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Investigating “Interconsultas”: a Mixed-Methods Study of Pediatric Patient Attendance in Santiago, Chile

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Investigating “Interconsultas”: a Mixed-Methods Study of Pediatric Patient Attendance in Santiago, Chile INVESTIGATING “INTERCONSULTAS”: A MIXED-METHODS STUDY OF PEDIATRIC PATIENT ATTENDANCE IN SANTIAGO, CHILE by Evan Andrew Rusoja A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy Baltimore, Maryland May, 2016 © 2016 Evan Andrew Rusoja All Rights Reserved Abstract Statement of problem: While missed health care appointments can lead to wasted health system resources and long-term poor health outcomes particularly in children, few studies have comprehensively explored pediatric patient attendance and mechanisms for improving attendance. Methods: This mixed-methods study sought to capture the health beliefs, characteristics, and opinions associated with pediatric patient attendance at a public referral hospital in Chile, and evaluate whether Health Call, an interactive appointment reminders system, could improve attendance. After testing the reliability and validity of an adapted Health Belief Model in a subset of the guardian participants (N=295), the relationship of these patient and guardian characteristics with attendance were then analyzed using regression models for all patients enrolled in the study (N=513). Next, differences between attendance outcomes from guardians randomized to a Health Call reminder (N=107) compared with no call (N=156) were compared with the system’s performance in actual use across multiple visits. Finally, in-depth interviews were conducted with guardians (N=12) as well as administrators, clinicians, and other staff from around the health system (N=12), to complement and contextualize quantitative results, as well as better understand referral appointment processes and decisions. Results: With the exception of some appointment characteristics and a few health beliefs, most patient, guardian, and appointment characteristics, were not associated with attendance at referral appointments. No attendance differences were detected in the randomized trial. However, observational data showed that when implemented at scale, the reminder system improved attendance for guardians who received the reminder and ii confirmed their appointment. The interviews revealed important differences between the fluid family, health, and situational constraints that guardians noted drove attendance decisions and the fixed value assigned to these referral appointments by the front line, primarily non-clinical staff members who controlled the many different appointment allocation policies and reminder systems. Conclusions: This study challenges prior assumptions about the determinants of pediatric patient attendance and adequacy of existing approaches to missed visits. Results from this study can be used to refine data collection processes, improve referral and scheduling processes, and advance the understanding of pediatric patient attendance in this and similar settings. Readers: Shannon Doocy, PhD; Bill Weiss, DrPH, MA; Jill Owczarzak, PhD, MA; Carlos Castillo-Salgado, MD, JD, DrPH, MPH; Alec Hoon Jr, MD, MPH iii Acknowledgements Academic Advisor Shannon Doocy, PhD Associate Professor Department of International Health Johns Hopkins Bloomberg School of Public Health Dissertation Review Committee Members Carlos Castillo-Salgado, MD, JD, DrPH, MPH Professor Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Alexander “Alec” Hoon Jr, MD, MPH Associate Professor Phelps Center for Cerebral Palsy and Neurodevelopmental Medicine Kennedy Krieger Institute Jill Owczarzak, PhD, MA Assistant Professor Department of Health Behavior and Society Johns Hopkins Bloomberg School of Public Health William “Bill” Weiss, DrPH, MA Associate Scientist Department of International Health Johns Hopkins Bloomberg School of Public Health Dissertation Review Committee Alternates Jamil Bayram, MD, MPH, EMDM, MEd Associate Professor Department of Emergency Medicine Johns Hopkins School of Medicine Alain Labrique, PhD, MHS, MS Associate Professor Department of International Health Johns Hopkins Bloomberg School of Public Health Administrative Support Cristina Salazar, MA Academic Program Manager Department of International Health Johns Hopkins Bloomberg School of Public Health iv Study Partners First and foremost, I would like to thank all of the guardians and staff who volunteered to participate in this study. I hope this document honors their voices and experiences. At Hospital Luis Calvo Mackenna I would like to thank Director Jorge Lastra for his patience over a long evaluation period as well as Juan Sandoval, Jessica García, Manuel Galaz, and Nicolas Gonzalez from the Unidad de Informática for their consistent, timely support. Thank you also to the dozens of consultorio staff members who provided important logistical support to this study while juggling many other responsibilities. At Merlin Telecom, many thanks to Mario, Mauro, and Marcelo Arancibia as well as Felipe Pini and Inti Paredes (now at Saludinnova) for their foresight in bringing together the partners in this project and for their technical support throughout the process. Thanks to the many members of the Institutional Review Boards at the Johns Hopkins Bloomberg School of Public Health and the Region Servicio de Salud Metropolitano Oriente in Chile for the many thoughtful ways they contributed to improving study design while protecting participant data. Thank you to Rafael Alaniz for his leadership and on-site data collection support. Thank you to our excellent team of data collectors Alexis Cerda Bizama,Barbara Latin Ignamarca, Catalina Neira Kullmer, Claudia Belén Caballero Fontecilla, Daniel Weaver, Edgardo (Antonio) Vera, Felipe Bocic W, Felipe Figueroa Peys, Felipe Valenzuela Acuña, Francisco Garcia Coya, Javiera Manzanera, John Cerda Chacana, Juan Carlos Picand, Juan Sotelo Torres, Natalia Orrego, Nicole Vásquez Donoso, Pablo Vega Rojas, Patricio Meza Tello, Rodolfo Werner Julian, Rodrigo Carlos Iglesias Cárdenas, Rosario Alvial, Rosa Ogrodnik Orellana, Valentina Pantoja, Sofía Pradenas, Consuelo Tastets, and Daniela Goretta for their help carrying out the study, piloting the instruments, and enrolling participants, and to Alexandra Edwards and Loreto Soto Bustos for their help with transcription and translation of interview transcripts. At Hopkins, thank you to the MD/PhD program, School of Medicine, and at the Bloomberg School of Public Health, the Department of International Health for accommodating my unique career trajectory, and particularly Cristina Salazar for helping me through the unique administrative challenges therein. I would like to give special thanks to Shannon Doocy for advising me throughout my graduate studies and to Bill Weiss for guiding me through this project as the study’s Principal Investigator. Thank you also to Kitty Chan for her support with the psychometric methods portion. Finally, I would like to thank my partner Alicia for accompanying me on literally every step of this journey through medical and graduate school. Her unwavering support made this possible. v Conflict of Interest Statement1 Work under consideration for publication The Johns Hopkins School of Medicine MD/PhD program, the Department of International Health at the Bloomberg School of Public Health, provided Evan Rusoja (ER) with salary support throughout his graduate studies including through the duration of this study. The Johns Hopkins University Global mHealth Initiative provided $2,000 which supported Rafael Alaniz during the data collection period. Hospital Luis Calvo Mackenna contributed the expertise and assistance of their health informatics unit throughout the study. Merlin Telecom provided the Health Call system free of charge as well as contributed approximately $5,000 of general study funds. Relevant financial activities outside the submitted work. Integramedica and Clinica Indisa, private Chilean health networks, have previously contracted ER to analyze patient attendance across their health facilities. Merlin Telecom used the results from these analyses to develop interventions aimed at reducing attendance. All consultancies fees generated through these projects were used for study funds as well as to offset the travel costs incurred by the study team. ER neither participated in subsequent partnership nor has any financial stake in any ongoing interventions including the Health Call system evaluated in this study. In the early phases of study design, Inti Paredes was part of the study team as the local Co-Investigator and Study Manager while also being a paid consultant for Merlin Telecom. He assisted with organizing meetings with local stakeholders, document translation, and navigating the local ethical approval process. Around the implementation phase of the trial, he subsequently became employed by an unrelated company and the majority of his functions were assumed by ER. Neither he nor the study funders played a role in study design, data collection, analysis or preparation of this thesis. Relationships not covered Mauro, Mario, and Marcelo Arancibia (Merlin Telecom) are family friends of ER’s partner, Alicia Rusoja, which is how they initially approached ER with the idea of conducting an evaluation of their Health Call system. Results from this study have generated a fellowship program called the Arancibia Fellowship for Health, Technology, and Social Change. The Fellowship brings together representatives from Hospital Luis Calvo Mackenna, Merlin Telecom, the School of Public Health at Universidad de Chile, and the Johns Hopkins University Global mHealth Initiative
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