Missed appointments adversely affect clinical outcomes, clinic efficiency, and quality of care and could worsen the impact of pediatric workforce shortages on health care access. Telemedicine has the potential to reduce missed appointments. However, interventions that do not account for neighborhood factors could widen disparities. We analyzed the relationship between missed appointments and type of pediatric appointment and the role of telemedicine and neighborhood factors.
Methods:
This retrospective cohort study used three data sources: (1) electronic health records, (2) American Community Survey, and (3) Housing and Urban Development crosswalk data. The analyses were restricted to pediatric patients (<18 years) with completed or missed outpatient visits (March 2020–December 2022). The outcome was missed appointments. The primary predictors were pediatric visit type, appointment modality, census tract (CT) residential segregation, and CT poverty level. Generalized estimating equations were used.
Results:
The final sample size was 90,712 appointments for 32,305 unique patients. The overall no-show rate was 20.75%. The no-show rate for general pediatrics was 20.36% and 27.82% for specialty appointments. In multivariable analyses, there was an increased likelihood of missed appointments for pediatric subspecialty appointments compared to general pediatrics (Odds Ratio (OR): 1.62; 95% Confidence Interval (CI): 1.51, 1.74). Telemedicine appointments were associated with a decreased likelihood of missed appointments compared to in-person appointments (OR: 0.41; 95% CI:0.39, 0.44). There was a positive interaction between appointment type and pediatrics visit type with a larger effect for subspecialty visits.
Conclusions:
Tailored interventions that integrate telemedicine uptake and contextual factors have the potential to reduce missed appointments.
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References
1.
McQueenieR, EllisDA, McConnachieA, et al.Morbidity, mortality and missed appointments in healthcare: A national retrospective data linkage study. BMC Med, 2019; 17(1):2; doi: 10.1186/s12916-018-1234-0
2.
NutiLA, LawleyM, TurkcanA, et al.No-shows to primary care appointments: Subsequent acute care utilization among diabetic patients. BMC Health Serv Res, 2012; 12:304; doi: 10.1186/1472-6963-12-304
3.
DantasLF, FleckJL, Cyrino OliveiraFL, et al.No-shows in appointment scheduling - a systematic literature review. Health Policy, 2018; 122(4):412–421; doi: 10.1016/j.healthpol.2018.02.002
4.
GuzekLM, GentrySD, GolombMR. The estimated cost of “no-shows” in an academic pediatric neurology clinic. Pediatr Neurol, 2015; 52(2):198–201; doi: 10.1016/j.pediatrneurol.2014.10.020
5.
PerezFD, XieJ, SinA, et al.Characteristics and direct costs of academic pediatric subspecialty outpatient no-show events. J Healthc Qual, 2014; 36(4):32–42; doi: 10.1111/jhq.12007
6.
MooreCG, Wilson-WitherspoonP, ProbstJC. Time and money: Effects of no-shows at a family practice residency clinic. Fam Med, 2001; 33(7):522–527.
7.
BergBP, MurrM, ChermakD, et al.Estimating the cost of no-shows and evaluating the effects of mitigation strategies. Med Decis Making, 2013; 33(8):976–985; doi: 10.1177/0272989x13478194
8.
KiruparanP, KiruparanN, DebnathD. Impact of pre-appointment contact and short message service alerts in reducing ‘Did Not Attend’ (DNA) rate on rapid access new patient breast clinics: A DGH perspective. BMC Health Serv Res, 2020; 20(1):757; doi: 10.1186/s12913-020-05627-2
9.
HuangZ, AshrafM, Gordish-DressmanH, et al.The financial impact of clinic no-show rates in an academic pediatric otolaryngology practice. Am J Otolaryngol, 2017; 38(2):127–129; doi: 10.1016/j.amjoto.2016.11.004
10.
TriemstraJD, LoweryL. Prevalence, predictors, and the financial impact of missed appointments in an academic adolescent clinic. Cureus, 2018; 10(11):e3613; doi: 10.7759/cureus.3613
11.
FloresEJ, DayeD, PeñaMA, et al.Analysis of socioeconomic and demographic factors and imaging exam characteristics associated with missed appointments in pediatric radiology. Pediatr Radiol, 2021; 51(11):2083–2092; doi: 10.1007/s00247-021-05111-x
12.
DrewekR, MireaL, AdelsonPD. Lead time to appointment and no-show rates for new and follow-up patients in an ambulatory clinic. Health Care Manag (Frederick), 2017; 36(1):4–9; doi: 10.1097/hcm.0000000000000148
13.
RustCT, GallupsNH, ClarkWS, et al.Patient appointment failures in pediatric resident continuity clinics. Arch Pediatr Adolesc Med, 1995; 149(6):693–695; doi: 10.1001/archpedi.1995.02170190103018
14.
GroverA, SlavinPL, WillsonP. The economics of academic medical centers. N Engl J Med, 2014; 370(25):2360–2362; doi: 10.1056/NEJMp1403609
15.
HudersonA, HabermanM, ConroyJ. Medicare patient hospital transfers in the era of health care reform. Vol. AAMC Analysis in Brief, 2013; 13:1–2. https://www.aamc.org/media/6206/download
TurnerA, RickettsT, LeslieLK. Comparison of number and geographic distribution of pediatric subspecialists and patient proximity to specialized care in the US between 2003 and 2019. JAMA Pediatr, 2020; 174(9):852–860; doi: 10.1001/jamapediatrics.2020.1124
19.
VinciRJ. The pediatric workforce: Recent data trends, questions, and challenges for the future. Pediatrics, 2021; 147(6):e2020013292; doi: 10.1542/peds.2020-013292
20.
AlkilanyR, TarabichiY, HongR. Telemedicine visits during COVID-19 improved clinic show rates. ACR Open Rheumatol, 2022; 4(2):136–141; doi: 10.1002/acr2.11372
21.
AdepojuOE, ChaeM, LiawW, et al.Transition to telemedicine and its impact on missed appointments in community-based clinics. Ann Med, 2022; 54(1):98–107; doi: 10.1080/07853890.2021.2019826
22.
BramatiPS, Amaram-DavilaJS, ReddyAS, et al.Reduction of missed palliative care appointments after the implementation of telemedicine. J Pain Symptom Manage, 2022; 63(6):e777–e779; doi: 10.1016/j.jpainsymman.2022.02.001
23.
DrerupB, EspenschiedJ, WiedemerJ, et al.Reduced No-Show rates and sustained patient satisfaction of telehealth during the COVID-19 pandemic. Telemed J E Health, 2021; 27(12):1409–1415; doi: 10.1089/tmj.2021.0002
CrumeB, SuufiM, NabbosaG, et al.Analysis of missed clinic visits, preferred languages, and telemedicine in a pediatric gastroenterology practice. J Pediatr Gastroenterol Nutr, 2024; 78(5):1069–1081; doi: 10.1002/jpn3.12176
26.
HowieF, KreofskyBL, RaviA, et al.Rapid rise of pediatric telehealth during COVID-19 in a large multispecialty health system. Telemed J E Health, 2022; 28(1):3–10; doi: 10.1089/tmj.2020.0562
27.
KronforstK, BarreraL, CasaleM, et al.Pediatric telehealth access and utilization in Chicago during the first year of the COVID-19 pandemic. Telemed J E Health, 2023; 29(9):1324–1331; doi: 10.1089/tmj.2022.0481
28.
ChouEY, MooreK, ZhaoY, et al.Neighborhood effects on missed appointments in a large Urban academic multispecialty practice. J Gen Intern Med, 2022; 37(4):785–792; doi: 10.1007/s11606-021-06935-x
29.
FiorilloCE, HughesAL, CIC, et al.Factors associated with patient no-show rates in an academic otolaryngology practice. Laryngoscope, 2018; 128(3):626–631; doi: 10.1002/lary.26816
30.
YaoJ, PerzynskiAT, TarabichiY, et al.Socioeconomic distress as a predictor of missed first outpatient newborn visits. Cureus, 2021; 13(3):e14132; doi: 10.7759/cureus.14132
31.
American Community Survey. Explore census data. Available from: https://data.census.gov/ [Last accessed: March18, 2024].
CarthonMB, BromH, NikpourJ, et al.Supportive practice environments are associated with higher quality ratings among nurse practitioners working in underserved areas. J Nurs Regul, 2022; 13(1):5–12.
34.
MasseyDS, DentonNA. Hypersegregation in U.S. metropolitan areas: Black and Hispanic segregation along five dimensions. Demography, 1989; 26(3):373–391.
35.
KramerMR, HogueCR. Is segregation bad for your health? Epidemiol Rev, 2009; 31:178–194; doi: 10.1093/epirev/mxp001
36.
StataCorp. Stata Statistical Software: Release 15. StataCorp LLC: College Station, TX; 2017.
37.
ShipmanSA, LanJ, ChangCH, et al.Geographic maldistribution of primary care for children. Pediatrics, 2011; 127(1):19–27; doi: 10.1542/peds.2010-0150
38.
MayerML. Are we there yet? Distance to care and relative supply among pediatric medical subspecialties. Pediatrics, 2006; 118(6):2313–2321; doi: 10.1542/peds.2006-1570
39.
ZuckermanKE, PerrinJM, HobreckerK, et al.Barriers to specialty care and specialty referral completion in the community health center setting. J Pediatr, 2013; 162(2):409–414.e1; doi: 10.1016/j.jpeds.2012.07.022
40.
NakamuraY, LabergeM, DavisA, et al.Barriers and strategies for specialty care access through federally qualified health centers: A scoping review. J Health Care Poor Underserved, 2019; 30(3):910–933; doi: 10.1353/hpu.2019.0064
41.
ChaudhrySB, SiegfriedE, SheikhUA, et al.Improving nonattendance rates among pediatric patients with medicaid or private insurance. J Am Acad Dermatol, 2019; 81(2):412–416; doi: 10.1016/j.jaad.2019.02.018
42.
LinCL, MistryN, BonehJ, et al.Text message reminders increase appointment adherence in a pediatric clinic: A randomized controlled trial. Int J Pediatr, 2016; 2016:8487378; doi: 10.1155/2016/8487378
LaGangaLR, LawrenceSR. Clinic overbooking to improve patient access and increase provider productivity. Decision Sciences, 2007; 38(2):251–276.
45.
NarringF, Junod PerronN, Dominicé DaoM, et al.Text-messaging to reduce missed appointment in a youth clinic: A randomised controlled trial. J Epidemiol Community Health, 2013; 67(10):888–891; doi: 10.1136/jech-2013-202510
46.
Pérez-StableEJ, Jean-FrancoisB, AklinCF. Leveraging Advances in Technology to Promote Health Equity. Med Care, 2019; 57(Suppl 2):S101–S103; doi: 10.1097/mlr.0000000000001112
47.
HershWR, HelfandM, WallaceJ, et al.Clinical outcomes resulting from telemedicine interventions: A systematic review. BMC Med Inform Decis Mak, 2001; 1:5; doi: 10.1186/1472-6947-1-5
48.
National Academies of Sciences E, Medicine. The Future Pediatric Subspecialty Physician Workforce: Meeting the Needs of Infants, Children, and Adolescents. 2023.
49.
OjinnakaCO, JohnstunL, DunniganA, et al.Telemedicine reduces missed appointments but disparities persist. Am J Prev Med, 2024; 67(1):90–96; doi: 10.1016/j.amepre.2024.02.012
