Examining the Association of Social Determinants of Health with Missed Clinic Visits in Patients with Heart Failure in the Veterans Health Administration

Missed clinic visits, or no-shows, are a significant resource drain on the Veterans Health Administration (VA). The VA reports that 15–18% of scheduled primary care appointments are not completed, costing an estimated half a billion dollars per year. While some social determinants of health (SDOH) are shown to influence clinic no-show rates in other populations, no prior work has explored their effect among Veterans. Focusing on a cohort that require frequent clinic visits, our goal was to assess the association of three SDOH with missed clinic visits among Veterans hospitalized for congestive heart failure (CHF). From a national sample, we first identified all Veterans 65 and older who were hospitalized for hearth failure, then randomly selected 1500 hospitalized with a primary diagnosis of CHF in 2012. Based on previous work, three SDOH (lives alone, social support, and housing situation) were extracted and verified through chart abstraction by two reviewers. We determined the number of missed clinic visits (primary care, general internal medicine, geriatrics, and cardiology) in the year prior to admission. Missed clinic visits were then dichotomized into those with ≤ 1 and ≥ 2. We utilized a multivariate logistic regression model to examine the effect of the SDOH on missing ≥2 scheduled clinic appointments, adjusting for previously described confounders: age, race, the Charlson Comorbidity Index (CCI), mental health disorders, substance abuse, and other SDOH covariates. Of the 1500 patients, 1282 (85%) had ≤ 1 missed clinic visit, while 218 (14%) had ≥ 2 missed clinic visits in the assessed year. Patients with ≥ 2 missed clinic visits had higher prevalence of all three SDOH compared with those with ≤ 1 and were more commonly black (34% vs. 14%), while rates of poor mental health (25% vs. 25%) and underlying comorbid conditions (CCI; 8.06 (±2.59) vs. 8.43 (±2.63)) were equally present in both groups (Table 1 ). In a multivariate analysis, living alone (OR 1.71, 95% CI 1.21-2.41), marginal housing (OR 6.93, 95% CI 2.88–17.38), and being black (OR 2.71, 95% CI 1.38–5.75) were significantly associated with having ≥2 missed clinic appointments. Higher age was associated with lower odds (OR 0.96, 95% CI 0.94–0.98) of having ≥ 2 missed clinic visits (Table 2 ).