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First Author: Andrew Hwang, Tufts University School of
INTRODUCTION: To improve care and achieve performance targets,
healthcare systems focus on patients at high risk for not achieving
preventive cancer screening and chronic disease management goals.
We hypothesized that patients with a higher propensity for missed
outpatient appointments, or "no-shows," will have lower colorectal
cancer (CRC) screening and low-density lipoprotein (LDL) goal
attainment over the following year.
METHODS: We calculated the "no-show propensity factor" (NSPF)
for 142,173 patients seen in an academic primary care practice
network from 2007-2009 using 5 years (2005-2009) of outpatient
appointment data. NSPF transforms a patient's count of arrivals and
no-shows into a score that represents appointment adherence,
correcting for patients with few appointments to avoid undue
influence on the model. We divided patients into two groups:
patients in the highest quartile and patients in the lower 3
quartiles of NSPF, and assessed CRC screening completion among
patients aged 52-75 years without prior colectomy and LDL goal
(LDL<100mg/dl) attainment in patients with diabetes or vascular
disease at one year follow-up (2010).
We evaluated the association between NSPF and our two binary
outcomes using logistic regression models adjusting for number of
visits. Using a "change-in-estimate" strategy, we included patient
(age, gender, race, language, insurance, neighborhood median
household income, Charlson comorbidity index, and diagnosis of
depression or alcoholism) and provider factors (gender, years in
practice, and whether the patient received primary care at a
community health center) in the models if they altered the odds
ratio by >5%. We also ran models adjusting for all
RESULTS: Compared to patients in the lower 3 quartiles for NSPF,
patients in the highest quartile were significantly (P<0.0001
for all) younger (45 vs. 52 years) and more likely to be male (44%
vs. 42), non-white (39% vs. 18%), non-English speaking (18% vs.
7%), uninsured (7% vs. 4%), live in neighborhoods with low median
household income ($50,518 vs. $63,736), receive primary care at a
community health center (15% vs. 7%), and have a diagnosis of
depression (20% vs. 11%) or alcoholism (3% vs. 0.9%). Compared to
eligible patients in the lower 3 quartiles for NSPF, eligible
patients in the highest quartile were significantly more likely to
have not completed CRC screening (adjusted OR 1.72 [1.63-1.81]
adjusting for number of visits and neighborhood median household
income) or have an above goal LDL (adjusted OR 1.72 [1.60-1.85]
adjusting for number of visits and age). Inclusion of all variables
in the models did not change the significance or direction of the
effect, and the effect changed by less than 7% for both
CONCLUSIONS: NSPF was a strong, independent predictor of
subsequent colonoscopy completion and LDL goal attainment. Using
NSPF may help healthcare systems identify patients at increased
risk for non-adherence to recommended care for targeted
interventions to improve care and achieve performance targets.
September 2014 Issue of IMpact