title: Care utilization in a pediatric diabetes clinic: cancellations, parental attendance, and mental health appointments.
abstract: OBJECTIVE
  To examine care utilization, family attendance, and hemoglobin A1c levels in a multidisciplinary pediatric diabetes clinic.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Pediatric, Adolescent, and Young Adult Section, and the Section on Genetics and Epidemiology, Joslin Diabetes Center, Boston, MA. Electronic address: jessica.markowitz@joslin.harvard.edu.
authors.forename: Jessica T
authors.initials: JT
authors.lastname: Markowitz
authors.affiliation: Pediatric, Adolescent, and Young Adult Section, and the Section on Genetics and Epidemiology, Joslin Diabetes Center, Boston, MA.
authors.forename: Lisa K
authors.initials: LK
authors.lastname: Volkening
authors.affiliation: Pediatric, Adolescent, and Young Adult Section, and the Section on Genetics and Epidemiology, Joslin Diabetes Center, Boston, MA.
authors.forename: Lori M B
authors.initials: LM
authors.lastname: Laffel
mesh_terms: D000293:Adolescent; D000553:Ambulatory Care / Q000379:methods; D000704:Analysis of Variance; D001071:Appointments and Schedules; D001900:Boston; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D016001:Confidence Intervals; D016208:Databases, Factual; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000628:therapy*; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000706:statistics & numerical data*; D008991:Monitoring, Physiologic / Q000379:methods; D015999:Multivariate Analysis; D020380:Needs Assessment; D016017:Odds Ratio; D010044:Outpatient Clinics, Hospital; D010287:Parent-Child Relations; D005791:Patient Care / Q000706:statistics & numerical data*; D010348:Patient Care Team / Q000458:organization & administration; D010349:Patient Compliance / Q000706:statistics & numerical data*; D010353:Patient Education as Topic; D012189:Retrospective Studies; D018570:Risk Assessment; D055815:Young Adult
chemical_list: D006442:Glycated Hemoglobin