed there are several logistical, situational, and clinical reasons for patients' missed scheduled outpatient appointments.

Medicaid Patients Have Greater Difficulty Scheduling Health Care Appointments Compared With Private Insurance Patients: A Meta-Analysis

Medicaid patients are known to have reduced access to care compared with privately insured patients; however, quantifying this disparity with large controlled studies remains a challenge. This meta-analysis evaluates the disparity in health services accessibility of appointments between Medicaid and privately insured patients through audit studies of health care appointments and schedules. Audit studies evaluating different types of outpatient physician practices were selected. Studies were categorized based on the characteristics of the simulated patient scenario. The relative risk of appointment availability was calculated for all different types of audit scenario characteristics. As a secondary analysis, appointment availability was compared pre- versus post-Medicaid expansion. Overall, 34 audit studies were identified, which demonstrated that Medicaid insurance is associated with a 1.6-fold lower likelihood in successfully scheduling a primary care appointment and a 3.3-fold lower likelihood in successfully scheduling a specialty appointment when compared with private insurance. In this first meta-analysis comparing appointment availability between Medicaid and privately insured patients, we demonstrate Medicaid patients have greater difficulty obtaining appointments compared with privately insured patients across a variety of medical scenarios.

Low and Higher Wage Workers Report No Differences in Four Barriers to Primary Care Access

Lower wage workers, known to seek more care in the emergency department (ED), may encounter more barriers to timely outpatient primary care. This study aimed to identify differences in self-reported delays in care related to 4 modifiable barriers (phone availability, appointment wait time, in-clinic wait time, and limited service hours) across self-reported wage and to examine the relationship between these care delays and self-reported ED use. The authors examined data from the 2011-2015 National Health Interview Surveys for 58,298 self-identified full-time workers. Multivariable logistic models with geographical region and year fixed effects were used to test the association of wage group and barriers to care. In addition, the multiplicative and additive interaction effects upon self-reported ED use were tested. No association was observed between wage level and barrier to timely care. Lower wage workers (<$25,000 vs. >$75,000/yr.; OR 1.53, 95% CI 1.20-1.94, P = 0.001) and those reporting any of the 4 barriers to care (OR 1.99, 95% CI 1.71-1.94, P < 0.001) were more likely to report 2 or more ED visits in the past year. Multiplicative effects were not statistically significant. Additive interaction effects of wage and barriers were only significant among workers with wages $35,000-$44,999 annually (vs. >$75,000: relative excess risk coef. 1.23, 95% CI 0.07-2.38, P = 0.037) for 2 or more ED visits in past year. Although these modifiable barriers may explain the differences in repeat ED use for workers earning $35,000-$44,999 annually, these barriers do not explain disparities in ED use between highest and lowest wage workers.

A Mobile Health Intervention for Prostate Biopsy Patients Reduces Appointment Cancellations: Cohort Study

BACKGROUND

Inadequate patient education and preparation for office-based procedures often leads to delayed care, poor patient satisfaction, and increased costs to the health care system. We developed and deployed a mobile health (mHealth) reminder and education program for patients scheduled for transrectal prostate biopsy.

OBJECTIVE

We aimed to evaluate the impact of an mHealth reminder and education program on appointment cancellation rates, communication frequency, and patient satisfaction.

METHODS

We developed a text message (SMS, short message service)-based program with seven reminders containing links to Web-based content and surveys sent over an 18-day period (14 days before through 3 days after prostate biopsy). Messages contained educational content, reminders, and readiness questionnaires. Demographic information, appointment cancellations or change data, and patient/provider communication events were collected for 6 months before and after launching the intervention. Patient satisfaction was evaluated in the postintervention cohort.

RESULTS

The preintervention (n=473) and postintervention (n=359) cohorts were composed of men of similar median age and racial/ethnic distribution living a similar distance from clinic. The postintervention cohort had significantly fewer canceled or rescheduled appointments (33.8% vs 21.2%, P<.001) and fewer same-day cancellations (3.8% vs 0.5%, P<.001). There was a significant increase in preprocedural telephone calls (0.6 vs 0.8 calls per patient, P=.02) in the postintervention cohort, but not a detectable change in postprocedural calls. The mean satisfaction with the program was 4.5 out of 5 (SD 0.9).

CONCLUSIONS

An mHealth periprocedural outreach program significantly lowered appointment cancellation and rescheduling and was associated with high patient satisfaction scores with a slight increase in preprocedural telephone calls. This led to fewer underused procedure appointments and high patient satisfaction.

Online referral and immediate appointment selection system empowers families and improves access to public community paediatric clinics

AIM

We aimed to introduce a low-cost combined online referral and immediate appointment selection system (CORIAS) to empower referrers and parents by allowing them to schedule an appointment at a time and location of their choosing in conjunction with the referrer at the time of referral. This was because an unacceptably high rate of reported lost referrals, combined with a high rate of failure to attend initial appointments (FTAs), was noted at a six-site community paediatric clinic service. We aimed to analyse the impact of CORIAS on important outcomes including timely appointment scheduling, attendance, loss of referrals, user acceptance, overall cost and administrative burden.

METHODS

For 3-month periods before and after the implementation of CORIAS, data were collected regarding all new referrals received and initial appointments scheduled, as well as reports of lost referrals. The number of attended initial appointments, FTAs, failures in successfully scheduling appointments, referrer background, CORIAS cost and qualitative feedback received from relevant parties was collated and analysed.

RESULTS

The proportion of referrals reported lost was 6% following the implementation of the combined online system in comparison to 17% pre-implementation. The FTA rate for scheduled initial appointments pre-implementation was 16%; post-implementation, the FTA rate was 9%. Qualitative benefits included a decrease in the administrative burden associated with appointment scheduling and increased service access for culturally and linguistically diverse families.

CONCLUSION

Appropriately designed and implemented novel online systems may improve timely and equitable access to health care by providing secure, reliable pathways for referrers and by empowering and improving communication with patients and families.

Patient trade-offs between continuity and access in primary care interprofessional teaching clinics in Canada: a cross-sectional survey using discrete choice experiment

OBJECTIVE

Timely access to care and continuity with a specific provider are important determinants of patient satisfaction when booking appointments in primary care settings. Advanced access booking systems restrict the majority of providers' appointment spots for same-day appointments and keep the number of prebooked appointments to a minimum. In the teaching clinic environment, continuity with the same provider can be a challenge. This study examines trade-offs that patients may consider during appointment bookings for six different clinical scenarios across a number of key access and continuity attributes using a discrete choice experiment (DCE) method.

DESIGN

Cross-sectional survey.

SETTING

Two urban family medicine teaching clinics in Canada.

PARTICIPANTS

Convenience sample of 430 patients of family medicine clinics aged 18 and older.

INTERVENTION

Discrete choice conjoint experiment survey.

PRIMARY OUTCOME MEASURES

Patient preferences on six attributes: appointment booking method, appointment wait time, time spent in the waiting room, appointment time convenience, familiarity with healthcare provider and position of healthcare provider. Data were analysed by hierarchical Bayes analysis to determine estimates of part-worth utilities for each respondent.

RESULTS

Patients rated appointment wait time as the most highly valued attribute, followed by position of provider, then familiarity with the provider. Patients showed a significant preference (p<0.02) for their own physician for booking of routine annual check-ups and other logical preferences across attributes overall and by clinical scenario.

CONCLUSIONS

Patients preferred timely access to their primary care team over other attributes in the majority of health state scenarios tested, especially urgent issues, however they were willing to wait for a check-up. These results support the notion that advanced access booking systems which leave the majority of appointment spots for same day access and still leave a few for continuity (check-up) bookings, align well with trends in patient preferences.

Features of Online Hospital Appointment Systems in Taiwan: A Nationwide Survey

BACKGROUND

In the Internet era, many web-based appointment systems for hospitals have been established to replace traditional systems. Our study aimed to highlight the features of online appointment systems for hospitals in Taiwan, where patients can visit outpatient departments without a referral.

METHODS

All hospitals online appointment systems were surveyed in October 2018. Features of first-visit registrations were analyzed and stratified according to the hospitals' accreditation levels.

RESULTS

Of the 417 hospitals, 59.7% (249) had public online appointment systems. For first-visit patients, only 199 hospitals offered the option of making appointments online from 7 to 98 (mean 38.9) days prior to the appointment itself. Before appointments, 68 (34.2%) hospitals recommended specialties for patients to choose according to their symptoms, and only 11 (5.5%) had a function for sending messages to doctors. After appointments, 176 (88.4%) provided links to real-time monitoring of outpatient service progress.

CONCLUSIONS

More than half of the hospitals in Taiwan have public online appointment systems. However, most of these systems simply fulfill the function of registration, and rarely take the opportunity to improve efficiency by gathering information regarding patients' medical history or reasons for making the appointment.

Qualitative study of patient views on a 'telephone-first' approach in general practice in England: speaking to the GP by telephone before making face-to-face appointments

OBJECTIVE

To understand patients' views on a 'telephone-first' approach, in which all appointment requests in general practice are followed by a telephone call from the general practitioner (GP).

DESIGN

Qualitative interviews with patients and carers.

SETTING

Twelve general practices in England.

PARTICIPANTS

43 patients, including 30 women, nine aged over 75 years, four parents of young children, five carers, five patients with hearing impairment and two whose first language was not English.

RESULTS

Patients expressed varied views, often strongly held, ranging from enthusiasm for to hostility towards the 'telephone-first' approach. The new system suited some patients, avoiding the need to come into the surgery but was problematic for others, for example, when it was difficult for someone working in an open plan office to take a call-back. A substantial proportion of negative comments were about the operation of the scheme itself rather than the principles behind it, for example, difficulty getting through on the phone or being unable to schedule when the GP would phone back. Some practices were able to operate the scheme in a way that met their patients' needs better than others and practices varied significantly in how they had implemented the approach.

CONCLUSIONS

The 'telephone-first' approach appears to work well for some patients, but others find it much less acceptable. Some of the reported problems related to how the approach had been implemented rather than the 'telephone-first' approach in principle and suggests there may be potential for some of the challenges experienced by patients to be overcome.

Evaluating the Effectiveness of Text Messaging and Phone Call Reminders to Minimize No Show at Pediatric Outpatient Clinics in Pakistan: Protocol for a Mixed-Methods Study

BACKGROUND

Missing health care appointments without canceling in advance results in a no show, a vacant appointment slot that cannot be offered to others. No show can be reduced by reminding patients about their appointment in advance. In this regard, mobile health (mHealth) strategy is to use text messaging (short message service, SMS), which is available on all cellular phones, including cheap low-end handsets. Nonattendance for appointments in health care results in wasted resources and disturbs the planned work schedules.

OBJECTIVES

The purpose of this study is to evaluate the efficacy of the current text messaging (SMS) and call-based reminder system and further explore how to improve the attendance at the pediatric outpatient clinics. The primary objectives are to (1) determine the efficacy of the current clinic appointment reminder service at pediatric outpatient clinics at Aga Khan University Hospital, (2) assess the mobile phone access and usage among caregivers visiting pediatrics consultant clinics, and (3) explore the perception and barriers of parents regarding the current clinic appointment reminder service at the pediatric outpatient clinics at Aga Khan University Hospital.

METHODS

The study uses a mixed-method design that consists of 3 components: (1) retrospective study (component A) which aims to determine the efficacy of text messaging (SMS) and phone call-based reminder service on patient's clinic attendance during January to June 2017 (N=58,517); (2) quantitative (component B) in which a baseline survey will be conducted to assess the mobile phone access and usage among parents/caregivers of children visiting pediatrics consultant clinics (n=300); and (3) qualitative (component C) includes in-depth interviews and focus group discussion with parents/caregivers of children visiting the pediatric consultancy clinic and with health care providers and administrative staff. Main constructs will be to explore perceptions and barriers related to existing clinic appointment reminder service. Ethics approval has been obtained from the Ethical Review Committee, Aga Khan University, Pakistan (4770-Ped-ERC-17).

RESULTS

Results will be disseminated to pediatric quality public health and mHealth communities through scientific meetings and through publications, nationally and internationally.

CONCLUSIONS

This study will provide insight regarding efficacy of using mHealth-based reminder services for patient's appointments in low- and middle-income countries setup. The finding of this study will be used to recommend further enhanced mHealth-based solutions to improve patient appointments and decrease no show.

Factors Affecting Missed Appointments in a Pediatric Urology Outpatient Clinic

INTRODUCTION

Missed appointments can have an adverse effect on patient care and clinic efficiency. We hypothesized that increased fuel costs and travel distance, nonchronic health conditions, different seasons, government subsidized insurance and older age would result in higher no-show rates in our pediatric urology outpatient clinic.

METHODS

We retrospectively reviewed 1,315 consecutive scheduled visits from 514 patients during 2008 to 2009. Patient arrival status was recorded, as well as demographic data, chief complaint, type of visit, the month and day of the week of the scheduled appointment, and distance traveled. The average gas price at the time of the appointment was also recorded. A logistic regression model analysis fitted by the method of generalized estimating equations was used to determine correlations of the outcome with a single independent variable. Factors that had an association with p <0.10 were then included in a multifactor logistic model fitted by the generalized estimating equation method.

RESULTS

The overall rate of no-shows was 39%. On multifactor analysis the variables associated with higher rates of missed appointments included increasing patient age (p <0.01), having federal insurance (p=0.04), being uninsured (p <0.01), nonchronic conditions (p=0.03), return visits (p <0.01), Friday appointments (p=0.04) and summer appointments (p=0.05).

CONCLUSIONS

No-show rates varied by multiple factors such as age, insurance status, chief complaint and new or return status. Contrary to conventional wisdom, distance traveled and gas prices were not associated with missed appointments. This pilot information may present an opportunity to improve clinic efficiency and improve patient access.

Characteristics of children who do not attend their hospital appointments, and GPs' response: a mixed methods study in primary and secondary care

BACKGROUND

Children who do not attend (DNA) their hospital outpatient appointments are a concern because this potentially compromises the child's health and incurs financial cost. Little is known about children who DNA or the views of GPs to non-attendance.

AIM

To describe the characteristics of children who DNA hospital paediatric outpatient appointments, and explore how GPs view and respond to DNAs.

DESIGN AND SETTING

A mixed methods study of data from all new referrals to a children's hospital in the South West of England between 1 September and 31 October 2012.

METHOD

Data were extracted from patients' hospital and GP records, and Stata was used to analyse the data quantitatively. Analysis focused on describing the characteristics of children who DNA, and the process of care that followed. Practices that had either the highest or lowest number of DNAs were purposefully sampled for GPs who had referred children to secondary care at the study hospital within the previous year. Interviews were held between May 2014 and July 2015, and were analysed thematically.

RESULTS

Children who DNA are more likely to be from an area of greater deprivation (adjusted odds ratio [AOR] 1.02, 95% confidence interval [CI] = 1.00 to 1.02, P = 0.04), and with a child protection alert in their hospital notes (AOR 2.72, 95% CI = 1.26 to 5.88, P = 0.01). Non-attendance is communicated poorly to GPs, rarely coded in patients' GP records, and few GP practices have a formal policy regarding paediatric DNAs.

CONCLUSION

Non-attendance at hospital outpatient appointments may indicate a child's welfare is at risk. Communication between primary and secondary care needs to be improved, and guidelines developed to encourage GPs to monitor children who DNA.

Web-Based Medical Appointment Systems: A Systematic Review

Background

Health care is changing with a new emphasis on patient-centeredness. Fundamental to this transformation is the increasing recognition of patients' role in health care delivery and design. Medical appointment scheduling, as the starting point of most non-urgent health care services, is undergoing major developments to support active involvement of patients. By using the Internet as a medium, patients are given more freedom in decision making about their preferences for the appointments and have improved access.

Objective

The purpose of this study was to identify the benefits and barriers to implement Web-based medical scheduling discussed in the literature as well as the unmet needs under the current health care environment.

Methods

In February 2017, MEDLINE was searched through PubMed to identify articles relating to the impacts of Web-based appointment scheduling.

Results

A total of 36 articles discussing 21 Web-based appointment systems were selected for this review. Most of the practices have positive changes in some metrics after adopting Web-based scheduling, such as reduced no-show rate, decreased staff labor, decreased waiting time, and improved satisfaction, and so on. Cost, flexibility, safety, and integrity are major reasons discouraging providers from switching to Web-based scheduling. Patients’ reluctance to adopt Web-based appointment scheduling is mainly influenced by their past experiences using computers and the Internet as well as their communication preferences.

Conclusions

Overall, the literature suggests a growing trend for the adoption of Web-based appointment systems. The findings of this review suggest that there are benefits to a variety of patient outcomes from Web-based scheduling interventions with the need for further studies.

Investigating the relationship between consultation length and patient experience: a cross-sectional study in primary care

BACKGROUND

Longer consultations in primary care have been linked with better quality of care and improved health-related outcomes. However, there is little evidence of any potential association between consultation length and patient experience.

AIM

To examine the relationship between consultation length and patient-reported communication, trust and confidence in the doctor, and overall satisfaction.

DESIGN AND SETTING

Analysis of 440 videorecorded consultations and associated patient experience questionnaires from 13 primary care practices in England.

METHOD

Patients attending a face-to-face consultation with participating GPs consented to having their consultations videoed and completed a questionnaire. Consultation length was calculated from the videorecording. Linear regression (adjusting for patient and doctor demographics) was used to investigate associations between patient experience (overall communication, trust and confidence, and overall satisfaction) and consultation length.

RESULTS

There was no evidence that consultation length was associated with any of the three measures of patient experience (P >0.3 for all). Adjusted changes on a 0-100 scale per additional minute of consultation were: communication score 0.02 (95% confidence interval [CI] = -0.20 to 0.25), trust and confidence in the doctor 0.07 (95% CI = -0.27 to 0.41), and satisfaction -0.14 (95% CI = -0.46 to 0.18).

CONCLUSION

The authors found no association between patient experience measures of communication and consultation length, and patients may sometimes report good experiences from very short consultations. However, longer consultations may be required to achieve clinical effectiveness and patient safety: aspects also important for achieving high quality of care. Future research should continue to study the benefits of longer consultations, particularly for patients with complex multiple conditions.

Weekend opening in primary care: analysis of the General Practice Patient Survey

BACKGROUND

Seven-day opening in primary care is a key policy for the UK government. However, it is unclear if weekend opening will meet patients' needs or lead to additional demand.

AIM

To identify patient groups most likely to use weekend opening in primary care.

DESIGN AND SETTING

The General Practice Patient Survey 2014, which sampled from all general practices in England, was used.

METHOD

Logistic regression was used to measure the associations between perceived benefit from seeing or speaking to someone at the weekend and age, sex, deprivation, health conditions, functioning, work status, rurality, and quality of life.

RESULTS

Out of 881 183 participants who responded to the questionnaire, 712 776 (80.9%) did not report any problems with opening times. Of the 168 407 responders (19.1%) who reported inconvenient opening times, 73.9% stated that Saturday opening, and 35.8% Sunday opening, would make it easier for them to see or speak to someone. Only 2.2% of responders reported that Sunday, but not Saturday, opening would make it easier for them. Younger people, those who work full time, and those who could not get time off work were more likely to report that weekend opening would help. People with Alzheimer's disease, learning difficulties, or problems with walking, washing, or dressing were less likely to report that weekend opening would help.

CONCLUSION

Most people do not think they need weekend opening, but it may benefit certain patient groups, such as younger people in full-time work. Sunday opening, in addition to Saturday, is unlikely to improve access.

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.

Patient demographics as a predictive tool of consultation duration

This paper reports on a study undertaken to test the hypothesis that known patient demographics will be a reasonably reliable predictor of the duration of a patient's consultation with a general practitioner, regardless of the medical experience of an individual physician.

A longitudinal linear model of patient characteristics to predict failure to attend an inner-city chronic pain clinic

Patients often fail to attend appointments in chronic pain clinics for unknown reasons. We hypothesized that certain patient characteristics predict failure to attend scheduled appointments, pointing to systematic barriers to accessing chronic pain services for certain underserved populations. We collected retrospective data from a longitudinal observational cohort of patients at an academic pain clinic in Newark, New Jersey. To examine the effect of demographic factors on appointment status, we fit a marginal logistic regression using generalized estimating equations with exchangeable correlation. A total of 1,394 patients with 3,488 total encounters between January 1, 2006, and December 31, 2009, were included. Spanish spoken as a primary language (alternatively Hispanic or other race) and living between 5 and 10 miles from the clinic were associated with reduced odds of arriving for an appointment; making an appointment for a particular complaint such as cancer pain or back pain, an interventional pain procedure scheduled in connection with the appointment, unemployed status, and continuity of care (as measured by office visit number) were associated with increased odds of arriving. Spanish spoken as a primary language and distance to the pain clinic predicted failure to attend a scheduled appointment in our cohort. If these constitute systematic barriers to access, they may be amenable to targeted interventions.

PERSPECTIVE

We identified certain patient characteristics, specifically Spanish spoken as a primary language and geographic distance from the clinic, that predict failure to attend an inner-city chronic pain clinic. These identified barriers to accessing chronic pain services may be modifiable by simple cost-effective interventions.

Walk-in clinics in Quebec, Canada: patients and doctors do not agree on appropriateness of visits

INTRODUCTION

Walk-in clinics aim to be highly accessible facilities, in particular for urgent primary care cases. A perceived increase of walk-in clinic visits in Canada could put this accessibility at risk. We aimed to study the appropriateness of walk-in clinic visits in Québec, Canada.

METHODS

We performed a cross-sectional pilot study in Montréal and surrounding areas, Québec, in 2012, in which both patients and either family physicians or family medicine residents completed a questionnaire about the walk-in clinic visit, including the rating of appropriateness on a three-level scale and patients' motives. Patients' and doctors' surveys were matched for their corresponding visits and next analysed for their agreement on appropriateness of visits by kappa statistic. Influence of modifying factors on appropriateness ratings was analysed by Pearson's chi-square testing.

RESULTS

A total of 142 visits were included. Physicians judged more than half of the visits as appropriate, whereas most patients scored their visits' urgency as low or medium. Agreement between both scores by kappa statistics was low (0.05) and non-significant. Visits were rated less appropriate in evenings, in teaching hospitals and by less-experienced doctors (mainly working in teaching hospitals). Common motives for visiting the walk-in clinics included worries about symptoms getting worse, persistence of symptoms and not being able to get regular appointments.

CONCLUSION

In our study, doctors rated most visits to walk-in clinics as appropriate, whereas most patients rated the same visits' urgency as medium or low. Doctors in Québec appear to judge patient factors like worries and logistics as legitimate reasons for attending these facilities.

Can we predict a national profile of non-attendance paediatric urology patients: a multi-institutional electronic health record study

BACKGROUND

Non-attendance at paediatric urology outpatient appointments results in the patient's failure to receive medical care and wastes health care resources.

OBJECTIVE

To determine the utility of using routinely collected electronic health record (EHR) data for multi-centre analysis of variables predictive of patient noshows (NS) to identify areas for future intervention.

METHODS

Data were obtained from Children's Hospital Colorado, Rady Children's Hospital San Diego and University of Virginia Hospital paediatric urology practices, which use the Epic® EHR system. Data were extracted for all urology outpatient appointments scheduled from 1 October 2010 to 30 September 2011 using automated electronic data extraction techniques. Data included appointment type; date; provider type and days from scheduling to appointment. All data were de-identified prior to analysis. Predictor variables identified using χ(2) and analysis of variance were modelled using multivariate logistic regression.

RESULTS

A total of 2994 NS patients were identified within a population of 28,715, with a mean NS rate of 10.4%. Multivariate logistic regression determined that an appointment with mid-level provider (odds ratio (OR) 1.70 95% CI (1.56, 1.85)) and an increased number of days between scheduling and appointment (15-28 days OR 1.24 (1.09, 1.41); 29+ days OR 1.70 (1.53, 1.89)) were significantly associated with NS appointments.

CONCLUSION

We demonstrated sufficient interoperability among institutions to obtain data rapidly and efficiently for use in 1) interventions; 2) further study and 3) more complex analysis. Demographic and potentially modifiable clinic characteristics were associated with NS to the outpatient clinic. The analysis also demonstrated that available data are dependent on the clinical data collection systems and practices.

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.

Physician office vs retail clinic: patient preferences in care seeking for minor illnesses

PURPOSE

Retail clinics are a relatively new phenomenon in the United States, offering cheaper and convenient alternatives to physician offices for minor illness and wellness care. The objective of this study was to investigate the effects of cost of care and appointment wait time on care-seeking decisions at retail clinics or physician offices.

METHODS

As part of a statewide random-digit-dial survey of households, adult residents of Georgia were interviewed to conduct a discrete choice experiment with 2 levels each of 4 attributes: price ($59; $75), appointment wait time (same day; 1 day or longer), care setting-clinician combination (nurse practitioner in retail clinic; physician in private office), and acute illness (urinary tract infection [UTI]; influenza). The respondents indicated whether they would seek care under each of the 16 resulting choice scenarios. A cooperation rate of 33.1% yielded 493 completed telephone interviews.

RESULTS

The respondents preferred to seek care for both conditions; were less likely to seek care for UTI (beta = -0.149; P = .008); preferred to seek care from a physician (beta = 1.067; P < .001) and receive same day care (beta = -2.789; P < .001). All else equal, cost savings of $31.42 would be required for them to seek care at a retail clinic and $82.12 to wait 1 day or more.

CONCLUSIONS

Time and cost savings offered by retail clinics are attractive to patients, and they are likely to seek care there given sufficient cost savings. Appointment wait time is the most important factor in care-seeking decisions and should be considered carefully in setting appointment policies in primary care practices.

Reduction and management of no-shows by family medicine residency practice exemplars

PURPOSE

We wanted to describe the methods used by family medicine residency practices with low no-show rates (rate exemplars) and those able to keep visit rates high despite no-shows (management exemplars).

METHODS

Program directors of US family medicine residency programs were asked to respond to a survey questionnaire. Telephone interviews were conducted with the administrators of rate exemplars (no-show rates of 10% or less) and management exemplars (average of 8 to 10 patient visits per half-day plus high administrator satisfaction with no-show management strategies).

RESULTS

Directors of 14 rate and 8 management exemplars, identified from among the 141 practices (31.5%) that returned the initial survey instrument, were interviewed and subsequently resurveyed. All of the rate exemplars used multiple strategies, including patient education, patient reminders, patient sanctions, and some degree of open-access scheduling. Practices that managed no-shows well encouraged walk-ins and work-ins and overbooked resident schedules either equally or based upon individual no-show rates. Practice exemplars of both types were highly committed to addressing the no-shows problem and were diligent about following their policies and procedures regarding no-shows.

CONCLUSION

Some family medicine residency practices are able to achieve low no-show rates or keep them from affecting practice volume. Those that do use combinations of well-established methods.

Implementation of Advanced Access in general practice: postal survey of practices

BACKGROUND

Advanced Access has been strongly promoted as a means of improving access to general practice. Key principles include measuring demand, matching capacity to demand, managing demand in different ways and having contingency plans. Although not advocated by Advanced Access, some practices have also restricted availability of pre-booked appointments.

AIM

This study compares the strategies used to improve access by practices which do or do not operate Advanced Access.

DESIGN OF STUDY

Postal survey of practices.

SETTING

Three hundred and ninety-one practices in 12 primary care trusts.

METHOD

Questionnaires were posted to practice managers to collect data on practice characteristics, supply and demand of appointments, strategies employed to manage demand, and use of Advanced Access.

RESULTS

Two hundred and forty-five from 391 (63%) practices returned a questionnaire and 162/241(67%) claimed to be using Advanced Access. There were few differences between characteristics of practices operating Advanced Access or not. Both types of practice had introduced a wide range of measures to improve access. The proportion of doctors' appointments only available for booking on the same day was higher in Advanced Access practices (40 versus 16%, difference = 24%, 95% CI = 16% to 32%). Less than half the practices claiming to operate Advanced Access ((63/140; 45%) used all four of this model's key principles.

CONCLUSION

The majority of practices in this sample claim to have introduced Advanced Access, but the degree of implementation is very variable. Advanced Access practices use more initiatives to measure and improve access than non-Advanced Access practices.

Do physicians spend more time with non-English-speaking patients?

OBJECTIVE

To determine whether physicians at a general internal medicine clinic spend more time with non-English-speaking patients.

DESIGN

A time-motion study comparing physician time spent with non-English-speaking patients and time spent with English-speaking patients during 5 months of observation. We also tested physicians' perceptions of their time use with a questionnaire.

SETTING

Primary care internal medicine clinic at a county hospital.

PATIENTS/PARTICIPANTS

One hundred sixty-six established clinic patients, of whom 57 were non-English speaking and 109 were English speaking, and 15 attending physicians and 8 third-year resident physicians.

MEASUREMENTS AND MAIN RESULTS

Outcome measures included total patient time in clinic, wait for first nurse or physician contact, time in contact with the nurse or physician, physician time spent on the visit, and physician perceptions of time use with non-English-speaking patients. After adjustment for demographic and comorbidity variables, non-English-speaking and English-speaking patients did not differ on any time-motion variables, including physician time spent on the visit (26.0 vs 25.8 minutes). A significant number of clinic physicians believed that they spent more time during a visit with non-English-speaking patients (85.7%) and needed more time to address important issues during a visit (90. 4%), (both p <.01). Physicians did not perceive differences in the amount they accomplished during a visit with non-English-speaking patients.

CONCLUSIONS

There were no differences in the time these physicians spent providing care to non-English-speaking patients and English-speaking patients. An important limitation of this study is that we were unable to measure quality of care provided or patients' satisfaction with their care. Physicians may believe that they are spending more time with non-English-speaking patients because of the challenges of language and cultural barriers.