The rate of attendance to scheduled clinic visits have been linked to health outcomes in several chronic disease groups such as diabetes, hypertension, HIV and congenital heart disease. Higher clinic attendance rates are generally associated with better outcomes in these patients. However, the potential effects of non-attendance (NA) for individuals with bleeding disorders is not well understood. Investigators from a large hemophilia treatment center (HTC) in Atlanta, Georgia therefore looked at attendance rates of their own patients to uncover possible demographic, clinical characteristic links and the utilization of healthcare services among their patients, including emergency department (ED) visits and hospitalizations.
The lead author of the study was Vaughn Barry, PhD, MPH, Department of Hematology and Medical Oncology at the Emory University School of Medicine. Barry and her colleagues analyzed HTC clinic attendance data for all patients scheduled for at least one appointment between January 1, 2010 and December 31, 2014 at the Comprehensive Bleeding Disorders Center at Emory University and Children’s Healthcare of Atlanta. NA appointments were defined as those that a patient was not present for and did not cancel in advance. Rates for each patient was calculated as the number of NA visits divided by the number of years as patient during the five years.
The study encompassed 8,028 appointments that were scheduled for 950 HTC patients over a five-year period. Of these, 5,387 (67%) were attended, 1,537 (19%) were cancelled, 988 (12%) NA and 116 (1%) were undetermined. Most patients (75%) were followed for the entire 5-year study period. Less than half of NA appointments (43%) were followed by an attended appointment within 60 days; average time until attendance at clinic after a NA appointment was 137 days. Of the 950 HTC patients, only 30 individuals scheduled appointments while never actually visiting the HTC. Of the remaining 920, each person on average attended 5.9 appointments, spaced evenly over the five years.
Investigators found that young adults aged (20-29 years), race (black) and those with public insurance were all associated with NA visits. Disease severity was not “significantly associated” with consistent NA. They also observed that the odds of a NA appointment increased from childhood to adulthood, then dropped from adulthood to older age. Notably, distance travelled from the patient’s home residence to the HTC was not associated with scheduled appointment attendance. Higher NA rates were associated with significantly more hospitalizations and visits to the ED, particularly for those small groups of patients who were consistently NA. Further, consistent non-attenders, representing just 7% of the HTC population, accounted for more than a third of the NA appointments and more than quarter of the hospitalizations.
The authors noted limitations in the study, including potentially unreported ED visits which were not captured in Emory hospital records – these records, in large part, informed the authors’ findings. Secondly, the reasons for ED visits were not available to study investigators, omitting other possible explanations for trips to the ED. In addition, because of the cross-sectional study design, it was difficult to establish with any certainty whether HTC NA caused the ED visits and hospital admissions or whether the ED visits and hospitalizations resulted in HTC NA. The study also did not measure other potentially key factors such as a patient’s rapport with their physician and the HTC team.
Barry and her colleagues also cited several strengths, including the study concept itself. The authors surmised that this is likely the first to examine NA amongst bleeding disorder patients. The study also represented a diverse patient population, both in terms of age and ethnic/racial diversity, allowing investigators to measure additional impacts on NA rates. Further, because most patients in the study population received care at the HTC for an extended period, it allowed investigators access to a longer period of investigation.
Barry and her colleagues ultimately hone in on consistent non-attenders as a group that warrants follow-up investigation. “Our findings suggest that frequent clinic non-attendance may serve as a type of indicator that can be used to identify a small but at-risk population in any bleeding disorder clinic. Increased attention to this at-risk population could lead to reductions in unnecessary healthcare utilization,” concluded the authors.
Barry V, Steffens C, Mattis S, et al. A Cross‐Sectional Study of Non‐Attendance Among Patients at a US Hemophilia Treatment Center 2010‐2014. Haemophilia. 2018 November; 24(6): 902-910.