INTRODUCTION
Communities with Limited English Proficiency (LEP) often face inequitable access to healthcare and are at higher risk of poor health outcomes.1 Studies of populations with LEP have focused on access and delay of healthcare,2, 3 availability and use of trained interpreters,4 or accessibility of linguistically appropriate health information.5 However, less is known about no-show rates for primary care visits in patients with LEP. No-show rates are associated with lower quality of care, increased utilization of emergency departments, missed revenue and higher costs for health systems.6 The objective of this study was to evaluate no-show rates of patients with LEP for primary care visits at a large urban academic safety-net hospital with a minority-majority population and a large proportion of patients with LEP.
METHODS
This retrospective cohort study used electronic medical record (EMR) data from January to December 2022. The study sample was limited to adults > = 18 years that had a scheduled new, follow up, or e-health appointment in one of three internal medicine clinics. The three clinics included were an internal medicine resident clinic, an internal medicine faculty clinic and a combined resident and faculty internal medicine/pediatrics clinic. The primary study outcome was the no-show rate for scheduled appointments. Scheduled appointments which were not completed were considered a “no-show.”
All patients identified in the EMR as needing an interpreter were categorized as having LEP. Sociodemographic variables for the selected cohort included self-reported age, race, ethnicity, gender and insurance type. Analysis of associations between the primary outcome and sociodemographic variables were evaluated using bivariate analyses and a multilevel mixed effects logistic regression. The regression model was adjusted for all sociodemographic variables. Patients were nested within providers to account for the random effects of correlated observations. A secondary bivariate analysis and multivariate logistic regression stratified by LEP status evaluated differences in sociodemographic variables. Analyses were conducted using Stata 17. The study was approved by the Institutional Review Board of Rutgers New Jersey Medical School.
RESULTS
A total of 18,746 schedule appointments were included in the analysis, of which 4,264 (23%) of visits were for patients with LEP. Chi-square analyses indicated a statistically significant difference for no-show rates for patients with LEP (p-value < 0.001). The study sample (Table 1) was majority-minority; 58% of the overall sample identified as Black/African American and 35% identified as Hispanic (all races). The adjusted multivariable analysis found that patients with LEP were more likely than English proficient (EP) patients to have a no-show visit (aOR 1.32[1.12–1.55]). New patients (aOR 1.53 [1.36–1.73]) and those scheduled for the resident clinic (aOR 1.62 [1.44–1.83]) were also more likely to no-show than those scheduled for follow up visits or the faculty clinic. Finally, males (aOR 1.48 [1.32–1.65]) and self-pay (aOR 5.66 [4.65–6.89]) were more likely to no-show than females and those with commercial insurance, respectively (Table 2). The secondary analysis indicated that LEP patients were overwhelmingly women and scheduled for follow up care. LEP patients had higher proportions of self-pay and scheduled resident clinic visits than EP patients. The adjusted logistic regression stratified by LEP status, indicated that patients with LEP were more likely to no-show (aOR 1.24 [1.12–1.37]) (Table 2).
Table 1.
Sample Demographics
| Completed Visits | No-Show Visits | Visits of EP Patients | Visits of Patients with LEP | |
|---|---|---|---|---|
| Visit Completion N (%) | N = 10,631 | N = 8,115 | N = 14,482 | N = 4,264 |
| Completed Visit | 57% (8,314) | 54% (2,317) | ||
| No Show | 43% (6,168) | 46% (1,947) | ||
| LEP | ||||
| No | 78% (8,314) | 76% (6,168) | ||
| Yes | 22% (2,317) | 24% (1,947) | ||
| Gender | ||||
| Female | 65% (6,925) | 59% (4,803) | 60% (8,683) | 71% (3,045) |
| Male | 34% (3,612) | 40% (3,267) | 39% (5,691) | 28% (1,188) |
| Choose not to answer | 1% (94) | 1% (45) | 1% (108) | 1% (31) |
| Race | ||||
| Other Race | 36% (3,846) | 39% (3,129) | 21% (3,095) | 91% (3,880) |
| AAPI | 1% (142) | 2% (183) | 2% (266) | 1% (59) |
| Black/AA | 60% (6,404) | 56% (4,556) | 74% (10,710) | 6% (250) |
| White | 2% (239) | 3% (247) | 3% (411) | 2% (75) |
| Hispanic | ||||
| Non-Hispanic (any race) | 66% (7,029) | 64% (5,160) | 81% (11,681) | 12% (508) |
| Hispanic (any race) | 34% (3,602) | 36% (2,955) | 19% (2,801) | 88% (3,756) |
| Appointment Type | ||||
| Follow Up | 70% (7,478) | 63% (5,097) | 65% (9,468) | 73% (3,107) |
| New Patient | 11% (1,212) | 24% (1,987) | 17% (2,528) | 16% (671) |
| E-Health | 18% (1,941) | 13% (1,031) | 17% (2,486) | 11% (486) |
| Department | ||||
| Faculty IM Clinic | 34% (3,646) | 26% (2,090) | 33% (4,811) | 22% (925) |
| Academic IM Clinic | 49% (5,222) | 61% (4,918) | 49% (7,058) | 72% (3,082) |
| Med-Peds Clinic | 17% (1,763) | 14% (1,107) | 18% (2,613) | 6% (257) |
| Insurance Type | ||||
| Commercial | 15% (1,613) | 11% (880) | 15% (2,213) | 7% (280) |
| Charity Care | 17% (1,834) | 11% (878) | 6% (939) | 42% (1,773) |
| Medicaid | 44% (4,728) | 35% (2,847) | 47% (6,875) | 16% (700) |
| Medicare | 8% (886) | 6% (491) | 8% (1,157) | 5% (220) |
| Self-Pay | 6% (664) | 22% (1,786) | 10% (1,460) | 23% (990) |
| Other | 9% (906) | 15% (1,233) | 13% (1,838) | 7% (301) |
| Age Group | ||||
| 18–40 | 13% (1,374) | 27% (2,151) | 20% (2,909) | 14% (616) |
| 41–64 | 51% (5,465) | 50% (4,074) | 50% (7,305) | 52% (2,234) |
| 65 + | 36% (3,792) | 23% (1,890) | 29% (4,268) | 33% (1,414) |
| Median Scheduled Visits (IQR) | 2 (1–4) | 1 (1–2) | 3 (2) | 2 (2) |
Table 2.
Logistic Regression Models of No-Show Visits
| Factors associated with overall No-Show Visits | Correlates of Primary Care No-Show within LEP Population | |
|---|---|---|
| Adjusted Odds Ratios [95% CI] |
Adjusted Odds Ratios [95% CI] |
|
| Visit Completion | ||
| Completed Visit | Ref | |
| No Show | 1.24 [1.12–1.37]* | |
| LEP | ||
| No | Ref | |
| Yes | 1.32 [1.12–1.55]* | |
| Gender | ||
| Female | Ref | Ref |
| Male | 1.48 [1.32–1.65]* | 0.58 [0.53–0.65]* |
| Choose not to answer | 0.79 [0.43–1.45] | 1.38 [0.78–2.42] |
| Race | ||
| Other Race | Ref | Ref |
| AAPI | 1.58 [1.04–2.40]‡ | 0.37 [0.26-0.050]* |
| Black/AA | 0.97 [0.77–1.21] | 0.09 [0.08–0.11]* |
| White | 1.49 [1.04–2.12]‡ | 0.37 [0.28–0.49]* |
| Hispanic | ||
| Non-Hispanic (any race) | Ref | Ref |
| Hispanic (any race) | 0.90 [0.72–1.12] | 4.01 [3.43–4.69]* |
| Appointment Type | ||
| Follow Up | Ref | Ref |
| New Patient | 1.53 [1.36–1.73]* | 0.85 [0.75–0.97]† |
| E-Health | 0.59 [0.52–0.70]* | 0.75 [0.65–0.87]* |
| Department | ||
| Faculty IM Clinic | Ref | Ref |
| Academic IM Clinic | 1.62 [1.44–1.83]* | 1.41 [1.25–1.60]* |
| Med-Peds Clinic | 0.95 [0.80–1.11] | 0.73 [0.61–0.88]* |
| Insurance Type | ||
| Commercial | Ref | Ref |
| Charity Care | 0.59 [0.48–0.73]* | 3.32 [2.76–3.99]* |
| Medicaid | 0.88 [0.75–1.03] | 0.82 [0.68-0.98]‡ |
| Medicare | 1.47 [1.18–1.84]* | 1.12 [0.85–1.42] |
| Self-Pay | 5.66 [4.65–6.89]* | 2.18 [1.79–2.64]* |
| Other | 4.60 [3.74–5.65]* | 1.23 [0.98–1.54] |
| Age Group | ||
| 18–40 | 2.58 [2.24–2.98]* | 0.64 [0.56–0.73]* |
| 41–64 | Ref | Ref |
| 65 + | 0.63 [0.55–0.72]* | 1.87 [1.66–2.11]* |
|
Intraclass correlation coefficient (ICC) for provider and patient random effects [95% CI] | ||
| Patient | 2.01 [1.75–2.31] | |
| Patient > Provider | 0.09 [0.01–1.03] | |
Calculated p-value using logistic regression statistically significant at *p < 0.001, † p < 0.01, and ‡ p < 0.05
DISCUSSION
This study suggests that patients with LEP have an independent risk of being a no-show for their scheduled appointment. This disparity in no-show rates may worsen existing inequities in healthcare for patients with LEP. The study findings are limited by the integrity of the available EMR data and cannot account for unmeasured confounders affecting communication for patients with LEP, such as the use of trained or ad-hoc interpreters. The experience of patients with LEP may be impacted by interactions with signage, written materials, and communication with clinic staff. Nonetheless, the study findings are relevant for clinicians, healthcare administrators and policy makers who care for communities with LEP. Proper implementation of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) may provide clinicians and health systems with actionable steps for ameliorating disparities affecting communities with LEP.7 Subsequent studies should explore the underlying reasons for no-shows among patients with LEP and the relationship between no-show rates and the implementation of CLAS Standards. Ultimately, improving the quality of care for populations with LEP should place an emphasis on addressing no-show rates for primary care visits.
Funding
This study was funded in part by the Hispanic Center of Excellence at Rutgers New Jersey Medical School through the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS), Centers of Excellence Grant (Grant # D34HP49551). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
Data Availability
The health system whose data was analyzed as part of this study did not provide consent for their data to be shared publicly. Due to privacy and confidentiality considerations, the data from this study cannot be made accessible to the public.
Declarations
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Footnotes
Publisher's Note
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Associated Data
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Data Availability Statement
The health system whose data was analyzed as part of this study did not provide consent for their data to be shared publicly. Due to privacy and confidentiality considerations, the data from this study cannot be made accessible to the public.