title: No-shows to primary care appointments: subsequent acute care utilization among diabetic patients.
abstract: BACKGROUND
  Patients who no-show to primary care appointments interrupt clinicians' efforts to provide continuity of care. Prior literature reveals no-shows among diabetic patients are common. The purpose of this study is to assess whether no-shows to primary care appointments are associated with increased risk of future emergency department (ED) visits or hospital admissions among diabetics.
  
  
  METHODS
  A prospective cohort study was conducted using data from 8,787 adult diabetic patients attending outpatient clinics associated with a medical center in Indiana. The outcomes examined were hospital admissions or ED visits in the 6 months (182 days) following the patient's last scheduled primary care appointment. The Andersen-Gill extension of the Cox proportional hazard model was used to assess risk separately for hospital admissions and ED visits. Adjustment was made for variables associated with no-show status and acute care utilization such as gender, age, race, insurance and co-morbid status. The interaction between utilization of the acute care service in the six months prior to the appointment and no-show was computed for each model.
  
  
  RESULTS
  The six-month rate of hospital admissions following the last scheduled primary care appointment was 0.22 (s.d. = 0.83) for no-shows and 0.14 (s.d. = 0.63) for those who attended (p < 0.0001). No-show was associated with greater risk for hospitalization only among diabetics with a hospital admission in the prior six months. Among diabetic patients with a prior hospital admission, those who no-showed were at 60% greater risk for subsequent hospital admission (HR = 1.60, CI = 1.17-2.18) than those who attended their appointment. The six-month rate of ED visits following the last scheduled primary care appointment was 0.56 (s.d. = 1.48) for no-shows and 0.38 (s.d. = 1.05) for those who attended (p < 0.0001); after adjustment for covariates, no-show status was not significantly related to subsequent ED utilization.
  
  
  CONCLUSIONS
  No-show to a primary care appointment is associated with increased risk for hospital admission among diabetics recently hospitalized.
authors.affiliation: School of Nursing, College of Health and Human Sciences, Purdue University, West Lafayette, IN 47907-2069, USA.
authors.forename: Lynn A
authors.initials: LA
authors.lastname: Nuti
authors.forename: Mark
authors.initials: M
authors.lastname: Lawley
authors.forename: Ayten
authors.initials: A
authors.lastname: Turkcan
authors.forename: Zhiyi
authors.initials: Z
authors.lastname: Tian
authors.forename: Lingsong
authors.initials: L
authors.lastname: Zhang
authors.forename: Karen
authors.initials: K
authors.lastname: Chang
authors.forename: Deanna R
authors.initials: DR
authors.lastname: Willis
authors.forename: Laura P
authors.initials: LP
authors.lastname: Sands
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001071:Appointments and Schedules; D016009:Chi-Square Distribution; D003920:Diabetes Mellitus / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007196:Indiana; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000706:statistics & numerical data*; D016012:Poisson Distribution; D011320:Primary Health Care / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors