4012 — Social Determinants of Health and Missed Clinic Visits: Factors Underlying Wasted Resources in VA Ambulatory Care?

Lead/Presenter: Charlie Wray,  San Francisco VA Medical Center
All Authors: Wray CM (San Francisco VA Medical Center, University of California, San Francisco), Vali M (Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center), Byers A (Mental Health Services, San Francisco Veterans Affairs Medical Center) Keyhani S (San Francisco VA Medical Center, University of California, San Francisco)

Objectives:
Medical access failures, specifically missed clinic visits (MCV), are a significant resource drain on the Veterans Health Administration (VA). The VA reports that 15-18% of scheduled primary care appointments (~3 times higher than in the private sector) are not completed. VA strategic goals include improving the timeliness, efficiency, and effectiveness of care -- with missed clinic visits representing a high-priority area. While previous appointment history, and patient demographics are shown to be associated with patients' propensity to ‘no-show', no previous work has examined the association of social determinants of health (SDOH) with missed clinic visits. Our goal was to assess the association of four SDOH (lives alone, lack of social support, substance abuse and marginal housing) with MCV among Veterans hospitalized for congestive heart failure (CHF).

Methods:
We randomly identified 1500 elderly ( > = 65 years) Veterans hospitalized with a primary diagnosis of CHF in 2012. SDOH were identified and extracted through chart abstraction by two independent 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 dichotomized into those with ?1 and ?2. We utilized multivariate logistic regression to examine the effect of the four SDOH on MCV rate; adjusting for age, psychiatric disorders, and the other SDOH covariates.

Results:
Of the 1500 patients, 1282 (85%) had ?1, while 218 (14%) had ?2 MCV. Patients with ?2 MCV had higher prevalence of all four SDOH compared to those with ?1 MCV, while psychiatric disorders were equally present in both groups. In multivariate analysis, living alone (OR 1.71, 95%CI 1.21-2.41), marginal housing (OR 6.93, 95%CI 2.88-17.38), a history of substance abuse (OR 1.48, 95%CI 1.01-2.12) were significantly associated with having ?2 MCV. Higher age was associated with a lower risk (OR 0.96, 95%CI 0.94-0.98) of having ?2 MCV.

Implications:
SDOH are more common among Veterans who represent "access failures" in the VA.

Impacts:
Primary care redesign strategies tailored to Veterans with a higher burden of SDOH may help improve delivery of care, reduce wasted resources, and improve access to care for all Veterans.