Original Article
Care Utilization in a Pediatric Diabetes Clinic: Cancellations, Parental Attendance, and Mental Health Appointments

https://doi.org/10.1016/j.jpeds.2014.01.045Get rights and content

Objective

To examine care utilization, family attendance, and hemoglobin A1c levels in a multidisciplinary pediatric diabetes clinic.

Study design

This retrospective electronic record review of deidentified data included patients (99% with type 1 diabetes) with established diabetes care, aged <30 years (mean age, 15 ± 5.2 years), and duration of diabetes >1 year (mean 8.5 ± 5.1 years) at first visit during a 2-year period. Outcomes included care utilization, family attendance, and glycemic control, as indicated by hemoglobin A1c level. Analyses included t tests, ANOVA, χ2 tests, ORs and 95% CIs, and multivariate analyses.

Results

The study cohort comprised 1771 patients, with a mean of 5.8 ± 2.8 visits per patient. Roughly 15% of the scheduled appointments resulted in a cancellation or no-show; 61% of patients missed ≥1 visit. Patients with ≥2 missed appointments had higher A1c values and were older than those with <2 missed visits. Almost one-half of visits were attended by mothers alone; fathers attended 22% of visits. Patients whose fathers attended ≥1 visit had lower A1c values than patients whose fathers never attended. Eighteen percent of patients had onsite mental health visits. Patients with ≥1 mental health visit had higher mean A1c values, shorter duration of diabetes, and were younger compared with those with no mental health visits.

Conclusion

Our observations suggest the need to encourage attendance at diabetes visits and to include fathers to improve A1c values. The high rate of missed visits, especially in patients with poor glycemic control, identifies wasted provider effort when late cancellations/no-shows result in vacant clinic time. It is important to explore reasons for missed visits and to identify approaches to maximizing attendance, such as extended evening/weekend clinic hours and virtual visits.

Section snippets

Methods

The Joslin Diabetes Center is located in Boston in an urban setting. Approximately 95% of the clinic's pediatric patients reside in Massachusetts or in neighboring New England states. These patients reflect the ethnic mixture of New England and represent all socioeconomic strata.

Our multidisciplinary pediatric diabetes team recommends visits according to American Diabetes Association (ADA) guidelines (roughly every 3-4 months) with a medical provider (MD, nurse practitioner [NP], or registered

Results

The 1771 individual patients (51% female) eligible for inclusion in this study had a total of 17 984 scheduled appointments during the 2-year observation period. The mean patient age at the time of the first visit during this 2-year period was 15 ± 5.2 years. The age distribution was 3% young children (0-5 years), 31% school-aged children (6-12 years), 32% adolescents (13-17 years), and 35% young adults (18-29 years). The mean duration of diabetes was 8.5 ± 5.1 years. At the first visit during

Discussion

Over a 2-year observation period, 15% of scheduled visits at an outpatient pediatric diabetes clinic yielded a cancellation or no-show, with an average of 1.6 ± 2.1 missed visits per patient. Sixty-one percent of patients missed at least 1 visit over the 2-year period, although the majority (60%) completed ≥6 visits over the 2-year period, consistent with ADA recommendations for visits every 3-4 months.31 Missed visit rates were higher for mental health providers and dieticians and lower for

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    Funded by the National Institute of Diabetes and Digestive and Kidney Diseases (K23DK092335 and P30DK036836), the Eleanor Chesterman Beatson Fund, the Katherine Adler Astrove Youth Education Fund, and the Maria Griffin Drury Pediatric Fund. The authors declare no conflicts of interest.

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