Factors That Decrease Likelihood of Attending Early Post-Discharge Office Visits

In previous research, patients discharged after a hospital stay for heart failure were more likely to be readmitted in 30 days if they did not show for early follow-up appointments (generally defined as seven to 14 days post-discharge). Factors associated with missing an appointment are not completely clear, as research on the topic has been limited. What is clear is that many medical centers across the U.S. experience the same phenomena.

Karen Distelhorst, MSN, RN, GCNS-BC

“We can educate patients on the importance of follow-up visits and schedule them, but it doesn’t guarantee they’ll actually come,” says Karen Distelhorst, MSN, RN, GCNS-BC, a clinical nurse specialist at Cleveland Clinic South Pointe Hospital.

Transition care involves coordination between inpatient and outpatient teams. It was apparent to Distelhorst that the inpatient team was doing a thorough job of arranging follow-up appointments for patients, but feedback from the outpatient team revealed that patients frequently did not show up. Nursing teams wondered if there was a way to predict factors that increased patients’ likelihood of missing follow-up appointments. Predicting factors associated with missed appointments could be the first step in preventing them.

Medical records reveal trends

That idea spurred Distelhorst, along with Kelly Dion, CNP, and Renee Claussen, RN, of Chronic Care Services, to design a research study on factors associated with non-adherence to early follow-up appointments in heart failure. Investigators from the hospital’s inpatient and outpatient areas collaborated, says Distelhorst, who was the principal investigator and focused on data management. Dion and other chronic care nurses helped with data collection, interpretation of findings and clinical implications.

Data collection involved a review of medical records of patients with heart failure discharged from Cleveland Clinic’s Euclid, Hillcrest and South Pointe hospitals, three regional hospitals within the system. Although the missed appointment rate was low (16.2 percent) among patients included in this study, the sample size was large enough to show clear associations between factors of interest and the outcome of missed appointments. The categories of data collected were:

1. Patient demographic, comorbid conditions, social and economic factors
2. Heart failure factors, and
3. Hospitalization factors

Using a multivariable analysis, the team uncovered eight factors associated with not attending early follow-up appointments. Odds ratios were calculated for each. Of factors linked to missed appointments, three were demographics, three were comorbid conditions, one was a social factor and another was a heart failure factor.

“All eight predictors can be easily retrieved from a medical record during the hospital stay,” says Distelhorst. “It’s quite feasible for care coordinators or discharge planners to identify risk and potentially intervene by providing extra encouragement or removing barriers to follow-up appointments.”

In other research reports on this topic, patients with Medicare status were selected and Medicare claims were used to identify early discharge appointment status. “Our study was different, as we had a wider range of patients aged 25 to 101 years,” says Distelhorst. “Our patients came from regional hospitals, so there was a decrease in the likelihood that the follow-up appointments would be a far distance away from where patients lived.”

Next steps

Even before a research paper of findings is published, the team has already anticipated next steps. From a research perspective, it is important to learn if implementing a program that assesses and addresses our eight factors of interest will:

• Improve attendance at follow-up appointments
• Be feasible for healthcare providers to incorporate into daily care planning
• And ultimately, if the first two areas are successful, it reduces 30-day hospital readmission rates

“After reviewing the results of this research project, we have a better understanding of our role as healthcare providers in identifying patients who may require additional information and support so they can manage their treatment plan,” says Dion. “We can be more patient-centric in planning care based on the eight factors of missed appointments, when we know one or more are present. Also, interventions we create may improve patient adherence to other services, prescriptions and self-care.”