A Longitudinal Linear Model of Patient Characteristics to Predict Failure to Attend an Inner-City Chronic Pain Clinic

Abstract

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 access 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. 1394 patients with 3488 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 five and ten 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 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 amendable to targeted interventions. Perspective We identified certain patient characteristics, specifically Spanish spoken as primary language and geographic distance from the clinic, that predict failure to attend an inner-city chronic pain clinic. These identified barriers to access chronic pain services may be modifiable by simple cost effective interventions.

A pragmatic trial to improve adherence with scheduled appointments in an inner-city pain clinic by human phone calls in the patient's preferred language

“…Poor adherence with scheduled appointments (PASA) remains a particular concern in inner-city chronic pain clinics, with PASA rates up to 80%[1–3]. Not only is PASA a significant financial burden for the institution[4,5], it causes frustration for providers[6].…”

“…Without the benefit of a cancellation call, PASA deprives other patients of the opportunity to schedule an appointment[8]. On the other hand, PASA may indicate barriers to healthcare[9], depriving our most vulnerable patients of needed specialized pain services[1,10,11]. The reasons for missed appointments often without a cancelation call, have long been studied[12], but remain elusive[13].…”

“…The reasons for missed appointments often without a cancelation call, have long been studied[12], but remain elusive[13]. We identified language as a barrier to access of chronic pain services, specifically to adherence with scheduled appointments[1]. We hypothesized that patient concerns about cultural incongruence may be ameliorated by human outreach in the patient’s preferred language[1,7].…”

“…We identified language as a barrier to access of chronic pain services, specifically to adherence with scheduled appointments[1]. We hypothesized that patient concerns about cultural incongruence may be ameliorated by human outreach in the patient’s preferred language[1,7]. Based on retrospective cohort studies, we demonstrated that targeted health system improvements can improve access[2].…”

“…With limited evidence available on how to influence the demand side of health care disparity in pain medicine[7,14,22], we postulated that native language personnel and unified clinics (seeing all patients in the same outpatient location with equitable access) helps to overcome such barriers, but that individualized outreach to patients by phone[13], in a language the patient understands, prior to scheduled appointments would establish a human rapport[23] before the actual encounter and improve adherence[1,2]. While PASA certainly imparts considerable costs to the institution[24], counter measures also consume resources and need to be justified to be financially sustainable considering the current pressures to cut cost[25].…”