Examining the Association of Social Determinants of Health with Missed Clinic Visits in Patients with Heart Failure in t
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Department of Medicine, University of California, San Francisco, USA; 2Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, University of California San Francisco, San Francisco, CA, USA; 3Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center, San Francisco, USA; 4Department of Psychiatry, University of California, San Francisco, USA; 5Mental Health Services, San Francisco Veterans Affairs Medical Center, San Francisco, USA; 6Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, USA.
J Gen Intern Med DOI: 10.1007/s11606-019-05507-4 © Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019
Comorbidity Index (CCI), mental health disorders, substance abuse, and other SDOH covariates.
RESULTS BACKGROUND
Missed clinic visits, or no-shows, are a significant resource drain on the Veterans Health Administration (VA).1 The VA reports that 15–18% of scheduled primary care appointments are not completed, costing an estimated half a billion dollars per year.2 While some social determinants of health (SDOH) are shown to influence clinic no-show rates in other populations, no prior work has explored their effect among Veterans. Focusing on a cohort that require frequent clinic visits, our goal was to assess the association of three SDOH with missed clinic visits among Veterans hospitalized for congestive heart failure (CHF).
METHODS
From a national sample, we first identified all Veterans 65 and older who were hospitalized for hearth failure, then randomly selected 1500 hospitalized with a primary diagnosis of CHF in 2012. Based on previous work,3 three SDOH (lives alone, social support, and housing situation) were extracted and verified through chart abstraction by two reviewers. We determined the number of missed clinic visits (primary care, general internal medicine, geriatrics, and cardiology) in the year prior to admission. Missed clinic visits were then dichotomized into those with ≤ 1 and ≥ 2. We utilized a multivariate logistic regression model to examine the effect of the SDOH on missing ≥2 scheduled clinic appointments, adjusting for previously described confounders:4 age, race, the Charlson Received July 8, 2019 Revised September 17, 2019 Accepted October 16, 2019
Of the 1500 patients, 1282 (85%) had ≤ 1 missed clinic visit, while 218 (14%) had ≥ 2 missed clinic visits in the assessed year. Patients with ≥ 2 missed clinic visits had higher prevalence of all three SDOH compared with those with ≤ 1 and were more commonly black (34% vs. 14%), while rates of poor mental health (25% vs. 25%) and underlying comorbid conditions (CCI; 8.06 (±2.59) vs. 8.43 (±2.63)) were equally present in both groups (Table 1). In a multivariate analysis, living alone (OR 1.71, 95% CI 1.21-2.41), marginal housing (OR 6.93, 95% CI 2.88–17.38), and being black (OR 2.71, 95% CI 1.38–5.75) were significantly associa
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