Missed Clinic Appointments Research Articles

Association of Unmet Social Needs With Missed In-Person Urology Clinic Appointments.

Social determinants of health (SDH) are nonbiologic influencers of disease and health care disparities. This study focused on understanding the association between SDH and urology clinic "no-show" visits within a diverse urban population. We retrospectively identified patients scheduled for urology clinic visits from October 2015 to June 2022 who completed a 10-question social needs screener. For each patient, demographic variables, and number of missed clinic appointments were abstracted. Multivariable logistic regression was performed to determine the association of unmet social needs and no-shows. Of 5761 unique patients seen in clinic, 5293 completed a social needs screener. Respondents were most commonly male (62.8%), Hispanic (50.3%), English-speaking (75.5%), and insured by Medicare (46.0%). Overall, 8.2%, 4.6%, and 6.1% reported 1, 2, and 3+ unmet social needs, respectively. Most patients (61.7%) had 0 no-shows; 38.3% had 1+ no-shows. Between the 0 and 1+ no-show groups, we found significant differences with respect to gender (P =.05), race/ethnicity (P = .002), preferred language (P = .006), insurance payer (P < .001), SDH status (P = .003), and total number of unmet social needs (P = .006). On multivariable analysis, patients concerned about housing quality (odds ratio [OR] = 1.50, P = .002), legal help (OR = 1.53, P = .009), and with 3+ unmet social needs (OR = 1.39, P = .006) were more likely to have 1+ no-shows. Unmet social needs were associated with increased no-show urology clinic visits. Routine social needs screening could identify at-risk patients who would benefit from services. This may be particularly pertinent for patients with urgent diagnoses or those requiring frequent office visits where missing appointments could impact morbidity and mortality.

Feasibility, Acceptability, and Preliminary Effectiveness of a Combined Digital Platform and Community Health Worker Intervention for Patients With Heart Failure: Pilot Randomized Controlled Trial.

Heart failure (HF) is a burdensome condition and a leading cause of 30-day hospital readmissions in the United States. Clinical and social factors are key drivers of hospitalization. These 2 strategies, digital platforms and home-based social needs care, have shown preliminary effectiveness in improving adherence to clinical care plans and reducing acute care use in HF. Few studies, if any, have tested combining these 2 strategies in a single intervention. This study aims to perform a pilot randomized controlled trial assessing the acceptability, feasibility, and preliminary effectiveness of a 30-day digitally-enabled community health worker (CHW) intervention in HF. Adults hospitalized with a diagnosis of HF at an academic hospital were randomly assigned to receive digitally-enabled CHW care (intervention; digital platform +CHW) or CHW-enhanced usual care (control; CHW only) for 30 days after hospital discharge. Primary outcomes were feasibility (use of the platform) and acceptability (willingness to use the platform in the future). Secondary outcomes assessed preliminary effectiveness (30-day readmissions, emergency department visits, and missed clinic appointments). A total of 56 participants were randomized (control: n=31; intervention: n=25) and 47 participants (control: n=28; intervention: n=19) completed all trial activities. Intervention participants who completed trial activities wore the digital sensor on 78% of study days with mean use of 11.4 (SD 4.6) hours/day, completed symptom questionnaires on 75% of study days, used the blood pressure monitor 1.1 (SD 0.19) times/day, and used the digital weight scale 1 (SD 0.13) time/day. Of intervention participants, 100% responded very or somewhat true to the statement "If I have access to the [platform] moving forward, I will use it." Some (n=9, 47%) intervention participants indicated they required support to use the digital platform. A total of 19 (100%) intervention participants and 25 (89%) control participants had ≥5 CHW interactions during the 30-day study period. All intervention (n=19, 100%) and control (n=26, 93%) participants who completed trial activities indicated their CHW interactions were "very satisfying." In the full sample (N=56), fewer participants in the intervention group were readmitted 30 days after hospital discharge compared to the control group (n=3, 12% vs n=8, 26%; P=.12). Both arms had similar rates of missed clinic appointments and emergency department visits. This pilot trial of a digitally-enabled CHW intervention for HF demonstrated feasibility, acceptability, and a clinically relevant reduction in 30-day readmissions among participants who received the intervention. Additional investigation is needed in a larger trial to determine the effect of this intervention on HF home management and clinical outcomes. Clinicaltrials.gov NCT05130008; https://clinicaltrials.gov/study/NCT05130008. RR2-10.2196/55687.

HIV symptom severity and associated factors among young people with HIV in Ghana

ABSTRACT Adolescents and young adults (young people) with HIV (YPWH) often struggle with treatment self-management. Many have symptoms due to HIV disease, medication side-effects, or comorbid conditions. Our study investigated the severity of HIV-related symptoms among YPWH aged 18–24 with detectable viral loads from an HIV clinic in Ghana (N = 60) and potential correlates of severity across a range of factors. Results indicated that YPWH currently experienced, on average, 13 symptoms (SD = 12.33). Six of the 10 most common symptoms were from two domains: fatigue and psychological. The most common symptoms were headaches (62%), weakness (53%), and fear/worries (52%). No differences were observed in number or severity of symptoms between youth based on HIV transmission status. Bivariate correlates of symptom severity were found with six that remained significant or approached significance in a multivariate model predicting severity: living with a parent/guardian, higher perceived access to HIV care, and higher treatment readiness were associated with lower severity while greater travel time to the HIV clinic, psychological distress, and more missed clinic appointments were associated with higher severity. Our findings suggest that interventions to address symptoms among YPWH should be multilevel and include strategies (e.g., telehealth, home care) to increase access to care.

Abstract 11804: Implementing a Digitally-Enabled Community Health Worker Intervention for Patients With Heart Failure: A Randomized Controlled Trial

Introduction: Heart failure (HF) readmissions are a leading cause of US 30-day hospital readmissions. Factors related to clinical complexity and unmet social needs are among the key drivers associated with HF negative clinical outcomes. Digital platforms have shown promise in improving HF outcomes but limitations like patient lack of familiarity with technology and unmet social needs continue to limit implementation and adoption. Hypothesis: An intervention pairing HF patients with a digital platform and a community health worker (CHW) for 30 days post-hospital discharge is (a) feasible, (b) acceptable, and (c) can demonstrate preliminary effectiveness in reducing 30-day hospital readmissions, emergency department (ED) visits, and missed clinic appointments compared to control (CHW only). Methods: Participants (n=50; enrolled 9/2022-6/2023) were randomized to intervention (CHW + digital platform) or control (CHW only). Intervention participants received a digital platform within a mobile phone application (daily symptoms questionnaire, educational videos) connected to a biometric sensor (tracking heart rate, oxygenation, steps taken), a digital weight scale, and a digital blood pressure monitor. Feasibility (use of the platform and engagement with the CHW), acceptability (willingness to use the intervention again), and clinical outcomes (30-day readmissions, ED visits, and missed appointments) were tracked. Results: As of June 1, 2023 (n=42), preliminary analysis demonstrates intervention feasibility (participant use of the sensor (avr 11.1 hrs/day), digital blood pressure (1.3 times/day; SD=0.22) and weight scale (1.1 times/day (SD=0.18) on 81-86% of study days; symptom questionnaire completion on 75% of study days; &gt;3 CHW interactions occurred for 71% of participants) and acceptability (84% of participants indicated willingness to use the intervention again). Clinical outcome data analysis completion is forthcoming September 2023. Conclusions: A novel intervention combining a digital platform with CHW social needs care in HF was feasible and acceptable. Clinical outcome data analysis completion is forthcoming September 2023. A larger future clinical trial is needed to determine the intervention’s true effectiveness.

Perceptions and factors associated with the uptake of the community client-led antiretroviral therapy delivery model (CCLAD) at a large urban clinic in Uganda: a mixed methods study

IntroductionCommunity Client-Led ART Delivery (CCLAD) is a community HIV care model. In this model, a group of persons living with HIV (PLHIV) in a specific location, take turns going to the HIV clinic to pick up Antiretroviral Treatment refills for members. The uptake of this model, however, remains low despite its improvements in patient retention. In this study, we explored PLHIV’s perceptions of this model and identified the factors associated with its low uptake.MethodsThis was a mixed methods study based on a retrospective review of records of PLHIV and in-depth interviews. We reviewed the medical records of people receiving ART to determine their current model of ART delivery and conducted in-depth interviews with 30 participants who were eligible to be enrolled in the CCLAD model at the Mulago ISS clinic. We performed logistic regression to identify factors associated with the uptake of the CCLAD model and inductive thematic analysis to explore PLHIV’s perceptions of the CCLAD model.ResultsA total of 776 PLHIV were sampled for the study, 545 (70.2%) of whom were female. The mean age (standard deviation) was 42 (± 9.3) years. Overall, 55 (7.1%) received ART using the CCLAD model. Compared to other ART-delivery models, CCLAD was associated with being on ART for at least eight years (AOR 3.72; 95% CI: 1.35–10.25) and having no prior missed clinic appointments (AOR 10.68; 95% CI: 3.31–34.55). Mixed perceptions were expressed about the CCLAD model. Participants interviewed appreciated CCLAD for its convenience and the opportunities it offered members to talk and support each other. Others however, expressed concerns about the process of group formation, and feeling detached from the health facility with consequences of lack of confidentiality.ConclusionThe current uptake of the CCLAD model is lower than the national recommended percentage of 15%. Its uptake was associated with those who had been in care for a longer period and who did not miss appointments. Despite CCLAD being perceived as convenient and as promoting support among members, several challenges were expressed. These included complexities of group formation, fear of stigma and feelings of detachment from health facilities among others. So, while CCLAD presents a promising alternative ART delivery model, more attention needs to be paid to the processes of group formation and improved patient monitoring to address the feelings of detachment from the facility and facility staff.

Increasing COVID-19 Vaccination Rates for Children With Sickle Cell Disease.

The COVID-19 vaccine is important for children with sickle cell disease (SCD). This quality improvement project'sobjective was to increase the proportion of children with SCD receiving ≥2 COVID-19 vaccine doses to ≥70% by June 2022. We used the Model for Improvement framework. We assessed COVID-19 vaccination rates biweekly. Three plan-do-study-act cycles focusing on patient education, provider awareness, and access were performed. Process measures included the outcome of outreach calls and educational video views. Missed clinic appointments was our balancing measure. Line graphs and statistical process control charts were used to track changes. Interrupted time series was used to model implementation rates while accounting for preexisting trends. A total of 243 patients were included. During the preintervention (September 2021-January 2022) and intervention periods (February 2022-June 2022), overall vaccination rates increased from 33% to 41% and 41% to 64%, respectively. Mean vaccination rate in eligible children in each 2-week period increased from 2.1% to 7.2%. The achieved vaccination rate was 11% greater than predicted for patients with SCD. For the general population the achieved vaccination rate was 23% lower than predicted. The proportion of missed visits did not change (9.0% vs. 9.6%). During outreach calls, 10 patients (13.5%) booked a vaccine. Forty percent of patients watched the promotional video. A significant number of patients with SCD are not vaccinated against COVID-19. Targeting misinformation and improving vaccine access aided in increasing vaccination. Additional interventions are needed as a large number of patients remain unvaccinated.

Exploring Self-reported Adherence Measures to Screen for Elevated HIV Viral Load in Adolescents: A South African Cohort Study

The timely identification of ART non-adherence among adolescents living with HIV presents a significant challenge, particularly in resource-limited settings where virologic monitoring is suboptimal. Using South African adolescent cohort data (N = 933, mean age 13.6 ± 2.89 years, 55.1% female, follow-up = 2014–2018), we examined the association between elevated viral load (VL ≥ 1000 copies/mL) and seven self-reported adherence measures on missed doses, and clinic appointments –with varying recall timeframes. The best performing measures, which were significantly associated with elevated viral load in covariate-adjusted models are: any missed dose –past 3 days (sensitivity = 91.6% [95%CI: 90.3–92.8], positive predictive value (PPV) = 78.8% [95%CI: 77.2–80.4]), –past week (sensitivity = 87% [95%CI: 85.4–88.6], PPV = 78.2% [95%CI: 76.5–79.9]), –past month (sensitivity = 79.5% [95%CI: 77.5–81.4], PPV = 78.2% [95%CI: 76.4–79.9]), any past-month days missed (sensitivity = 86.7% [95%CI: 85.1–88.3], PPV = 77.9% [95%CI:76.2–79.6]), and any missed clinic appointment (sensitivity = 88.3% [95%CI: 86.8–89.8], PPV = 78.4% [95%CI: 76.8–79.9]). Combining the three best performing measures missed dose –past 3 days, –past week, and any past-year missed clinic appointment increased sensitivity to 96.4% while maintaining a PPV of about 78%. The discriminatory power of simple and easy-to-administer self-reported adherence measures in detecting elevated viral load warrants consideration in resource-limited settings and may contribute to the aims of the new Global Alliance to End AIDS in children and adolescents by 2030.

The Health Belief Model Modifying Factors Associated with Missed Clinic Appointments among Individuals with Sickle Cell Disease in the Jazan Province, Saudi Arabia.

In treating chronic illnesses, such as sickle cell disease (SCD), outpatient care is essential; poor adherence in attending clinic appointments can lead to serious outcomes. SCD is highly prevalent in Saudi Arabia, and patients with SCD are advised to follow up with their treating physician in order to control this disease manifestation and to better forecast its complications. Studies evaluating missed appointments among patients with SCD are rare. Therefore, the current study aimed to use the health belief model's modifying factors in order to evaluate the variables associated with poor adherence in attending appointments. A total of 381 participants with SCD from various regions in the Jazan Province, southwestern Saudi Arabia, were included. The survey instrument included socioeconomic determinants, factors associated with poor adherence in attending outpatient appointments, and solutions under the conceptual framework of the health belief model. A descriptive analysis was conducted and the factors that impacted adherence in attending the appointments were evaluated. In the current sample, respondents with SCD from 21 to 30 years represented 41%, which was followed by participants who were 11 to 20 years at 21.5%. In addition, about 60% of the participants were women. Further, approximately 62% of the patients admitted were missing one or more outpatient appointments in the previous year, which was significantly related to various factors, such as socioeconomic characteristics and patient residence. Forgetting the appointment was the main reason for skipping outpatient appointments for patients with SCD; as such, reminders appear to be a good solution for most participants. Our findings indicated that modifying components of the health belief model, including age, level of education, income, patients' residence, and lacking cues to action (such as reminders) are important in explaining the reason for poor adherence in attending appointments. Thus, efforts are needed to address these factors and to ensure that SCD patients uphold their appointments. Future studies should examine the clinical, psychological, and epidemiological aspects that are linked with missed consultations.

A New Look at Barriers to Clinical Care Among Appalachian Residents Living With Diabetes.

In the United States, diabetes is the seventh leading cause of death and continues to rise in prevalence, with type 2 diabetes accounting for 90-95% of all cases. Rates of diabetes in Kentucky, and, in particular, the Appalachian region, are among the highest in the nation and are increasing faster than the national average. Despite this disproportionate burden, barriers to clinical appointment attendance have not been fully explored in this population. This article examines the association among perceived barriers to clinical attendance, glycemic control, and diabetes self-care as part of an ongoing study. We used a 25-item checklist developed using the Chronic Care Model to assess participants' barriers to clinic attendance. Glycemic control was assessed via A1C measurement. Diabetes self-care was assessed using the Summary of Diabetes Self-Care Activities measure. At the time of analysis, 123 of the 356 participants (34.6%) did not report any barriers to clinic attendance. For the remainder, the major reported barriers included forgetting appointments, inability to afford medicines or other treatment, and placing faith above medical care. The average A1C was 7.7%, and the average diabetes self-care summary score was 17.1 out of 35 points (with higher values indicating better self-care). Missing clinic appointments is associated with lower health outcomes, especially in vulnerable populations. This study can help educate clinic staff on perceived barriers to type 2 diabetes management among people with diabetes in Appalachia.

Abstract 14191: Text Message Reminders Are Feasible in Haiti and May Increase Clinic Attendance for Non-Communicable Diseases: A Pilot Study

Introduction: Chronic non-communicable disease (NCD) care requires long-term compliance with clinic appointments. In rural Haiti, remembering appointments is a barrier to visit adherence. While short message service (SMS) text reminders can improve attendance in other settings, this has not been assessed Haiti. This quality improvement study assesses the feasibility and acceptability of using SMS reminders to promote clinic attendance in rural Haiti. Methods: We included patients at the NCD and type 1 diabetes clinics of Hôpital Universitaire de Mirebalais, Haiti. Patients with upcoming visits were sent 2 SMS reminders 3 days and 1 day before their visit. Patients who attended their clinic visit completed a survey regarding the feasibility, acceptability, and usefulness of the SMS reminders. The primary study outcome was the proportion of patients who received SMS messages. Secondary outcomes included the proportion of patients who found SMS reminders acceptable, missed clinic appointments, and could not be reached by phone. Results: Of the 96 patients with scheduled visits during the study period, we sent SMS reminders to 88 (91.2%) patients; 8 did not have recorded phone numbers. 25% of patients missed their visit and 9% were unable to be reached by phone. The 72 patients that attended their visit had a mean age of 49.5 years and 58.2% were female. Half of those who attended their visit (36) received the SMS. Of the 36 patients that received the SMS, 100% liked the reminder, 97.2% wanted to receive future messages, and 22.2% reported they would not have attended their visit without the reminder. Of the 36 patients who did not receive the SMS, 14 (38.9%) had a new phone number while 12 (33.3%) did not have access to a phone. The biggest patient-reported barriers to receiving SMS were inconsistent cellular signal (25%) and lack of access to a phone (22%). Conclusion: Sending SMS reminders was feasible and acceptable to NCD patients in rural Haiti. The messages were universally liked by the patients who received them and influenced the decision to attend their visit. For some patients, inconsistent signal and lack of phone access will need to be addressed. If implemented at full scale, SMS reminders could significantly improve appointment attendance in rural Haiti.

Magnitude and associated factors of anti-retroviral therapy adherence among children attending HIV care and treatment clinics in Dar es Salaam, Tanzania.

The HIV pandemic continues to contribute significantly towards childhood mortality and morbidity. The up-scaling of the Anti-retroviral therapy (ART) access has seen more children surviving and sanctions great effort be made on ensuring adherence. Adherence is a dynamic process that changes over time and is determined by variable factors. This necessitates the urgency to conduct studies to determine the potential factors affecting adherence in our setting and therefore achieve the 90-90-90 goal of sustainable viral suppression. To assess the magnitude and associated factors of ART adherence among children (1-14 years) attending HIV care and treatment clinics during the months of July to November 2018 in Dar es Salaam. A cross-sectional clinic-based study, conducted in three selected HIV care and treatment clinics in urban Dar es Salaam; Muhimbili National Hospital (MNH), Temeke Regional Referral Hospital (TRRH), Infectious Disease Centre- DarDar Paediatric Program (IDC-DPP) HIV clinics during the months of July to November 2018. HIV-infected children aged 1-14 years who had been on treatment for at least six months were consecutively enrolled until the sample size was achieved. A structured questionnaire was used for data collection. Four-day self-report, one-month self-recall report and missed clinic appointments were used to assess adherence. Frequencies and percentages were used to describe categorical data. The odds ratio was used to analyse the possible factors affecting ART adherence Logistic regression models were used to determine the factors associated with ART adherence. Analysis was conducted using SPSS version 20.0 and p-value <0.05 were considered statistically significant. 333 participants were recruited. The overall good adherence (≥95%) was approximated to be 60% (CI-54.3-65.1) when subjected to all three measures. On multivariable logistic regression, factors associated with higher odds of poor adherence were found to be caregivers aged 17-25 years [AOR = 3.5, 95%CI-(1.5-8.4)], children having an inter-current illness [AOR = 10.8, 95%CI-(2.3-50.4)], disbelief in ART effectiveness [AOR = 5.495; 95%CI-(1.669-18.182)] and advanced clinical stage [AOR = 1.972; 95% CI-(1.119-3.484)]. The major reasons reported by caregivers for missing medications included forgetfulness (41%), high pill burden (21%), busy schedule (11%) and long waiting hours at the clinic (9%). In the urban setting of Dar es Salaam, ART adherence among children was found to be relatively low when combined adherence measures were used. Factors associated with poor ART adherence found were younger aged caregivers, and child intercurrent illness, while factors conferring good adherence were belief in ART effectiveness and lower HIV clinical stage. More attention and support should be given to younger aged caregivers, children with concomitant illness and advanced HIV clinical stages. Educating caregivers on ART effectiveness may also aid in improving adherence.

Medicaid insured persons with diabetes have increased proportion of missed appointments and high HbA1c

ObjectiveThis study was conducted to evaluate whether the type of insurance coverage is associated with missed appointments and to evaluate the effect of missed appointments on diabetes control. MethodsAll patients with diabetes mellitus (DM) managed at a major academic medical center between Jan 2015 and Dec 2020 were included in analysis. Association between insurance coverage and the proportion of missed appointments was evaluated with adjustments for demographic variables and social determinants of health. The relationship between proportion of missed appointments and glycemic control was also evaluated. ResultsThe dataset included 30,633 patients, out of which 14,064 (46%) reported commercial insurance, 13,376 (44%) reported Medicare and 3,193 (10%) reported Medicaid coverage. Proportion of missed appointments was 18.1 ± 18.1% among Medicaid covered patients,12.1 ± 15.3% among commercially insured and 10.2 ± 14.1% among Medicare covered patients (p < 0.001). Type of insurance was found to be a significant predictor of proportion of missed appointments after adjusting for age, race, language, marital status, smoking, BMI, HbA1c and type of diabetes (p < 0.001) in series regression analysis. Proportion of missed appointments was associated with HbA1c with partial correlation coefficient +0.104 (p < 0.005) after adjusting for age, race, gender, type of insurance coverage, BMI and type of diabetes. ConclusionsMedicaid covered patients with diabetes have higher proportion of missed clinic appointments and higher HbA1c. More research is needed to evaluate the root causes of inability to keep appointments in this population so that strategies for improved healthcare delivery can be designed.

944-P: Medicaid Insured Persons with Diabetes Have Increased Proportion of Missed Appointments and Poor Diabetes Control

Poor socioeconomic status and inadequate insurance coverage may affect an individual’s ability to utilize healthcare services. This study was conducted to evaluate whether the type of insurance coverage is associated with missed appointments for diabetes care. Data analysis included all patients with diabetes mellitus (DM) managed at a major academic center between Jan 2015 and Dec 2020. Association between insurance coverage and proportion of missed appointments was evaluated using analysis of covariance with adjustments for demographic variables and social determinants of health. The relationship between proportion of missed appointments and glycemic control was also evaluated in multivariate analyses. The final dataset included 30,633 patients, out of which 14,064 (46%) reported commercial insurance, 13,376 (44%) reported Medicare and 3,193 (10%) reported Medicaid coverage. Medicaid group was identified to have the highest proportion of Spanish-speakers, African Americans, women, current smokers and single individuals. Proportion of missed appointments was 18.1 ± 18.1% in Medicaid covered patients as compared to 12.1 ± 15.3% among commercially insured and 10.2 ± 14.1% among Medicare covered patients (p &amp;lt;0.001) . Type of insurance was found to be a statistically significant predictor of the proportion of missed appointments after adjusting for age, race, preferred language, marital status, smoking, BMI, HbA1c and type of diabetes (p&amp;lt;0.001) . Proportion of missed appointments was associated with HbA1c with partial correlation coefficient +0.1 (p &amp;lt;0.001) after adjusting for age, race, gender, type of insurance, BMI and type of diabetes. We conclude that Medicaid covered patients with diabetes have higher proportion of missed clinic appointments and higher HbA1C. More research is needed to evaluate the root causes of inability to keep appointments in this population so that strategies for improved healthcare delivery can be designed. Disclosure R.Radhakrishnan: None. W.H.Cade: None. E.Bernal-mizrachi: None. R.Garg: None.

Associations with sub-optimal clinic attendance and reasons for missed appointments among heterosexual women and men living with HIV in London

Poor engagement in HIV care is associated with poorer health outcomes and increased mortality. Our survey examined experiential and circumstantial factors associated with clinic attendance among women (n = 250) and men (n = 106) in London with heterosexually-acquired HIV. While no associations were found for women, among men, sub-optimal attendance was associated with insecure immigration status (25.6% vs. 1.8%), unstable housing (32.6% vs. 10.2%) and reported effect of HIV on daily activities (58.7% vs. 40.0%). Among women and men on ART, it was associated with missing doses of ART (OR = 2.96, 95% CI:1.74–5.02), less belief in the necessity of ART (OR = 0.56, 95% CI:0.35–0.90) and more concern about ART (OR = 3.63, 95% CI:1.45–9.09). Not wanting to think about being HIV positive was the top reason for ever missing clinic appointments. It is important to tackle stigma and the underlying social determinants of health to improve HIV prevention, and the health and well-being of people living with HIV.

Telemedicine Improves Access to Care for Spine Patients With Low Socioeconomic Status.

Study DesignRetrospective cohort study.ObjectivesThe objective of this study is to compare the likelihood of missing a scheduled telemedicine and in-person appointments for spine patients. The secondary objective is to assess the impact of socioeconomic status on missed telemedicine and in-person appointments.MethodsPatients with scheduled outpatient appointments with orthopedic spine faculty between 2019 and 2021 were divided by appointment type: telemedicine (N = 4,387) and in-person (N = 3810). Socioeconomic status was assessed using Area Deprivation Index (ADI) stratified based on percentile: low (<25), medium (25–75), and high (>75) levels of socioeconomic disadvantage. The primary outcome measure was missed clinic appointments, which was defined as having at least one appointment that was cancelled or labeled “no show.”ResultsPatients with in-person appointments missed appointments more often than patients with telemedicine visits (51.3% vs 24.7%, P < .001). Patients with high ADI missed their in-person appointments more often than patients with medium and low ADI (59.5% vs 52.2% and 47.5%, P < .001). There was no difference in missed telemedicine visits between patients with high, medium, and low ADI (27.6% vs 24.8% vs 23.8%, P = .294). Patients that missed an appointment were 41.9% more likely to be high ADI (OR 1.42, 95% CI 1.20–1.68, P < .001) and 13.4% more likely to be medium ADI (OR 1.13, 95% CI 1.03–1.26, P = .015) compared with low ADI patients.ConclusionsTelemedicine may serve a role in reducing disparity in appointment attendance. While further studies are needed to validate these findings, spine surgeons should consider offering telemedicine as an option to patients.

Pragmatic Randomized Study of Targeted Text Message Reminders to Reduce Missed Clinic Visits.

Missed clinic appointments ("no-shows") waste health system resources, decrease physician availability, and may worsen patient outcomes. Appointment reminders reduce no-shows, though evidence on the optimal number of reminders is limited and sending multiple reminders for every visit is costly. Risk prediction models can be used to target reminders for visits that are likely to be missed. We conducted a randomized quality improvement project at Kaiser Permanente Washington among patients with primary care and mental health visits with a high no-show risk comparing the effect of one text message reminder (sent 2 business days prior to the appointment) with 2 text message reminders (sent 2 and 3 days prior) on no-shows and same-day cancellations. We estimated the relative risk (RR) of an additional reminder using G-computation with logistic regression adjusted for no-show risk. Between February 27, 2019 and September 23, 2019, a total of 125,076 primary care visits and 33,593 mental health visits were randomized to either 1 or 2 text message reminders. For primary care visits, an additional text message reduced the chance of no-show by 7% (RR = 0.93, 95% CI: 0.89-0.96) and same-day cancellations by 6% (RR = 0.94, 95% CI: 0.90-0.98). In mental health visits, an additional text message reduced the chance of no-show by 11% (RR = 0.89, 95% CI: 0.86-0.93) but did not impact same-day cancellations (RR = 1.02, 95% CI: 0.96-1.11). We did not find effect modification among subgroups defined by visit or patient characteristics. Study findings indicate that using a prediction model to target reminders may reduce no-shows and spend health care resources more efficiently.

How scheduling systems with automated appointment reminders improve health clinic efficiency

Missed clinic appointments or no-shows burden health care systems through inefficient use of staff time and resources. Scheduling software with automatic appointment reminders shows promise to improve clinics’ management through timely cancellations and re-scheduling, but at-scale evidence is missing. We study a nationwide text message appointment reminder program in Chile implemented at primary care clinics for patients with chronic disease. Using longitudinal clinic-level data, we find that the program did not change the number of visits by chronic patients eligible to receive the reminder but visits from other patients ineligible to receive reminders increased by 5.0% in the first year and 7.4% in the second. Clinics treating more chronic patients and those with a relatively younger patient population benefited more from the program. Scheduling systems with automatic appointment reminders were effective in increasing clinics’ ability to care for more patients, likely due to timely cancellations and re-scheduling.

Missed Appointments at a Child Development Centre and Barriers to Access Special Needs Services for Children in Klang Valley, Malaysia: A Mixed Methods Study.

Attending appointments is vital for children with special needs, as such appointments involve long-term interdisciplinary care to ensure continuity of care and improve health and well-being. This study was performed to determine the prevalence of missed clinic appointments and identify the factors among those who have ever missed appointments and barriers of access to children’s special needs services at the Child Development Centre (CDC) at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Moreover, suggestions for improvement from the caregivers’ perspectives were explored. This is an explanatory sequential mixed methods study among caregivers of children with developmental disabilities aged up to 17 years old. Of 197 caregivers, 62 (31.5%) had missed clinic appointments. Forgetfulness was the most frequently cited reason. The bi-variable analysis showed significant differences in missed appointment rates by gender of caregivers and duration of follow-up. The final logistic regression model demonstrated that, when combined with the effect of being a male caregiver as an independent variable, follow-up duration of more than 6 years increased 2.67 times the risk of missing an appointment. Caregivers’ perceived barriers were transportation, caregiver, child and healthcare services factors. Policies and strategic plans should be focused on key findings from these factors to improve appointment adherence and accessibility to services for children with special needs.

Leveraging technology for health services continuity in times of COVID-19 pandemic: Patient follow-up, and mitigation of worse patient outcomes.

BackgroundSince the outbreak of the COVID-19 pandemic in Wuhan, China, which has now spread globally, the health systems continue to face challenges in the provision of health care, there is a risk of exposure for both the physicians and the patients. While there is significant progress in the adoption of technology in health care. This study sought to examine the adverse effects of the measures put in place by the government to curb the spread of COVID-19 and come up with an intervention to prevent worse outcomes for chronic conditions.MethodsBooking registers for four specialty clinics in Machakos Level 5 Hospital were reviewed to identify patients who missed clinic appointments for follow-up. An automated data collection tool (ODK-collect) was used for data collection. COVID-19 Machakos App was developed to facilitate follow-up and referral of patients to the nearest facilities, capturing and posting of information in real-time to a central database. The mobile App also facilitated the tracking of patients and aided doctors to give feedback on whether the patients reported to the referred facilities. The doctors were also able to capture doctors’ notes on the patients' status while ensuring the confidentiality and privacy of the patients. An interactive dashboard was developed to generate analytics reports and summaries to monitor clinic attendance and trends in the provision of health care during the pandemic period.ResultsRegister data showed 977 (81.5%) out of a total of 1199 patients had missed their scheduled appointments. Among the 977, 746 (76%) were residents of Machakos County and qualified for follow-up. Missed appointments varied by clinic: Cancer Clinic 12 (1.6) %), Diabetes Clinic 212 (28.4%), Hypertension 293 (39.3%), and Paediatrics Clinic 229 (30.7%). Contact was made and follow-up was attempted for 746 patients, of which 453 patients (60.7%) were successful. The follow-up distribution of the 453 patients varied by the clinic as follows: Cancer Clinic 10, Diabetes Clinic 146, Hypertension 185, and Paediatrics Clinic 112. During the follow-up process, 331 patients from diabetes and hypertension clinics were requested to choose a preferred or nearby facility to be referred to. 191 (58%) patients chose Machakos Level 5 Hospital as their preferred facility and 137 (41%) patients chose to be referred to level 3 or 4 hospitals within the County. Three deaths were reported from the medical (Hypertension) clinic. Through the developed App, a total, 82 (60%) patients out of the 137 were reviewed at the referral facilities jointly with a specialist at Machakos Level 5 Hospital. For the duration of the study, some patients reported worse conditions by the time of review after missing scheduled appointments.ConclusionsThis intervention demonstrated that mobile phone technology could be leveraged to provide specialty treatment services remotely to mitigate against worse patient outcomes. The study reveals that there is a dire need to integrate technological interventions in the provision of health care services to ensure continuity.

Non-adherence to Antiretroviral Treatment Episodes and Contributing Factors among Fully Disclosed Adolescents with Perinatal HIV in the Kingdom of Lesotho

Children and adolescents with Perinatal Acquired HIV (PHIV) face many challenges to remain adherent to long-term Antiretroviral Therapy (ART). Among adolescents, adherence is often not static but changes over time due to the circumstances of the individual. The study assessed the ART adherence levels and patterns of adolescents with PHIV who were receiving long-term ART. This quantitative cross-sectional study was conducted in Mohale's Hoek, a rural Health District in Lesotho between May and December 2018. Adolescents aged 10-19 years who were aware of their HIV status were recruited from selected youth-friendly HIV clinics. Adherence was measured through a self-report of the last pills missed, based on 30 days recall. Stata version 13 was used for analysis. The sample consisted of 130 adolescents, 57% were females, the mean age was 15 years, the mean age of ART initiation was nine years, and the mean ART duration was four years. Self-reported adherence was very high at 92%, and 88% reported not delaying taking ART. Self-reported optimal ART adherence was achieved by 85% of the adolescents, 15% were non-adherent, and 92.3% had not missed clinic appointments in the past 30 days. Episodes of non-adherence among those who delayed taking ART on time occurred in the evenings, mornings, weekdays, and weekends. Non-adherence episodes for 59% occurred more in the evenings than other periods of the day. Conclusion: The results suggest that despite high self-reported adherence, adolescents take medication inconsistently and have situational adherence patterns. The dosing of medication and regimens should be flexible and take into consideration the context of the adolescents.