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J Am Acad Orthop Surg Glob Res Rev
J Am Acad Orthop Surg Glob Res Rev
JAAOS Glob Res Rev
JAAOS Glob Res Rev
JAAOS Global Research & Reviews
2474-7661
Wolters Kluwer Philadelphia, PA

39254588
JAAOSGlobal-D-24-00231
10.5435/JAAOSGlobal-D-24-00231
00004
3
006
Research Article
Transportation Barriers in Pediatric Orthopaedic Clinic Visits
Hauschild Maia H. BA mhh82@med.miami.edu

Wren Tishya A. L. PhD twren@chla.usc.edu

Chavez Michelle BA mchavez@chla.usc.edu

Omar Hanna BS hanna.nidal.omar@gmail.com

https://orcid.org/0000-0002-3691-7529
Goldstein Rachel Y. MD, MPH
From the Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA.
Correspondence to Dr. Goldstein: rgoldstein@chla.usc.edu
9 2024
9 9 2024
8 9 e24.0023126 6 2024
29 6 2024
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.
2024
American Academy of Orthopaedic Surgeons
https://creativecommons.org/licenses/by-nd/4.0/ This is an open access article distributed under the Creative Commons Attribution-NoDerivatives License 4.0 (CC BY-ND) which allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author.

Objectives:

To identify what transportation barriers pediatric patients face when traveling to a major metropolitan orthopaedic center, how these barriers affect care, and what changes can be made to address this issue.

Study Design:

A cross-sectional transportation survey was administered to 107 caregivers of patients being seen in the orthopaedic clinic at a tertiary children's hospital in a large metropolitan area. Using logistic regression analysis, we compared socioeconomic characteristics, transportation methods, and scheduling practices among caregivers who reported missing at least one visit in the past and those who reported never missing a visit.

Results:

13% (14/108) of caregivers reported missing one or more past visits due to late arrival or transportation issues. Families that traveled more than 45 minutes to clinic (P = 0.04), waited more than one week to schedule a visit (P = 0.002), or reported difficulty scheduling a visit (P = 0.02) were significantly more likely to have a history of nonattendance. In addition, patients who were nonambulatory (P = 0.007), used a mobility device (P = 0.007), or were non-White (P < 0.05) were significantly more likely to have missed a visit.

Conclusion:

Travel time, difficult or delayed scheduling, and patient ambulatory status were all associated with missing orthopaedic clinic visits although other socioeconomic factors were not related. Interventions to improve orthopaedic clinic attendance should focus on promoting accessibility for patients with mobility limitations and encouraging simple and timely scheduling practices.

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pmcNonattendance impedes the efficiency of health systems by increasing costs, wasting time and resources, and lengthening patient wait time.1 It is important to understand the factors that result in missed appointments because barriers to timely access to care have been markedly associated with repeated emergency department visits.2

Previous studies estimate that, at pediatric outpatient clinics, between 20% and 35% of patients miss their scheduled appointments.3,4 Nonattendance at pediatric outpatient visits contributes to adverse health outcomes on both individual and community levels by disrupting continuity of care and missing opportunities for immunizations, preventive care, developmental screenings, and patient education.5

The common “did not attend” label for missed clinic visits has recently been reconceptualized as “failure to bring” (FTB) in the context of pediatric appointments.6 An often-overlooked factor that results in FTB is lack of access to efficient transportation. In a study on referral completion, transportation was among the three highest barriers to care cited by parents.7 Previous studies on transportation have shown that the combination of longer travel time, lack of access to a car, family size over two people, and socioeconomic factors such as lower income are markedly associated with clinic nonarrival.3,5,8,9

Although losing patients to follow-up is a common issue in orthopaedic surgery,10 there have been limited studies addressing reasons for FTB. While payor type and duration between scheduling appointments have been cited as reasons for nonattendance, existing studies on no-show rates in pediatric orthopaedic outpatient clinics have not included data on details of transportation.11 The purpose of this study was to investigate factors resulting in nonattendance at pediatric orthopaedic appointments that cannot be captured in the electronic medical record (EMR), specifically focusing on transportation barriers and details of appointment scheduling. We hypothesized that caregivers with access to a private vehicle and those who traveled a shorter time to get to the hospital would have markedly lower rates of FTB compared with those who relied on an alternative mode of transportation and had longer travel time.

Materials and Methods

Institutional review board approval was obtained before study initiation, and informed consent was obtained from all caregivers before participation. This study was conducted at an urban academic health center in a large metropolitan area in Southern California. Our patient population is 65% Hispanic/Latino and 12% non-Hispanic White, and over 60% of outpatients have public (Medi-Cal) insurance.

English or Spanish-speaking caregivers aged 18 years or older, whose children were seen at the outpatient pediatric orthopaedic clinic between October 2020 and November 2021, were approached to participate in a one-time transportation survey (Appendix A, http://links.lww.com/JG9/A358). Patients were excluded if the patient/caregiver declined to participate, caregiver did not speak English or Spanish, or caregiver did not accompany the patient to the visit.

Using daily patient clinic rosters, members of the research team completed study recruitment in person during clinic hours. A convenience sample of participants representative of the overall clinic population was recruited during morning and afternoon clinics, Monday through Friday. Recruitment was conducted in either English or Spanish. To prevent duplicate enrollment, an enrollment log was created and updated by the research team after the completion of the informed consent process. Surveys were administered electronically with Research Electronic Data Capture12,13 in compliance with the Health Insurance Portability and Accountability Act of 1996. Most surveys were completed in the examination room during appointment time. If there was no opportunity to complete the survey during the visit, the patient or caregiver was given a Quick Response code to complete the survey after the appointment. Surveys consisted of 20 questions and took less than five minutes to complete. Survey questions were related to patient demographics, mode of transportation, distance from home to hospital, history of missed appointments, preferred appointment time, and visit scheduling practices (Appendix A, http://links.lww.com/JG9/A358).

In addition to cross-sectional data collection, retrospective data were collected from the EMR in a chart review. Data extracted from the EMR included sex, height, weight, race/ethnicity, date of presentation, age at presentation, visit type (new patient, follow-up, preoperative visit, postoperative visit), patient mobility and assistive devices used, diagnosis, and type of insurance. No EMR data past the date of survey administration were collected.

Caregiver characteristics, transportation patterns, visit scheduling practices, and payor type were examined to identify variables predictive of missing an appointment in the past. The statistical package STATA 14 (StataCorp LLC.) was used to calculate frequency and percentage for categorical variables, mean and SD for continuous variables, and P-values from inferential statistics. Results were calculated excluding missing data, and counts were reported for each variable. For categorical variables, frequencies were compared between families who reported missing at least one visit in the past and those who reported never missing a visit using the Fisher's exact test. Additional analysis applied logistic regression to evaluate the effect of potential predictors on the odds of having missed at least one visit in the past. A P-value of less than 0.05 was considered significant. All variables with P < 0.05 in univariate analysis were evaluated for inclusion in a multivariable model.

Results

Of 134 caregivers approached to be in the study, 118 (88%) agreed to participate and completed the informed consent process. Of all families who completed the informed consent process, 90.7% (107/118) completed the survey. Caregiver characteristics are presented in Table 1. Most of the caregivers were female (82.2%, 88/107) and drove a personal car to the hospital (82.1%, 87/106). The average caregiver age was 39.1 years. The average time taken for traveling to the hospital was 63.9 minutes. Approximately half of the caregivers identified as Hispanic or Latino/a/x (48.6%, 53/105) and were employed full time (52.3%, 56/107). Most (66.4%, 71/107) reported English as their primary language and used public (Medi-Cal) insurance (65.1%, 69/106) (Table 1).

Table 1 Characteristics of Caregivers Completing Survey

Characteristics	All Caregivers Who Completed Survey	
Caregiver sex (N = 107)		
 Male	19 (17.8)	
 Female	88 (82.2)	
Caregiver race/ethnicity (N = 107)		
 Non-Hispanic White	31 (29.0)	
 Non-Hispanic Black	8 (7.5)	
 Hispanic or Latino/a/x	51 (47.7)	
 Asian	5 (4.7)	
 Other/multiple races/decline to state	12 (11.2)	
Transportation method (N = 106)		
 Personal car	87 (82.1)	
 Other	19 (17.9)	
Primary language (N = 107)		
 English	71 (66.4)	
 Spanish	30 (28.0)	
 Other	6 (5.6)	
Marital status (N = 106)		
 Married/domestic partnership	65 (61.3)	
 Single	30 (28.3%)	
 Divorced/separated	11 (10.4%)	
Employment status (N = 107)		
 Full time	56 (52.3%)	
 Part time	16 (15.0%)	
 Not employed	35 (32.7%)	
Education level (N = 107)		
 Did not complete high school	12 (11.2%)	
 High school graduate	21 (19.6%)	
 Vocational/technical school	11 (10.3%)	
 Some college	17 (15.9%)	
 Completed college	26 (24.3%)	
 Graduate school	20 (18.7%)	
Insurance type (N = 106)		
 Public	69 (63.9%)	
 Private	37 (34.3%)	
Parent age (years) (N = 84)	39.1 (8.9)	
Patient age (years) (N = 107)	8.9 (5.2)	
Patient mobility (N = 107)		
 Ambulatory	93 (86.9%)	
 Nonambulatory	14 (13.1%)	
Assistive devices (N = 107)		
 No	75 (70.1%)	
 Yes	32 (29.9%)	
Time traveled to hospital (min) (N = 88)	63.9 (100.5)	
Categorical variables are presented as n (%). Continuous variables are presented as mean (SD).

The patients were being treated for a variety of congenital and hereditary conditions, including cerebral palsy, clubfoot, scoliosis, Charcot-Marie-Tooth disease, brachial plexus birth palsy, and developmental dysplasia of the hip, in addition to acute conditions such as fractures of the femur, tibia, humerus, and radius/ulna. The average patient age was 8.9 years. Most patients were ambulatory (86.9%, 93/107) (Table 1). 30% (32/107) of patients used mobility devices including wheelchairs, braces/orthoses, casts, and strollers (Table 1).

Of 107 families who completed the survey, 25% (27/107) had missed at least one clinic visit due to late arrival (n = 14) and/or transportation issues (n = 25) (Table 2). Missed visits were more common for patients who were nonambulatory (odds ratio [OR], 5.2; 95% confidence interval (CI), 1.6 to 16.8; P = 0.006) or used a mobility device (OR, 3.7; 95% CI, 1.5 to 9.3; P = 0.005), found scheduling a visit to be difficult (OR, 3.2; 95% CI, 1.3 to 8.0; P = 0.01), waited more than one week to schedule a visit (OR, 2.9; 95% CI, 1.2 to 7.4; P = 0.02), or traveled more than 45 minutes to the appointment (OR, 3.1; 95% CI, 1.1 to 9.0; P = 0.04). A trend toward lower odds of patients missing a visit was found if they traveled in their personal car (OR, 0.38; 95% CI, 0.14 to 1.09; P = 0.08), although this did not reach statistical significance. Missed visits were also more likely for non-White children compared with White children (OR, 6.4; 95% CI, 1.4 to 28.9; P = 0.02). The likelihood of missing a visit was not affected by marital status, employment, insurance type, patient or parent age, patient body mass index, or primary language.

Table 2 Predictors of Missing a Clinic Visit (Due to Transportation Issues or Being Late)

Predictors	Caregivers Who Reported Missing a Visit	P Value	
Caregiver sex		0.78	
 Male	4/19 (21.1%)	
 Female	23/88 (26.1%)	
Patient sex		0.18	
 Male	18/58 (31.0%)	
 Female	9/49 (18.4%)	
Caregiver race/ethnicity		0.06	
 Non-Hispanic White	4/31 (12.9%)	
 Non-Hispanic Black	2/8 (25.0%)	
 Hispanic or Latino/a/x	13/51 (25.5%)	
 Asian	1/5 (20.0%)	
 Other/multiple races	6/10 (60.0%)	
Patient race/ethnicity		0.04*	
 Non-Hispanic White	2/29 (6.9%)	
 Non-Hispanic Black	2/8 (25.0%)	
 Hispanic or Latino/a/x	14/48 (29.2%)	
 Asian	1/3 (33.3%)	
 Other/multiple races	7/16 (43.8%)	
Primary language		0.55	
 English	16/71 (22.5%)	
 Spanish	10/30 (33.3%)	
 Other	1/6 (16.7%)	
Parent age		0.43	
 Younger than 40 yr	12/48 (66.7%)	
 40 yr and older	6/36 (33.3%)	
Patient age		0.25	
 Younger than 2 yr	2/12 (7.4%)	
 2–12 yr	18/56 (66.7%)	
 12 yr and older	7/39 (25.9%)	
Marital status		0.67	
 Married/domestic partnership	16/65 (24.6%)	
 Single	7/30 (23.3%)	
 Divorced/separated	4/11 (36.4%)	
Employment status		0.59	
 Full time	13/56 (23.2%)	
 Part time	3/16 (18.8%)	
 Not employed	11/35 (31.4%)	
Education level		0.57	
 Did not complete high school	5/12 (18.5%)	
 High school graduate	6/21 (22.2%)	
 Vocational/technical school	4/11 (14.8%)	
 Some college	3/17 (11.1%)	
 Completed college	5/26 (18.5%)	
 Graduate school	4/20 (14.8%)	
Insurance type		0.35	
 Public	20/69 (29.0%)	
 Private	7/37 (18.9%)	
Time waited to schedule visit		0.03	
 1 wk or less	15/77 (19.5%)	
 More than 1 wk	12/29 (41.4%)	
Difficulty scheduling visit		0.02	
 Easy/neutral	14/76 (18.4%)	
 Difficult	13/31 (41.9%)	
Type of visit		0.58	
 New patient	4/22 (18.2%)	
 Follow-up	23/85 (27.1%)	
Childcare		0.81	
 Hired babysitter	8/30 (66.7%)	
 No babysitter	19/77 (24.7%)	
Time traveled to hospital		0.04	
 Less than 45 min	5/38 (13.2%)	
 45 min and more	22/69 (31.9%)	
Transportation method		0.08	
 Personal car	19/87 (21.8%)	
 Other	8/19 (42.1%)	
Patient mobility		0.007	
 Ambulatory	19/93 (20.4%)	
 Nonambulatory	8/14 (57.1%)	
Use of mobility device		0.007	
 Yes	14/32 (43.8%)	
 No	13/75 (17.3%)	
Patient body mass index		0.19	
 Less than 25 (normal weight)	20/65 (30.8%)	
 25 or more (overweight)	4/25 (16.0%)	
P-values from the Fisher's exact test.

In multivariable analysis, the only significant predictors of missing a visit were finding scheduling to be difficult and the patient being non-White. Those who found scheduling difficult had 4.4 (95% CI, 1.6 to 12.1; P = 0.004) times greater odds of missing a visit, and non-White children had 7.3 (95% CI, 1.5 to 35.0; P = 0.01) times greater odds of missing a visit. The other univariate predictors of missing a visit were no longer significant once these two variables were taken into account.

Discussion

Consent and survey completion rates over 85% corroborate previous studies that patients are willing to participate in survey research of this nature.8,14 Consistent with our hypothesis, longer travel time was associated with missing a past visit. While patients who traveled in a personal vehicle were less likely to miss a visit, the association did not reach statistical significance in this study. Socioeconomic factors were largely nonpredictive of FTB; however, we found that non-White patients had 7.3 times greater odds of likely missing a past visit compared with their White counterparts.

Patient ambulatory status and mobility device use were markedly associated with FTB in our univariate analysis; however, these factors did not reach statistical significance in our multivariate analysis. While only 20.4% (19/93) of ambulatory patients reported missing a past visit, 57.1% (8/14) of nonambulatory patients reported having missed a visit. Of patients who used mobility devices, 43.8% (14/32) reported missing a past appointment while only 17.3% (13/75) of patients who did not report using mobility devices missed a past visit. The greater difficulty of transporting patients with mobility limitations may contribute to their higher rate of missed medical appointments.

Scheduling difficulties and miscommunication have been cited as reasons for missing appointments in similar studies.5,11 Our results are consistent with these findings and further supported by our multivariate analysis that patients experienced 4.4 times greater odds. While 41.9% (13/31) of patients who reported difficulty scheduling their visit missed a past visit, only 18.4% (14/76) of patients who reported an easy scheduling experience had missed a visit. While the reasons for having difficulty scheduling an appointment were not collected, it may be related to having less familiarity or comfort with the healthcare system, although it was not directly related to caregiver age, language, or education in our study. Of those respondents who waited more than one week to schedule their appointment after realizing their child needed to come to the clinic, 31% (9/29) had missed a past visit while only 6% (5/77) of respondents who scheduled in less than one week reported missing a past visit. A similar study highlighted duration between scheduling and subsequent appointment as a predictive covariate for no-show visits.11 These findings suggest that developing effective and accessible scheduling processes may promote clinic attendance. Patients should be encouraged to schedule follow-up visits as early as possible, and appointment reminders should be issued after the initial appointment scheduling.

Previous studies have suggested that more flexible clinic time, including weekend or after-hour options to accommodate caregivers' work schedules, has the potential to reduce rates of FTB.15 While employment status was not markedly associated with missed appointments in our sample, 36% (9/25) of caregivers who missed a past appointment reported that a weekend appointment would have been more convenient while 20% (5/25) reported that an evening appointment after 5 pm would have been more convenient.

This study is limited by a modest sample size, single-site design, and the convenience sampling method. As a metropolitan safety-net hospital, a higher proportion of patients seen at our institution belong to minority ethnic groups and have public insurance. The public transportation system in our metropolitan area is also considered poor. A larger sample size from multiple sites would provide a more representative portrayal of transportation barriers faced by patients across the county. Nevertheless, it is important to understand barriers to health care in this at-risk population to be able to reduce disparities in the care received. Another important limitation of this study is that comparison groups were analyzed based on whether the respondent missed a singular past clinic appointment, reflecting a single point in time. It would be useful to study the pattern of kept appointments over an extended period. In addition, official records would be more reliable than self-reporting in assessing clinic attendance history.

Conclusion

In conclusion, our results show that interventions to improve FTB rates should focus on promoting accessibility for patients who are nonambulatory or use mobility devices and encouraging simple and timely scheduling practices. Reducing the FTB rate would improve patient care and reduce inefficiency in the delivery of pediatric orthopaedic care.

Ms. Hauschild or an immediate family member has stock or stock options held in Johnson and Johnson. Ms. Omar or an immediate family member serves as a paid consultant to Accenture. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Wren, Ms. Chavez, and Dr. Goldstein.

This study has been carried out with approval from the Institutional Review Board at Children's Hospital Los Angeles.
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