To our knowledge, this is the first study to evaluate ethnic differences in primary care appointment-keeping in a large, ethnically diverse diabetic patient population with uniform access to health care. Our study is unique in that we had sufficient sample size to disaggregate “minority” ethnicity and examine utilization patterns separately. We observed substantial ethnic differences in PAK, with the highest rates among Latinos and African Americans. These differences were not fully explained by the confounders and mediators included in our models (i.e., demographics, education, socioeconomic status, and patient–provider relationship [trust-in-provider]) previously thought to account for these findings. Medical center was an effect modifier of the ethnicity–PAK association. PAK was associated with a 20–40 percent greater rate of poor control for the major cardiometabolic risk factors (HbA1c, LDL, and BP), underscoring the public health relevance of these findings. Our results suggest that ethnic differences in PAK are not spurious and deserve more attention.
While offered care and total utilization were, for the most part, uniform across ethnic groups in this health care setting after adjustment for demographic, socioeconomic, and clinical risk factors, Latinos and African Americans were at much higher risk of missing
planned visits. In as much as planned visits are scheduled with providers to ensure a proactive approach to disease management and prevention of comorbidities, PAK may represent missed opportunities for treatment intensification and preventive care, even for patients with seemingly adequate overall utilization based on visit number. Latinos and African Americans were more likely to have negative perceptions of their PCP communication style (i.e., reporting they were not patient-centered, or relationship-centered) and were more likely to be in ethnic discordant patient–PCP dyads (data not shown). Previous research has shown that satisfaction may be poorer among vulnerable populations (Rothschild 1998
), where differences in patients’ and providers’ social class (i.e., social distance) may reinforce stereotypes, give rise to unintentional discrimination (van Ryn and Burke 2000
; Sequist, Fitzmaurice, and Marshall 2008
), or in the case of this study, foster differential utilization patterns among ethnicities. Appointment-keeping may also be influenced by patients’ attachment styles with regard to the patient–provider relationship, which may differ across ethnic groups (Ciechanowski, Russo, and Katon 2006
We found variability in ethnic-specific PAK rates across medical centers despite the largely uniform standards of care at KPNC. Another study also indicated that site of care was an important determining factor in missed appointment rates in a community clinic setting (Lasser, Mintzer, and Lambert 2005
). Site-specific structural features, potentially identifiable and modifiable, may influence ethnic differences in appointment-keeping behavior. A recent review article, which examined the effect of open access scheduling, found that in practice, its implementation was imperfect. In “real world” scenarios, outcomes varied across sites. No-show rates improved only in practices with a high prevalence (>15 percent) of missed appointments at baseline, and there was some evidence suggesting that patients were more likely to be lost to follow-up in open access systems (Rose, Ross, and Horwitz 2011
). Site differences in the availability and type of same-day appointments (e.g., extended evening and weekend hours, PCP or non-PCP) may give rise to unexpected utilization patterns (e.g., considering same-day visit as compensating for needed scheduled appointments) and potentially increase ethnic disparities. In this study, we saw a greater propensity among some ethnic groups, particularly Latinos, to use same-day appointments, and this was strongly predictive of PAK (RR ~ 4) even after adjusting for disease severity.
Perceptions of the importance and purpose of planned versus same-day primary care appointments may differ between health care providers and patients. Some patients may have a preference for using same-day services, as acute problems arise at the expense of preventive, primary care visits. Other patients may not distinguish between planned and same-day visits, and consider them interchangeable. For example, if a patient has recently seen his/her PCP at a same-day visit, s/he may consider the upcoming, planned appointment as optional or unnecessary. Conversely, a patient who misses a planned appointment may subsequently make and attend a same-day appointment with the PCP to compensate for the no-show.
Whichever is the directionality, the quality of care provided may differ between the two visit types, even if the PCP attends both. Planned primary care appointments in diabetes maintain continuity of care by evaluating risk factor control and the need for treatment intensification (Rodondi, Peng, and Karter 2006
; Schmittdiel, Uratsu, and Karter 2008
), monitoring adherence to and tolerance of new medications, and checking for depressive symptoms as well as complications. Same-day appointments are typically intended for patients with acute illness or injury. Even in cases where the PCP conducts the same-day appointment, health care providers are trained to listen to patient complaints (typically requesting symptom relief) before imposing an agenda. Thus, time constraints may leave little time to focus on the preventive diabetes care agenda that would dominate a visit planned by the PCP. As a result, patients who are habitually seen at same-day rather than planned primary care appointments may receive less preventive care or have less continuity with one PCP, thus undermining a personal, ongoing patient–provider relationship that has been shown to improve glycemic control (Dearinger, Wilson, and Griffith 2008
We also found evidence suggesting that PAK may negatively impact outcomes as it was associated with a 20–40 percent increased risk of inadequate control of HbA1c, LDL, and sBP in models that adjusted for prebaseline clinical control. Continuity of care with a PCP is particularly critical for patients with diabetes. If certain ethnic subgroups are receiving the majority of care through same-day rather than planned primary care visits, it may further the disparities commonly observed in blood pressure, lipid, and glycemic control (Karter, Ferrara, and Liu 2002
; Brown, Gregg, and Stevens 2005
; Kirk, D'Agostino, and Bell 2006
; Chew, Bradley, and Boyko 2008
). Even though the evidence is suggestive, caution is needed when inferring from these observational data that poor attendance actually caused a worsening of control. Nonetheless, our data confirm that PAK is clearly useful as a marker of poor clinical control (Karter, Parker, and Moffet 2004
; Schectman, Schorling, and Voss 2008
Our study has numerous strengths, including many potential explanatory variables from a large, ethnically diverse cohort collected via self-report and electronically. However, some limitations should be mentioned. Given that our findings are based on survey responses from a sample of patients with diabetes, selection bias (e.g., survey nonresponse bias) could reduce generalizability. However, we controlled for selection bias by incorporating survey nonresponse weights in the multivariable analysis. In addition, we have no reason to believe that the relationship between ethnicity and PAK would be different among survey responders versus nonresponders. Given the slightly higher rate of missed appointments in survey nonresponders (18 percent) compared with responders (15 percent), it is likely that our estimates are conservative and biased toward the null. We studied a fully insured population, and so interpretation of the findings is limited to this group. However, approximately one-third of Northern California's residents are members of Kaiser Permanente, and so our study results should have wide applicability. Finally, as in all observational research, residual confounding due to unmeasured or poorly measured factors is possible.
Our study suggests that the poorer intermediate health outcomes commonly observed in African Americans and Latinos with diabetes may be attributable to some extent to PAK. PAK was associated with increased utilization of same-day appointments and was also predictive of poor clinical outcomes in a lagged cross-sectional analysis. While this study's objective did not include identifying the reasons for ethnic differences in PAK, we did find that the size of these disparities varied across medical centers. Future research needs to evaluate the tension between facility-level structural features (e.g., providing greater convenience and access via extended hours for same-day appointments) and missing planned primary care appointments; those tradeoffs may impact ethnic groups differently and perpetuate disparities in unexpected ways.
These results may have important implications for public health and health plan policy as managed care settings rapidly expand open access to care supported by the PCMH model (Rittenhouse and Shortell 2009
). On an individual level, heavier use of same-day appointments was associated with higher likelihood of missing planned appointments. Research is needed to evaluate the impact of health care system-level structural changes including: (1) whether increasing availability of same-day appointments at medical centers via open access could actually increase the rate of missing planned appointments for the care of chronic diseases; (2) whether expanding same-day access increases PAK in planned appointments in a way that is detrimental for health outcomes for chronic disease; and (3) whether these negative impacts (1 and 2) are amplified in medically vulnerable populations. If so, it will be crucial that PCMH develop systems to monitor that quality of care will not be compromised among patients who prefer same-day appointments as a substitution for planned appointments. Given our disparate findings across ethnic groups, we will also need to monitor outcomes separately across populations to ensure that open access is not compromising care for medically vulnerable subgroups. Finally, interventions to address PAK deserve special attention, given the simplicity of identifying patients who have missed appointments, potential clinical consequences of missed appointments overall, and its contribution to health disparities.