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Transportation doesn't fix all no-show woes

(from the November/December 2018 ACP Internist)

(from the November/December 2018 ACP Internist)

Health care systems are creating transportation programs to shuttle patients not only to appointments, but to pharmacies and locations to help with treatment.

By Beth Thomas Hertz

When patients miss appointments because they lack reliable transportation, valuable time slots are wasted and health outcomes can decline. Paying for and providing rides to patients may seem like a straightforward and cost-effective solution, whether it involves using local cab companies or coordinating health care-specific options offered by ride-sharing services such as Uber or Lyft. However, some health systems have found that it is not necessarily the answer they hoped it would be.

“Patients missing appointments is a large, complex, multifactorial issue,” said Bailey Miles, MD, medical director of the Priority Access Primary Care Program at Johns Hopkins Community Physicians at East Baltimore Medical Center.

One study of nearly 800 Medicaid patients coming for a primary care visit in a six-month period from October 2016 to April 2017 in West Philadelphia illustrates this point well. Patients who were offered free rides in the study had a missed appointment rate of 36.5%, nearly identical to the 36.7% seen in a control arm in which rides were not offered.

Krisda H. Chaiyachati, MD, MPH, MSHP, medical director of FirstCall Virtual Care at the University of Pennsylvania's Perelman School of Medicine in Philadelphia and lead author on that study, which appeared in JAMA Internal Medicine in March, said he was extremely surprised by these findings, as patients who are late to or miss appointments often say it is because their ride fell through.

However, a follow-up qualitative study done in conjunction with the first study, in which 45 patients were asked the reason why they missed appointments, revealed more insights.

“By and large, the response that we got is that transportation can be a thing, but it's not always the thing that causes them to miss their appointments,” Dr. Chaiyachati said.

People with low incomes can live tumultuous lives, he said, and they are dependent on the network around them. They may need someone to take care of them, or they may be taking care of a family member, and problems with those arrangements, such as a sick child, were often at the core of why they missed an appointment.

“Transportation in that storyline becomes one of many different things that competes with their ability to make it to an appointment. Understanding these larger contexts for why patients are missing appointments is very important,” he said. “I did not walk away pessimistic about ride-sharing or transportation, but I think that, like everything we do, it's more complex than it appears at first, and it's just one tool amongst many.”

Similar findings

Dr. Miles' clinic, which he co-runs with colleague Kate Rediger, MSN, CRNP, and which serves a high-utilizer population at Johns Hopkins' urban medical home, started using a taxi service about three years ago to reduce barriers to patients getting to their appointments. The clinic team worked with a local taxi company that was already contracted to provide rides for other parts of the larger Johns Hopkins community, primarily for one-time use such as when a patient is discharged from the hospital.

As in Dr. Chaiyachati's experience, their results were disappointing. Dr. Miles and Ms. Rediger estimated that about one in every four or five people for whom they sent a taxi did not actually make it to their appointment.

“Patients have a lot of other barriers and might cite transportation as the major issue, but when it came right down to it, and we sent cabs to their homes, many other barriers would arise,” said Ms. Rediger, director of clinical operations in the priority access clinic. “[Providing a ride] was not a simple, quick fix.”

Read the full article in ACP Internist.

ACP Internist provides news and information for internists about the practice of medicine and reports on the policies, products, and activities of ACP.

Back to the December 2018 issue of ACP IMpact